Granite Creek Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Prescott, Arizona.
- Location
- 1045 Scott Drive, Prescott, Arizona 86301
- CMS Provider Number
- 035131
- Inspections on file
- 23
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Granite Creek Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and incontinence was admitted without documented skin problems but was identified as at risk for pressure ulcers and ordered to receive frequent repositioning, barrier cream, weekly skin evaluations, and weekly Braden Scale assessments. Within days, CNAs, therapy staff, and nurses documented redness, rashes, open areas, and bleeding on the sacral/coccyx and perineal regions, while provider notes continued to describe the skin as warm and dry without wounds, and there was no evidence that early sacral redness and breakdown were promptly communicated to a provider. Required weekly skin assessments and Braden Scales were missed or incompletely documented, physician orders for barrier cream and repositioning were not consistently recorded as completed on the MAR/TAR, and detailed wound measurements and descriptors for MASD were delayed and backdated. Staff interviews confirmed that the resident experienced severe pain with pericare, that sacral skin was raw, red, and bleeding, that staffing shortages sometimes prevented turning and changing every two hours, and that documentation and communication about the MASD and sacral wound did not meet facility expectations or policy requirements.
The facility failed to provide required written transfer/discharge notices and to notify the State LTC Ombudsman for three residents who were either transferred to the hospital or discharged home. One resident with multiple comorbidities, including dementia and failure to thrive, was sent to the ED at a family member’s request, but there was no documentation of Ombudsman notification. Two cognitively intact residents with complex medical histories had planned discharges home with complete discharge paperwork, including medication lists and personal effects inventories, yet no Ombudsman notification was documented. The Ombudsman office reported not receiving discharge notices for an extended period, the Social Services Manager admitted she had not been formally notifying the Ombudsman, and the DON acknowledged the facility was unaware that notification must be in writing; the written discharge/transfer policy did not address resident notice content or Ombudsman notification.
The facility failed to ensure that meals were palatable, appealing, and consistently served at appetizing temperatures. Multiple residents reported that food was cold, repetitive, mushy, tasteless, or otherwise unappealing, and group interviews revealed concerns about food quality, portion sizes, and being told the kitchen was out when requesting more food. A test tray showed hot items at acceptable temperatures but with overcooked, grayish broccoli, stale bread, and unappealing chicken in the pasta. Staff, including CNAs, an LPN, and the DON, acknowledged that residents had complained about cold and unappetizing food and that staffing shortages contributed to delayed meal delivery. Facility records, including grievance logs and Resident Council minutes, documented ongoing dietary concerns, while written policies addressed food temperatures and nutritional adequacy but did not address the requirement that food be appetizing or appealing.
Surveyors found that medications were left at the bedside for two residents without provider orders or completed self-administration assessments, contrary to facility policy. One resident with pneumonia, AFib, and HTN had Metoprolol and a probiotic left on the bedside table; the resident delayed taking them while on the phone, spilled the pills, and required repeated nurse involvement to replace doses. Another resident with GERD had multiple Tums tablets left in a cup at the bedside, which the resident reported nurses routinely left for self-use. An LPN acknowledged leaving the Tums despite knowing there was no self-administration assessment, while a CNA, RN, and DON all stated that medications should not be left at the bedside without a specific order and proper assessment, and facility policies required locked storage and formal evaluation before self-administration.
Staff failed to consistently follow hand hygiene and TBP protocols. On multiple halls, CNAs and other staff entered and exited resident rooms, handled items such as breakfast trays, beds, and call lights, and moved between rooms without performing hand hygiene, despite stating in interviews that they understood hand hygiene should be done when entering and leaving rooms and before and after resident care. In a shared room with two residents, both EBP and Contact Precaution signs were posted, but a RN did not know which applied to which resident, and a CNA believed the precautions did not apply and therefore did not follow them. Staff entered this room to provide hygiene supplies without PPE or hand hygiene, and the RN later removed both precaution signs and placed them on an isolation cart. The IP and DON reported that posted TBP signs are to be followed until clarified, that stricter precautions should be used when there is conflicting information, and that staff are expected to know and follow TBP and standard precautions for their assigned residents.
The facility failed to protect residents from abuse, leading to incidents where a resident repeatedly entered others' rooms without clothes, causing fear and distress. Despite complaints, the facility's response was inadequate, resulting in continued intrusions. Additionally, a physical altercation between two residents resulted in injuries, highlighting the facility's failure to prevent and address abuse effectively.
A resident, initially assessed as low risk for wandering, repeatedly entered other residents' rooms uninvited, causing distress and fear. Despite reports to the administration, the facility failed to provide adequate supervision or update care plans, leading to ongoing incidents.
The facility failed to maintain a homelike environment for residents, with issues such as scraped paint, damaged drywall, and a ceiling crack with a liquid stain. Residents expressed dissatisfaction with these conditions, which were not addressed in a timely manner despite the facility's policy to maintain a clean and well-repaired building.
The facility failed to secure a medication cart and controlled substances properly. A medication cart was left unlocked in a hallway while a nurse attended to a resident, and backup e-kit boxes containing controlled substances were not double-locked as required. The DON confirmed the expectation for medication carts to be locked and acknowledged the malfunctioning e-kit, with backup boxes awaiting pickup by the pharmacy.
