Desert Haven Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 2645 East Thomas Road, Phoenix, Arizona 85016
- CMS Provider Number
- 035062
- Inspections on file
- 20
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Desert Haven Care Center during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, behavioral symptoms, and hearing loss was seated in the dining room when another cognitively intact resident with schizophrenia, behavioral disturbances, and a history of aggression entered, asked about a blue folder, became agitated, and repeatedly struck the seated resident in the face with a closed fist before CNAs could separate them. The injured resident sustained bilateral nasal bone fractures, a laceration to the ear requiring sutures, and extensive facial bruising, with blood observed on his face, ear, and the surrounding area. Both residents had existing behavior care plans and psychiatric assessments addressing behavioral issues and the need to protect the rights and safety of others, but the interaction in the dining room escalated into physical abuse, which the facility’s investigation and DON confirmed met the definition of abuse under the facility’s Abuse Guidelines policy.
A resident with a history of psychosis-related behaviors and verbal aggression created a cardboard gun, covered his face with a bandana, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not be quiet, causing the threatened resident to become intimidated and withdraw to bed. Staff, including a CNA and an LPN, witnessed the event and described the aggressor as intimidating and aggressive, particularly around women, and the LPN reported the incident to a unit manager and wrote a statement. However, there was no documentation of the incident in either resident’s clinical record, no self-report or grievance logged for the period, and the DON reported having no knowledge of the event, despite facility policy requiring immediate reporting and documentation of suspected abuse, including resident-to-resident abuse.
The facility failed to implement its abuse policy after an incident in which a resident with a history of aggressive behaviors created a cardboard gun, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not quiet down. Staff, including a CNA and an LPN, witnessed the event, described it as resident-to-resident emotional abuse, and reported it verbally to a unit manager, but there was no documentation of the incident in either resident’s clinical record, no incident report, and no evidence of an investigation or required notifications. The DON, who is responsible for abuse coordination and reporting, was unaware of the event, despite facility policy requiring immediate reporting, documentation, resident examination, and notification of state agencies, the physician, and the resident representative for any suspected or alleged abuse.
The facility failed to report and document a resident-to-resident abuse incident in which a cognitively intact resident with a history of psychosis-related behaviors created a cardboard gun, covered his face, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not be quiet. A CNA and an LPN witnessed the event, with the LPN stating the threatened resident appeared intimidated and became unusually withdrawn afterward. The LPN reported the incident and the cardboard gun to a unit manager and was told to write a statement, but the DON and unit manager later denied knowledge of or action on the incident. Review of clinical records, internal reports, and the state complaint database showed no documentation or external reporting of the event, despite facility policy and staff statements that abuse, including intimidation and resident-to-resident abuse, must be reported immediately and documented in progress notes and incident reports.
The facility failed to investigate and document an alleged resident-to-resident abuse incident in which a cognitively intact resident with a history of verbal aggression and threatening behaviors entered the room of a severely cognitively impaired resident while holding a cardboard gun, covered his face with a bandana, and threatened to shoot the other resident if he did not quiet down. Staff, including a CNA and an LPN, reported that they witnessed the event, considered it abuse, and informed a unit manager, but there was no documentation of the incident in either resident’s clinical record, no evidence of a self-report, grievance, or investigation, and the DON reported having no knowledge of the event. This inaction conflicted with the facility’s Abuse Guidelines policy, which required immediate reporting, documentation, examination, and investigation of all suspected abuse, including resident-to-resident abuse.
A resident with type 1 diabetes and a history of diabetic ketoacidosis experienced repeated failures in blood glucose monitoring and insulin administration, including missed and undocumented blood sugar checks, lack of provider notification for abnormal readings or refusals, and insufficient monitoring for symptoms of hypo- or hyperglycemia. These deficiencies led to the resident's hospitalization in the ICU for hyperglycemia and diabetic ketoacidosis.
A resident with type 1 diabetes had multiple physician orders for frequent blood glucose (BS) checks and insulin administration, including use of both fingerstick and continuous glucose monitoring devices. Despite these orders, staff failed to consistently document BS readings in the medical record, with many values missing or only noted as 'high' or 'low' without specifics. Interviews revealed the facility lacked a specific BS monitoring policy, and staff did not always ensure orders were properly reflected in the MAR, leading to incomplete and inaccurate medical records.
