Desert Cove Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chandler, Arizona.
- Location
- 1750 West Frye Road, Chandler, Arizona 85224
- CMS Provider Number
- 035095
- Inspections on file
- 19
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Desert Cove Nursing Center during CMS and state inspections, most recent first.
A resident with muscle weakness and neurological impairment did not receive a physician-ordered speech evaluation due to an order entry error that marked the order as completed before services were provided. The speech therapist was not notified of the order, and the resident confirmed never receiving speech therapy.
A resident with multiple health conditions, including bilateral below-the-knee amputations and a high risk for falls and skin breakdown, was left unattended in the shower room for about an hour after the assigned CNA became ill and left the facility. Although the CNA attempted to notify other staff, the information was not effectively communicated, resulting in the resident being left alone without a call light. Facility policy requiring staff to remain nearby during showers and check on residents every 5 to 10 minutes was not followed, and the resident was only discovered when they moved themselves to the door and were found by staff.
A CNA was observed emptying a resident's indwelling urinary catheter bag while wearing gloves but not a gown, contrary to facility policy and Enhanced Barrier Precautions (EBP). The CNA admitted to skipping the gown due to being in a hurry, despite having received infection control training. Interviews with an LPN and the DON confirmed that both gloves and a gown are required for catheter care, as outlined in facility policies.
A resident who was fully dependent on staff for bathing did not consistently receive scheduled showers as outlined in their care plan, with multiple missed or undocumented bathing events and no evidence of refusals. Staff interviews revealed confusion over assignments and improper documentation practices, including the use of another staff member's login credentials. Facility policies required regular assistance and documentation for ADLs, but these were not followed, resulting in unmet hygiene needs.
A resident with a urinary catheter did not consistently receive care and monitoring as ordered by the physician, with multiple instances of missing documentation for catheter emptying and urine output. The resident reported that the catheter bag was sometimes not emptied for extended periods, and staff interviews confirmed lapses in following care protocols and documentation requirements.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
A resident with multiple comorbidities, including diabetes and ulcers, did not receive wound care as ordered by the provider on several occasions, with no documentation to support that care was provided or refused. Interviews with staff and review of records confirmed that wound care was not consistently performed or recorded, contrary to facility policy and physician orders.
A resident with moderate cognitive impairment was inappropriately touched by another resident during a Christmas party, despite existing interventions for the latter's history of inappropriate behavior. The facility's policies on preventing abuse and ensuring consent were not effectively implemented, as no immediate psychiatric evaluation or care plan revision was conducted for the affected resident.
A facility failed to provide adequate supervision, resulting in multiple resident altercations. A resident with severe cognitive impairment and a history of aggression was involved in incidents where they hit other residents, despite care plan interventions requiring staff presence. Another resident with Alzheimer's exhibited aggression, striking a peer in the dining room. A third resident, with moderate cognitive impairment, was a victim of aggression due to lack of staff supervision during transitions. Staff interviews highlighted inconsistent adherence to care plans, contributing to these incidents.
The facility failed to provide necessary services for personal hygiene and meal assistance for two residents. One resident received fewer showers than required, and another did not receive consistent feeding assistance, as documented and confirmed by staff interviews.
The facility failed to ensure the environment remained free of accident hazards by leaving medications unattended. A medication cup with a red capsule was observed on a medication cart with no staff present. The DON disposed of the medication, and interviews confirmed that the RN had left it unattended after being called away.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Staff schedules for January and March 2023 showed no RN coverage for 8 consecutive hours on at least 4 days each month, and in November and December 2023, there was no RN coverage for one day each month. Interviews with the staffing coordinator and DON confirmed awareness of the regulations but indicated inconsistent compliance. The census was 63 residents.
The facility failed to administer pain medication within the prescribed pain scale parameters for two residents, leading to potential overmedication. One resident was given 10 mg of oxycodone for pain levels 0 to 3, and another was given 5 mg of oxycodone for pain levels 0 to 6, contrary to physician orders. Staff interviews and the MAR confirmed these discrepancies, which did not meet the facility's policies and expectations.
The facility failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, and did not enforce the use of beard guards/nets for staff with facial hair. Observations revealed multiple instances of staff not washing hands after touching unsanitary surfaces and not wearing beard guards, which was confirmed by staff interviews and a review of facility policies.
The facility failed to ensure proper infection control practices, as an X-Ray Technician performed an ECG on a resident without PPE despite enhanced barrier precautions, and a nurse improperly sanitized a glucometer between uses. The Infection Preventionist and DON emphasized the importance of adhering to infection control policies.