The facility failed to maintain safe food temperatures, risking foodborne illnesses. Observations showed improper food temperatures during lunch service, with staff failing to sanitize temperature rods between uses. The dietary manager acknowledged the lack of a policy for maintaining appropriate food temperatures.
The facility's kitchen was found unsanitary, with grease build-up, debris, and undated food items, risking foodborne illnesses. Six residents received incorrect meals, not matching their dietary needs or preferences. The facility lacked policies for personal food preferences and proper diet execution.
The facility failed to adhere to infection control policies during food preparation and resident care. In the kitchen, staff did not use proper hygiene practices, such as wearing beard coverings and sanitizing equipment, leading to food being served at improper temperatures. Additionally, a nurse did not follow Enhanced Barrier Precautions while caring for a resident with multiple diagnoses, including end-stage renal disease, by failing to wear a gown during medication administration.
A resident with congestive heart failure and other conditions was observed receiving oxygen without a physician's order upon admission to the facility. The facility's records lacked documentation of the initiation or administration of oxygen, and staff interviews revealed no communication with the provider regarding the resident's respiratory status. The facility's policy required physician orders for oxygen therapy, which were not obtained in a timely manner.
A resident with multiple health issues experienced prolonged dental pain due to the facility's failure to ensure timely dental consultations and follow-ups. Despite physician orders and ongoing reports of pain, the resident's clinical records lacked documentation of dental appointments or treatments. Interviews with staff revealed a lack of communication and coordination in managing the resident's dental care, leading to a deficiency in meeting the facility's policy for providing necessary dental services.
A resident with a gluten allergy did not receive appropriate dietary accommodations, as the facility failed to update the care plan and menu options to reflect the need for a gluten-free diet. Despite evaluations indicating the allergy, staff were unaware and did not provide suitable meal alternatives, leading to resident dissatisfaction and potential health risks.
A resident with multiple health issues, including a recent surgery, did not receive physician-ordered wound care services due to a failure in the facility's admission process. The care plan omitted necessary wound vac instructions, and the order was not entered into the system. Staff interviews revealed miscommunication and a lack of oversight, resulting in a delay in applying the wound vac. The facility's policy on implementing orders was not followed, leading to a deficiency in care.
A resident with a seizure disorder did not receive their prescribed clonazepam due to unavailability, resulting in a seizure and the resident leaving the facility AMA. Staff interviews revealed that the facility's emergency kits and pyxis machine did not have the correct dose, and the LPN did not notify the provider about the delay. The facility's policy requires medications to be administered as prescribed.
A resident with lung cancer and dyspnea had their oxygen tubing fall on the floor, and staff failed to replace or sanitize it, violating infection control guidelines. Despite the facility's policy to replace fallen tubing, staff did not notice or address the issue, as confirmed by interviews with an LPN and the ADON.
The facility did not provide written notification to a resident regarding changes in charges for services during their stay, as required by the Admission Agreement. The resident, undergoing IV antibiotic therapy, was discharged without being informed of a $2,800 bill and the expiration of their insurance coverage. Staff interviews revealed confusion and lack of documentation about the resident's financial responsibility, including the issuance of necessary notices like the Advance Beneficiary Notice of Non-Coverage (ABN) or Notice of Medicare Non-Coverage (NOMNC). The resident was verbally informed about the copay requirement but did not receive a formal letter, leading to a deficiency in communication and documentation.
A resident with multiple diagnoses, including ischemic cardiomyopathy and stage 4 chronic kidney disease, was found unresponsive on the toilet by a hospitality aide (HA) who lacked lift and transfer training. The HA assisted the resident without using the call light, contrary to protocol. Interviews with LPN and CNA revealed unclear understanding of HA duties and limitations, indicating communication gaps regarding roles and responsibilities in resident care.
The facility failed to maintain resident shower rooms in good repair, with only 2 out of 5 functional stalls in the Area 100/200 shower room and 3 out of 5 in the Area 300/400 shower room. Observations revealed dirty, stained, and cracked tiles, inadequate water pressure, and potential mold. Staff interviews confirmed the need for deep cleaning and repairs, but no work orders were found addressing these issues.
A resident with multiple diagnoses was not administered prescribed oxyCODONE as ordered, with MAR indicating the resident was sleeping without corresponding notes. Staff interviews and policy review confirmed the deficiency in medication administration and documentation.
