Coronado Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 11411 North 19th Ave, Phoenix, Arizona 85029
- CMS Provider Number
- 035132
- Inspections on file
- 23
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Coronado Healthcare Center during CMS and state inspections, most recent first.
Two residents’ care plans were not updated to reflect known behaviors and treatment needs. One resident with multiple sclerosis, anxiety, bipolar disorder, and moderate cognitive impairment repeatedly called 911 for brief changes due to confusion and anxiety, but this behavior was not included in the care plan despite staff awareness and facility expectations that behaviors be care planned. Another resident with TBI, epilepsy, dementia, and mood disorders had an active order and care plan focus to wear a helmet when out of bed, supported by physician notes and therapy training, yet was repeatedly observed ambulating without the helmet, while staff were unsure of the order, could not find it on the MAR/TAR, and had not documented refusals or any discontinuation. The DON and policies confirmed that refusals and high-risk services must be documented and incorporated into the care plan, but the resident’s electronic care plan lacked the noted refusal, demonstrating a failure to maintain accurate, updated care plans.
A resident with COPD, dementia, bipolar disorder, anxiety, moderate cognitive impairment, and documented depression had a care plan calling for participation in activities, structured interventions for elopement risk, and non-pharmacological approaches to support psychotropic use, yet activity logs over a month showed participation on only two days and almost no documented attendance over two months. Observations revealed the resident alone in a hallway or in bed while other residents sat in common areas with a loud TV, no structured activities, and minimal staff interaction. The Activity Director reported very limited activities staffing, no dedicated weekend coverage, reliance on CNAs to provide undocumented activities when time allowed, and no consistent documentation of refusals or inability to participate, despite a policy requiring documentation when residents cannot participate and affirming residents’ rights to choose activities.
A resident with epilepsy and traumatic brain injury had an active physician order and care plan intervention to wear a protective helmet when out of bed, with no documented discontinuation or pattern of care refusal. Over multiple observations, the resident was repeatedly seen standing, ambulating, and participating in activities without the helmet, despite visible room signage directing helmet use. Nursing staff, including an LPN and a CNA, were unaware or uncertain about the ongoing helmet order, assumed it had been discontinued, and could not locate a corresponding treatment entry or refusal documentation on the MAR/TAR. Therapy leadership confirmed the resident had been trained to use the helmet and was discharged from therapy with the expectation of continued helmet use and staff cueing, while the DON verified the order remained active and emphasized that orders and refusals should be accurately implemented and documented, consistent with facility policies on physician orders and charting.
Surveyors found multiple food storage and sanitation issues in the dietary department, including food debris under shelving in dry storage, an ice machine with gray, wet debris on its rubber rims, and unit refrigerators with spilled liquid left on shelves. In the main kitchen refrigerator and freezer, several food items such as applesauce, sheet cakes, burger patties, ground beef, cheese, and egg rolls were observed uncovered, exposed to air, and undated. During a tray line observation, hot foods including chicken, mixed vegetables, and baked bread pudding were recorded at 115–120°F. The dietary manager reported that dishwashing staff are responsible for sweeping and mopping floors after meals, that cleaning is not done after breakfast due to workload, and that he oversees these tasks, despite a facility policy requiring food storage areas to be clean at all times.
A resident with severe cognitive impairment and a court-appointed legal guardian experienced multiple changes in medical condition, including medication adjustments and new diagnoses. Despite facility policy and staff understanding that the legal guardian should be notified, documentation showed that only the resident was informed of these changes, and there was no evidence of communication with the legal guardian during key events.
A resident with multiple pressure ulcers and diabetic foot ulcers did not receive ordered wound care treatments on several occasions. Documentation showed missed treatments without evidence of follow-up attempts, coordination for alternate times, or communication to subsequent shifts. Nursing staff and the DON confirmed that facility expectations and policies required follow-up and documentation, but these actions were not reflected in the clinical record.
A resident admitted with multiple infections did not receive IV site dressing changes as ordered by the physician. Although the MAR indicated the dressing was changed, observation revealed the original hospital dressing remained in place past the required interval. Staff confirmed the dressing had not been replaced, contrary to facility policy and physician orders.
A registered nurse failed to don a gown, as required by Enhanced Barrier Precautions (EBP), while providing central line care to a resident with wounds and a central line. Despite physician orders and facility policy specifying the use of both gown and gloves for high-contact care activities, only gloves were used during the procedure.
