Desert Peak Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 8825 South 7th Street, Phoenix, Arizona 85042
- CMS Provider Number
- 035175
- Inspections on file
- 33
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Desert Peak Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and behavioral symptoms had an existing care plan addressing elopement risk and sundowning behaviors, but the plan was not revised after multiple significant elopement and behavioral events. The resident repeatedly exited the unit and facility, climbed over fences and walls, ran off the grounds, displayed agitation, refused medications and vitals, entered other residents’ rooms and the nurses’ station, and called 911 multiple times. Staff attempted redirection and maintained visual contact, and the resident was returned with assistance from police and EMS and sent for hospital and psychiatric evaluations, but no new elopement or behavioral interventions were added to the care plan. Interviews with a CNA, an LPN, and the DON confirmed that the resident had climbed the fence several times, that hospital and psych evaluations were not reflected in the care plan, and that the care plan was not updated despite these events, contrary to facility policy requiring care plan review and revision after significant changes or unmet outcomes.
A resident with multiple comorbidities, contractures, moderate cognitive impairment, and a documented fall risk was care planned for Hoyer lift transfers and a safe environment, including staff assistance with ADLs. One morning, a CNA used a Hoyer lift alone to transfer the resident from bed to a wheelchair, did not follow the facility’s two‑person transfer process, and failed to properly manage the sling, resulting in the resident sliding from the chair to the floor. The resident later reported that the transfer occurred in the dark, that he told the CNA the sling strap was stuck, and that the CNA continued pulling until he fell onto his bottom, after which he experienced increased leg and knee problems. Staff interviews and facility policy confirmed that Hoyer transfers are required to be performed by two staff members with all sling loops correctly attached and unhooked after transfer, and that failure to follow this process can allow a resident to slip off the sling.
A resident with dementia and a history of behavioral issues entered another resident's room and allegedly committed physical abuse, resulting in visible bruising. Despite care plans and interventions for supervision, the incident occurred and was reported after the fact, with staff and documentation confirming the abuse. The facility's policies require prompt reporting and investigation, but the events leading up to the incident showed a failure to protect the resident from abuse.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with severe dementia and behavioral disturbances experienced two major accidents: one during a hoyer lift transfer, where movement and manipulation of the sling led to a fall and multiple injuries, and another after sliding from a wheelchair due to inadequate supervision and improper use of wheelchair cushions. The care plans did not address the resident's specific behavioral risks during transfers or specify supervision requirements, and staff were unclear about the circumstances and interventions in place at the time of both incidents.
Multiple incidents occurred in which residents physically assaulted other residents, including hitting, slapping, and kicking, during disputes in shared rooms and on the smoking patio. Despite existing care plans addressing behavioral issues and staff presence, these altercations were witnessed by staff and other residents, and facility investigations substantiated the abuse. The facility did not prevent these episodes of resident-to-resident physical abuse.
A resident with morbid obesity, immobility, and incontinence did not receive timely incontinence care as required by her care plan and facility policy. The resident was found in bed with a strong odor of urine and reported discomfort and distress due to inadequate repositioning and lack of space in her bed. Staff interviews confirmed that the assigned CNA had not checked or changed the resident since the start of the shift, citing short staffing and workload as reasons for the delay. Nursing leadership confirmed that this did not meet facility expectations for incontinence care.
A resident with morbid obesity and chronic pain did not receive a physician-ordered bariatric bed of appropriate size due to insurance denial and supplier limitations, resulting in discomfort and inability to reposition. Additionally, the resident's scheduled opioid pain medication was not administered as ordered due to delays in prescription processing and lack of medication availability, leading to unmanaged pain and distress.
A resident with chronic pain and opioid dependence did not receive a scheduled dose of long-acting opioid medication due to the facility's failure to reorder and obtain the necessary prescription in time. Nursing staff did not follow established procedures for medication reordering and did not check the medication dispensing system before the missed dose, resulting in unmanaged pain and resident dissatisfaction.
During a period of construction, the facility repurposed its dining, activity, day care, and medical record rooms to house displaced residents, resulting in the absence of a dedicated space for communal dining and activities. Residents received meals and care at their bedsides in these temporary sleeping areas, with staff confirming the lack of a designated dining or activity room throughout the construction period. Several cognitively intact residents were affected, and personal belongings were stored in a maintenance area.