Failure to Prevent, Assess, and Treat MASD and Sacral Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to prevent, assess, and treat moisture associated skin damage (MASD) for one resident in accordance with physician orders, facility policy, and professional standards. The resident was admitted with multiple comorbidities, including a periprosthetic fracture around an internal prosthetic left knee, left femur fracture, COPD, pneumonia, atrial fibrillation, breast cancer, and a need for assistance with personal care. An initial admission assessment documented no skin problems, and a care plan and physician orders were put in place for pressure ulcer risk, including frequent repositioning, barrier cream to the perineal area every shift, weekly skin evaluations, and weekly Braden Scale assessments. Early documentation on daily skilled notes and Braden assessment indicated no skin issues and low risk for pressure-related skin impairment, despite the resident being dependent for toileting hygiene and having incontinence. Within days of admission, multiple staff documents and shower sheets began to note redness and abnormal skin color on the lower back and coccyx area, as well as redness, rashes, open areas, and skin tears in the genital and sacral/coccyx regions. These findings were recorded on March 7, 8, and 12 by CNAs and nurses, and an Occupational Therapist documented decubitus ulcers on the inner thighs, vagina, buttocks, and right heel, along with improper healing of a pelvic incision. However, there was no evidence that the redness and skin changes on the lower back and coccyx were communicated to the physician at those times, and provider progress notes repeatedly described the skin as warm and dry without rashes, lesions, or wounds. There was also no evidence of detailed skin assessments or change-of-condition monitoring orders when significant redness, rashes, open areas, and bleeding were documented on shower sheets. Nursing documentation was inconsistent, with several days lacking daily skilled notes, and some weekly skin assessments and non-pressure ulcer assessments created later and backdated, omitting the sacral/coccyx issues. Physician orders for skin care, including barrier cream to the perineal area every shift and frequent repositioning, were not consistently documented as completed on the MAR/TAR for multiple day shifts. Required weekly skin evaluations and Braden Scale assessments were missed or not documented as completed according to the orders, with only the initial Braden assessment and one later assessment recorded. When a coccyx skin injury/ulcer and MASD to the coccyx and upper rear thighs were eventually documented, there were no early measurements or detailed descriptors, and the onset date for the sacro-coccyx MASD wound was later recorded as March 19 with a 6 cm x 5 cm partial thickness wound and peripheral tissue edema. Staff interviews revealed that CNAs and nurses were aware of raw, red, painful, and bleeding skin on the perineal and sacral areas, and that the resident experienced excruciating pain during pericare. Staff also reported that there were times when there were not enough staff to change and reposition the resident every two hours as expected, and that management had been informed of staffing concerns. The wound nurse acknowledged that, based on the documentation, he could not determine when he first assessed the wound, its progression, or whether it was improving or worsening, and the ADON confirmed that the documentation did not meet expectations for identifying, assessing, and treating the resident’s skin condition. Throughout this period, multiple provider progress notes continued to state that the resident’s skin was warm and dry without rashes, lesions, or wounds, even on days when other documentation or staff interviews indicated significant MASD, excoriation, open areas, and bleeding on the sacral/coccyx and perineal regions. The facility’s own policies on wound management, physician orders, documentation and charting, and change of condition reporting required comprehensive assessments, accurate transcription and implementation of orders, complete documentation of care and resident status, and prompt communication of changes in condition to the physician. The clinical record and staff interviews showed that these processes were not consistently followed for this resident, resulting in delayed and incomplete assessment and treatment of MASD and related skin breakdown. The CNA task log for turning and repositioning showed missing entries for required repositioning on certain shifts, and staff interviews indicated that CNAs were expected to check incontinent residents at least every two hours and that nurses were to perform weekly skin checks and notify the wound nurse of any issues. Despite these expectations, there were gaps in documentation of repositioning, missed or incomplete weekly skin assessments, and delayed or absent communication to the provider and wound nurse about the resident’s worsening sacral and perineal skin condition. The ADON and wound nurse both acknowledged that the available documentation did not allow them to determine the wound’s progression or whether interventions were effective, and that the documentation and response to the resident’s MASD did not meet their expectations for quality of care and prevention of worsening skin conditions.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notices and to notify the State Long-Term Care Ombudsman of resident transfers and discharges, as required by the State Operations Manual Appendix PP. For one resident with failure to thrive, dementia, right-sided hemiplegia, and other comorbidities, the clinical record showed a decline in oral intake, facial and eye twitching, inability to follow commands, and abnormal vital signs. The family requested transfer to the emergency room, and the resident was sent to the hospital; however, there was no documentation in the clinical record or facility documentation that the Ombudsman was notified of this transfer. Two other residents experienced planned discharges home without documented Ombudsman notification. One resident with dysphagia, dysarthria, chronic ischemic heart disease, type 2 diabetes mellitus, parkinsonism, and other conditions had a physician order for discharge home with remaining narcotics, a discharge summary and post-discharge plan of care, and a signed transfer/discharge report including personal effects and medication information. The resident was cognitively intact per a BIMS score of 15 and was discharged home, but the record contained no documentation of Ombudsman notification, and no separate facility documentation of such notification was available. Another cognitively intact resident with paroxysmal atrial fibrillation, neuropathy, and morbid obesity had a planned discharge home documented by physician order, discharge nursing summary, MDS discharge assessment, and a signed transfer/discharge report with personal effects and medication details. Again, there was no documentation of Ombudsman notification in the clinical record or elsewhere. Email correspondence from the Ombudsman office indicated they had not received discharge notices from the facility since June 2024. The Social Services Manager acknowledged she had not been notifying the Ombudsman in the required manner, and the DON stated her expectation that Social Services notify the Ombudsman but admitted the facility did not know the notification had to be in writing. Review of the facility’s discharge/transfer policy showed it did not address transfer/discharge notification to residents or their representatives, did not specify required notice content, and did not state that the Ombudsman must be notified.