The facility failed to protect residents from abuse by other residents and visitors. Incidents included physical altercations between residents with cognitive impairments and a visitor hitting a resident with a purse, resulting in injuries. The facility documented these as isolated events and took immediate action to separate and assess the residents involved.
A resident with cognitive impairments and multiple medical conditions eloped from the facility. Despite being assessed as low risk for elopement, the resident set off the front door alarm and was later found walking down a nearby avenue. Staff were unable to catch up to the resident, who refused to return. The facility lacked proper documentation and did not inform the resident's public fiduciary, who had full guardianship.
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation where one resident kicked and caused a skin tear on the other's forearm. Despite the facility's abuse prevention policy, staff interviews and progress notes confirmed the incident, and the Operations Manager could not recall the event.
A resident was discharged with medications not prescribed to her, including those belonging to other residents. The discharge process failed to properly reconcile and verify medications, leading to potential harm.
Failure to Update Care Plans for Behavioral 911 Calls and Ordered Helmet Use
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect known behaviors and treatment needs for two residents. For the first resident, who had multiple sclerosis, bipolar disorder, anxiety disorder, and a cognitive communication deficit, the MDS documented moderate cognitive impairment and dependence on staff for multiple ADLs. A complaint was filed stating that this resident had called 911 to request a brief change and had a history of doing so. Staff interviews confirmed that the resident experienced anxiety and sundowning, frequently believed she had pressed the call light when she had actually pressed the bed remote, and then, in a panic, dialed 911 for assistance with brief changes. Despite this ongoing behavior, the resident’s care plan, initiated in early 2022 and revised over time, did not include the behavior of calling 911 for brief changes. The acting DON stated that residents’ behaviors are always supposed to be documented in the care plan so clinical staff know what behaviors to expect. CNAs interviewed described the resident’s pattern of anxiety, confusion, and repeated 911 calls when she believed she had not received needed incontinence care, even though staff reported that brief changes were completed frequently. However, there was no evidence in the care plan that this behavior had been identified, addressed, or incorporated into the resident’s person-centered interventions, despite the facility’s own expectation that such behaviors be care planned. For the second resident, who had epilepsy, traumatic brain injury with brain compression and herniation, alcoholic cirrhosis, thrombocytopenia, hypertension, unspecified dementia with moderate cognitive impairment, anxiety disorder, and mood disorders including depression, the care plan and orders required the resident to wear a helmet when out of bed. A care plan focus initiated in mid-2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included wearing a helmet out of bed. An active order entry and physician progress notes documented that the resident was to utilize a helmet when out of bed. There was no evidence in the care plan that the resident refused the helmet or that helmet use had been discontinued. Observations over multiple days showed the resident repeatedly out of bed, standing, walking in his room, in activities, and in the dining room without the helmet, even though a sign in the room initially stated “HELMET ON AT ALL TIMES OUT OF BED,” and the helmet was visible on the nightstand. Nursing and CNA staff interviews revealed uncertainty about why the resident needed the helmet, whether the order was still active, and whether therapy had discontinued it. One LPN stated she had not seen the resident wear the helmet and was unaware of the order, and could not locate the helmet treatment on the MAR/TAR, even though she acknowledged that such an appliance should be documented there and that refusals should be recorded and communicated. A CNA reported that the resident used to wear the helmet more frequently but did not know why he stopped or why he should be wearing it, and had never been instructed to assist with or educate about helmet use. The director of rehabilitation confirmed that therapy had assessed and trained the resident and staff on helmet use, that the resident had been discharged from therapy with the expectation to continue helmet use out of bed, and that there was no documentation that the helmet had been discontinued. The interim DON stated that the facility is expected to follow provider orders as written, that care plans must be updated quarterly and as needed, and that refusals of care should be documented and reflected in the care plan so providers can make necessary changes. When reviewing the resident’s care plan, the interim DON believed there was a note indicating the resident refused the helmet, but the care plan retrieved from the electronic health record did not contain such a note, and she was unsure about the documentation discrepancy. Facility policies on comprehensive person-centered care planning and documenting and charting required that refusals of services posing health and safety risks be identified in the care plan, including the declined care, associated risks, and the interdisciplinary team’s educational efforts, and that the medical record provide a complete account of care and treatment. For both residents, the survey findings showed that the care plans were not updated and revised to accurately reflect known behaviors and treatment orders, leading to incomplete and inconsistent documentation of their current care needs and interventions.
