Dr Guy Gorman Sr Care Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Chinle, Arizona.
- Location
- Highway 191 & Hospital Road, Chinle, Arizona 86503
- CMS Provider Number
- 035242
- Inspections on file
- 26
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Dr Guy Gorman Sr Care Home during CMS and state inspections, most recent first.
The facility did not submit required direct care staffing data for a fiscal quarter, as mandated by CMS, due to a change in personnel and lack of training for the new COO responsible for PBJ submissions. This was confirmed through interviews and review of staffing data reports.
The facility did not assess or document the need for bed rails, failed to attempt or record alternatives, and did not obtain informed consent or discuss risks and benefits with residents or their representatives before installing bed rails. All beds were observed to have bed rails, and staff confirmed the absence of a policy and consistent evaluation process.
Several CNAs did not complete the required 12 hours of annual in-service education, with some receiving little or no training in abuse prevention, dementia care, and infection control. Training records and staff interviews revealed barriers such as lack of internet access and insufficient time during work hours, resulting in incomplete training for multiple staff members.
A resident with multiple medical and behavioral diagnoses was discharged to another facility due to ongoing aggression and self-harm, but the required physician documentation stating the reason for discharge was missing from the medical record, resulting in a deficiency.
A resident with severe cognitive impairment and multiple medical conditions was inaccurately coded on the MDS for a stage two pressure ulcer, despite a lack of supporting documentation in the EMR during the required look-back period. The MDS Coordinator based the coding on an earlier note and the absence of healing documentation, which did not align with RAI manual guidelines.
The facility did not have an RN on duty for eight consecutive hours on one reviewed day, as confirmed by schedule and time card reviews and staff interview. The RN coverage was split into two non-consecutive shifts, failing to meet regulatory requirements.
A resident with a history of heart failure, hypertension, and other conditions was given anti-hypertensive medication despite physician orders to hold the drug when systolic blood pressure was below a specified threshold. Medication was administered multiple times outside of these parameters, contrary to both the care plan and facility policy.
A resident with multiple chronic conditions was prescribed Hydralazine for hypertension with instructions to hold the medication if systolic blood pressure was below a certain level. The MAR showed the medication was given on several occasions when the resident's blood pressure was below the threshold, but interviews with LPNs revealed these were documentation errors in the electronic health record. The DON confirmed the importance of following physician orders and maintaining accurate records, while the facility's policy did not specifically address documentation accuracy.
The facility did not ensure that the QAA committee included the required participants, as the Medical Director and Administrator/Board member were absent from two quarterly meetings, resulting in noncompliance with regulatory requirements for committee composition.
A CNA did not change gloves between dirty and clean tasks while providing personal care to a dependent resident with multiple medical conditions, resulting in a failure to follow infection control protocols as confirmed by observation, staff interviews, and facility policy.
Two residents were not provided with education or the opportunity to receive an updated pneumococcal conjugate vaccine (PCV20 or PCV21) as required by policy and CDC guidelines. Documentation was missing for both education and vaccine administration, despite prior vaccinations and signed consents. Staff interviews confirmed these omissions.
The facility did not provide required compliance and ethics training to multiple CNAs and other staff, as confirmed by missing documentation in training records and staff interviews. The compliance and ethics program was not discussed in staff meetings attended by all staff, and the facility's policy requiring orientation and annual refresher training was not followed.
The facility did not notify resident representatives of significant changes in condition or transfers for two residents. In one instance, a resident was sent to the ER without the RP being informed, and in another, a resident with a foot fracture had no successful notification to the designated family member. Staff interviews and record reviews showed inconsistent notification practices and the absence of a formal policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not transmit required MDS discharge assessments to CMS within the mandated timeframe for two residents. In both cases, staff delayed submission due to uncertainty about the residents' return and incomplete MDS sections, resulting in late transmission of critical assessment data.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Three residents experienced preventable falls with major injuries due to the facility's failure to provide adequate supervision, implement recommended interventions such as 1:1 monitoring and anti-rollback wheelchair devices, and follow post-fall assessment protocols. One resident with a history of frequent falls did not receive required neuro checks after an unwitnessed fall and later died from a subdural hematoma. Another resident repeatedly fell due to not locking wheelchair brakes, with the recommended anti-rollback device never implemented, resulting in hospitalization for a subdural hematoma. A third resident with severe cognitive impairment did not receive needed mobility assistance, leading to a fatal fall.
A resident with dementia and a history of frequent falls suffered multiple unwitnessed falls due to inadequate supervision, lack of required neurological assessments, and insufficient CNA staffing. Despite recommendations for 1:1 monitoring, the facility did not update the care plan or provide the necessary supervision, and staff failed to complete required fall prevention training. Additionally, two residents experienced physical abuse from peers, with investigations confirming that staff could not provide the recommended supervision or interventions to prevent these incidents.
The facility did not implement any performance improvement activities for identified quality concerns, despite tracking and discussing data on issues such as falls, incidents, infections, and complaints. While the QAPI committee met quarterly and reviewed reports, there was no evidence of completed or ongoing process improvement projects for over a year, except for a new initiative in Social Services.
Several MDS assessments were found to be inaccurate, including incorrect documentation of antipsychotic medication use for multiple residents, misreporting of a wound infection when only a minor skin tear was present, and errors in recording the frequency and type of restorative care provided. These inaccuracies were confirmed through MAR, TAR, physician orders, and staff interviews, with staff citing confusion over medication classifications and look-back periods.
Two residents did not receive comprehensive care plans addressing their specific needs: one resident's care plan lacked input from PT regarding mobility aids and transfer methods, resulting in staff being unaware of essential recommendations, while another resident experiencing significant weight loss did not have a care plan addressing this issue, despite ongoing interventions by the RD and physician. Staff interviews and documentation reviews confirmed these omissions.
A resident with dementia and diabetes developed multiple wounds that were not consistently assessed or documented according to physician orders and facility policy. Wound measurements and care plan updates were missed, and some wounds were not included in the care plan. The DON confirmed that wound assessments and care planning did not meet expectations, and the facility lacked a wound-certified nurse. These failures increased the risk for pain, infection, and rehospitalization.