A resident with multiple diagnoses was found with medications at the bedside without proper assessment or physician orders. Interviews with staff revealed a lack of adherence to the facility's policy on self-administration of medications, and the DON confirmed that the resident had not been assessed or authorized to self-administer medications.
A resident with ESRD and a dialysis shunt in the left arm had blood pressure measured from the shunt arm on seven occasions, contrary to the care plan and facility policy. Interviews revealed inconsistent understanding among RNs about the policy, potentially risking harm to the resident.
The facility failed to ensure unused medications were disposed of according to accepted professional standards. A red capsule was found unattended on a medication cart and was improperly disposed of in an uncovered bin by the DON. Interviews with staff confirmed that this practice was against facility policy and posed a risk to residents.
Failure to Implement Physician-Ordered Speech Services Due to Order Entry Error
Penalty
Summary
The facility failed to ensure that professional standards of care were followed regarding the implementation of physician-ordered speech services for a resident. The resident was admitted with multiple diagnoses, including muscle weakness and a neurological disorder, and was assessed as cognitively intact. A physician order was entered for a one-time speech evaluation due to increased weakness in the resident's voice. However, the order was incorrectly entered with a one-day stop date, causing it to be automatically marked as completed in the system, even though the evaluation was never performed. The speech therapist did not receive notification of the order and therefore did not conduct the evaluation. The Director of Nursing confirmed that the speech evaluation was not completed and could not be located. The resident reported never receiving speech therapy, and the speech therapist stated he was unaware of any new orders for the resident. Facility documentation and interviews revealed that the failure to properly enter and communicate the physician's order resulted in the resident not receiving the required speech evaluation as ordered.
Resident Left Unattended in Shower Room Due to Staff Communication Failure
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including bilateral below-the-knee amputations, chronic heart failure, diabetes, chronic respiratory failure, and muscle weakness, was left unattended in the shower room for an extended period. The resident's care plan identified them as being at risk for falls and impaired skin integrity, requiring maximal assistance with bathing and toileting, and the use of a motorized wheelchair with orthotics/prosthetics. During a bathing session, the assigned CNA became ill and was sent home by the DON, who instructed the CNA to notify other staff about the resident. The CNA reported informing an LPN and another CNA, but the information was not effectively communicated, resulting in the resident being left alone in the shower room without a call light nearby. The resident reported being left in the shower room for approximately an hour, during which time they were seated in a shower chair and eventually had to pull themselves toward the door to seek assistance. Facility policy required staff to stay nearby during showers and check on residents every 5 to 10 minutes, but this protocol was not followed. Interviews with staff confirmed that residents should not be left unattended in shower chairs due to the risk of injury, yet the resident was left alone, and the incident was only discovered when a staff member found the resident after they had moved themselves to the door.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed entering a resident's room and emptying the resident's indwelling urinary catheter bag while wearing gloves but not a gown, as required by the facility's infection control policies. The resident had a medical history that included infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, and obstructive and reflux uropathy. The CNA acknowledged during an interview that she should have worn a gown in addition to gloves but failed to do so because she was in a hurry, despite having received infection control training and having access to personal protective equipment. Further interviews with an LPN and the Director of Nursing confirmed that Enhanced Barrier Precautions (EBP), including the use of gloves and a gown, are required when providing catheter care or emptying a catheter, in accordance with facility policy. Review of the facility's policies on indwelling urinary catheter management and transmission-based precautions also specified the need for gloves and gowns during manipulation of the catheter or high-contact resident care activities. The failure to follow these infection control practices was identified through clinical record review, observation, and staff interviews.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with paraplegia and a history of chronic pain, hypertension, and recent infection was not provided assistance with bathing or showering according to their care plan and preferences. The resident was assessed as cognitively intact and fully dependent on staff for bathing, with a care plan specifying two showers per week. Facility records and shower schedules indicated multiple missed or undocumented showers over a period of several weeks, with no evidence of resident refusal or proper documentation in the clinical record for those dates. Interviews with the resident and various staff members revealed inconsistencies in the assignment and documentation of bathing tasks. The resident reported not receiving scheduled showers and recounted a previous period of four weeks without a shower. Staff interviews confirmed that showers were to be documented on shower sheets and in the electronic record, with refusals also to be documented. However, several staff members either did not offer showers as scheduled or were not assigned to the resident, and one staff member's electronic documentation was found to be completed by someone else using their login credentials while they were not present in the facility. Review of facility policies confirmed that residents are to receive assistance with ADLs, including bathing, in accordance with their care plan and professional standards. Documentation of showers, including skin condition and refusals, was required but not consistently completed. The lack of proper documentation and failure to provide scheduled showers as per the resident's care plan constituted a failure to meet the resident's needs and preferences for personal hygiene.