Failure to Provide Palatable, Appealing Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food items were palatable, appealing, and consistently served at safe and appetizing temperatures. Review of the 2025 grievance log showed multiple food-related grievances across several months, including general dietary concerns, food temperature concerns, and food preference issues. Resident Council minutes from multiple months documented ongoing concerns about menu variety, food portions, dietary restrictions, and the need to educate residents on proper food serving temperatures. These documented concerns indicate that residents had been voicing dissatisfaction with various aspects of the food service over an extended period. During resident interviews conducted on January 4, 2026, multiple residents reported that the food was cold, repetitive, unappealing, and sometimes not edible despite appearing so. Several residents specifically stated that the food was always cold, not good, or “yucky,” and one resident reported having constantly complained to staff about the food. A lunch test tray observed on January 5, 2026 showed that hot food temperatures were within acceptable ranges, but the steamed broccoli appeared grayish-green, bland, overcooked, and mushy; the chicken in the fettucine alfredo resembled tuna flakes; and the garlic breadstick tasted stale. In a group interview with approximately 12 residents, attendees reported that food was unappealing, mushy, and tasteless, that requests for more food were sometimes met with statements that the kitchen was out of the item, and that double portions appeared the same as regular portions. Staff interviews further confirmed that residents had ongoing concerns about food quality and temperature. The Social Services Manager acknowledged that food concerns had previously been trending in Resident Council meetings, though she believed complaints had decreased. The Dietary Supervisor stated that dietary staff attend Resident Council meetings and that food concerns are usually brought up there or via nursing staff, and she described her practice of checking food temperatures when issues are reported, but she stated she had not received complaints about food not being appealing or appetizing. CNAs and an LPN reported that residents had complained about food being cold, not appetizing, or not appealing, and one CNA attributed cold food to insufficient staffing delaying meal delivery. The DON and other staff recognized that food should be edible, nutritious, hot, and at appropriate temperatures, and acknowledged that unappealing or non-appetizing meals could result in residents not eating enough. Review of facility policies showed guidance on food temperatures and menus meeting nutritional needs and resident choices, but no policy content addressing the requirement that food be appetizing or appealing.
Medications Left at Bedside Without Orders or Self-Administration Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were not left at the bedside for two residents without a provider order and without completion of a self-administration assessment, contrary to facility policy and professional standards. For one resident with pneumonia, atrial fibrillation, hypertension, and a need for assistance with personal care, orders were in place for Metoprolol Tartrate 12.5 mg twice daily for high blood pressure and Saccharomyces boulardii 250 mg twice daily as a probiotic. The resident’s BIMS score indicated that she was cognitively intact and she was independent with eating and oral hygiene, but there was no documentation in the clinical record of an assessment for self-administration or a physician order allowing medications to be left at the bedside. The MAR showed that both medications were administered at the scheduled morning time. During an observation later that same morning, the resident’s medications were found left on her bedside table. As the resident attempted to take the pills, she knocked over the medicine cup, causing both pills to spill. She reported that she was able to retrieve the white probiotic capsule but could not find the small pill for her irregular heart rate, and explained that she had not taken the medications immediately when the nurse brought them because she was on the phone with her brother. Over the next several minutes, a CNA and an LNA entered the room, and the resident informed them that the medication cup had flipped; both staff members indicated they would inform the nurse. When an LPN entered the room, the resident again reported that the medication cup had gone flying. The LPN stated she would provide another pill, then returned with Metoprolol 12.5 mg and also reported finding the other pill in the trash can. While the LPN was present, the resident dropped another pill from her mouth, and the LPN left again to obtain another dose. Interviews with the LPN charge nurse and the DON confirmed that facility expectations were that nurses observe residents swallow medications and do not leave medications at the bedside unless there is a specific order and a completed self-administration assessment, which were not present for this resident. For a second resident with acute posthemorrhagic anemia, atrial fibrillation, GERD without esophagitis, and alcohol dependence, the care plan included a focus on GERD related to medication use, with interventions to give medications as ordered and monitor side effects and effectiveness. The resident’s BIMS score indicated that she was cognitively intact. A physician order directed that Calcium Carbonate (Tums) 500 mg be given by mouth before meals for GERD, and the MAR showed that the medication was documented as administered as ordered. However, there was no evidence in the clinical record from admission through the date of observation that the resident had been assessed for self-administration of medications, and there was no physician order authorizing self-administration of Tums. During an observation, the resident was seen in bed with a glass of water and a clear cup containing three pink circular pills at the bedside. The resident identified the pills as Tums that she takes for stomach issues and stated that nurses leave them there for her to take when needed. An LPN confirmed that the pills were Tums and acknowledged that they were usually left on the bedside table for the resident to take independently, and that she had left them there that day even though the resident did not have a self-administration assessment and medications should not be left at the bedside. A CNA and an RN both stated that no medications, including Tums, should be left at the bedside without a physician order, and the RN noted that if there were an order for self-administration, the medication should be stored in an appropriate container. The DON similarly stated that no medication should be left at the bedside without a physician order for self-administration and that leaving medications such as Tums at the bedside could pose a risk to the resident or others. Facility policies on Medication Access and Storage and Self-Administration of Medications required that drugs be stored in locked compartments accessible only to authorized personnel and that self-administration be based on an interdisciplinary assessment and provider order, conditions that were not met in these instances.