A resident with dementia, diabetes, frequent falls, orthostatic hypotension, and a history of stroke experienced multiple falls on days when there were fewer than the required number of CNAs on duty, as outlined in the facility's own assessment. Staffing records and interviews confirmed that only two CNAs were present during these incidents, despite the resident's need for supervision or touch assistance with transfers and ambulation. Facility leadership acknowledged ongoing staffing shortages and the inability to provide necessary 1:1 supervision.
The facility did not ensure that an LPN completed required annual training modules, including fall prevention, for multiple years, and allowed a CNA to work with an expired CPR certification. These lapses were confirmed by facility leadership and placed residents, including one with a full code status, at risk for unmet and unsafe care needs.
A resident with poor oral health and broken teeth was not provided with routine dental care despite documented needs and a care plan intervention. The resident reported ongoing dental pain and had requested dental services, but staff interviews revealed unclear processes and missed referrals, resulting in delayed dental care.
Surveyors identified multiple deficiencies in food storage and temperature monitoring, including open and undated frozen food, expired baking soda on pantry shelves, incomplete refrigerator temperature logs, and improper storage of personal food in resident refrigerators. Staff interviews confirmed inconsistent adherence to facility policies regarding food safety and documentation.
The facility did not ensure that most direct care staff completed required QAPI training, as evidenced by electronic records showing the majority had not finished the module. The ADON and DON confirmed the absence of a formal staff education policy and a lack of structured follow-up, resulting in incomplete training for the majority of staff.
The facility did not ensure that all CNAs and LNAs completed the required 12 hours of annual in-service education, with some missing key topics such as abuse, dementia, and infection control. Training records and staff interviews confirmed that the required hours and subjects were not met, and the facility lacked a policy for staff competency or annual CNA training.
A resident with hemiplegia and other medical conditions was fed by a CNA who stood over him instead of sitting, despite a chair being available. The CNA acknowledged this was not in line with facility expectations, and the DON confirmed staff should be seated when assisting with meals or snacks. Facility policy requires residents to be treated with dignity and respect at all times.
An LPN was allowed to work multiple shifts without completing the required Arizona Public Safety Fingerprinting Clearance, which serves as the facility's criminal background check. Despite repeated reminders and expired credentials, the LPN continued to provide care to residents, with facility leadership citing staffing shortages as the reason for not removing the LPN from the schedule.
A resident was struck in the face and grabbed by another resident, resulting in minimal redness. Although the incident was witnessed and separated by a nurse aide, the required report to CMS was not made within the mandated 2-hour timeframe due to a lack of immediate action and direction from nursing leadership.
The facility did not transmit discharge MDS assessments to CMS within the required timeframe for two residents, with both assessments being over 120 days late. The MDS Nurse identified issues with the electronic health record system that prevented timely submission, and the DON confirmed expectations for timely completion and transmission.
A facility did not update or correct the PASRR Level I form or notify the state mental health authority for a resident with dementia, major depressive disorder with psychotic features, and PTSD. Despite documentation of severe cognitive impairment, behavioral symptoms, and ongoing mental health services, staff did not review or refer the PASRR for Level II screening, and the form was simply filed without reassessment.
A resident with dementia developed multiple wounds, including pressure ulcers and open areas on the lower leg and great toe, but the care plan was not updated to include these new wounds. Nursing staff and the DON confirmed that the wounds should have been added to the care plan for proper monitoring and intervention, but this was missed despite facility policy requiring such updates.
A resident with severe cognitive impairment and multiple health conditions developed pressure ulcers on both ankles, and the facility failed to complete weekly wound assessments and did not implement the care plan intervention of a multi-podus boot to offload pressure. Staff were unaware of the wound type and the required interventions, and the resident was observed without the prescribed orthopedic device. The care plan lacked clarity on key interventions, and facility policy for wound care documentation was not followed.
A resident with an indwelling urinary catheter did not receive care in accordance with infection control practices and evidence-based guidelines. Staff allowed the catheter bag spigot to touch the inside of a urinal during emptying, and the resident's catheter and drainage bag were changed at routine intervals without clinical justification, contrary to facility policy and CDC recommendations. Facility staff and the physician were not aligned on current guidelines, and there was a lack of communication regarding proper catheter care procedures.
A resident was not seen by a physician within the required 30-day period following admission, as mandated by facility policy and federal regulations. Staff interviews and record review confirmed the missed visit, with the DON acknowledging the oversight and the physician unable to provide documentation of a timely assessment.
A resident with multiple medical conditions was administered both apixaban and enoxaparin following a hospital stay for a renal vein clot, without clear documentation or physician clarification on whether both anticoagulants should be given together. Nursing staff and the DON acknowledged the addition of enoxaparin but could not confirm if dual therapy was intended, and facility policy requiring physician clarification for potentially excessive medication orders was not followed.
A facility-wide assessment was completed without input from the governing body, medical director, residents, their representatives, or direct care staff, as required by regulation. The assessment also lacked documentation of review by the QAA/QAPI committee, and there was no policy in place for conducting the assessment. Interviews confirmed that a process to obtain input from all required parties was not established.
An LPN was observed administering medications to multiple residents without changing gloves or performing hand hygiene between each resident. The LPN used the same gloves while preparing and giving medications, and while assisting a resident with eating and drinking. Facility leadership confirmed that this practice did not follow the facility's infection control policy, which requires hand hygiene and glove changes between each resident.
Failure to Submit Required Payroll-Based Staffing Data
Penalty
Summary
The facility failed to submit mandatory direct care staffing information for Fiscal Year Quarter 2, 2025, as required by the Centers for Medicare and Medicaid Services (CMS) Payroll-Based Journal (PBJ) system. During the entrance conference, the Administrator confirmed that the PBJ report for the specified quarter was not submitted. Interviews revealed that the responsibility for PBJ submissions had shifted after the previous payroll specialist left approximately four months prior, and a new Chief Operations Officer (COO) began in May. The Interim Director of Nursing (IDON) stated that the new COO was not trained on the PBJ submission process. Review of the CMS policy manual confirmed the requirement for quarterly electronic submission of staffing data based on payroll and other auditable sources.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were properly evaluated for the need and safety of bed rail use prior to installation. For three residents reviewed, there was no documentation of assessments, evaluations, or informed consent regarding bed rail use. These residents, who had various medical diagnoses including diabetes, dementia, cerebral infarction, COPD, visual loss, osteoarthritis, and moderate cognitive impairment, were observed with bilateral bed rails in use. Interviews with these residents revealed that none had been informed of the risks or benefits associated with bed rail use, and their care plans did not include any mention of bed rails or related bed mobility plans. Additionally, the facility did not document attempts to use alternatives to bed rails or reasons for the failure of such alternatives. Observations showed that all resident beds were equipped with some type of bed rail, and staff interviews confirmed that bed rails were not removed between residents. The facility lacked a policy for bed rail use, and there was no evidence of risk/benefit discussions or informed consent being obtained from residents or their representatives prior to the installation of bed rails.