Failure to Provide Catheter Care and Output Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide care and services for a urinary catheter according to physician orders for a resident with paraplegia, neurogenic bladder, and a history of sepsis and catheter-related infection. The resident had physician orders to have the catheter emptied and urine output recorded three times daily, with documentation required in the electronic clinical record. Review of the Medication and Treatment Administration Record (MAR/TAR) revealed multiple instances across several months where the required documentation was missing, indicating that the catheter may not have been emptied or the output recorded as ordered. There was no evidence in the clinical record that the resident refused care on these occasions. Interviews with the resident confirmed that the catheter bag was not always emptied as scheduled, with reports of the bag not being emptied for 12-14 hours at times, and the resident having to empty the bag himself. Staff interviews corroborated that both CNAs and nurses are responsible for catheter care and output monitoring, and that failure to empty the catheter bag as ordered could lead to complications. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of adhering to physician orders for catheter care and recognized that the lack of documentation meant there was no way to confirm if care was provided as required. Facility policy required regular emptying of catheter bags and documentation to prevent infection and ensure proper care. The policy also specified the use of clean containers and ongoing monitoring for signs of infection. The review of records and staff interviews demonstrated that the facility did not consistently follow these protocols, resulting in a failure to provide care and services in accordance with physician orders and established standards.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Provide and Document Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received wound care in accordance with physician orders. The resident, who had diagnoses including heart failure, cellulitis, diabetes with ulcers, obesity, and muscle weakness, was admitted with a care plan requiring treatment as ordered and weekly skin checks. Physician orders specified detailed wound care steps for ulcers on the left lower extremity and right inner calf, to be performed daily or twice daily. However, clinical record review showed that wound care for both areas was not documented as performed or refused on multiple identified dates. Interviews with facility staff confirmed that wound care was the responsibility of licensed nurses, and that refusals or missed treatments were to be documented and reported. The Director of Nursing acknowledged that there was no evidence in the Treatment Administration Record to support that wound care was provided or refused on the specified dates, and that facility expectations for documentation and care were not met. Facility policies required accurate documentation of care and resident condition, as well as resident participation in care planning.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in an incident where one resident was inappropriately touched by another resident. Resident #26, who has moderate cognitive impairment due to dementia, was involved in an incident at a Christmas party where Resident #13, also with moderate cognitive impairment, was observed with his hand down Resident #26's pants. This incident was witnessed by the Admissions Assistant, who noted that Resident #26 did not appear distressed at the time. Resident #13 has a history of inappropriate sexual behavior, including making inappropriate comments and touching staff. His care plan included interventions for these behaviors, such as monitoring and supervision. Despite these measures, the incident with Resident #26 occurred, indicating a failure in the facility's ability to prevent such interactions between residents. The facility's policies on intimacy and abuse prevention were not effectively implemented, as evidenced by the lack of immediate psychiatric evaluation or care plan revision for Resident #26 following the incident. The Director of Nursing acknowledged that both residents lacked the capacity to consent to sexual activity, yet the facility did not take adequate steps to prevent the abuse or address the aftermath appropriately.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, as evidenced by incidents involving three residents. Resident #1, who has severe cognitive impairment and a history of physical aggression, was involved in multiple altercations. Despite care plan interventions requiring staff presence and maintaining distance from other residents, Resident #1 was observed hitting another resident in the hallway. This incident occurred without staff escorting Resident #1, contrary to the care plan requirements. Resident #2, diagnosed with Alzheimer's Disease and severe cognitive impairment, exhibited physical aggression towards peers. An incident was documented where Resident #2 struck another resident in the dining room. The care plan for Resident #2 included interventions to manage aggression, such as allowing extra time for responses and maintaining a consistent routine, but these measures were not effectively implemented to prevent the altercation. Resident #3, with moderate cognitive impairment, was a victim of physical aggression by Resident #1. Despite being aware of Resident #1's aggressive tendencies, the facility did not ensure staff supervision during transitions in and out of the dining room, leading to Resident #3 being hit. Interviews with staff revealed a lack of consistent supervision and adherence to care plan interventions, contributing to the incidents of resident-to-resident aggression.