A resident with dementia, muscle weakness, type 2 DM, and unstageable pressure ulcers to the sacrum and right ischium had active orders for wound care that required cleansing with wound cleanser, patting dry, applying skin prep, then packing with Dakin’s-soaked gauze and covering with a dry dressing. During an observed treatment, an LPN removed old dressings and packed both wounds with Dakin’s-soaked gauze without cleansing them first, despite the orders. The LPN reported being told by the wound provider not to clean the wounds and was unsure if this was correct. The DON referenced an unsigned statement suggesting Dakin’s did not require prior cleansing, which was not supported by the manufacturer’s article cited, while the wound physician later clarified that wounds should be cleansed at treatment and that Dakin’s could be used to cleanse and then separately to pack the wound, consistent with facility policy requiring medications to be administered per orders.
Surveyors observed kitchen staff preparing food without required hair nets and beard covers while a pot of vegetables was actively cooking on the stove. The Food Service Director later confirmed that the item being prepared was buttered spinach for a meal service and acknowledged that staff are required by facility policy to wear hair restraints and facial hair guards to prevent hair from getting into food. The Administrator also stated that staff are expected to follow infection control policies, including use of appropriate PPE such as hair nets and facial hair covers during food prep, consistent with the written personal hygiene and sanitation policy.
A resident with severe cognitive impairment and mobility issues was found with a call light out of reach, leading to distress and inability to call for help. Observations revealed the call light was improperly placed, and the facility lacked a Call Light Policy, contributing to the deficiency.
A resident with a high risk of wandering and a history of elopement exited the facility unsupervised after a nurse was distracted by a medication delivery. Despite being on 1:1 monitoring, the resident managed to leave when the alarm was triggered. The resident was found the next day with blisters on both feet, indicating a lapse in supervision and monitoring.
The facility failed to maintain a dignified dining experience by using disposable dishware and utensils due to a lack of dishwashing staff on certain nights. A resident noted that Styrofoam was used occasionally, and the dietary director confirmed this practice occurred monthly. The Executive Director was unaware of the staffing issue until recently and expected a homelike dining environment.
The facility failed to update the PASRR for two residents with new psychiatric diagnoses, potentially impacting their care. One resident had a new diagnosis of anxiety disorder, and another was diagnosed with schizoaffective disorder, but their PASRR screenings were not updated. Interviews with staff confirmed the oversight, despite the facility's policy requiring such updates.
The facility failed to properly label and store food items, as well as maintain the correct potency of the Quaternary Sanitizer solution. Observations revealed unsealed and undated food items, including bacon and various bread products, in the kitchen. The Dietary Director was uncertain about storage requirements, and the Executive Director confirmed the need for proper sealing and dating to prevent oxidation. Additionally, the Quat solution was found to be too strong, requiring adjustment to meet the recommended 200 ppm.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a PEG tube, risking the transmission of multi-drug resistant organisms. Despite the resident's severe cognitive impairment and the presence of a PEG tube, no EBP signs or PPE were visible. Staff interviews revealed a lack of adherence to EBP guidelines, with the DON expressing disagreement with the guidelines due to concerns about maintaining a homelike environment.
The facility failed to maintain a safe and clean environment, with broken window blinds, stained walls, and dusty vents observed in residents' rooms. Staff interviews revealed that maintenance issues were not consistently reported or addressed, despite expectations for prompt action. The maintenance director acknowledged that housekeeping should have cleaned the affected areas.