Failure to Provide Ongoing, Individualized Activities Program for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing program of activities designed to meet the interests and physical, mental, and psychosocial well-being of a resident. The resident was admitted with COPD, unspecified dementia of moderate severity, bipolar disorder, anxiety, and was receiving scheduled antipsychotic and psychotropic medications. The comprehensive care plan identified that the resident participated in activities such as bingo and ice cream socials, and included interventions such as inviting the resident to scheduled activities, providing a monthly activities calendar, and establishing and recording prior activity involvement and interests. Additional care plan focuses included elopement risk/wandering, with interventions such as structured activities (toileting, walking inside and outside, reorientation strategies), and psychotropic medication use with non-pharmacological interventions including back rubs, redirection, calm approach, repositioning, providing a quiet environment, and taking the resident to activities. Review of the most recent quarterly MDS showed the resident had a BIMS score of 9 (moderate cognitive impairment) and a Resident Mood Interview score of 13, indicating moderate depression and that the resident sometimes felt socially isolated. The MDS also documented that the resident required maximum assistance with toileting, bathing, and transfers. Review of the social activity task log for a 30-day period showed the resident participated in activities on only two days. Paper activity participation logs for two consecutive months showed the resident had no documented attendance for one month and only one documented activity for the prior month. Activity calendars for both the secured and non-secured units listed only a limited set of group activities (bingo, coffee social, woodworking, table games, open activities) and were identical for both units, without individualized or unit-specific programming for residents on the secured unit. Multiple observations showed a lack of structured or documented activities and minimal staff engagement. The resident was observed alone in a hallway in a wheelchair with no staff nearby while other residents sat in a common area with a loud television and some staring at the wall. During a scheduled ice cream social, no activities were occurring and the resident was not present in the common area. On another occasion, several residents were in the common area while staff sat in a secluded nursing desk area conversing, with the television on but no staff interaction, structured activities, or resident socialization observed; later, the resident was found in bed with covers drawn and lights off. The Activity Director reported having only one light-duty CNA to assist on limited days, no activities staff on weekends, and reliance on CNAs to provide activities when they had time, without consistent documentation of refusals or non-applicability. CNAs confirmed there was no set time for activities on the secured unit, that they provided activities only if time allowed, and that they did not document these activities. The facility’s policy stated that residents have the right to choose activities and that reasons for inability to participate should be documented in the medical record, but such documentation was not described in the findings.
Failure to Implement and Document Physician Order for Protective Helmet Use
Penalty
Summary
The deficiency involves the facility’s failure to implement and document a physician’s order for a resident to wear a protective helmet when out of bed. The resident was admitted with epilepsy, traumatic brain injury with brain compression and herniation, anxiety disorder, mood disorder, and major depressive disorder. A care plan focus initiated in early June 2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included the intervention for the resident to wear a helmet out of bed. An active order dated June 6, 2023, and subsequent physician progress notes, including one dated January 9, 2026, directed that the resident wear a helmet when out of bed. A quarterly therapy screen and a quarterly MDS assessment showed no indication that the resident refused the helmet or that its use had been discontinued, and the MDS documented no rejection of necessary care in the seven days prior to that assessment. Despite these orders and care plan interventions, surveyor observations over multiple days showed the resident repeatedly out of bed and ambulating without the helmet. On the first survey day at 9:00 AM, the resident was observed standing in his room without a helmet, while the helmet was on the nightstand under a wall sign stating “HELMET ON AT ALL TIMES OUT OF BED.” The resident reported that staff had helped him apply the helmet in the past. Shortly thereafter, a nurse entered to administer medications and did not assist with helmet application, and the resident was observed walking out of the room without the helmet. On subsequent days, the resident was observed in the activities room, in the dining room, and walking out of the dining room without the helmet. During an interview, the resident described the extent of his traumatic brain injury, stated he needed to be careful with ambulation due to risk of re-injury, acknowledged awareness of the helmet signage, and stated that staff assisted him with helmet application when needed. The medical record lacked documentation that the helmet order was being implemented and lacked documentation of any refusals by the resident. An LPN who provided care to the resident stated she was unsure why the resident required a helmet, had not seen him wear it, and was unaware of the helmet order or the signage until it was pointed out; she confirmed that refusals of treatment should be documented on the MAR/TAR and communicated to the charge nurse, but