Deficiencies in Personal Hygiene and Meal Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for one resident and assistance with meals for another resident. Resident #39, who has multiple diagnoses including paraplegia and chronic pain, was documented to have received only one shower during the week of January 24, 2024, despite the care plan indicating a need for two showers per week. Interviews with staff revealed that the facility had been short-staffed for the past 3 to 4 weeks, leading to delays in providing showers. The Director of Nursing confirmed that a 6-day gap between showers did not meet the facility's expectations and acknowledged the potential risk of infection due to lack of hygiene. Resident #10, diagnosed with quadriplegia and other conditions, required assistance with feeding as per the care plan. However, documentation revealed inconsistencies in the assistance provided, with several instances where the resident did not receive the necessary help during meal times. An interview with the resident confirmed that she did not receive assistance with her meal on the morning of February 5, 2024. Staff interviews indicated that the resident required extensive assistance with all meals, and the Director of Nursing acknowledged that the documentation did not meet expectations, suggesting a possible documentation error. The facility's ADL policy, reviewed in August 2023, mandates that residents receive assistance with activities of daily living, including bathing and feeding. The failure to adhere to this policy for residents #39 and #10 highlights deficiencies in the facility's ability to provide consistent and necessary care, potentially compromising the residents' health and well-being.
Unattended Medication on Cart
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards by leaving medications unattended. On February 08, 2024, at 9:34 A.M., a small clear plastic measuring cup with a red capsule was observed on top of a medication cart with no staff present. The Director of Nursing (DON) also observed the unattended medication on the cart and disposed of it in an uncovered bin located at the bottom end of the medication cart. The medication was identified as docusate belonging to a resident. Interviews conducted with a registered nurse (RN) and the DON confirmed that the medication was left unattended. The RN stated that they were called away and it slipped their mind to secure the medication. The administrator confirmed that medications should always be within view and not left unattended on carts, as they can be picked up by unauthorized individuals.
Failure to Maintain RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulations. Review of staff schedules for January and March 2023 revealed that there were no RNs on duty for 8 consecutive hours for at least 4 days each month. Additionally, in November and December 2023, there were no RNs for 8 consecutive hours for one day in each month. Interviews with the staffing coordinator and the Director of Nursing (DON) confirmed awareness of the regulations but indicated that the facility did not consistently meet the requirement. The staffing coordinator mentioned that typically an RN, such as the Infection Preventionist or the DON, would be present, and the DON stated that she would cover if no licensed nurse was available within a 24-hour period. The census at the time was 63 residents, and this deficiency has the potential to affect resident care.
Failure to Administer Pain Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to administer pain medication within the prescribed pain scale parameters for two residents, leading to potential overmedication. Resident #39, who has diagnoses including paraplegia, chronic pain, and anxiety disorder, was administered 10 mg of oxycodone for pain levels ranging from 0 to 3, despite the physician's order specifying it should only be given for pain levels 4 to 10. This occurred at least seven times, as confirmed by the Director of Nursing (DON) and the Medication Administration Record (MAR). Interviews with staff revealed that the medication was administered outside the prescribed parameters, which did not meet the facility's expectations and policies. Similarly, Resident #17, with diagnoses including a displaced intertrochanteric fracture of the right femur and chronic back pain, was given 5 mg of oxycodone for pain levels 0 to 6, contrary to the physician's order for administration only for pain levels 7 to 10. This occurred on at least eleven occasions, as confirmed by the DON and the MAR. Staff interviews indicated that the medication was not administered according to the prescribed parameters, which could lead to serious health risks. The facility's policy on the administration of medications, reviewed in August 2023, mandates that medications be administered safely and appropriately per physician orders. The policy also emphasizes adherence to the 10 rights of medication administration. The DON acknowledged that the administration of oxycodone outside the prescribed parameters did not meet the facility's standards and posed potential risks to the residents.