Failure to Prevent Resident‑on‑Resident Physical Abuse Resulting in Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in significant facial trauma. One resident with dementia, moderate cognitive impairment (BIMS score of 8), behavioral symptoms, a history of falling, and hearing loss was care planned for behavior problems such as placing himself on the floor, banging his head, yelling, paranoia, refusing care and medications, verbal and physical aggression, territorial behavior in the dining room, and making false accusations. His care plan included anticipating his care needs before he became overly stressed and implementing interventions as needed to protect the rights and safety of others. On the day of the incident, he was seated in his wheelchair in the dining room watching television when another resident approached him. The other resident, who was cognitively intact (BIMS score of 15) and had diagnoses including schizophrenia, mild neurocognitive disorder with behavioral disturbance, psychoactive substance use disorder, anxiety disorder, insomnia, suicidal and homicidal ideations, and schizoaffective disorder bipolar type, had a care plan for behavioral problems including self-isolation, aggression, and a history of suicidal and homicidal ideation. Interventions for this resident included intervening as needed to protect the rights and safety of others, approaching him calmly, diverting his attention, and removing him from situations as needed. A psychiatry assessment recommended maintaining firm boundaries regarding appropriate and acceptable communication and behavior and consideration of a two-person assist for safety and accountability. On the day of the incident, this resident approached the nurse at the medication cart asking to speak with the unit manager about paperwork, was informed the manager had left, stated he did not need assistance, and then walked into the dining room. Shortly after entering the dining room, the cognitively intact resident approached the resident with dementia and asked about a blue folder. Due to hearing loss, the seated resident responded that he did not have the folder or said “what,” and the interaction quickly became confrontational. Two CNAs in the dining room observed the resident who had entered calmly become agitated and strike the seated resident with a closed fist. Staff reported that, due to the size and strength of the aggressor, it required significant effort to separate them, and the aggressor was able to strike the other resident multiple times (approximately five times) before they were fully separated. A nurse, alerted by CNA yelling, arrived after the residents had been separated and found the injured resident in his wheelchair with blood dripping from his nose, blood coming from his left ear, a hematoma near his left eyebrow, and blood on the floor and surrounding area, with his hearing aids in his hand. The injured resident was transported to the hospital, where CT imaging revealed mildly displaced bilateral nasal bone fractures and a 1.5 cm laceration to the left ear that required suture repair. Upon return, he was noted to have a swollen nose, bruising around the nose and left eye, and later two black eyes, with ongoing bruising and discoloration documented in weekly skin assessments. He reported that his hearing aids were damaged by his attacker and stated he had been beaten up by another resident. The facility’s investigation, including staff interviews and review of the incident, concluded that the allegation of physical abuse was verified. The DON stated that the incident met the definition of physical abuse under the facility’s Abuse Guidelines policy, which defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and requires assessment and care planning for residents with behavioral problems to protect the rights and safety of others.
Failure to Recognize, Document, and Report Resident-to-Resident Abuse Involving Threats with a Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident and to recognize, document, and report the incident as required by policy. One resident had a documented history of behavioral problems related to psychosis, including delusions, refusing care, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances toward females. Care plans identified these behaviors and included an intervention to protect the rights and safety of others. Behavior progress notes over several weeks documented multiple episodes of verbal aggression, threats toward peers and staff, and at least one incident where the resident physically placed his hands on another resident’s arms while attempting to redirect him, leading to an argument that required staff separation. Despite this pattern of escalating behaviors, there was no documentation in the clinical record regarding a later resident-to-resident incident that occurred on January 20, 2026. The other resident involved had vascular dementia with severe cognitive impairment, as evidenced by a BIMS score of 03, and a care plan that identified behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and educating the resident on appropriate behaviors when on the patio with peers. The clinical record for this resident also lacked any documentation of the resident-to-resident incident on January 20, 2026. When surveyors requested the facility’s self-reports, grievances, and investigations for the prior four months, the facility reported that there had been no incidents or grievances during that period, despite staff accounts of a serious resident-to-resident event. Multiple staff interviews described the unreported incident and the facility’s failure to follow its abuse policy. A CNA stated that the aggressive resident had a pattern of trying to intimidate people, especially when women were present, and reported that within the prior week he made a cardboard gun, covered his face with a bandana, entered the cognitively impaired resident’s room, and threatened to “teach [him] a lesson” if he did not be quiet. An LPN reported witnessing the same event, stating that the resident held a pretend cardboard gun, told the other resident to go to sleep or he would shoot him, and that the threatened resident appeared intimidated and later stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, saw it had been colored to look more realistic, but returned it to the resident because she was afraid of what he might do. She reported the incident to the unit manager and was told to write a statement, but the DON later stated she was unaware of any such abuse incident, and the unit manager stated she did not recall the incident being reported and had not investigated it. The facility’s abuse policy required immediate reporting of suspected abuse to the DON and administrator and documentation of incidents, but there was no evidence of documentation, self-reporting, or investigation of this resident-to-resident abuse. The DON stated that allegations of abuse were expected to be documented in an incident report and progress note and reported within two hours to applicable state agencies, physicians, case managers, and family, and that resident-to-resident physical or verbal abuse was considered reportable. The unit manager similarly stated that staff were expected to document all progress notes, including incidents of abuse or allegations, and that allegations should be reported immediately, but no longer than two hours, to the DON. Despite these stated expectations and the written Abuse Guidelines policy defining abuse as willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and requiring immediate reporting of suspected abuse, the incident involving the cardboard gun and threats was not documented in either resident’s clinical record, not entered as a self-report or grievance, and not brought to the DON for investigation. This failure to follow policy and to recognize and report the resident-to-resident intimidation and threats constituted the identified deficiency.