Failure to Ensure Required Annual CNA Training and In-Service Education
Penalty
Summary
The facility failed to ensure that four out of five sampled Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in-service education based on their hire dates. Specifically, training records showed that one CNA completed only 7.82 hours, another 8.57 hours, a third only 0.17 hours, and a fourth had no documented annual training. Additionally, two CNAs did not receive annual training in abuse prevention, dementia care, and infection control as required. These findings were based on a review of staff lists, training records, and interviews with staff and management. Interviews revealed that staff training was conducted and tracked through the Relias online system, but some CNAs faced barriers to completing the training, such as lack of internet access at home and insufficient time during work hours. One CNA confirmed her training record was accurate and noted the challenges of completing training outside of work due to distance and lack of compensation. The Interim Assistant Director of Nursing and the Director of Nursing acknowledged the ongoing challenge of ensuring all CNAs meet the annual training requirements, with some staff unable to complete the necessary modules due to these logistical issues.
Lack of Physician Documentation for Resident Discharge
Penalty
Summary
The facility failed to ensure that required physician documentation for a resident's discharge was present in the medical record. Specifically, for one resident with diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, acute kidney failure, and diabetes, there was no physician-documented reason for discharge or transfer. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 9, was discharged to another nursing facility due to ongoing verbal and physical aggression towards staff and self-harm behaviors. Although the facility's policy requires physician documentation to support the necessity of transfer or discharge, the medical record only contained a provider order to discharge and transfer the resident, without specifying the reason for the action. Progress notes and interviews with facility staff, including the Interim Director of Nursing, confirmed that the decision to discharge was based on the resident's escalating aggressive behaviors and the facility's inability to manage her needs. However, there was no evidence in the medical record that a physician had documented the basis for the transfer or discharge, as required by facility policy and federal regulations. This omission resulted in a deficiency related to the documentation of the discharge process.
Inaccurate MDS Assessment for Pressure Ulcer Documentation
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a history of multiple medical conditions, including dementia, type II diabetes, protein calorie malnutrition, age-related physical debility, and hemiplegia/hemiparesis following cerebrovascular disease. The resident, who was non-interviewable and had severe cognitive impairment, was identified for review due to a facility-acquired pressure ulcer. Review of the resident's MDS skin assessments over several quarters showed inconsistent documentation regarding the presence of pressure ulcers, with the most recent quarterly MDS indicating a stage two pressure ulcer. However, examination of the electronic medical record (EMR), including assessments, progress notes, and miscellaneous documentation, did not reveal any supporting evidence of a pressure ulcer during the relevant look-back period. The MDS Coordinator reported coding the pressure ulcer based on an earlier progress note and the absence of documentation indicating healing, despite a subsequent note stating the wounds were healed. Review of the RAI manual confirmed that coding should be based on the presence of a pressure ulcer within the 7-day look-back period, which was not supported by the available documentation. The MDS Coordinator acknowledged the MDS was coded incorrectly for a pressure ulcer.
Failure to Provide RN Coverage for Required Consecutive Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for eight consecutive hours on one of the 203 days reviewed for staffing. Specifically, a review of the Licensed Nurses Schedule for the week in question showed that there was no RN on duty for the required consecutive hours on a particular day. The Interim Director of Nursing's time card for that day indicated work shifts from 8:30 AM to 1:00 PM (4.5 hours) and then from 6:30 PM to 9:15 PM (2.75 hours), which did not meet the eight consecutive hour requirement. The facility census was less than 60 at the time. During a concurrent review and interview, the Interim Director of Nursing confirmed that there was no RN present for eight consecutive hours on that day.
Failure to Hold Antihypertensive Medication per Physician Order
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including congestive heart failure, hypertension, dementia, diabetes, and cerebral infarction, received anti-hypertensive medication that did not comply with the physician's ordered blood pressure parameters. The resident's care plan specified a goal for blood pressure to remain within normal limits, and the physician's order directed that Hydralazine should be held if the systolic blood pressure (SBP) was less than 130. Despite this, medication administration records showed that Hydralazine was given on several occasions when the resident's SBP was below the ordered threshold. During an interview and record review, the Interim Director of Nursing confirmed that the medication should have been held according to the physician's order and that nurses are expected to follow these orders. Facility policy also requires medications to be administered in accordance with physician orders.
Inaccurate Medication Administration Documentation for Antihypertensive Therapy
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for one resident reviewed for unnecessary medication use. The resident, who had multiple diagnoses including congestive heart failure, hypertension, dementia, diabetes, and a history of stroke, was prescribed Hydralazine for hypertension with specific instructions to hold the medication if the systolic blood pressure (SBP) was less than 130. Despite this, the Medication Administration Record (MAR) documented that Hydralazine was administered on several occasions when the resident's SBP was below the threshold specified in the physician's order. Interviews with nursing staff revealed that the medication was not actually given on those occasions, and the inaccurate documentation was attributed to errors in the electronic health record system. The Interim Director of Nursing confirmed that blood pressure medications should be held according to physician orders and that accurate documentation is essential. Additionally, the facility's policy provided did not specifically address the need for accuracy in medical record documentation.
QAA Committee Lacked Required Participants at Quarterly Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required participants for two out of four quarters reviewed. Specifically, review of the QAPI binder for 2024 and 2025 revealed that the QAA meetings held on 3/26/25 and 10/2/24 did not have the Medical Director present, and the 3/26/25 meeting also lacked attendance by the Administrator or Board member. Documentation and interviews confirmed that the Medical Director was not present at these meetings, and there was no proof of attendance for the required participants. The facility's QAPI committee membership list otherwise met the minimal regulatory requirements, and meetings were held at least quarterly. However, the absence of the Medical Director and Administrator/Board member at the specified meetings resulted in noncompliance with participation requirements. This deficiency was identified through record review and interviews with facility staff, including the Interim Assistant Director of Nursing and Interim Director of Nursing.