Failure to Follow Hand Hygiene and Transmission-Based Precaution Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently followed hand hygiene protocols when entering and exiting resident rooms and after contact with resident environments. On one unit, a CNA entered a resident’s room, removed a breakfast tray, then went into another resident’s room, touched the bed and call light, exited, and proceeded directly into a third resident’s room without performing hand hygiene at any point. On another unit, a staff member entered a resident’s room, turned off the call light, and exited without using hand sanitizer or washing hands before or after room entry. A similar observation on a different hall showed another staff member entering and exiting a resident’s room without performing hand hygiene. These observations occurred despite staff interviews confirming their understanding that hand hygiene should be performed when entering and leaving resident rooms and before and after resident care or contact with resident belongings and surfaces. The deficiency also includes failure to follow posted Transmission-Based Precaution (TBP) signage and protocols. In one room with two female residents, two different precaution signs were posted on the door: one for Enhanced Barrier Precautions (EBP) and one for Contact Precautions, with the Contact Precaution sign specifying that gloves and gowns must be worn before entering and discarded before exiting. A RN assigned to the area stated he did not know which TBP posting applied to which resident and deferred to management for clarification. A CNA later stated that one sign was intended for the resident in bed A and the other for the resident in bed B, but he did not know why the residents were on precautions and believed the precautions did not apply, so he did not think the posted signs needed to be followed. Further observations showed that staff entered the same room with the two female residents to provide hygiene supplies without wearing any PPE and without performing hand hygiene prior to entry. Shortly afterward, another staff member also entered the room without PPE or hand hygiene. The RN subsequently removed both the EBP and Contact Precaution signs from the door and placed them on top of the isolation cart across from the room. The Infection Preventionist later stated that two residents with different TBP are not usually placed in the same room, that the stricter TBP should be followed if this occurs, that posted signs must be followed until confirmed otherwise, and that signs should not be removed without consulting her. The DON stated that staff were expected to follow TBP signage unless told otherwise, that nurses should know the TBP status and infection-related information for their assigned residents, and that staff must follow standard precautions, including hand hygiene and the most stringent TBP when there is conflicting information.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of three residents to be free from abuse, resulting in incidents of resident-to-resident abuse. Resident #22, who had intact cognition and was on anti-anxiety medication, reported multiple instances of resident #60 entering her room without clothes, causing her fear and distress. Despite notifying the administrator and director of nursing, no effective action was taken to address the inappropriate behavior of resident #60, leading to further emotional harm to resident #22. Resident #54 also experienced similar intrusions by resident #60, who entered her room and attempted to get into her bed, causing her to feel unsafe. The facility's response was inadequate, as resident #60 continued to roam into other residents' rooms, including resident #54's, despite a red label ribbon being placed on the door. Resident #89 was involved in a physical altercation with his roommate, resident #238, resulting in visible bruising and scratches on resident #89's face. The incident occurred after a disagreement over the television, and although the facility separated the residents and documented the incident, the response did not prevent the initial harm. The facility's investigation revealed that resident #238 had poked resident #89 in the face, causing the injuries. Despite the altercation, the facility's response was limited to documenting the incident and monitoring the injuries, without addressing the underlying issues that led to the altercation. Interviews with staff, including the CNA and the DON, highlighted a lack of effective measures to prevent and address abuse within the facility. The facility's policy on abuse prevention and prohibition was not effectively implemented, as evidenced by the repeated incidents involving resident #60 and the altercation between residents #89 and #238. The facility's failure to create a safe environment and adequately respond to grievances and incidents of abuse resulted in emotional and physical harm to the residents involved.
Inadequate Supervision Leads to Resident Wandering
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to incidents where the resident wandered into other residents' rooms uninvited. Resident #60, who was initially assessed as low risk for elopement or wandering, exhibited behaviors that were not documented in the clinical record, such as entering other residents' rooms without clothing. Despite being care planned for potential dementia-related behaviors, there was no documentation of the supervision required for the resident. Multiple residents reported feeling scared and unsafe due to Resident #60's behavior. Resident #22 expressed fear and distress after Resident #60 entered her room unclothed and attempted to lie on her bed. She reported these incidents to the facility's administration, but felt that her concerns were not adequately addressed. Similarly, Resident #54 reported that Resident #60 repeatedly entered her room, drank her beverages, and watched her sleep, causing her to feel unsafe. Interviews with staff revealed that the facility's response to these incidents was inadequate. The CNA and social service director acknowledged the residents' grievances but did not ensure their safety. The DON and administrator were aware of the residents' concerns but failed to take effective action to prevent further incidents. The facility's policy on elopement and unsafe wandering was not properly implemented, as evidenced by the lack of updated care plans and interventions for Resident #60.
Facility Fails to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for seven sampled residents, as observed through various deficiencies in room conditions. In the case of two residents, the paint on the walls behind and surrounding the headboards of their beds was scraped off, revealing white patches against the tan wall color. Despite the room being vacated and a new resident moving in, the paint damage remained unrepaired. The new resident expressed that the unsightly condition of the room was bothersome. In another room, two residents experienced similar issues with paint scraped off the walls behind their beds, along with additional damage to the drywall below the window. Another resident's room had a significant area of paint scraped off the wall, with visible damage to the drywall, easily seen from the doorway. These conditions were noted during observations and interviews with the residents, who expressed dissatisfaction with the state of their living environment. Additionally, two residents in another room were affected by a crack in the ceiling above one of the beds, accompanied by a liquid residue stain. The residents reported that the crack had been present for an extended period, with one resident stating it had been there since before their admission over a year ago. Interviews with the Maintenance Director revealed that daily walk-throughs were conducted, but room checks were only done weekly. Despite the facility's policy to maintain a homelike environment, these deficiencies were not addressed in a timely manner, leading to resident dissatisfaction.
