Desert Terrace Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 2509 North 24th Street, Phoenix, Arizona 85008
- CMS Provider Number
- 035014
- Inspections on file
- 21
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Desert Terrace Healthcare Center during CMS and state inspections, most recent first.
A resident with vascular dementia and moderate cognitive impairment became private pay after insurance coverage ended, and the business office processed a credit card payment using a "Credit Card Authorization Form" that lacked the resident’s signature and did not document the time of completion. Staff recorded detailed card information and the amount to be charged, but only wrote "via phone" on the signature line to reflect the resident’s telephone consent, without any additional documentation of the exchange. Financial records showed room and board charges, a partial payment, and an outstanding balance, while the resident’s later-appointed fiduciary reported that funds were taken during the resident’s stay and that financial mail was left unsecured in the room. Review of federal guidance and facility policies showed that required systems for written authorization and complete documentation of resident fund transactions were not followed.
A resident with vascular dementia and moderate cognitive impairment, who transitioned from insurance coverage to private pay, had large sums of money allegedly drained from personal accounts while residing in the facility. The resident’s private fiduciary reported suspected fraud to the facility and police, requested records, and stated that the resident’s financial mail and retirement statements were kept unsecured in a nightstand accessible to anyone entering the room. Although the Business Manager notified the then-administrator of the fiduciary’s allegations and request that facility staff be investigated, the current administrator later acknowledged that no investigation was conducted, contrary to the facility’s abuse policy requiring prompt, thorough investigation of all allegations of misappropriation and exploitation.
A resident with vascular dementia and moderate cognitive impairment had a private fiduciary who reported that the resident’s account had been drained of a large sum of money and that police were investigating possible fraud involving facility staff. The BM documented the fiduciary’s allegations and informed the administrator, who indicated he would seek further advice, but no investigation or self-report to the state agency was completed. Later, the fiduciary stated that money had been taken while the resident was in the facility and that she could not pay the facility, yet records confirmed there were no self-reports, despite facility policies requiring external reporting of suspected crimes, abuse, and misappropriation.
A resident with multiple chronic conditions and a cognitively intact BIMS score was found with two medications, including Fluticasone nasal spray and Bacitracin ointment, left at the bedside without any care plan, physician order, or interdisciplinary documentation authorizing self-administration. The resident reported using the medications independently, and a follow-up observation with the DON again confirmed the medications at the bedside, contrary to facility policies requiring interdisciplinary assessment for self-administration and locked storage of all drugs and biologicals.
A resident with cognitive and physical impairments was physically assaulted by a roommate, resulting in multiple facial lacerations. The incident was discovered after another resident alerted a CNA, who found the injured resident and the aggressor in the room. The aggressor admitted to the assault following a verbal altercation. Facility documentation and staff interviews confirmed the event, which occurred despite policies prohibiting abuse and requiring resident protection.
Two residents with significant cognitive and physical impairments, both dependent on staff for personal hygiene, were found with markedly overgrown and discolored toenails, and in one case long fingernails with food debris, indicating that nail care was not consistently provided as part of ADL assistance. Observations over several days showed one resident’s toenails curling over the tops and pads of the toes despite an existing podiatry-related order and shower documentation noting the need for nail clipping, with no corresponding podiatry visit ordered or documented. For the other resident, shower sheets were inconsistently completed regarding nail care, and toenails remained long even after fingernails were clipped. Staff interviews across CNAs, an RN, an LPN, MDS, social services, and case management revealed confusion and conflicting understandings about who was responsible for arranging nail care and podiatry services, contributing to the failure to meet grooming and hygiene needs as required by facility policy.
A resident with a history of mood disorders and substance abuse assaulted another resident on the smoking patio, resulting in a physical altercation. Despite staff training on deescalation and supervision, the incident occurred, indicating a lapse in monitoring and intervention. The facility's policy on preventing abuse was not effectively implemented, leading to a deficiency in resident protection.
Two residents were involved in separate incidents of abuse by another resident with behavioral issues. The first incident involved a verbal altercation where a cellphone was thrown, and the second involved a physical kick. Both incidents were witnessed by staff, who noted the aggressor's history of verbal aggression and behavioral issues.
A resident with type 2 diabetes and other conditions had missing documentation of blood sugar results and vital signs in their medical records. Insulin was administered without recorded blood glucose monitoring, contrary to facility policy. Staff interviews revealed inconsistencies in documentation practices, and the Director of Nursing acknowledged the failure to meet facility expectations.