Following a major plumbing failure, residents were relocated to non-traditional spaces such as the dining room, day care room, and medical record room, where beds, call bells, and privacy curtains were set up as temporary accommodations. Residents ate meals at their bedsides, shared bathrooms, and had personal belongings stored in a maintenance area with housekeeping equipment. Staff and resident interviews confirmed that these arrangements persisted for at least a week, impacting the safety, sanitation, and comfort of the environment.
Two residents with behavioral health diagnoses were involved in a physical altercation, resulting in one sustaining a finger laceration after being slapped and grabbed by her roommate. Despite care plans addressing behavioral risks and staff training on abuse prevention, the incident was not witnessed and led to injury, indicating a failure to protect residents from abuse.
A resident with dysphagia was not given the prescribed honey thick liquid diet, leading to coughing during a meal. The restorative nursing assistant altered the liquid's consistency without a physician's order, contrary to facility policy. The resident was at risk for aspiration and on antibiotics for aspiration pneumonia.
Two residents experienced abuse in a facility due to inadequate intervention and oversight. One resident, with severe cognitive impairment, was physically assaulted by a cognitively intact roommate after a confrontation over personal belongings. Another resident, who was cognitively intact, suffered verbal abuse from an LPN, despite previous warnings and discussions about separating them. The facility's failure to implement its abuse prevention policies led to these incidents.
A resident with a history of diabetes and other conditions experienced swelling and redness in the right leg, which was not promptly reported or addressed by LTC facility staff. Despite symptoms of cellulitis, there was a delay in communicating lab results to the provider, leading to inadequate treatment and eventual hospitalization. Interviews revealed systemic communication and documentation issues, contributing to the resident's deteriorating condition and subsequent leg amputation.
Failure to Update Care Plan After Repeated Elopement and Behavioral Incidents
Penalty
Summary
The deficiency involves the facility’s failure to review and update a resident’s comprehensive care plan after multiple elopement and behavioral incidents. The resident had vascular dementia, mood disorder, constipation, venous thrombosis and embolism, hypotension, dysphagia, anxiety disorder, and post-traumatic stress disorder. A quarterly MDS showed severely impaired cognitive skills for daily decision-making and no BIMS assessment. The existing care plan, dated June 9, 2025, identified the resident as at risk for elopement related to a history of elopement before admission and during the stay, with interventions such as assessing for fall risk, monitoring for fatigue and weight loss, and residing on a secure unit. A behavioral treatment care plan dated November 24, 2025, addressed sundowning behaviors with interventions including reassurance, a structured and soothing environment, reduced stimulation before sundown, a consistent evening routine, calming activities, gentle redirection, and monitoring for physical needs. On December 4, 2025, an incident occurred in which the resident was pacing in the hallway, appeared restless, and then ambulated toward a north exit door, exiting into the smoking area. Staff followed immediately and observed the resident climbing a wall. Verbal redirection was attempted but was not effective, and a facility code was initiated. One nurse positioned outside the wall while additional staff remained inside with the resident. The resident jumped over the wall to the outside area and began running off facility grounds. Staff continued attempts to redirect the resident back to safety but were unsuccessful. The resident was ultimately returned with assistance from 911 and sent to the hospital for evaluation, with no injuries noted. Despite this elopement event, review of the care plan showed no updated care plan or new interventions for the elopement risk focus area, and no evidence that the behavioral care plan was updated after this incident. A second incident on December 7, 2025, documented that the resident was restless, agitated, and pacing in the hallway, refusing all medications, treatments, and vital signs. The resident entered other residents’ rooms, entered the nurses’ station, went through drawers, and called 911 multiple times. Redirection and distraction were unsuccessful, and after the police arrived, the resident exited the unit and the facility. Staff called 911, and the ADON was notified. The resident was observed with a large rock, posturing and attempting to throw it at staff, then climbing a brick wall with the rock in hand and proceeding toward the street. The nurse and another staff member remained present, and with the arrival of the ADON and police, the resident was helped back to the facility. A scrape on the left wrist was noted, and a psych provider ordered psychiatric evaluation and stabilization at a medical center. Review of the care plan again revealed no updated care plan or new interventions for elopement risk after this second incident, and no updates to the behavioral care plan or elopement care plan were found. A discharge summary later documented that the resident made his way outside by holding the exit door onto the patio, climbed over the fence, and jumped, with uncertainty about whether he hit his head. Staff went outside and called 911 for assistance; the resident returned inside the facility and later exited the patio again, leading to a call to AMR for assessment as directed by the DON. Interviews with staff showed that a CNA recognized elopement risk by resident behaviors such as wandering and stated that interventions included close observation, redirection, and monitoring movements, but also stated she did not handle care plans or know what new interventions would be placed after the resident left the facility. An LPN stated that nurses do not create care plans and that the ADON and DON update care plans and add interventions, and that she could only suggest interventions. The DON stated that the resident had climbed the fence three times, that the resident was sent to the hospital after the first and second incidents and seen by a psych provider, and that these actions were not reflected in the care plan. The DON acknowledged that no new interventions or medication changes were placed when the resident returned and that interventions should have been implemented in the care plan but were not, and that failure to update the care plan can risk a resident not getting proper care. The facility’s care plan policy required the interdisciplinary team to review and update the care plan when there has been a significant change in the resident’s condition or when desired outcomes are not met, which did not occur in this case.