Failure to Change Gloves Between Dirty and Clean Tasks During Personal Care
Penalty
Summary
Certified Nursing Assistant (CNA) 26 failed to change gloves between dirty and clean tasks while providing personal care to a resident who was dependent on staff for all activities of daily living due to severe cognitive impairment, limited mobility, and multiple medical conditions including heart failure, diabetes, and dementia. During the observed care, CNA 26 removed the resident's soiled brief and cleaned the resident's private area with gloved hands, then, without changing gloves, handled a clean brief and repositioned the resident, completing the care with the same pair of gloves. When questioned, CNA 26 acknowledged using only one pair of gloves throughout the procedure and admitted that the gloves were likely contaminated when touching the clean brief. The facility's policy, as well as statements from the Interim Assistant Director of Nursing and the Director of Nursing, confirmed that staff are expected to change gloves and perform hand hygiene when moving from a soiled to a clean task. The failure to follow this protocol was directly observed and confirmed through staff interviews and record review.
Failure to Provide Education and Offer Updated Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that two of five residents reviewed for immunizations were provided with education and the opportunity to decline or receive an updated pneumococcal conjugate vaccine (PCV20 or PCV21), as required by facility policy and CDC recommendations. For one resident, the electronic medical record showed previous pneumococcal vaccinations but lacked documentation that the resident or responsible party had been educated about the need for the updated vaccine or offered the opportunity to receive it. For the second resident, records indicated a prior PCV13 vaccination and a general vaccine consent, but there was no documentation of education or administration of the PCV20 vaccine after consent was obtained. Interviews with facility staff, including the Clerk and the DON, confirmed that there was no documentation of education or vaccine administration for these residents regarding the updated pneumococcal vaccine. The DON acknowledged that the expectation was to check vaccine status, provide education, and offer the vaccine to all residents, but this process was not followed for the two residents in question.
Failure to Provide Compliance and Ethics Training to Staff
Penalty
Summary
The facility failed to provide training on its compliance and ethics program to all sampled Certified Nursing Assistants (CNAs), as evidenced by a review of training records and staff interviews. Specifically, five CNAs hired between 2008 and 2024 had no documented evidence of receiving compliance and ethics training. The Interim Assistant Director of Nursing/Quality Assurance Quality Improvement/Infection Control Nurse confirmed that no compliance and ethics training modules were assigned in the Relias system, and both the previous and current compliance officers had not provided such training. Staff interviews further confirmed that neither CNAs nor Licensed Nurse Aides had received training on the facility's compliance and ethics program. Additionally, a review of a staff meeting agenda and attendance records did not show that compliance and ethics were discussed, and not all staff attended the meeting. The facility's Compliance and Ethics Program policy requires orientation and annual refresher training for all associates and affiliates, but this requirement was not met for the sampled staff. This lack of training placed residents at risk for non-compliant and unethical treatment, as staff were not educated on the facility's expectations or their responsibilities regarding compliance with laws.
Failure to Notify Resident Representatives of Change in Condition
Penalty
Summary
The facility failed to notify the resident's representative party (RP) of a change in condition or transfer for two out of seven residents reviewed for changes. In one case, a resident was transferred to the emergency room due to a change in condition, including decreased activity and lack of urine output, without prior notification to the RP. The RP only learned of the transfer upon seeing the resident at the hospital and subsequently called the facility for information. Documentation in the electronic medical record confirmed that the family was not notified until after the transfer had occurred and only after the RP initiated contact. In another case, a resident with multiple diagnoses, including heart failure, diabetes, and dementia, sustained a minimally displaced fracture of the right heel. The resident was dependent on staff for all activities of daily living and required total assistance. The facility's records showed that the designated family member was not informed of the injury, despite being listed as the emergency contact and substitute decision-maker. Attempts to contact the family member were unsuccessful due to a non-working phone number, and there was no evidence that the notification responsibility was handed off to the next shift as per the facility's stated practice. Interviews with staff and review of facility policy revealed that there was no formal policy for notification of change in condition. The interim director of nursing confirmed that the charge nurse was responsible for notification, but this was not consistently documented or carried out. The lack of a clear policy and failure to ensure notification led to the deficiency, as family members were not informed in a timely manner about significant changes in the residents' conditions.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Failure to Timely Transmit MDS Discharge Assessments
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services within the mandated timeframe for two residents. For one resident, the discharge MDS with an Assessment Reference Date (ARD) was not submitted and accepted until more than two years after the ARD, exceeding the required 14-day submission window. The MDS nurse indicated that uncertainty among staff regarding the resident's potential return delayed the completion and submission of the MDS, despite reminders about the deadline. The Interim Director of Nursing confirmed the expectation for timely MDS completion and transmission. For another resident, the discharge MDS assessment was also submitted late, with the MDS Coordinator stating that the sections did not meet the required completion times, resulting in a delayed submission. Both cases were identified through interviews and record reviews, which confirmed that the facility did not adhere to the RAI manual's requirements for timely MDS completion and transmission. The failure to submit these assessments within the required timeframe was directly observed and acknowledged by facility staff.
Failure to Timely Develop and Review Comprehensive Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Prevent and Manage Falls Resulting in Major Injuries and Deaths
Penalty
Summary
The facility failed to ensure that three residents did not sustain preventable falls with major injuries due to inadequate supervision, failure to implement recommended interventions, and failure to follow post-fall assessment protocols. One resident with a history of dementia, diabetes, frequent falls, and orthostatic hypotension experienced 16 falls during a four-month stay, including multiple unwitnessed falls after which recommended 1:1 monitoring was not implemented. After the last unwitnessed fall, the assigned LPN did not conduct required neuro checks as per facility policy, and the necessary post-fall documentation was not completed. This resident subsequently developed symptoms such as vomiting and lethargy, was transferred to the emergency department, diagnosed with a subdural hematoma, and died after hospitalization and ventilator support. Another resident, admitted with diagnoses including non-Hodgkin lymphoma, unsteadiness, and repeated falls, experienced 15 falls during their stay. The root cause of many falls was identified as the resident not locking wheelchair brakes and not requesting assistance with transfers, despite repeated education. The interdisciplinary team recommended the use of an anti-rollback device for the wheelchair, but this intervention was not implemented or documented in the care plan. The resident continued to fall, and after a significant fall, was diagnosed with a subdural hematoma and required hospitalization. A third resident with severe cognitive impairment and ADL dependence did not receive necessary mobility assistance to safely propel her wheelchair. This lack of assistance resulted in a preventable fall with major injury, hospitalization, and death. Across these cases, the facility failed to provide adequate supervision, did not implement or document recommended fall prevention interventions, and did not consistently follow its own policies for post-fall assessment and monitoring.