could not locate a helmet treatment on the MAR/TAR. A CNA reported that the resident used to wear the helmet more frequently when first admitted but could not say why he stopped and assumed therapy had discontinued the order, though she had not been informed of any change. Later, the helmet signage in the resident’s room was found removed, and the charge nurse stated she did not know why it was taken down and believed therapy would discontinue such an order, yet there was no documentation of discontinuation in the record. The director of rehabilitation stated that therapy had assessed and educated the resident on helmet use, including modifications to make it easier to don and doff, and that the resident was discharged from therapy with the expectation that helmet use out of bed would continue and that floor staff would cue and assist as needed. She stated that any caretaker could apply the helmet and that discontinuation of such an appliance would be documented in the chart, which was not evident for this resident. The interim DON confirmed that the active order for helmet use out of bed had not been discontinued and that facility expectations were to follow physician orders as written, update care plans as needed, and document completion of orders and refusals so providers are aware. Facility policies on documenting and charting and on physician orders required complete documentation of care and accurate implementation and transcription of treatment orders into the eMAR/eTAR. The lack of implementation and documentation of the helmet order, and absence of documented refusals or discontinuation, constituted the deficiency.
Deficient Food Storage, Sanitation, and Temperature Control in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in food storage and sanitation practices in the facility’s dietary services. During an initial kitchen observation, food debris described as dry, crumb-like items was found under the bottom shelf in the dry storage area. The dietary manager acknowledged the debris and stated it could draw vermin, and reported that dishwashing staff are responsible for sweeping and mopping all floors after every meal, including the dry storage area. In the main kitchen refrigerator, surveyors observed an individual plastic cup of applesauce with a loosened snap-on lid open approximately 1/4 inch, three uncovered and undated sheet cakes on separate shelves, undated tubes of ground beef in original packaging, and an open, undated block of cheese exposed to air. In the freezer, three sheet trays containing a total of ninety uncovered burger patties were observed exposed to air, along with an opened and undated bag of frozen egg rolls. The dietary manager stated these practices could allow foodborne illness potential. Debris particles that appeared gray and wet were also seen on the rubber rims inside the ice machine when its door was lifted, and the dietary manager stated this area needed cleaning. On a subsequent observation of unit refrigerators, spilled liquid resembling yogurt was noted on the bottom shelf of the 500 wing refrigerator; the dietary manager stated that staff come daily at a set time to clean all unit refrigerators. During observation of the tray line, surveyors followed the last unit tray cart and recorded food temperatures taken by the dietary manager: chicken measured 120°F, mixed vegetables measured 115°F (with difficulty obtaining an accurate reading due to inability to maintain a discrete pile), and baked bread pudding measured 120°F. Later, the dietary manager stated that sweeping and mopping are done after lunch and at night, and that they do not clean after breakfast due to how busy they are at that time, while also stating he is responsible for overseeing completion of these tasks. The facility’s “Resident/Personal Food Storage” policy stated that food storage areas shall be clean at all times, which contrasted with the observed conditions in the dry storage area, refrigerators, freezer, and ice machine.
Failure to Notify Legal Guardian of Resident's Change in Condition
Penalty
Summary
The facility failed to honor a resident's rights by not notifying the court-appointed legal guardian of multiple changes in the resident's medical condition. The resident, who had diagnoses including acute on chronic congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, unspecified dementia, and dysphagia, was determined to have severely impaired cognition with a BIMS score of 6. Documentation confirmed the presence of a permanent legal guardian, and the resident's electronic medical record included the guardian's contact information. Despite this, there was no evidence that the legal guardian was notified of significant changes in the resident's condition, such as elevated INR, uncontrolled blood glucose, medication adjustments, new orders for diagnostic procedures, or care conferences. Multiple notes in the resident's medical record indicated that only the resident was notified of these changes, even though the resident was not cognitively capable of making informed decisions. Staff interviews confirmed that facility policy and staff understanding required notification of the legal guardian in such cases, regardless of the resident's wishes, due to the guardian's court-appointed authority. However, the documentation repeatedly showed that the legal guardian was not informed during several key events, including medication changes, new diagnoses, and care planning meetings. Facility policies reviewed stated that residents or their responsible agents must be informed of changes in condition and that legal guardians are to be involved in decision-making for residents deemed incapacitated. Despite these policies, the facility did not consistently communicate with the legal guardian as required, as evidenced by the lack of documentation of such notifications during multiple changes in the resident's condition and care.