Failure to Implement Abuse Policy After Resident-to-Resident Threat with Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy following a resident-to-resident abuse incident involving two residents. The facility’s own "Abuse Guidelines" policy requires that any suspected or actual abuse, including intimidation and resident-to-resident abuse, be immediately reported to facility management, that the DON and administrator be notified, that the resident be examined by a physician or licensed nurse with findings documented in the medical record, and that an unusual occurrence form and written witness statements be completed with an immediate investigation. Despite these requirements, there was no documentation in either resident’s clinical record of the alleged abuse incident that occurred on January 20, 2026, and the DON reported having no knowledge of any recent abuse incident between the two residents. One of the residents involved, identified as Resident #89, had a history of behavioral issues documented in the clinical record. Diagnoses included mild neurocognitive disorder, major depressive disorder, and other chronic medical conditions. Care plans noted behavior problems related to psychosis, including delusions, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances, with interventions to protect the rights and safety of others. Behavior notes over several weeks documented repeated episodes of verbal aggression, threats toward staff and peers, and at least one incident where he physically placed his hands on another resident’s arms during an argument. However, there was no behavior note or other documentation regarding the cardboard gun incident on January 20, 2026, despite staff describing it as resident-to-resident abuse. The other resident, identified as Resident #78, had vascular dementia with severe cognitive impairment (BIMS score of 03) and multiple chronic conditions. His care plan documented behavioral symptoms related to dementia, including physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Staff interviews revealed that within the week prior to the survey, Resident #89 created a cardboard gun, entered Resident #78’s room, and threatened him, telling him to be quiet or he would "teach [him] a lesson" and stating "go to sleep, or I am going to shoot you." Staff witnesses, including a CNA and an LPN, described the incident as resident-to-resident emotional abuse and reported that Resident #78 appeared intimidated and frightened afterward, staying in bed and not wanting to do anything. The LPN who witnessed the event stated she reported the incident to the unit manager and was instructed to write a statement, but the unit manager later stated she did not recall the incident being reported and did not investigate it. The facility’s records showed no self-reports, grievances, or investigations for the prior four months, and there was no clinical documentation or formal reporting of this abuse incident as required by the facility’s abuse policy. Interviews with multiple staff members further demonstrated the breakdown in implementing the abuse policy. The CNA described Resident #89 as aggressive and intimidating, especially around women, and confirmed that the cardboard gun incident occurred and that he considered it resident-to-resident abuse. The LPN who witnessed the incident stated that abuse incidents should be documented in progress notes and reported immediately to the DON or administrator, and that she did report the event to the unit manager and requested that the cardboard gun be taken away. The DON stated that allegations of abuse must be documented in the clinical record and reported to state agencies within two hours, and that resident-to-resident verbal or physical abuse is reportable, yet she was unaware of the incident. The unit manager stated that abuse allegations should be reported immediately and documented, but she denied having recently reported anything and said she only learned of the cardboard gun situation minutes before her interview and did not investigate it. This combination of absent documentation, lack of reporting to the DON and state agencies, and failure to initiate an investigation after a witnessed resident-to-resident abuse incident constitutes the core deficiency in implementing the facility’s abuse policy.