Improper One‑Person Hoyer Lift Transfer Leads to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate assistance and proper use of assistive devices, specifically a mechanical (Hoyer) lift, for a resident identified as being at risk for falls. The resident had multiple diagnoses, including bipolar disorder, COPD, anxiety disorder, extrapyramidal and movement disorder, hyponatremia, and age-related osteoporosis, and was care planned as at risk for falls related to high‑risk medication use, incontinence, poor mobility, hand contractures, and involuntary movements. The care plan interventions included anticipating and meeting needs, ensuring a reachable call light, prompt response to requests for assistance, maintaining a safe environment, and using a Hoyer lift for transfers with monitoring for safety. The resident also had an ADL self‑care performance deficit care plan that specified the need for staff assistance with ADLs due to pain and contractures and identified Hoyer lift transfers as part of the resident’s care. On a morning in November, the resident reported to a CNA that he had fallen at approximately 5:30 a.m. The nurse’s post‑fall assessment documented that the resident stated he had been helped with a Hoyer lift by a CNA who forgot to remove the sling, and that he slid down to the floor. The RN assessment noted the resident’s range of motion was within normal limits for his baseline, with contractures to his legs and hands, intact skin without bruising or abrasions, and resident‑reported mild to moderate pain in the knees and left hip. Neuro checks were within normal limits, and the resident denied hitting his head. An X‑ray of the left hip and knee later showed no acute fracture or dislocation, with intact osseous structures and modest joint space narrowing. A fall risk evaluation completed in November documented that the resident was chair‑bound, had 1–2 falls in the last three months, was at risk for falls with a score of 14, and had a BIMS score of 11 indicating moderate cognitive impairment. Interviews and facility documentation described the circumstances leading to the fall and the manner in which the Hoyer lift was used. The resident’s representative stated that the resident told her a staff member attempted to get him up with a mechanical lift in the dark, that the resident asked for the light to be turned on, and that the staff member proceeded anyway, resulting in a fall. The resident stated that the CNA came alone at about 5:30 a.m. to assist him with the Hoyer lift, hooked the sling strap to the lift, and that the strap felt stuck; despite the resident telling the CNA it was stuck, the CNA continued pulling until the resident suddenly fell onto his bottom. The resident reported that he already had trouble with his left knee and that his leg became worse after this incident. Review of the CNA’s employee file showed a disciplinary action documenting that the CNA transferred the resident from bed to wheelchair alone using the Hoyer lift, did not have a second staff member present, and that the resident slipped from the wheelchair onto the floor. The documentation also stated that the CNA failed to report the incident to a nurse and got the resident up before an assessment for injuries could be completed. Multiple staff interviews confirmed the facility’s established process for Hoyer lift use and contrasted it with what occurred for this resident. CNAs and licensed nursing staff consistently stated that the facility’s process requires two staff members for Hoyer transfers, that all four sling loops must be correctly attached and double‑checked before lifting, and that the sling must be unhooked after the transfer is completed. Staff described that one staff member operates the lift while the other supports and guides the resident’s body, and that improper hookup or incomplete securing of the sling can allow a resident to slip off. The DON stated that the facility’s process is to have two staff members perform a Hoyer transfer, with the sling placed under the resident, color‑coded loops attached to the lift, the resident lifted and transferred to the receiving surface, and the sling then removed. The DON acknowledged that, for this resident, the staff member did not use a second person and forgot to unhook the sling, which resulted in the resident sliding from the chair to the floor. A written policy titled “Lifting Machine, Using A Mechanical,” revised in October 2017, specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift, underscoring that the actions taken with this resident did not follow the facility’s own policy and procedures for safe mechanical lift use.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with dementia, COPD, and hypertension, who was cognitively intact according to a recent assessment, reported being physically abused by another resident with severe cognitive impairment and a history of behavioral issues. The incident involved the alleged perpetrator entering the victim's room, hitting her, and causing visible bruising to her arm and face. Documentation and staff interviews confirmed that the victim reported the abuse to staff, and a skin assessment revealed multiple bruises consistent with her account. The alleged perpetrator had a documented history of wandering, impulsive behavior, and physical aggression, as noted in his behavioral treatment plan. The facility's records show that the two residents had been sharing the same unit for an extended period, and the care plans for both included interventions for supervision and maintaining a safe environment. Despite