Failure to Obtain Proper Written Authorization for Resident Financial Transaction
Penalty
Summary
The facility failed to ensure proper safeguarding of a resident’s personal funds by not obtaining written authorization as required for financial transactions. A resident with a history of anxiety disorder, ureteral calculus, mood affective disorder, and vascular dementia was admitted and later became private pay after insurance coverage ended. An MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment. When the resident transitioned to private pay, the business office processed a credit card payment using a "Credit Card Authorization Form" that was completed by the Assistant Business Manager but did not contain the resident’s signature or a documented time of completion. The Credit Card Authorization Form listed the resident as the cardholder, described the services as private pay room and board for specific dates, and included the credit card number, expiration date, security code, and total amount to be charged. The form also contained a pre-printed statement agreeing to pay the total amount according to the card issuer agreement. However, in the signature section, staff documented only the words "via phone" instead of obtaining the resident’s written signature. Facility staff, including the Business Manager and Assistant Business Manager, stated that the form was required for each monetary transaction and that the resident had insisted on paying over the phone while away from the facility, but they did not document the details of the phone consent anywhere other than the notation "via phone" on the form. Financial records, including the Resident Ledger Report and Resident Activity Reports, showed the posting of room and board charges, a partial payment, and an outstanding balance. Later documentation indicated that, after the resident’s death, the resident’s private fiduciary reported to the facility that money had been taken from the resident while at the facility and that she was unable to pay the remaining balance. The fiduciary also reported that the resident’s mail, including financial statements and retirement fund information, had been kept in a nightstand drawer and left vulnerable to anyone entering the room. Review of the State Operations Manual and the facility’s job descriptions and policies showed that the facility was required to have systems and internal controls to ensure resident funds were maintained in accordance with federal and state regulations, including written authorization and documentation of date, time, amount, and source or recipient of funds, which were not followed in this case.
Failure to Investigate Alleged Financial Misappropriation and Protect Resident Financial Information
Penalty
Summary
The facility failed to implement its policies prohibiting financial misappropriation for one resident when it did not investigate allegations of fraud involving the resident’s finances. The resident had a history of anxiety disorder, calculus of the ureter, mood affective disorder, and vascular dementia, and an MDS BIMS score of 11 indicating moderate cognitive impairment. The resident was initially not private pay but became private pay after insurance coverage ended, and the business office monitored her financial status because private pay residents were considered rare and the office’s role was to collect money and be aware of when residents might need financial assistance. On a date in April, the Business Manager documented a call from the resident’s private fiduciary, who reported filing a Victim of Fraud claim on behalf of the resident, stating that the resident’s account had been drained of $265,000 and that the police were investigating. The fiduciary requested facility participation in the investigation and copies of financial statements and documentation of the resident’s private pay status. The Business Manager documented that she informed the then-Executive Director/Administrator of the fiduciary’s allegations, including that the fiduciary was asking for facility staff to be investigated for fraud. The fiduciary later stated in interview that the facility had paid itself from the resident’s accounts before she became the financial power of attorney, that she had reported the suspected fraud to both the police and the facility while the resident was still there, and that the resident kept a nightstand drawer full of mail and financial documents, including statements and retirement fund information, which were left vulnerable to anyone entering the room. In subsequent interviews, the current Administrator reported that he and the previous Administrator had gone over the fiduciary’s allegations with her, but that, after speaking with the previous Administrator, it appeared that nothing had been done in response to the fraud allegations and that the previous Administrator had determined there was nothing to investigate. The facility’s abuse policy, revised in October, stated that residents have the right to be free from misappropriation of resident property and exploitation, that staff with knowledge of an actual or potential violation must immediately report it to a supervisor or the Administrator, and that all allegations of abuse, neglect, misappropriation, or exploitation would be promptly and thoroughly investigated with interviews, record review, and documentation of the investigation and its results. Despite this policy, the allegation of financial misappropriation involving this resident was not investigated at the time it was reported.