Failure to Provide and Document Ordered Wound Care Treatments
Penalty
Summary
A resident with multiple complex medical conditions, including acute respiratory failure, MRSA infection, bacteremia, infective endocarditis, diabetes with foot ulcer, and congestive heart failure, was re-admitted to the facility with several unstageable pressure ulcers and diabetic foot ulcers. The care plan and physician orders specified daily wound care treatments for multiple wound sites, including the sacrum, heels, and feet, with specific instructions for cleansing, application of topical medications, and dressings. The resident's cognitive status was intact, as indicated by a BIMS score of 15. Despite these orders, documentation revealed that wound care treatments were not administered on multiple dates. The Medication and Treatment Administration Record (MAR/TAR) showed no evidence of wound care on certain days, and for several other dates, wound care orders were marked as "Hold/See Nurse Notes." Nurse notes indicated that the resident was often not in their room or on the unit at the time of scheduled treatments, or refused treatment, but there was no evidence that staff made follow-up attempts to provide care at a later time, coordinated with the resident for an alternate time, or communicated with the following shift to ensure treatments were completed. There was also no documentation of resident education regarding the importance of wound care or any modification of the care plan in response to missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to follow physician orders, attempt to locate the resident, and reschedule treatments if the resident was unavailable or refused at the scheduled time. However, the clinical record lacked evidence of these follow-up actions. Facility policies required that wound care be administered as ordered, documented at the time of administration, and that interventions be modified as needed based on the resident's condition. The failure to provide wound care as ordered and to document follow-up actions constituted a deficiency in the provision of necessary treatment and care.
Failure to Follow Physician Orders for IV Site Care
Penalty
Summary
The facility failed to provide treatment and services in accordance with physician orders and professional standards for a resident who required intravenous (IV) site care. The resident was admitted with multiple infections, including staphylococcal arthritis, methicillin susceptible staphylococcus aureus infection, cellulitis, and a cutaneous abscess. A physician order specified that all central line, PICC, and midline transparent dressings should be changed using sterile technique upon admission, every seven days, and as needed, with additional instructions for changing injection caps. The Medication Administration Record (MAR) indicated that the dressing change was documented as completed by a registered nurse on a specific date. However, during an observation, the IV site dressing was found to be dated prior to the resident's admission and had not been changed according to the physician's order. The dressing was identified as originating from the discharging hospital, and staff confirmed that it had not been replaced since admission. The Assistant Director of Nursing acknowledged that the order required the dressing to be changed every seven days and as needed, and that the MAR reflected a dressing change that had not actually occurred. Facility policy requires accurate implementation of physician orders, but in this instance, the order for IV site care was not followed.