these interventions, the resident with a history of behavioral symptoms was able to enter the other resident's room and allegedly commit physical abuse. Staff interviews indicated that the incident was reported after the fact, and the victim had to leave her room to alert staff. The facility's investigation included interviews, notification of authorities, and review of video footage, although the footage was no longer available at the time of the investigation. The deficiency was further substantiated by the facility's own policies, which require prompt reporting and thorough investigation of abuse allegations. Staff acknowledged the importance of immediate reporting and recognized the incident as abuse. However, the events leading up to the incident, including the lack of effective supervision and the ability of the perpetrator to access the victim's room, directly contributed to the failure to protect the resident from abuse as required by federal and state regulations.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Accidents During Hoyer Transfer and Wheelchair Use
Penalty
Summary
A deficiency occurred when the facility failed to prevent accidents and provide adequate supervision for a resident with severe cognitive impairment and multiple comorbidities, including dementia, diabetes, and chronic kidney disease. The resident required a hoyer lift for transfers and was known to exhibit behavioral disturbances, such as moving and yelling during care. Despite these known behaviors, there was no specific care plan addressing the resident's actions during hoyer transfers. During one transfer, the resident was moving and manipulating the sling straps, which resulted in a sling loop coming off the hook and the resident falling, sustaining significant injuries including head lacerations and fractures. Staff interviews revealed uncertainty about how the incident occurred, and there was no evidence of equipment malfunction or that staff failed to follow the two-person transfer policy, but the behavioral risks were not specifically addressed in the care plan. In a separate incident, the same resident, who was at risk for falls and known to wander and enter other residents' rooms, fell from a wheelchair and sustained fractures to the tibia and fibula. The care plan included general fall prevention interventions and the use of a Roho cushion to minimize falls, but did not specify the level or timing of supervision required. On the day of the fall, the resident was found alone in another resident's room, having slid out of the wheelchair along with the cushion. Staff interviews indicated that the cushion may have contributed to the fall, especially since there were two cushions present and only one piece of non-slip material (dycem) was used, which was insufficient to prevent sliding. The resident's tendency to wander and require frequent supervision was known, but the care plan lacked clear directives on supervision frequency or intensity. The facility's policies required thorough investigation and reporting of accidents, as well as individualized fall prevention plans based on assessment. However, the incident reports for both accidents were not made available for review, and staff interviews indicated a lack of clarity regarding the circumstances of the incidents and the interventions in place at the time. There was no evidence that the facility had implemented specific behavioral or supervision interventions tailored to the resident's known risks during transfers or while using the wheelchair, contributing to the occurrence of both accidents and resulting injuries.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect the rights of multiple residents to be free from physical abuse by other residents. Several incidents were documented in which residents engaged in physical altercations, resulting in substantiated cases of resident-to-resident abuse. In one case, a resident with a history of major depressive disorder, anxiety, and dementia became physically aggressive with her roommate following a dispute over bathroom use. Staff witnessed the resident strike her roommate multiple times on the back of the head, and the incident was confirmed through interviews and facility investigation. The care plans for both residents included interventions for behavioral issues, but the altercation still occurred, indicating a failure to prevent abuse. Another incident involved a resident with epilepsy and mood disorder who reported being slapped in the face by another resident during a disagreement on the smoking patio. Witnesses, including another resident, corroborated the account, stating that the aggressor used a partially closed hand to hit the victim twice. The aggressor, who had a history of bipolar disorder and severe cognitive impairment, did not recall the event. Staff interviews confirmed that the aggressor had recently exhibited increased aggression and had been moved to another unit due to these behaviors. The facility's investigation, supported by camera footage, substantiated the physical abuse. A further event involved the same aggressive resident physically assaulting another resident during an argument over the placement of an ashtray on the patio. The aggressor kicked the other resident and struck her with a smoking apron, as witnessed by staff and confirmed by the facility's investigation. The care plans for the involved residents included interventions for managing behavioral problems, but these measures did not prevent the incidents of abuse. The facility's policy states that residents have the right to be free from abuse, but the documented events demonstrate that this right was not upheld in these cases.