Failure to Report Alleged Financial Misappropriation to Authorities
Penalty
Summary
The facility failed to report an alleged financial misappropriation involving a resident in accordance with state law and facility policy. The resident, who had vascular dementia and a BIMS score of 11 indicating moderate cognitive impairment, had a private fiduciary (RPF) managing finances. On April 22, 2025, the Business Manager documented that the RPF reported filing a victim of fraud claim on the resident’s behalf, stating the resident’s account had been drained of $265,000 and that the police were investigating. The RPF requested that the facility be part of the investigation and asked for copies of financial statements and documentation related to the resident’s private pay status. Shortly thereafter, the Business Manager documented that she informed the then-Executive Director/Administrator of the RPF’s allegations, including that the RPF was asking for facility staff to be investigated for fraud, and the Administrator stated he would reach out to another staff member for advice. Subsequent documentation on September 2, 2025, reflected that the resident had died and that the RPF stated money had been taken while the resident was at the facility, leaving her unable to pay the facility. During interviews, the Business Manager confirmed she recognized financial abuse as a form of abuse and that she immediately informed the Administrator when the RPF made the fraud allegation. The current Administrator, who had been operations manager at the time, stated that after reviewing the prior allegations and speaking with the former Administrator, it appeared that nothing was done in response and that the former Administrator had determined there was nothing to investigate. The Administrator also confirmed that the allegations of fraud were not reported to the state agency. A review of facility records showed no self-reports related to this resident, despite facility policies requiring that suspected crimes, including fraud and forgery, and allegations of abuse, misappropriation, or exploitation be reported to the State Survey Agency and other appropriate agencies within required timeframes.
Unauthorized Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
Surveyors identified a deficiency related to medication storage and self-administration when a resident was found with medications left at the bedside without authorization. The resident, who had a history of Type 2 Diabetes Mellitus with diabetic neuropathy, COPD, dementia, and major depressive disorder, had a quarterly MDS with a BIMS score of 13, indicating cognitive intactness. Review of the resident’s care plan, physician’s orders, and electronic medical record showed no care plan, orders, or interdisciplinary team documentation authorizing self-administration of medications. Despite this, during a room observation, two medications—Fluticasone Propionate Suspension 50 mcg/act and Bacitracin Zinc 400 units—were observed at the resident’s bedside. During interviews, the resident confirmed that one medication was used every other day on her toes and that the other was a nasal spray used occasionally. A subsequent observation with the DON again revealed the two medications at the bedside. The DON confirmed that residents without self-administration orders should not have medications left out and acknowledged that this situation did not meet facility expectations. Review of facility policies showed that self-administration requires an interdisciplinary assessment and documentation in the chart, and that all drugs and biologicals must be stored in locked compartments accessible only to authorized personnel, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with hemiplegia, major depressive disorder, and cataracts, who was found with multiple superficial wounds and blood on his face after being struck by his roommate. The aggressor, who was cognitively intact and had diagnoses including cellulitis and diabetes, admitted to hitting the victim following a verbal altercation involving a racial slur. The incident was not directly witnessed by staff, but was reported by another resident who heard the altercation and alerted a CNA. Upon entering the room, the CNA observed the aftermath, with the victim wheeling himself into the bathroom and the aggressor walking away. Clinical documentation and staff interviews confirmed that the injured resident sustained lacerations to the forehead, nose, lip, and chin, but was not transferred to the hospital. The aggressor left the facility against medical advice the same day. The facility's investigation concluded that the event was unanticipated and isolated, occurring in an area with adequate staff supervision. However, prior to the incident, there were indications of behavioral issues, as the aggressor had been observed yelling at another resident the day before. Facility policies reviewed indicated that residents have the right to be free from all forms of abuse, including physical abuse. Despite these policies, the facility failed to prevent the physical altercation between the two residents, resulting in injury. Staff interviews revealed an understanding of abuse protocols, but the incident still occurred, demonstrating a lapse in protecting resident rights as required by both facility policy and regulatory guidelines.