Medication Security Deficiencies
Penalty
Summary
The facility failed to ensure that a medication cart was locked when unattended, as observed on October 1, 2024. A medication cart was left unlocked in the hallway of the 400 unit while a nurse was attending to a resident in a room across the hall. The nurse acknowledged leaving the cart unlocked during medication administration. The Director of Nursing (DON) confirmed that it is expected for medication carts to be locked if a nurse leaves their assigned cart. Additionally, the facility did not properly secure controlled medications in the medication storage room. On October 2, 2024, it was observed that two brown plastic storage containers, identified as backup e-kit boxes, were not locked and could be easily opened. These boxes contained various controlled substances, including tramadol, hydrocodone, hydromorphine, methadone, and temazepam, which were not stored under double lock as required by facility policy. The DON stated that the e-kit was malfunctioning, and the pharmacy provided backup boxes that needed to be picked up.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food within safe serving temperatures, which could result in foodborne illnesses among residents. On October 1, 2024, during the lunch tray line observation, the initial temperatures of the food were recorded: meat at 149 degrees Fahrenheit, starch at 178 degrees Fahrenheit, and pasta salad at 70 degrees Fahrenheit. Staff #123 mentioned that the pasta salad would be put on ice to cool it to the desired temperature range. Later, a test tray was monitored throughout the facility, and the final temperatures were recorded as follows: meat at 96.4 degrees Fahrenheit, tater tots at 95.7 degrees Fahrenheit, and pasta salad at 75.6 degrees Fahrenheit. Staff #11 was observed temping each food component without sanitizing the temperature rod between uses. Interviews with staff revealed that the temperatures of the food were not up to professional standards, and there was an expectation for proper sanitization of the temperature rod between temping food components. The dietary manager, staff #14, stated that the expectation for food storage, preparation, distribution, and serving is to label and date food, keep areas clean, wash hands, and maintain appropriate temperatures. However, a review of the kitchen policies showed no policy in place for maintaining appropriate food temperatures, contributing to the deficiency.
Sanitation and Dietary Compliance Issues in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could lead to foodborne illnesses among residents. During an observation, the stove and stacked oven were found with grease build-up and burned debris, and crackers and an applesauce cup were on the floor in the dry storage room. The dietary supervisor stated that cleaning occurs daily, but the cleaning logs lacked initials to confirm task completion. Additionally, yellow square slices were left unattended and undated near a preparation sink, and the kitchen refrigerator had hardened ice collecting on the floor. Cooking and baking sheet pans were stacked with a wet-like substance between them, and the wall behind them had chipped paint. An opened brown bag with a powder substance was also found near the preparation station. The facility also failed to provide meals according to residents' dietary needs and preferences. During a tray line observation, six residents received items not listed on their meal tickets or not in accordance with their prescribed diets. For example, residents with mechanical soft diets were given regular diets, and some residents received items they disliked. Staff reported that in the event of a non-gluten diet, residents receive non-gluten pasta and bread, but they forgot to provide a gluten-free option for burgers and pasta salad. The dietary manager stated that staff is expected to label and date food, keep areas clean, wash hands, and maintain appropriate temperatures. The review of kitchen policies revealed no policy addressing personal preferences or the execution of following established diets as stated on a resident's meal ticket. The policy titled 'Sanitization of Dining and Food Service Areas' requires staff to initial tasks as they are completed, but this was not done. The dietary manager acknowledged the risk of improper temperatures and the impact of not adhering to dietary restrictions, which can upset residents and affect their mood.