Failure to Report and Document Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to timely report and document a resident-to-resident abuse incident involving intimidation and threats, as required by its abuse policy and staff expectations. One resident, identified as having mild neurocognitive disorder, major depressive disorder, and a history of psychosis-related behaviors including verbal aggression, intrusiveness, and inappropriate sexual advances, had multiple prior behavior notes documenting verbal aggression and threats toward peers and staff. Another resident, diagnosed with vascular dementia and severe cognitive impairment, had a care plan identifying behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Despite these known behavioral risks, there was no documentation in either resident’s clinical record regarding the specific resident-to-resident incident that occurred on January 20, 2026. Staff interviews revealed that within the week prior to the survey, the first resident created a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” An LPN reported witnessing the resident holding the pretend cardboard gun and telling the other resident to go to sleep or he would shoot him, and stated that the second resident appeared intimidated and subsequently stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, then returned it to the resident because she was afraid of what he might do to her. She further stated that she reported the incident to the unit manager, was instructed to write a statement on paper, and requested that the unit manager take the cardboard gun from the resident. Despite this report, the DON stated she was unaware of any recent abuse incident between these two residents and only knew that the first resident had been verbally aggressive to staff over a recent weekend. The unit manager initially stated that she had not reported anything recently and only learned shortly before her interview that the resident had made a cardboard gun and was playing with staff and the other resident; she stated she did not recall the incident being reported to her and did not investigate or report it. Review of the facility’s self-reports, grievances, and investigations for the prior four months showed no reported incidents or grievances, and review of the State Agency complaint database showed no evidence that the incident had been reported. This inaction occurred despite the facility’s written Abuse Guidelines policy, which required immediate reporting of suspected abuse, including intimidation, to facility management, immediate notification of the administrator, and prompt notification of state agencies, the ombudsman, the resident representative, APS, and the physician, as well as documentation in incident reports and progress notes. The facility’s own policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and explicitly stated that resident abuse by anyone, including other residents, would not be condoned. Staff interviews confirmed that they understood reportable incidents to include physical, verbal, and resident-to-resident abuse, and that such incidents were to be reported immediately to the DON, administrator, or designated supervisor, and documented in the clinical record. Nonetheless, there was no evidence of progress notes, incident reports, or external notifications related to the cardboard gun incident, and the DON and unit manager both denied having reported or investigated it. This lack of reporting and documentation of a witnessed resident-to-resident abuse incident constituted the deficiency identified by the surveyors.
Failure to Investigate Alleged Resident-to-Resident Abuse Involving Threats with a Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an alleged incident of resident-to-resident abuse involving two residents. One resident had a history of behavioral issues, including psychosis-related behaviors, verbal aggression, intrusiveness, and inappropriate sexual advances, with care plan interventions to protect the rights and safety of others. Behavior notes over several weeks documented multiple episodes of verbal aggression, threats toward peers, and menacing behavior toward staff, including threatening language and attempts to put hands on another resident. Despite this pattern, there was no documentation in the clinical record regarding a specific resident-to-resident incident that occurred on January 20, 2026. The other resident involved had vascular dementia with severe cognitive impairment, as indicated by a BIMS score of 03, and a care plan identifying behavioral symptoms such as physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and education on appropriate behaviors. This resident’s MDS also showed frequent verbal behaviors. However, similar to the first resident, there was no documentation in this resident’s clinical record regarding the alleged resident-to-resident incident on January 20, 2026. Staff interviews revealed that a CNA described the first resident as aggressive and intimidating, particularly around women, and reported that within the prior week the resident made a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” The CNA stated that staff removed the resident from the room and that he considered the event resident-to-resident abuse, and that two nurses present reported it to their supervisor. An LPN separately reported witnessing an incident in which the same resident entered the other resident’s room with a cardboard gun and threatened to shoot him if he did not quiet down, stating, “go to sleep, or I am going to shoot you,” and that the other resident felt intimidated. This LPN reported the incident to the unit manager and was instructed to write a statement, but did not know if it was reported further or investigated. The DON, who is responsible for abuse coordination, investigation, and reporting, stated she was unaware of any recent abuse incident between these residents, and the unit manager stated she did not recall the incident being reported to her and did not investigate the cardboard gun incident. Review of facility records showed no self-reports, grievances, or investigations for the prior four months, and the facility’s Abuse Guidelines policy required immediate reporting, documentation, examination, and investigation of suspected abuse, including resident-to-resident abuse, which did not occur in this case. The facility’s Abuse Guidelines policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and stated that the facility would not condone abuse by anyone, including other residents. The policy required employees, consultants, and physicians to immediately report suspected abuse to the DON or, in her absence, to the nurse supervisor, and required immediate notification of the administrator, state licensing agency, ombudsman, resident representative, adult protective services, and the resident’s physician when an allegation or suspected case of mistreatment or abuse was reported. It further required that a physician or licensed nurse immediately examine the resident, record findings in the medical record, complete an unusual occurrence form with written witness statements, and conduct an immediate investigation with a copy provided to the administrator. Despite these policy requirements and staff accounts of a threatening resident-to-resident interaction involving a cardboard gun and verbal threats, there was no evidence that the incident was documented in either resident’s clinical record, reported to the DON or administrator, or investigated in accordance with facility policy.