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including morbid obesity, immobility, and incontinence, did not receive timely incontinence care as required by her care plan and facility policy. The resident was dependent on staff for activities of daily living, including toileting and personal hygiene, and was at risk for pressure ulcers. Despite a care plan intervention to provide peri-care after each incontinent episode and to check the resident every two hours, staff failed to provide incontinence care for an extended period during a shift. On the day of the incident, the resident was found in bed with a strong odor of urine, expressing discomfort and distress due to being unable to reposition herself and not having adequate space in her bed. The resident reported that staff had difficulty turning her and that she felt unsafe and uncomfortable. Staff interviews confirmed that the assigned CNA had not checked or changed the resident since the start of her shift, citing being busy with other duties and short staffing as reasons for the delay. The CNA acknowledged that the resident should have been checked every two hours but had not been able to do so. Interviews with nursing leadership confirmed that the facility's expectation was for incontinent residents to be checked every two hours, and that failure to do so did not meet facility standards. The facility's policy required providing necessary care to maintain personal hygiene for residents unable to perform activities of daily living independently. The lack of timely incontinence care was directly observed and confirmed by staff and leadership interviews, as well as by review of the resident's care plan and medical record.
Failure to Provide Bariatric Bed and Timely Pain Medication per Care Plan
Penalty
Summary
The facility failed to provide services and treatments according to the care plan and physician orders for a resident with multiple complex medical conditions, including morbid obesity, chronic pain, and opioid dependence. The care plan specified the need for a bariatric bed and scheduled opioid medication for pain management. Despite a STAT order for a bariatric bed, the facility was unable to obtain the appropriate size bed due to insurance denial and supplier limitations. The resident was placed in a standard bariatric bed that was too small, limiting her ability to reposition and causing discomfort, as observed by staff and reported by the resident. Staff interviews confirmed the bed was insufficient for the resident's needs, and efforts to locate a suitable bed from other suppliers and facilities were ongoing but unsuccessful at the time of the survey. In addition to the bed issue, the facility did not ensure the resident received her scheduled long-acting opioid medication (Xtampza) as ordered. Documentation and staff interviews revealed that the medication was not pre-ordered in time, resulting in a missed dose. The process for obtaining a new prescription was delayed due to a lack of provider signature, and the medication was not available in the facility's medication dispensing system (PIXIS). The resident reported significant pain and distress due to the missed medication, and staff acknowledged the oversight in the medication ordering process. The resident expressed discomfort, pain, and emotional distress related to both the inadequate bed and the lack of scheduled pain medication. Observations noted the resident was unable to reposition herself, was at risk of skin breakdown, and experienced pain that was not managed according to her care plan. Staff interviews confirmed awareness of the deficiencies in both equipment provision and medication administration, and facility policies required adherence to care plans and timely medication ordering, which were not followed in this case.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
A resident with multiple chronic conditions, including chronic pain syndrome and opioid dependence, was admitted with orders for scheduled and as-needed opioid pain medications. The resident's care plan specified the need for timely administration of pain medications and immediate response to pain complaints. Despite these interventions, the resident did not receive her scheduled dose of Xtampza ER, a long-acting opioid, as ordered on the morning of March 18, 2025. Review of the Medication Administration Record showed that the last dose of Xtampza ER was given the previous night, and the morning dose was missed due to the medication not being available. Nursing staff interviews revealed that the medication had not been pre-ordered in time, and the required prescription had not been signed by the provider. The nurse on duty was aware of the need to reorder but did not obtain the necessary e-script or check the medication dispensing system (PIXIS) until after the missed dose. The resident reported significant pain and dissatisfaction with her care, stating she was in a lot of pain and had to wait for her medication due to the facility's failure to order it. Further interviews with nursing leadership confirmed that the process for reordering medications was not followed as expected. Staff acknowledged that the oversight in obtaining the provider's signature and checking medication availability led to the missed dose. Facility policy required timely assessment and management of pain, but the failure to administer the scheduled pain medication as ordered resulted in unmanaged pain for the resident.