Failure to Follow Enhanced Barrier Precautions During Central Line Care
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow the facility's infection control policy regarding Enhanced Barrier Precautions (EBP) for a resident with multiple risk factors for infection. The resident had been admitted with diagnoses including staphylococcal arthritis, methicillin susceptible staphylococcus aureus infection, cellulitis, and a cutaneous abscess, and had a central line in place. Physician orders specified the use of EBP, requiring personal protective equipment (PPE) such as gown and gloves for high-contact care activities due to the presence of wounds and a central line. During an observation, the registered nurse entered the resident's room to disconnect an IV line and flush the central line, but only donned gloves and did not wear a gown as required by EBP protocols. The Assistant Director of Nursing confirmed in an interview that EBP should be applied for residents with central lines and wounds, and that staff are informed of these requirements through physician orders. Review of the facility's infection control policy further confirmed that both gown and gloves are required for high-contact care activities involving central lines or wounds.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse by other residents and visitors. Resident #49, who had severe cognitive impairment and wandering behaviors, was found with a facial bruise after an altercation with Resident #161, who also had severe cognitive impairment. The incident occurred when Resident #49 took Resident #161's wheelchair, leading to Resident #161 making contact with Resident #49's nose. The staff did not witness the altercation but found Resident #49 with a small amount of blood on her face and Resident #161 yelling about the wheelchair. Both residents were separated and assessed for injuries, and the incident was reported to the Administrator and DON immediately. In another incident, Resident #175, who had diagnoses including COPD, type II diabetes, and anxiety disorder, was hit on the back of the head by a visitor using a large black purse. The visitor was demanding her purse back from the resident, leading to an argument that escalated into physical abuse. The CNA witnessed the visitor hitting Resident #175, who sustained a small cut on the back of his head. The social services manager intervened, and the visitor was asked to leave and was subsequently banned from returning to the facility. A third incident involved Resident #216, who had intact cognition, and Resident #223, who had moderate cognitive impairment. Resident #216 was seen making closed-hand contact with the back of Resident #223 after an argument over a cigarette on the smoking patio. The CNA intervened and separated the residents. Resident #216 reported feeling threatened by Resident #223's swinging arms, which led to the physical contact. The facility documented these incidents as isolated events and took immediate action to separate and assess the residents involved.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to an elopement incident. The resident, who had a history of meningitis, sepsis, subperiosteal abscess of the mastoid in the left ear, pneumonia due to pseudomonas, chronic viral hepatitis C, and transient ischemic attack, was admitted with cognitive impairments and was not oriented to time, place, or person. Despite being ambulatory and having no wandering behaviors initially, the resident was identified as low risk for elopement. However, on a later date, the resident set off the front door alarm and was found missing after a head count. Staff observed the resident walking down a nearby avenue but were unable to catch up to him, and the resident refused to return to the facility. The Director of Nursing (DON) confirmed that the protocol for a missing resident involved searching the building and, if unsuccessful, calling the police to file a missing person report. The resident's public fiduciary, who had full guardianship, was not informed or did not consent to the resident leaving the facility. The facility did not have self-report documentation or witness statements for the incident. The public fiduciary confirmed that the resident exited through a fire exit door and refused to come back despite staff efforts to follow him.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to ensure that Resident #465 was free from abuse by another resident, Resident #464. Resident #465, who has a BIMS score of 13 and multiple diagnoses including metabolic encephalopathy and COPD, was physically assaulted by Resident #464, who has a BIMS score of 14 and diagnoses including rhabdomyolysis and mood disorder. The incident occurred when Resident #464 became upset with Resident #465 being in his room and kicked Resident #465, causing a skin tear on his right forearm. This incident was confirmed through interviews with staff and review of progress notes, where Resident #464 admitted to the assault and stated that he had threatened to kick Resident #465's ass before the physical altercation occurred. The incident was reported by Resident #465 to the Operations Manager and was further corroborated by a CNA who responded to the commotion in the room. Despite the facility's policy on abuse prevention, the Operations Manager could not recall the incident, and the Director of Nursing stated that the facility would file a report within 2 hours of any injury, whether serious or non-serious, to the State Agency. The facility's failure to protect Resident #465 from abuse by Resident #464 highlights a significant deficiency in ensuring resident safety and adherence to abuse prevention protocols.
Failure to Reconcile Post-Discharge Medications
Penalty
Summary
The facility failed to ensure that a resident had a reconciliation of post-discharge medications according to professional standards. Resident #613, who was moderately cognitively impaired, was discharged with medications that were not prescribed to her. The discharge documentation indicated that the resident was to be discharged with her current medications, but she was given blister packs containing medications belonging to three other residents. This included medications such as Diltiazem, Atorvastatin, and Apixaban, which were not prescribed to Resident #613. Interviews with staff revealed that the process for discharging residents involved printing out a medication sheet and physically gathering the medications to be given to the resident. The discharge nurse was responsible for verifying that the medications matched the discharge summary. However, this verification process failed, resulting in Resident #613 being discharged with inappropriate medications. The Director of Nursing acknowledged that the manual process posed a risk of such errors occurring. The facility's policy required a reconciliation of all pre-discharge medications with the resident's post-discharge medications, but this was not adhered to in this case. The failure to properly reconcile and verify the medications led to Resident #613 being discharged with medications that could potentially cause harm, such as Cardizem, which can lower heart rate if not required by the patient. The incident was reported by the resident's daughter, who found medications labeled with other residents' names in her mother's possession.
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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.
Trusted data from CMS and state health departments
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