Failure to Prevent Neglect, Inadequate Supervision, and Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from neglect and abuse, as evidenced by multiple incidents involving inadequate care, supervision, and staffing. One resident with a history of dementia, diabetes, frequent falls, and orthostatic hypotension experienced 16 falls during a four-month stay, with 12 of these being unwitnessed. After an unwitnessed fall, the responsible LPN did not conduct required neurological checks or complete the post-fall assessment documentation as mandated by facility policy. The resident later exhibited symptoms such as vomiting and confusion, was transferred to the hospital, diagnosed with a subdural hematoma, and subsequently died. Interviews with staff and review of records confirmed that neuro checks and fall protocols were not followed, and required documentation was missing. The facility also failed to provide adequate supervision and staffing for this resident, despite repeated recommendations from the interdisciplinary team for 1:1 monitoring due to the resident's high fall risk, confusion, and impulsive behaviors. The care plan was not updated to include 1:1 supervision, and the facility was unable to provide this level of care due to staffing shortages. On several occasions, the unit was staffed with fewer CNAs than required by the facility's own assessment, directly during times when the resident experienced falls. Leadership acknowledged that the lack of sufficient staff and inability to provide 1:1 supervision contributed to the resident's inadequate supervision and safety. Additionally, the facility failed to ensure that staff completed required annual training on fall prevention and management, with one LPN missing most mandatory modules over multiple years. The facility also did not protect residents from physical abuse by other residents, as evidenced by two separate incidents where residents were physically assaulted by peers. Investigations confirmed that staff were unable to provide the recommended supervision or interventions to prevent these altercations, and the facility lacked policies on resident supervision and dementia care.
Failure to Implement Performance Improvement Activities for Identified Quality Concerns
Penalty
Summary
The facility failed to implement any performance improvement activities for identified concerns, as required by their Quality Assurance and Performance Improvement (QAPI) program. Review of the 2024 QAPI Plan indicated that the QAPI team is responsible for determining which problems require a performance improvement project (PIP) and for chartering teams to investigate and address these issues. However, during interviews, the ADON/QAPI/IP and DON confirmed that while the committee meets quarterly and tracks data on quality concerns such as falls, incidents, infections, and complaints, they had not initiated or completed any process improvement projects for over a year. The ADON/QAPI/IP provided documentation of data tracking, such as infection rate graphs, and stated that concerns are discussed during meetings. Despite this, when asked to demonstrate an active or completed process improvement project, the ADON/QAPI/IP acknowledged that none had been undertaken, except for a new project in Social Services that was just starting. There was no evidence of systemic evaluation or testing of solutions for problem areas, including falls and abuse allegations, as required by the facility's QAPI plan.
Inaccurate MDS Assessments for Medications, Wound Status, and Restorative Care
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for several residents, resulting in incorrect documentation of medications, wound status, and restorative care. Specifically, for four residents, the MDS inaccurately indicated the use of antipsychotic medications. Upon review, the Medication Administration Records (MAR) and physician orders did not show that these residents were receiving antipsychotic medications. The MDS nurse misclassified cognition-enhancing medications such as Memantine and Donepezil as antipsychotics, citing confusion between antipsychotic and psychotropic medication classes. The Director of Nursing confirmed the expectation that MDS assessments should accurately reflect residents' medications. In another instance, a resident's MDS assessment documented a wound infection, but a review of the Treatment Administration Record (TAR), physician orders, and progress notes revealed only a minor skin tear with no evidence of a current wound infection or related treatment. The MDS nurse based the assessment on a previous diagnosis from several months prior, rather than the current status during the look-back period. The DON reiterated the expectation for accurate MDS assessments. Additionally, the MDS assessment for another resident inaccurately reported the frequency and type of restorative care received. The assessment indicated only one day of restorative services for walking, while restorative notes showed two days of treatment for transfers and one day for walking during the look-back period. The MDS nurse confirmed the discrepancy after reviewing the restorative documentation and the RAI Manual requirements for reporting restorative nursing programs.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with hemiparesis following a cerebral infection, the care plan did not incorporate the physical therapist's (PT) recommendations for a knee brace, trapeze bar, or consistent use of a sit-to-stand lift for transfers. Staff, including CNAs and LPNs, were unaware of these PT recommendations, and the tools they relied on, such as the Kardex and Treatment Record, were outdated or lacked the necessary information. The PT had communicated the need for a new knee brace and additional transfer equipment, but these recommendations were not reflected in the care plan or implemented in practice. The care plan also did not document whether the resident had refused any of the PT's recommendations. For another resident with multiple chronic conditions and a history of significant weight loss, the facility did not develop a care plan to address the ongoing weight loss, despite repeated documentation of the issue in the medical record and by the registered dietitian (RD). The RD had made dietary recommendations and the physician had agreed to interventions such as supplements, but the care plan only addressed risk for nutritional imbalance and did not include the actual weight loss or the interventions being provided. Staff interviews confirmed that the omission of a care plan for weight loss was an oversight. Facility policy required the interdisciplinary team, including professional therapies, to participate in care planning and for care plans to be updated as residents' conditions changed. However, the PT was not included in the care planning process for the first resident, and the care plan for the second resident was not updated to reflect significant changes in nutritional status. These failures were confirmed by staff interviews and review of facility documentation.