Failure to Follow Physician Orders for Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that physician orders for blood glucose monitoring and insulin administration were consistently followed for a resident with type 1 diabetes mellitus and a history of diabetic ketoacidosis. Despite multiple physician orders specifying the use of a Dexcom G7 sensor, scheduled blood glucose checks four times daily, and specific insulin administration parameters, the clinical record revealed repeated lapses. Blood glucose monitoring was not performed or documented as ordered, and the physician's order for scheduled checks was not transcribed onto the medication or treatment administration records for several months. There were also numerous instances where blood sugar readings were not recorded prior to insulin administration, and low or high blood sugar values were not consistently addressed or reported to the healthcare provider as required. The documentation showed that the resident frequently refused blood glucose checks and insulin administration, but there was no evidence that the physician was notified of these refusals or that the resident was monitored for signs and symptoms of hypo- or hyperglycemia following missed doses. On several occasions, the resident's blood sugar readings were outside of the ordered parameters, including both hypoglycemic and hyperglycemic episodes, yet there was no documentation of follow-up actions, rechecks, or provider notification. The care plan did not include specific interventions for blood sugar monitoring with either fingerstick or continuous glucose monitoring devices, and there was a lack of documentation regarding monitoring for symptoms or implementing change in condition protocols when abnormal readings occurred. Ultimately, the deficient practice resulted in the resident being admitted to the hospital's intensive care unit with hyperglycemia and diabetic ketoacidosis. The clinical record detailed that the resident was found with altered mental status, high blood sugar readings, and symptoms such as vomiting, tachypnea, and diaphoresis. Emergency services were called, and the resident was transferred to the hospital, where a diagnosis of diabetic ketoacidosis and acute encephalopathy was made. The failure to follow physician orders, monitor and document blood glucose levels, and notify the provider of abnormal findings directly contributed to the resident's acute medical deterioration.
Incomplete Documentation of Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that the medical record for a resident with type 1 diabetes was complete and accurate regarding blood glucose (BS) monitoring. The resident had multiple physician orders for frequent BS checks and insulin administration, including the use of both fingerstick (accucheck) and a continuous glucose monitoring device (Dexcom G7). Despite these orders, there was a lack of consistent documentation of BS readings in the medical record, including the Medication Administration Record (MAR), progress notes, and vitals log. On numerous occasions, BS values were either missing, not recorded as numerical values, or only noted as 'high' or 'low' without further detail. There were also instances where the resident refused BS checks or insulin, but the attempts and outcomes were not always fully documented. Interviews with nursing staff and the DON revealed that the facility did not have a specific policy for BS monitoring and relied on physician orders to guide practice. Staff reported that BS values should be recorded on the MAR, but review of the MAR for the relevant months showed no such documentation. Staff also indicated that the process for ensuring BS monitoring orders were properly reflected in the MAR was not always followed, as the nurse practitioner entering the order did not select the necessary options to trigger MAR documentation. Additionally, there was confusion among staff regarding the interpretation of the Dexcom device readings and when to notify providers of abnormal results. The resident involved had a complex medical history, including type 1 diabetes, cerebral infarction, and dementia, and required close monitoring of blood glucose levels. The care plan did not include specific interventions for BS monitoring with either the accucheck or Dexcom device. Throughout the period reviewed, there were multiple days with missing or incomplete BS documentation, and on several occasions, there was no evidence that providers were notified of abnormal BS readings or that appropriate follow-up occurred. The lack of complete and accurate documentation could result in an incomplete medical record for the resident.
Failure to Cleanse Pressure Ulcers Before Applying Dakin’s-Soaked Dressings
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in accordance with physician orders and professional standards for a resident with pressure ulcers. The resident was admitted with diagnoses including dementia with mood disturbance, muscle weakness, and type 2 diabetes mellitus, and had an unstageable right ischial wound and an unstageable sacral wound. The care plan included an intervention to provide wound care as ordered by the physician. Active physician orders for both the right ischium and sacrum directed staff to cleanse the wounds with wound cleanser, pat dry, apply skin prep to the surrounding area, pack with Dakin’s soaked gauze, and cover with a dry dressing daily and as needed. During an observed wound care treatment, the LPN serving as the wound care nurse prepared Dakin’s half-strength solution and soaked gauze, stating she had been told by the wound provider not to clean the wound and expressing uncertainty about the correctness of this method. The LPN removed the old dressings, performed hand hygiene, donned clean gloves, and then packed both the sacral and right ischial wounds with Dakin’s soaked gauze without cleansing either wound beforehand, contrary to the physician’s orders. A 6x6 dressing was applied to the sacral wound and a 4x4 dressing to the right ischial wound. Interviews with another LPN and the DON confirmed that nurses are expected to follow provider orders and receive training from the wound nurse, while the DON referenced an unsigned statement suggesting Dakin’s solution did not require prior cleansing, which was not supported by the manufacturer’s article cited. The wound physician later clarified that nurses should follow his orders, that wounds should be cleansed at the time of treatment, and that Dakin’s solution could be used as a cleanser but should be used first to clean and then separately to pack the wound. Facility policy required all medications to be administered in accordance with orders.