Failure to Ensure Proper Hand Hygiene and Beard Guard Use
Penalty
Summary
The facility failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, as well as donning beard guards/nets in the presence of facial hair. During a kitchen observation, a dietary aide was seen with facial hair and not wearing a beard guard/net. Additionally, a cook was observed answering the kitchen phone and returning to puree preparation without conducting hand hygiene. In the dining room, the activities director was seen pulling up his pants, scratching his face, and then passing out dining trays without washing his hands. Similarly, the staffing coordinator was observed cutting up food for multiple residents without performing hand hygiene between each resident's utensils. The activities director was also seen wiping under his eyes and then delivering a food tray without washing his hands first. Interviews with staff confirmed that the expected hand hygiene practices were not followed. The dietary director and the executive director both acknowledged that the failure to adhere to proper hand hygiene and beard guard policies could lead to contamination of food and potential infection. A review of the facility's policies on Associate Conduct and Dress Code, as well as Handwashing and Glove Use, revealed that these practices were required to prevent contamination and ensure sanitary conditions in the kitchen and dining areas.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices were observed, leading to potential spread of infections. Resident #60, who was cognitively intact and had a foley catheter, was placed under enhanced barrier precautions to prevent urinary infections. However, an X-Ray Technician entered the resident's room and performed an ECG without donning appropriate PPE, despite the presence of CDC signage indicating the need for enhanced barrier precautions. The technician admitted to not seeing the signage and acknowledged the risk involved in performing high-contact procedures without PPE. The Infection Preventionist expressed uncertainty about the necessity of PPE for an ECG, but emphasized the importance of adhering to posted signage and inquiring when unsure about precautions. Additionally, during a medication pass observation, a registered nurse was seen returning a glucometer to the medication cart without properly sanitizing it between uses. The nurse was unsure of the policy regarding glucometer sanitization and used an alcohol pad instead of the required bleach wipes. The Director of Nursing later provided the correct policy for cleaning and disinfecting the glucometer, which mandates the use of EPA-registered bleach wipes to prevent the transmission of bloodborne pathogens. The DON stated that the nurse was reeducated on the proper cleaning procedures and emphasized the importance of following infection control policies. The facility's policies for standard precautions, handwashing, and glove use were reviewed, revealing that the infection prevention and control program includes systems for preventing, identifying, reporting, investigating, and controlling infections. The policies also specify the appropriate use of PPE, hand hygiene, and cleaning and disinfecting procedures. Despite these policies, the observed deficiencies in infection control practices highlight lapses in adherence to established protocols, potentially jeopardizing the health and safety of residents and staff.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medication. Resident #6, who was admitted with diagnoses including type 2 diabetes, spinal stenosis, heart failure, and essential hypertension, was observed with hydrocortisone ointment and Vicks Vaporub at the bedside without any staff present. The resident confirmed that staff were aware of the medications. Interviews with a CNA and an LPN revealed that there was no consistent understanding or adherence to the policy regarding self-administration of medications. The CNA was unaware of any policy and stated that medications found at the bedside were typically disposed of by the nurse. The LPN confirmed that all medications should be stored in the wound or medication cart and administered by a nurse, and acknowledged the existence of a policy for self-administration but noted it was not commonly practiced. The DON confirmed that the resident had not been assessed for self-administration, and there were no physician orders or care plan entries to support self-administration for this resident. The facility's policy, dated August 29, 2023, requires an interdisciplinary team assessment and a physician's order for residents to self-administer medications. However, this policy was not followed for Resident #6, as there was no evidence of an assessment or physician's order in the resident's records. The DON verified that the resident was not authorized to self-administer medications, highlighting a failure to adhere to the established policy and procedure, which could result in residents self-administering medications without proper assessment and authorization.
Failure to Follow Dialysis Care Policy for Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease (ESRD) and a dialysis shunt in the left arm received safe monitoring of vital signs. Despite the care plan and facility policy explicitly stating that blood pressure should not be taken from the arm with the shunt, the resident's blood pressure was measured from the left arm on seven occasions between January 25, 2024, and February 7, 2024. This practice was contrary to the facility's Hemodialysis Offsite Policy, which was last reviewed on August 23, 2023, and could potentially lead to complications such as damage to the access site, clotting, or circulatory problems. Interviews with multiple registered nurses revealed a lack of consistent understanding and adherence to the policy. One RN incorrectly stated that it did not matter which arm was used for blood pressure measurements, while two other RNs correctly identified that using the arm with the shunt was inappropriate and could cause harm. The resident involved was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, and had no documented issues with the right arm that would necessitate using the left arm for blood pressure readings.
Improper Disposal of Unused Medications
Penalty
Summary
The facility failed to ensure unused medications were disposed of according to accepted professional standards. On February 08, 2024, at 9:34 A.M., a small clear plastic measuring cup with a red capsule was observed on top of a medication cart with no staff present. The Director of Nursing (DON) also observed the unattended medication on the cart and disposed of it in an uncovered rectangular bin located at the bottom end of the medication cart. This action was contrary to the facility's policy and professional standards for medication disposal. An interview with a Registered Nurse (RN) revealed that unused medications should be disposed of in a sharps container to prevent access by unauthorized personnel or residents. The RN emphasized that discarding medications in an uncovered trashcan poses a risk, especially for residents who are not cognitively aware. The facility's administrator confirmed that the trashcan is not an approved method for medication disposal and that the facility's policy requires medications to be disposed of in a manner that limits access and complies with applicable laws and environmental regulations.
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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