Failure to Provide Adequate Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care as part of activities of daily living (ADLs) for two residents who were unable to perform their own hygiene. One resident had generalized muscle weakness, lack of coordination, cognitive communication deficit, toxic encephalopathy, type 2 diabetes mellitus, and morbid obesity, with an MDS BIMS score indicating moderate cognitive impairment and a care plan identifying ADL deficits related to weakness. Observations over several days showed this resident in bed with feet exposed and toenails that were yellow-brown, markedly overgrown, and curling over the tops and onto the pads of the toes on both feet. Despite an active order stating the resident "may see Podiatry of Choice" and shower sheets on two dates indicating that nails needed clipping, there were no orders or documentation for a podiatry visit, and the toenails remained long and discolored on repeated observations. Multiple staff interviews revealed inconsistent and unclear processes for nail care and referrals. A CNA stated that podiatry would be called to clip nails and that the approach depended on whether the resident was diabetic or if nails were long and curving. An RN reported not knowing the process for clipping nails and needing to ask the CNA. An LPN described a process that began with asking a CNA, then notifying the physician for a podiatry order for diabetic residents, and stated that responsibility for clipping nails belonged to all staff. The MDS coordinator indicated that long toenails identified on assessment would be referred to social services, while the social services director stated she only scheduled podiatry and other services for long-term residents and that case managers handled skilled residents. The case manager, however, stated that she did not schedule appointments and believed social services did, indicating a breakdown in role clarity and follow-through. The second resident had hemiplegia and hemiparesis following cerebral infarction, opioid dependence, cognitive communication disorder, and anxiety disorder, with an MDS BIMS score indicating severe cognitive impairment and dependence on staff for personal hygiene with assistance of one staff member per the care plan. During a dining room observation, this resident was seen eating with the left hand while fingernails were long and had food noted under them, and the feet were covered. A later observation showed that the fingernails had been clipped, but the resident had no shoes or socks on and toenails on both feet were long and extended over the ends of the toes. Review of this resident’s shower sheets showed they were not consistently completed regarding whether nails were clipped or needed clipping, and on one date a CNA marked that nail clipping was not needed. The facility’s ADL policy stated that if a resident is unable to carry out ADLs, necessary services to maintain grooming and personal hygiene would be provided by qualified staff, but the documented observations and records showed that nail care needs for these two residents were not met.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #44, who has diagnoses including bipolar disorder and anxiety, was assaulted by Resident #55 on the smoking patio. The incident occurred when Resident #55, who has a history of aggressive behavior and was experiencing increased agitation, approached Resident #44 unprovoked and punched him behind the ear. A certified nursing assistant witnessed the event and intervened to separate the residents. Resident #44 sustained a reddened area behind the ear but refused further medical assessment. Resident #55 has a history of mood disorders and substance abuse, and was noted to have a significant change in mental status on the day of the incident. Despite being prescribed psychotropic medications for paranoid delusions, Resident #55 exhibited increased agitation and refused medication. The facility's staff, including a CNA and an LPN, acknowledged that they are trained to recognize and deescalate such situations, but the incident still occurred, indicating a lapse in supervision and intervention. Interviews with staff, including the Director of Nursing, revealed that there is an expectation for staff to monitor residents' behaviors and intervene when necessary to prevent harm. The facility's policy emphasizes the right of residents to be free from abuse, yet the incident highlights a failure to adhere to this policy, resulting in a deficiency in protecting residents from abuse.
Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to incidents of resident-to-resident abuse. Resident #20, who had no cognitive impairment, was involved in a verbal altercation with resident #75, who also had no cognitive impairment but had a history of trauma and behavioral issues. During the altercation, resident #75 threatened resident #20 and threw her cellphone on the floor. A Certified Nursing Assistant (CNA) reported that resident #75 had previous altercations with other residents and was often the instigator. In another incident, resident #40, who also had no cognitive impairment, was involved in a verbal exchange with resident #75 in the hallway. During this exchange, resident #75 physically kicked resident #40 in the abdomen. A CNA witnessed the incident and confirmed that resident #75 had been verbally aggressive before but had not been physically aggressive until this incident. The Licensed Practical Nurse (LPN) noted that resident #75 was alert and oriented but had behavioral issues and made paranoid statements. The Director of Nursing (DON) acknowledged that resident #75 had not been at the facility long and was on psychiatric medications. The DON initially thought the first incident with resident #20 was isolated but recognized a pattern after the second incident with resident #40. The facility's policy on abuse prevention states that each resident has the right to be free from abuse, neglect, and exploitation, and that willful actions are deliberate, even if not intended to inflict harm.
Deficient Documentation of Vital Signs and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, specifically regarding vital signs and blood glucose monitoring. The resident, who was readmitted with multiple diagnoses including type 2 diabetes mellitus and stage 4 pressure ulcers, had missing records of blood sugar results on two occasions when insulin glargine was administered. Additionally, there was no evidence of vital signs being recorded during specific evening shifts, which was against the facility's policy. Interviews with staff revealed inconsistencies in the documentation process. A CNA admitted to not completing documentation for the resident on a particular day, and an LPN confirmed that CNAs are responsible for charting vital signs. The Director of Nursing acknowledged that the lack of documentation did not meet facility expectations and could potentially lead to missing acute changes in the resident's condition. The facility's policies on documentation and insulin administration were not followed, as evidenced by the lack of blood glucose monitoring prior to insulin administration. Staff interviews highlighted that blood glucose levels should be checked before administering insulin, yet there was no record of such monitoring for the resident since a specific date. The Director of Nursing noted that insulin glargine is not held for low blood glucose levels, but the standard of care involves monitoring for hypoglycemia signs in the absence of specific physician orders.
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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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