Failure to Use Required Hair and Beard Restraints During Food Preparation
Penalty
Summary
The deficiency involves failure to maintain proper sanitary conditions in the kitchen during food preparation, specifically related to required use of hair restraints and facial hair covers. During a kitchen observation at 8:10 a.m. on September 2, 2025, one cook (Staff #107) was observed working in the kitchen without a hair net. Another cook (Staff #51) was observed in the kitchen without a hair net and with visible facial hair that was not covered by a beard guard/net. At the same time, a small pot containing a green substance resembling vegetables was observed boiling on the stove. In subsequent interviews, the Food Service Director (Staff #125) confirmed that staff working in the kitchen are required to wear hair nets and facial hair guards and acknowledged that failure to do so can result in hair getting into food, stating that the staff "know better." The Administrator (Staff #5) stated that expectations are for staff to follow facility policy and procedure to prevent cross contamination in the kitchen, including proper PPE such as hair nets and facial hair covers during food preparation. In a later interview, the Food Service Director identified the boiling green food observed during the initial kitchen observation as buttered spinach being prepared for lunch service and confirmed it is started early in the day for slow cooking. Review of the facility’s “Personal Hygiene and Health Reporting” policy showed that hair restraints must be worn around exposed foods in kitchen and food service areas, and that beards must be restrained with beard covers when around exposed foods.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, which could result in a preventable accident and the resident being unable to meet their needs. The resident, who was admitted to the facility with severe cognitive impairment and multiple diagnoses including atherosclerotic heart disease and bipolar disorder, was observed on two occasions with the call light out of reach. The resident has both upper and lower impairment on both sides and requires assistance with activities of daily living due to spinal stenosis and impaired mobility. On the day of observation, the call light was found in the resident's top dresser drawer and later pinned on the resident's lap, both positions out of reach. The resident was observed screaming for help, indicating distress and inability to access assistance. Interviews with the CNA and DON revealed that the call light should have been placed on the resident's upper chest for accessibility. The facility lacked a Call Light Policy, as confirmed by the DON, which contributed to the oversight in ensuring the call light was within reach.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was at high risk for wandering. The resident, who had a history of elopement and was diagnosed with conditions such as post-traumatic stress disorder, aphasia, and vascular dementia, was admitted to the facility with an incomplete minimum data set assessment. Despite being identified as a high risk for wandering, the resident was able to exit the facility when a nurse was distracted by a medication delivery and the exit door alarm was triggered. The resident was found the next day by a family member and returned to the facility with blisters on both feet. Interviews with staff revealed that the resident was initially on 1:1 monitoring, which was removed shortly before the elopement occurred. The staff were aware of the resident's elopement risk, and interventions were in place to distract the resident from wandering. However, the lapse in supervision allowed the resident to leave the facility unnoticed. The facility's policy required all nursing personnel to report and investigate missing residents, but the incident highlighted a failure in maintaining adequate supervision and monitoring of the resident's movements.
Use of Disposable Dishware in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during dining by using disposable cutlery and dishware. During a dining observation, it was noted that seven residents were served their meals in Styrofoam containers, cups, and bowls, and were using plastic utensils. A resident mentioned that Styrofoam was used sometimes, but not consistently. This practice was attributed to the absence of dishwashing staff, as the dietary director explained that meals were served on Styrofoam when there was an emergency or when the dishwasher staff called off. The dietary director admitted that the use of Styrofoam dishware occurred on a monthly basis due to the lack of dishwashing staff on Monday nights, and the administrator was aware of this situation. The Executive Director (ED) stated that he supervises the dietary manager and was informed about the kitchen staffing needs. However, he did not review the kitchen staff schedule and was unaware of the dishwasher staffing issue on Monday nights until just before the interview. The ED expressed that it was his expectation for the facility to provide a homelike environment in the dining room and that Styrofoam dishware should not be used. The facility's policy on Dining Room Service emphasized maintaining a comfortable and attractive atmosphere in the dining room, which was not upheld in this instance.