Failure to Provide Wound Care per Care Plan and Professional Standards
Penalty
Summary
The facility failed to provide wound care in accordance with the comprehensive care plan and professional standards of practice for a resident with multiple wounds. The resident, who had a history of dementia and type 2 diabetes mellitus, was admitted without skin issues but later developed several wounds, including on the right lower leg, buttocks, coccyx, and right great toe. Physician orders and facility policy required weekly wound assessments and documentation, as well as care plan updates for any open skin conditions. However, there were inconsistencies and gaps in wound assessments, measurements, and documentation. For example, some wounds were not measured or assessed as required, and there was a lack of clarity regarding whether wounds described in different assessments were the same or different. Additionally, the care plan was not updated to reflect changes in the resident's wound status. The facility's documentation showed that wound assessments were not consistently performed weekly as required by both physician orders and facility policy. There were periods where no wound assessments were documented, and some wounds were not measured or described in detail. The care plan for pressure ulcers was not revised to include new or changing wounds, and some wounds were not included in the care plan at all. The Director of Nursing confirmed during an interview that wounds should be assessed as ordered and included in the care plan, and acknowledged that the facility did not meet these expectations. She also noted that the facility did not have a wound-certified nurse on staff. These actions and inactions resulted in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals. The deficient practice increased the risk for pain, infection, and rehospitalization, as noted in the report. The facility's failure to follow its own policies and physician orders regarding wound care and documentation led to the cited deficiency.
Failure to Provide Sufficient CNA Staffing Resulting in Multiple Resident Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the care needs of residents, as required by its own Facility Assessment and staffing plan. On seven separate occasions, a resident with dementia, diabetes, frequent falls, orthostatic hypotension, and a history of stroke experienced falls when there were fewer than the required three Certified Nursing Assistants (CNAs) on duty in the unit. The Facility Assessment specified that three CNAs per unit were needed on each shift, but staffing records and interviews confirmed that only two CNAs were present during these incidents. The resident required supervision or touch assistance for transfers and ambulation, and the lack of adequate staffing resulted in delayed or unmet care needs and insufficient supervision. Interviews with facility leadership, including the ADON/QAPI/IP and DON, confirmed that the facility was short staffed and unable to provide the necessary 1:1 supervision for the resident, as previously provided by unit aides before the expiration of COVID waivers. The DON acknowledged that the resident was inadequately supervised due to staffing shortages and that efforts to transfer the resident to a memory care facility were unsuccessful due to insurance limitations. Payroll and scheduling records corroborated the staffing deficiencies on the dates when the resident fell.
Failure to Ensure Staff Competencies and Current Certifications
Penalty
Summary
The facility failed to ensure that nursing staff, including nurses and nurse aides, maintained the required competencies and certifications necessary to provide safe and appropriate care to residents. Specifically, a charge nurse (LPN) did not complete the required annual training modules, including those related to fall prevention, for multiple consecutive years. Documentation showed that in 2022, only a partial training on falls was completed, with the majority of required modules left incomplete in 2022, and none completed in 2023 and 2024. The Assistant Director of Nursing (ADON) confirmed that the LPN was repeatedly informed to complete the trainings but failed to do so. The Director of Nursing (DON) acknowledged that staff were expected to complete annual training but cited staffing shortages as a barrier. Additionally, a Certified Nursing Assistant (CNA) was found to be working with an expired CPR Basic Life Support (BLS) certification. The CNA's personnel file confirmed the expiration, and the Human Resources Manager acknowledged that the CNA continued to work despite the lapsed certification. The DON stated that staff were expected to keep CPR credentials current. Review of a resident's care plan indicated that the resident was a full code, requiring staff to initiate CPR if needed, highlighting the importance of current CPR certification for staff providing direct care.
Failure to Provide Routine Dental Care for Resident with Documented Dental Needs
Penalty
Summary
The facility failed to ensure that a resident with significant dental concerns received routine dental care. Upon admission, the resident was documented as having dental caries, broken teeth, and poor oral condition, with a care plan initiated to address impaired dentition and prevent infection, pain, or bleeding. Despite these findings and the care plan interventions to coordinate dental care, there was no evidence in the clinical record that the resident received any dental services to meet her needs. The resident, who was cognitively intact, reported ongoing dental pain and broken teeth, expressing that she had requested dental care multiple times without result. Interviews with facility staff revealed a lack of clear processes and communication regarding dental appointments. Social Services staff believed recommendations for dental visits were made during care plan meetings, but relied on reports of pain or physician orders to schedule appointments. The DON stated that dental visits were expected annually or as needed, but there was no policy in place. A CNA recalled the resident reporting dental pain but was unsure if it was communicated to nursing staff. The LPN noted a period when the dental clinic was closed and suggested the issue may have been overlooked. The MDS nurse acknowledged that the need for dental care was identified on admission and in assessments, but the referral was missed and not addressed as required.
Deficient Food Storage and Temperature Monitoring Practices
Penalty
Summary
The facility failed to store and manage food in accordance with professional standards and facility policy. During a kitchen observation, a box of frozen blueberries was found open and undated in the freezer, with the interior bag not resealed. In the food storage pantry, a scoop was left inside the powdered sugar bin, and eight boxes of expired baking soda were found on the pantry shelf. The Dietary Manager confirmed that these practices were not in line with facility expectations and that expired items should have been discarded. Additionally, refrigerator temperature logs for nourishment refrigerators in two households were incomplete, with missing temperature recordings, initials, and documentation of actions taken when temperatures exceeded the acceptable range. On several occasions, refrigerator temperatures were recorded above the required maximum, but the logs either had no action documented or simply stated "N/A." Staff interviews revealed inconsistent practices in monitoring and reporting refrigerator temperatures, and personal food items were found stored in resident refrigerators, contrary to facility policy. The facility's written policies required daily temperature checks, proper documentation, and separation of employee and resident food, but these were not consistently followed.
Failure to Ensure Completion of Mandatory QAPI Training by Staff
Penalty
Summary
The facility failed to ensure that staff completed mandatory Quality Assurance and Performance Improvement (QAPI) training as required by its QAPI program. During an extended survey, a review of electronic training records showed that approximately 48 out of 54 direct care staff had not completed the QAPI training for the current year. The Assistant Director of Nursing (ADON) confirmed that the training module was available and had a due date set for the end of the year, but most staff had not yet completed it. The Director of Nursing (DON) also acknowledged that there was no developed policy for staff education requirements at the time of the survey. Interviews with the ADON revealed that while she was responsible for assigning and following up on training modules, there was no formal process for ongoing staff training or for ensuring staff were trained when a performance improvement plan was implemented. The DON stated that completion of training was expected and was being incorporated into performance reviews, but staff continued to ignore the requirement. The lack of a structured approach and accountability for QAPI training resulted in the majority of direct care staff not being trained, which was identified during the survey.