Infection Control Deficiencies in Food Handling and Resident Care
Penalty
Summary
The facility failed to adhere to infection control policies during food preparation and distribution, as well as in the care of a resident. In the kitchen, the dietary supervisor was observed without a beard covering, and a cook was seen rinsing hands without using soap before meal preparation. Additionally, a dietary aide did not sanitize the temperature rod between checking different food components, leading to food being served at temperatures below professional standards. These practices could result in foodborne illnesses among residents. Regarding the care of a resident with multiple diagnoses, including metabolic encephalopathy and end-stage renal disease, the facility did not follow Enhanced Barrier Precautions (EBP) as required. A registered nurse entered the resident's room, performed hand hygiene, and donned gloves but failed to wear a gown while administering medications through the resident's feeding tube. The nurse was initially unaware of the EBP requirements and had to refer to the posted precautions to recall the necessary procedures. The Director of Nursing confirmed that EBP involves wearing a gown and gloves when providing direct care to residents with indwelling medical devices or a history of multi-drug resistant organism infections. The facility's infection prevention and control program, revised in July 2023, mandates that all personnel conduct themselves in a way that minimizes the spread of infection. However, the observed deficiencies in both food handling and resident care indicate a failure to adhere to these established protocols.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that respiratory services were provided according to professional standards for a resident who was admitted with diagnoses including congestive heart failure, hypertension, and coronary artery disease. Upon admission, there were no orders for oxygen use in the resident's hospital discharge orders. Despite this, the resident was observed receiving oxygen via nasal cannula on multiple occasions without a corresponding physician order documented in the facility's records until several days later. The facility's records, including the resident's care plan and progress notes, lacked documentation of the initiation or administration of oxygen. Interviews with staff revealed that there was no communication with the provider regarding a change in the resident's respiratory status or the need for oxygen. The facility's policy required that oxygen therapy be administered as ordered by a physician or as an emergency measure until an order could be obtained, but this protocol was not followed. Observations and interviews indicated that the resident was unsure of the oxygen dose and the reason for its administration. Staff interviews highlighted a lack of adherence to the facility's policies on documentation and communication regarding changes in the resident's condition. The Director of Nursing confirmed the absence of timely documentation and emphasized the importance of such documentation for continuity of care across shifts.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to ensure that the dental needs of a resident were met, leading to a deficiency in care. The resident, who was cognitively intact, was admitted with multiple diagnoses including subluxation of the right shoulder joint, sequelae of cerebral infarction, hypertension, major depressive disorder, hyperlipidemia, and acute kidney failure. Despite a physician's order for a dental consultation and treatment as needed, the resident's clinical records did not show any documentation of a dental referral or visit, even after the resident reported teeth pain and was prescribed antibiotics for a teeth infection. The resident's clinical records revealed multiple instances where dental issues were noted, yet no follow-up actions were documented. A physician's progress note indicated the resident's need for a dental consultation due to teeth pain, and subsequent notes showed the resident was experiencing ongoing pain and was prescribed antibiotics. However, there was no evidence of a dental appointment being scheduled or conducted, and the resident continued to report pain during assessments. The facility's failure to document and follow through with necessary dental care resulted in the resident experiencing prolonged discomfort and potential complications from untreated dental issues. Interviews with facility staff highlighted a lack of communication and coordination regarding the resident's dental care. The Director of Social Services and the Case Manager were unsure of their roles in managing dental follow-ups, and the Unit Secretary noted that the resident was last seen for dental care in August, with no further information on treatment needs. The Director of Nursing expressed that staff should alert providers to dental issues and ensure follow-up appointments are scheduled, emphasizing the importance of oral health in overall resident care. Despite these expectations, the facility's policy to provide access to dental services was not effectively implemented, resulting in the deficiency.
Failure to Accommodate Gluten Allergy in Resident's Diet
Penalty
Summary
The facility failed to meet the dietary needs of a resident with a gluten allergy, which could lead to malnutrition and dissatisfaction with meals. The resident, who was admitted with multiple diagnoses including a gluten allergy, had a care plan that did not address this allergy. Despite quarterly nutrition evaluations indicating the need for a gluten-free diet, the resident's diet order was not consistently updated to reflect this requirement. The facility's menu and alternative options did not clearly indicate gluten-free items, and during a tray line observation, the resident was served food items that were not gluten-free. Interviews with the resident and staff revealed a lack of awareness and communication regarding the resident's dietary restrictions. The resident expressed dissatisfaction with the food options, stating that they were not offered appropriate gluten-free substitutions. Staff members, including a CNA and an LPN, were not aware of the resident's gluten allergy and did not ensure that the dietary restrictions were communicated or adhered to. The Dietary Supervisor admitted to forgetting to provide gluten-free options on a particular day, and the CNA indicated that it was the resident's responsibility to request alternative meals. The Director of Nursing expressed expectations that dietary restrictions should be documented and communicated, but acknowledged uncertainty about whether the resident's needs were being met. The facility's policies on menus and nutrition emphasized the importance of meeting residents' dietary needs, but these were not effectively implemented in practice. The lack of proper dietary accommodations for the resident with a gluten allergy highlights a deficiency in the facility's ability to provide appropriate nutritional care.
Failure to Implement Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide a resident with physician-ordered wound care services, specifically the use of a wound vac, as indicated in the hospital discharge orders. The resident, who was admitted with multiple diagnoses including acute kidney failure, diabetes, and a recent surgical history, had a care plan that did not include the necessary wound care instructions. The care plan only mentioned interventions such as floating heels and monitoring the skin injury, but omitted the wound vac instructions. Upon review of the clinical records, it was found that there was no order for wound care instructions and wound vac in the Point Click Care (PCC) system. Interviews with staff revealed a breakdown in the admission process, where the admission nurse failed to input the wound vac order into the system. The resident had a wound vac at the bedside and mentioned that it needed to be changed every other day, but the facility initially did not have one available. Further interviews with staff, including the LPN, admission nurse, and director of nursing, highlighted a lack of communication and oversight in ensuring the wound vac order was placed and followed. The wound nurse confirmed that the wound vac was not applied until two weeks after the resident's admission, due to a lack of supplies and miscommunication about the order. The facility's policy requires accurate implementation of orders, but this was not adhered to in this case, leading to a deficiency in care.