Failure to Provide Designated Dining and Activity Room During Construction
Penalty
Summary
The facility failed to provide a designated room for resident dining and activities during a period of construction, resulting in the use of the dining room, activity room, day care room, and medical record room as temporary sleeping quarters for displaced residents. The dining room/activity room, which is typically used for meals and activities, was repurposed to accommodate ten resident beds, while the day care room and medical record room were used for seven additional residents. This arrangement left no dedicated space for communal dining or activities, and residents were instead served meals at their bedside tables within these makeshift sleeping areas. Staff interviews confirmed that the relocation was due to an emergency plumbing issue in one of the facility's locked units, necessitating the movement of residents to available spaces throughout the building. The rooms were cleared and cleaned to accommodate the residents, and privacy curtains and call bells were provided at each bedside. However, the lack of a designated dining or activity area persisted throughout the duration of the construction, with staff and residents reporting that meals and activities were conducted at the bedside. Some residents expressed awareness of the temporary arrangement and described eating and receiving care in these non-traditional settings. Clinical record reviews indicated that several residents involved were cognitively intact, as evidenced by their Brief Interview for Mental Status (BIMS) scores. Staff also reported that residents' personal belongings were stored in a maintenance area, which was observed to contain maintenance tools and housekeeping equipment. Facility policies reviewed by surveyors referenced the use of dining and activity rooms as safe areas during partial evacuations, but did not address the prolonged lack of a designated dining or activity space for residents during extended construction events.
Deficient Practice in Resident Relocation Following Plumbing Failure
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment for residents after an emergency plumbing issue rendered one of the locked units uninhabitable. As a result, residents from the affected unit were relocated to various areas throughout the facility, including the dining/activity room, day care room, and medical record room. These rooms, not originally intended for resident accommodation, were repurposed to house multiple residents in close proximity, with beds, call bells, and privacy curtains set up as temporary measures. Staff interviews confirmed that the relocation was due to ongoing plumbing repairs, and that the dining room, typically used for meals and activities, was now occupied by ten residents, while the day care and medical record rooms housed additional residents. Observations and interviews revealed that residents were eating meals at their bedside tables, and some residents' personal belongings, such as clothing, were stored in a maintenance area that also contained housekeeping equipment and tools. The maintenance and housekeeping staff confirmed that this area was being used for temporary storage of residents' clothes. The rooms used for resident accommodation were measured, and it was noted that the dining room, day care room, and medical record room varied in size, with the dining room being the largest. Despite the presence of call bells and privacy curtains, the environment was not consistent with a typical resident room, and the arrangement impacted the residents' privacy and comfort. Multiple residents interviewed reported being relocated for at least a week, with some indicating they had been in the dining room for up to three weeks. Residents described eating at their bedsides, using shared bathrooms, and receiving care such as showers outside of the temporary rooms. Staff also reported challenges related to staffing and the use of these non-traditional spaces for resident care. Facility policies reviewed indicated procedures for sheltering in place and partial evacuation, but the actual implementation resulted in residents being housed in areas not designed for long-term accommodation, affecting the overall safety, sanitation, and homelike environment for the residents involved.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in an incident involving physical altercation between roommates. One resident, with diagnoses including schizoaffective disorder, dementia, and bipolar disorder, reported being slapped in the face and having her right index finger grabbed and cut by her roommate. Clinical records confirmed a laceration to the resident's finger, and staff documentation indicated that the resident complained of being yelled at and physically assaulted by her roommate. The care plan for this resident identified behavioral risks and included interventions for managing behaviors, but the incident still occurred. The other resident involved, who had diagnoses of paranoid schizophrenia, dementia, PTSD, anxiety disorder, and bipolar disorder, was also part of the altercation. This resident had a history of behavioral symptoms, including delusions and social isolation, and had recently been moved to a new room due to a plumbing issue in the facility. Staff interviews and clinical notes indicated that the two residents engaged in yelling and blaming each other, with one resident claiming the other cut her own finger. The residents were separated after the incident, and 15-minute checks were initiated. Staff interviews revealed that abuse training included immediate separation of residents and prompt reporting of allegations. However, the incident was not witnessed by staff, and the altercation resulted in a physical injury. The facility's policies state that residents have the right to be free from abuse, but the failure to prevent the altercation and injury constituted a deficiency in protecting residents from abuse.