Failure to Ensure Required Annual Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that five currently employed Certified Nursing Assistants (CNAs) and Licensed Nursing Assistants (LNAs) completed the required 12 hours of annual in-service education based on their hire dates. Specifically, review of personnel files and training records showed that one CNA completed only 0.5 hours of annual training, which did not include abuse and dementia topics. Another LNA completed 8.47 hours of annual training, missing infection control content. Additional CNAs had completed between 4.17 and 10.94 hours of annual training, all below the required 12 hours. The facility's own assessment documented that CNAs, RNs, and LPNs were required to receive training on abuse, neglect, dementia, and infection control upon hire, annually, and as needed. During interviews and record reviews, the ADON/QAPI/IP confirmed that she oversaw nursing staff training, which was tracked through the Relias system, and acknowledged that the required annual topics and hours were not completed for the sampled staff. It was also confirmed that the facility did not have a policy for staff competency or for CNA annual training. The lack of completed training and absence of a formal policy were verified through both documentation and staff statements.
Resident Not Fed in a Dignified Manner
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) stood while feeding a resident with a history of cerebral infarction with hemiplegia, diabetes, and benign prostatic hyperplasia. The resident was observed sitting while the CNA, who remained standing, fed him several spoonfuls of applesauce until the container was empty. The CNA later confirmed that she stood during the feeding and acknowledged that a chair was available nearby. The Director of Nursing also confirmed that staff are expected to be seated while assisting residents with snacks or meals. Facility policy requires that residents be treated with dignity and respect at all times, including being assisted in a manner that maintains and enhances self-esteem and self-worth. This incident demonstrates a failure to provide care in a manner that promotes the resident's dignity and quality of life, as required by facility policy.
Failure to Complete Background Check Prior to Employment
Penalty
Summary
The facility failed to ensure that a criminal background check was completed prior to allowing an LPN to provide care to vulnerable adults. Review of staffing schedules and personnel files showed that the LPN worked multiple shifts over an extended period without having completed the required Arizona Public Safety Fingerprinting Clearance, which is used by the facility to conduct criminal background checks. Despite multiple memos and reminders sent to the LPN and the Director of Nursing regarding the expired fingerprint clearance, the LPN continued to work full-time until their employment ended. Interviews with the Human Resources Manager and the Director of Nursing confirmed that the LPN was hired as an emergency hire and never completed the fingerprinting process, even though it is required before employment and is to be renewed every five years. The facility's policy mandates that all staff must have a current fingerprint clearance and criminal background check before working with residents, but the LPN was allowed to remain on the schedule due to staffing shortages, despite not meeting these requirements.
Failure to Timely Report Resident-to-Resident Abuse to CMS
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident being hit in the face and grabbed by another resident within the required timeframe to CMS. According to the facility's policy, incidents involving reportable bodily injury must be reported to CMS within 2 hours. Documentation showed that a charge nurse was notified of the incident via text, but CMS was not informed until the following day, well beyond the required reporting window. The delay was attributed to a lack of immediate action by the charge nurse and a lack of direction from the Interim Director of Nursing. The incident involved a resident who sustained minimal redness to the right side of the face after being struck and grabbed by another resident. The event was witnessed by a Licensed Nurse Aide, who intervened to separate the residents. The facility's investigation, including video review, confirmed the occurrence of abuse. Despite clear policy guidelines and staff awareness of reporting requirements, the incident was not reported to CMS within the mandated 2-hour period.
Failure to Timely Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to transmit required Minimum Data Set (MDS) assessment data to the Centers for Medicare & Medicaid Services within the mandated timeframe for two sampled residents. For both residents, the discharge MDS assessments were not submitted within 14 days of the Assessment Reference Date (ARD) as required by the Resident Assessment Instrument (RAI) manual. Specifically, one resident's discharge MDS with an ARD of 5/17/24 was over 120 days late and not completed, as confirmed by the MDS Nurse during record review. The MDS Nurse noted that the assessment was marked as completed but not accepted or export-ready in the electronic health record system, indicating a problem with the submission process. Similarly, another resident's discharge MDS with an ARD of 05/07/24 was also over 120 days late. The MDS Nurse acknowledged awareness of the late transmission after being interviewed about the first resident's MDS and demonstrated that the assessment was eventually accepted, but confirmed it was transmitted late. The Director of Nursing stated an expectation for timely completion and transmission of MDS assessments. These findings were based on interviews and record reviews conducted by surveyors.
Failure to Update PASRR and Notify State Mental Health Authority for Resident with Mental Illness
Penalty
Summary
The facility failed to update or correct the Preadmission Screening and Resident Review (PASARR) and notify the state mental health authority for a resident with a mental health condition and an inaccurate Level I PASRR form. The resident was admitted with diagnoses including dementia, major depressive disorder recurrent severe with psychotic features, and post-traumatic stress disorder (PTSD). The PASRR Level I form, completed prior to admission, indicated that the resident did not have a serious mental illness or require a Level II referral, despite documentation in the medical record and care plan of significant mental health diagnoses and behavioral symptoms. The resident exhibited severe cognitive impairment, physical and verbal behavioral symptoms, and was receiving ongoing mental health services, including psychiatric care and medication for depression and psychosis. Interviews with facility staff revealed that the PASRR Level I form was not reviewed for accuracy upon admission, nor was it updated or referred for Level II screening after the resident's mental health needs became apparent. The social services staff stated that the PASRR form is simply filed upon receipt and not re-evaluated, and the director of nursing was unfamiliar with the PASRR process. The facility's policy and state requirements indicate that nursing facilities must notify the state mental health authority of the need for a resident review after a significant change in a resident's mental condition, but this was not done for the resident in question.
Failure to Update Care Plan for Resident with Multiple Wounds
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for a resident with multiple wounds, including pressure ulcers and other open areas, as required by facility policy and federal regulations. The resident, who had a history of unspecified dementia, was admitted with several wounds documented through weekly wound measurements, including wounds to the right lower leg, buttocks, and right great toe. Despite these documented wounds, the care plan was not updated to reflect the presence or treatment of the new wounds, except for an initial care plan related to a stage I pressure ulcer of the coccyx, which was later documented as healed and discontinued. Interviews with nursing staff and the DON confirmed that new wounds should have been added to the care plan for continuity of care, prevention, and monitoring, but this was not done. Facility policies reviewed indicated that any open skin condition should be included in the care plan with appropriate interventions, and that care plans should be revised as changes occur in the resident's condition. The failure to update the care plan was acknowledged by staff as an oversight, and the care plan did not provide evidence of inclusion or management of the additional wounds identified in the resident's assessments.