Failure to Update PASRR for Residents with New Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was updated for two residents, which could result in residents not receiving the care and services they needed. Resident #73 was admitted with diagnoses including bipolar disorder, major depressive disorder, and severe intellectual disability. A new diagnosis of anxiety disorder was made, but the PASRR Level I screening was not updated to reflect this change. Interviews with the Social Services Director and the Director of Nursing confirmed that the PASRR should have been updated following the new diagnosis. Resident #22 was admitted with multiple diagnoses, including cerebral infarction and bipolar disorder. A PASRR Level I screening was completed, and a Level II determination was submitted. However, after a new diagnosis of schizoaffective disorder, the PASRR was not updated, nor was a Level II determination completed. The resident exhibited behavioral symptoms, and a behavioral care plan was revised, but the PASRR remained outdated. Interviews with the Director of Social Services and the Director of Nursing confirmed that the PASRR should have been updated and a Level II determination submitted. The facility's policy on PASRR, reviewed in July 2022, requires screening for all individuals being considered for admission to a Medicaid-certified nursing facility to determine if they have a mental illness, intellectual disability, or related condition. The policy aims to prevent inappropriate placement in nursing homes. Despite this policy, the facility did not update the PASRR for residents with new psychiatric diagnoses, as required by federal regulations.
Deficiency in Food Storage and Sanitizer Testing
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in accordance with professional standards. During an initial tour of the kitchen, it was observed that a 15-pound box of bacon was not stored in a sealed bag or container, and a bag of shredded lettuce was not sealed or dated. Additionally, various bread items, including wheat bread, hamburger buns, and Hawaiian sweet rolls, were found without open dates. The Dietary Director was unsure about the necessity of sealing the bacon and acknowledged that the shredded lettuce should have been sealed. The Executive Director confirmed that open products should be dated and sealed to prevent oxidation, which can affect the nutritive value and quality of the food. Furthermore, the facility did not adhere to the correct procedures for testing the Quaternary Sanitizer (Quat) solution. The Dietary Director tested the Quat solution and found it to be at 400 parts per million (ppm), which is higher than the recommended 200 ppm. The Director stated that the solution was too strong and required adjustment. The facility's policy on food storage and date marking specifies that leftover food should be stored in covered containers, clearly labeled, and dated if stored for over 24 hours, and used within seven days or discarded. The Quaternary Sanitizer Test Strip directions also require the solution to be tested at 200 ppm.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, which could result in the transmission of multi-drug resistant organisms. The resident, who was admitted with diagnoses including hemiplegia, diabetes mellitus type 2, cerebral infarction, dementia, and gastrostomy status, had a severe cognitive impairment as indicated by a BIMS score of 03. Despite the resident's condition and the presence of a PEG tube, no signs related to EBP were posted outside the resident's room, and no personal protective equipment (PPE) was visible. Interviews with staff revealed a lack of adherence to EBP guidelines. A licensed practical nurse stated that no precautions were in use anywhere in the building, as it made it easier for staff to care for residents without having to gown up. The Director of Nursing also confirmed that no precautions were in use, expressing disagreement with the EBP guidelines due to concerns about maintaining a homelike environment. The facility's assessment indicated that infection prevention and control services were provided, yet the CDC and CMS guidelines for EBP, which include the use of gown and gloves during high-contact resident care activities for residents with indwelling medical devices, were not followed for the resident with a PEG tube.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and staff interviews. In one resident's room, the window blinds were broken, a light brown substance had dried on the walls, there was a strong odor of urine, and the plaster and paint were chipped off in multiple areas. Additionally, the bathroom ceiling vent was covered in brown dust and dirt. Another room was observed to have broken window blinds as well. Interviews with staff, including a CNA and an LPN, revealed that there was an expectation for maintenance issues to be reported and addressed promptly, but this was not consistently happening. Further observations with the maintenance director highlighted additional cleanliness issues, such as a bathroom vent emitting a puff of white and brown dust when poked, and a bathroom wall stained with a brown substance. The maintenance director acknowledged that these areas should have been cleaned by housekeeping. The facility's policy on maintenance services states that the maintenance director is responsible for ensuring that the building and equipment are maintained in a safe and operable manner, but the observations indicate that this policy was not being effectively implemented.
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A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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