Failure to Administer Liquid Diet as Ordered
Penalty
Summary
The facility failed to administer a liquid diet order as prescribed by the physician for a resident with a history of dysarthria, paralysis of vocal cords, and dysphagia. The resident was readmitted with specific dietary orders for a pureed texture with honey/moderate thick consistency and required 1:1 assistance during meals to prevent aspiration. Despite these orders, during a dining observation, the resident was served liquids that were not prepared according to the prescribed consistency, leading to coughing and the need for further thickening of the liquid by the restorative nursing assistant. The resident's care plan highlighted a nutritional risk due to swallowing difficulties and required monitoring for aspiration. However, during the meal, the restorative nursing assistant altered the consistency of the resident's drink without a physician's order, which is against the facility's policy. The registered nurse confirmed that the resident was at risk for aspiration and was on antibiotics for aspiration pneumonia, emphasizing that any changes to the diet should be made only by qualified personnel like a speech therapist. Interviews with the Director of Nursing and the facility administrator revealed that the staff involved were not authorized to make changes to the resident's diet. The facility's policy mandates that therapeutic diets are prescribed by the attending physician and should not be altered without proper evaluation and orders. The incident demonstrated a failure to adhere to these protocols, potentially compromising the resident's safety and health.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #8, who was severely cognitively impaired, was involved in an altercation with Resident #26, who was cognitively intact. Resident #8 was intrusive with Resident #26's belongings, leading to a verbal and physical confrontation. Resident #26 admitted to hitting Resident #8 in the face, resulting in a black eye. The facility's documentation and staff interviews revealed a lack of adequate intervention to prevent the altercation, despite prior warnings from Resident #8's daughter about potential behavioral issues. In another incident, Resident #12, who was cognitively intact, experienced verbal abuse from an LPN, identified as Staff #1. The resident was observed crying in the hallway after being called derogatory names by Staff #1. The social work assistant confirmed the verbal abuse and noted previous instances of aggression between Resident #12 and Staff #1. Despite discussions in interdisciplinary team meetings about separating the resident and staff, no changes were made to the care plan to prevent further incidents. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the need for adequate oversight to prevent such incidents. However, the facility failed to implement these policies effectively, as evidenced by the incidents involving Residents #8 and #12. The lack of timely and appropriate interventions contributed to the abuse and neglect of these residents, highlighting deficiencies in the facility's care and oversight practices.
Failure to Provide Timely Care Leads to Amputation
Penalty
Summary
The facility failed to provide care and treatment according to professional standards of practice for a resident, resulting in the hospitalization and subsequent amputation of the resident's leg. The resident, who had a history of diabetes mellitus and other conditions, was noted to have swelling and redness in the right leg, which was not promptly reported or adequately addressed by the facility staff. Despite the presence of symptoms indicative of a serious condition, such as cellulitis, the facility did not ensure timely communication of lab results to the provider, leading to a delay in appropriate medical intervention. The resident's clinical records showed multiple instances where swelling and redness were observed, but there was a lack of documentation and follow-up on these findings. The facility's staff, including CNAs and LPNs, failed to report significant changes in the resident's condition, such as the swelling and redness of the leg, to the attending physician or nurse practitioner in a timely manner. This oversight was compounded by the failure to review and act upon critical lab results that indicated a severe infection, which were only addressed five days after they were obtained. Interviews with facility staff revealed systemic issues in communication and documentation, with staff members acknowledging the delay in reporting lab results and the inadequacy of the initial treatment plan. The NP expressed concerns about the lack of notification regarding lab results and the presence of hardware in the resident's leg, which was only discovered at the hospital. The facility's policies on change in condition and wound care were not adhered to, contributing to the resident's deteriorating condition and eventual need for amputation.
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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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