Failure to Provide Consistent Pressure Ulcer Care and Implement Care Plan Interventions
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple comorbidities developed pressure ulcers on both ankles during their stay. The facility failed to complete weekly wound care assessments as required, with several weeks missing documentation of wound measurements. Additionally, the care plan intervention to use a multi-podus boot to offload pressure from the ankles was not implemented, and the resident was observed without this device in place. The care plan also lacked clarity regarding the use of wheelchair footrests, compression stockings, and the impact of the multi-podus boot on the resident's mobility. Observations and interviews revealed that the resident was seen in a wheelchair without footrests and was wearing slippers, with no specialized orthopedic device present in the room. Staff, including an LPN and a CNA, were unaware of the specific type of wounds or the need for the multi-podus boot, and the LPN was initially unaware that the wounds were pressure ulcers. The resident required extensive assistance with activities of daily living and had a history of edema in the lower legs, which further complicated wound care and prevention efforts. Podiatry notes confirmed the presence of pressure injuries on both ankles, attributed to repetitive and shearing forces. Despite the care plan being updated to include interventions such as elevating the feet and offloading pressure with a multi-podus boot, these interventions were not consistently implemented. Facility policy required weekly wound assessments and individualized care plans for residents with wounds, but these standards were not met in this case.
Failure to Follow Infection Control Practices and Evidence-Based Guidelines for Catheter Care
Penalty
Summary
Staff failed to provide appropriate care for a resident with an indwelling urinary catheter by not following infection control practices and not adhering to evidence-based guidelines for catheter and drainage bag changes. During an observation, a CNA emptied the resident's urinary catheter bag and allowed the spigot of the drainage bag to touch the inside of a urinal, which is contrary to facility policy and infection prevention standards. The CNA acknowledged that the spigot should not touch the urinal, confirming a lapse in proper technique. The resident involved had a history of cerebral infarction with hemiplegia, diabetes, and benign prostatic hyperplasia, and had an indwelling catheter in place. Physician orders and the resident's care plan directed routine changes of the catheter every 30 days and the drainage bag every week, without documented clinical indications such as obstruction, infection, or system compromise. Review of the resident's records showed that these changes were performed at fixed intervals, and there was no documentation of clinical justification for these routine changes, except for one instance of leakage that was not properly documented in the treatment record. Interviews with facility staff, including the physician, infection preventionist, and DON, revealed a lack of awareness and communication regarding current CDC guidelines and facility policy, which recommend changing catheters and bags only based on clinical indications rather than at routine intervals. The physician stated he was unaware of the facility's policy and CDC recommendations, and the infection preventionist admitted the inconsistency had not been discussed with the physician. The DON confirmed that infection control practices and policy should be followed.
Failure to Ensure Timely Physician Visit for New Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 30 days for the first 30 days after admission, as required by both facility policy and federal regulations. Review of the resident's admission record showed that the admission evaluation was completed, but the resident was 7 days overdue for a physician visit. Interviews with facility staff, including the Medical Director, a physician, the Director of Nursing, and a board member, confirmed that the expectation and policy were for new admissions to be seen by a physician within the first 30 days. However, the resident in question was not seen within this timeframe, and there was no documentation of a physician's note for the required visit. The Medical Director stated that he did not monitor the timeliness of physician visits and relied on nursing staff to track these visits. The physician interviewed was unaware of the missed visit and could not recall why the resident was not seen, noting that if a visit had occurred, it would have been documented. The Director of Nursing acknowledged that the resident was missed and described the usual process for scheduling physician visits, which involves the ward clerk and nursing staff. The deficiency was identified through record review and staff interviews, which confirmed that the required physician visit did not occur within the mandated timeframe.
Failure to Clarify and Prevent Duplicate Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident did not receive unnecessary duplicate anticoagulant therapy. The resident, who had a history of hypertension, stroke, COVID-19, atrial fibrillation, and gastroesophageal reflux disease, was admitted on anticoagulant therapy. After a hospitalization for a renal vein clot, the resident returned to the facility with new orders for enoxaparin injections, while the previous order for apixaban remained active. The hospital discharge instructions specified starting enoxaparin but did not clarify whether apixaban should be continued or discontinued. The medical record did not contain documentation clarifying whether both anticoagulants should be administered concurrently following the resident's return from the hospital. Interviews with nursing staff and the DON confirmed that the enoxaparin was added after hospitalization, but there was no clear indication that both medications were intended to be given together. The facility's policy required clarification from the physician if a medication order seemed excessive, but there was no evidence that such clarification was obtained in this case.
Facility Assessment Lacked Required Input and Documentation
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment (FA) with input from all required individuals as specified by regulation. The FA, dated 9/19/24, did not include participation from a representative of the governing body, the medical director, residents, their representatives, direct care staff, or representatives of direct care staff. Additionally, the FA lacked documentation of review by the Quality Assessment and Assurance/Quality Assurance and Performance Improvement (QAA/QAPI) committee, as the review date was left blank. Interviews with the ADON/QAPI/IP confirmed that the assessment had not yet been presented to the QAA/QAPI committee due to a scheduling conflict with the survey and acknowledged that there was no process in place to obtain input from residents, their representatives, or direct care staff. Further interviews revealed that the facility did not have a policy in place for conducting the Facility Assessment. The Director of Nursing stated that the ADON/QAPI/IP was responsible for developing and coordinating the FA and confirmed that the assessment should include all required participants. The lack of comprehensive input and absence of a formal policy contributed to the incomplete assessment process.
Failure to Change Gloves and Perform Hand Hygiene Between Residents During Medication Pass
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to change gloves and perform hand hygiene between administering medications to multiple residents during a medication pass. The LPN was observed wearing the same pair of gloves while preparing and administering medications to several residents in the dining room, including directly assisting a resident with eating and drinking. The LPN stated that gloves were changed only after every four residents, rather than between each resident as required. Interviews with facility leadership, including the Infection Preventionist and Director of Nursing, confirmed that the facility's expectation and policy require hand hygiene between each resident during medication administration, and that gloves, if used, must also be changed between residents. The facility's policy on medication administration, reviewed in January 2024, specifies adherence to universal precautions, including proper hand hygiene and glove use before and after direct contact with residents.
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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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