Medication Unavailability Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that medication was available for administration as ordered by the physician for a resident with a history of myoclonic seizures, hypertension, and neuropathy. The resident was admitted with a physician's order for clonazepam 1 mg at bedtime for anxiety, but the medication was not available at the time of administration. The electronic medication administration record noted that clonazepam was unavailable, and the pharmacy was contacted for delivery. The resident reported not receiving the medication during the scheduled medication pass, which led to a seizure and the resident leaving the facility against medical advice. Interviews with staff revealed that the facility had emergency kits, but they did not contain all medications, and the pyxis machine had clonazepam in a different dose than ordered. The LPN did not notify the provider about the delay in medication delivery, which could have medically impacted the resident. The Assistant Director of Nursing confirmed that clonazepam was available in the pyxis but in a different dose, and a new order from the doctor was needed to administer it. The Director of Nursing agreed that a new order was necessary to pull the medication from the pyxis. The facility's policy stated that medications should be administered as prescribed by the attending physician.
Infection Control Deficiency in Oxygen Use
Penalty
Summary
The facility failed to adhere to infection control guidelines related to oxygen use for a resident diagnosed with primary pulmonary adenocarcinoma and dyspnea. The resident had a physician order for oxygen therapy and a care plan that included continuous oxygen via nasal cannula. On a specific day, the resident's oxygen tubing was observed on the floor by her bed, and multiple staff members entered the room without addressing the fallen tubing. The resident later reported that staff picked up the tubing but did not sanitize it or provide new tubing, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to infection control protocols. An LPN stated that new tubing should be provided if it falls on the floor, but admitted not noticing the incident. The ADON confirmed that staff should replace any tubing that falls on the ground and use hand sanitizer when entering and exiting resident rooms. The facility's policy on oxygen administration allows for tubing replacement as needed, and the infection prevention policy aims to decrease infection risk and correct problems related to infection control practices.
Failure to Provide Written Notification of Payment Liability Changes
Penalty
Summary
The facility failed to ensure that Resident #3 was provided with a written notification of changes in charges for services during their stay. Despite the Admission Agreement stipulating that any changes in charges based on the resident's condition should be communicated in advance, there was no evidence that Resident #3 received written notice of a liability change for payment. The resident, who was on IV antibiotic therapy for an infected prosthetic knee joint, was discharged without being informed of a $2,800 bill received post-discharge and the expiration of their insurance coverage. Staff interviews revealed discrepancies in communication regarding the resident's liability for payment. The Assistant Business Office Manager indicated that the resident became responsible for a copay on the 21st day of their stay, but there was confusion about issuing a Notice of Medicare Non-Coverage (NOMNC) due to Medicare coverage dropping to 70%. The Business Office Manager acknowledged that there was a lack of documentation regarding discussions with Resident #3 about payor changes and the issuance of necessary notices like the Advance Beneficiary Notice of Non-Coverage (ABN) or NOMNC. The Business Office Manager mentioned that the resident was informed about the copay requirement verbally but admitted that no formal letter was given to Resident #3 regarding the liability change. Despite the resident expressing financial concerns and being unable to leave due to ongoing IV therapy, there was a delay in providing written notification of the payment liability change. The lack of proper communication and documentation regarding the resident's financial responsibility during their stay led to the deficiency in ensuring Resident #3 was adequately informed of potential liabilities for services not covered by Medicaid/Medicare.
Resident Care and Role Clarity Deficiency
Penalty
Summary
The facility failed to ensure that resident #5 received treatment and care in accordance with professional standards of practice. Resident #5 had pertinent diagnoses including Ischemic cardiomyopathy, atrial fibrillation, stage 4 chronic kidney disease, diabetes mellitus type 2, hypertension, and hyperlipidemia. On February 15, 2024, the resident was found unresponsive while sitting on the toilet by a hospitality aide (HA/staff #108) who did not have lift and transfer training. The HA, who was not a certified nursing assistant, assisted the resident to the bathroom without hitting the call light as promised, leading to the resident being found slumped over. The LPN and CNA interviewed were not clear on the duties and limitations of hospitality aides, indicating a lack of clarity and communication within the facility regarding roles and responsibilities in resident care.
Deficiencies in Shower Room Maintenance and Cleanliness
Penalty
Summary
The facility failed to ensure that all resident shower rooms were in good repair. During an initial observation and walk-through of both shower rooms, it was found that the Area 100/200 shower room had only 2 out of 5 shower stalls functional, and the Area 300/400 shower room had only 3 out of 5 shower stalls functional. Additionally, the Area 100/200 shower room had a dirty or stained/discolored tile floor, while the Area 300/400 shower room had cracked tiles on both the floor and lower wall of the shower stalls. Interviews with staff revealed that the maintenance director did not consider the limited number of functional shower stalls or the broken and discolored tiles to be a concern. However, CNAs reported that the shower rooms needed deep cleaning, the shower heads needed replacement, and the water pressure was inadequate. They also noted that the tiles were stained, the grout was dirty, and the cracked tiles posed a safety hazard for residents and staff. Further observations during a follow-up walk-through confirmed the issues reported by the CNAs. In the Area 300/400 shower room, there were missing floor tiles at the entrance/exit, stalls without shower heads and handles, brownish/gray material on the tile floor and bottom tile wall, cracked tiles with moist crevices containing dark/black unknown material, a broken shower head holder, a missing pull help string, and a cracked tub box with black material. In the Area 100/200 shower room, there was brownish/gray material on the tile floor, stalls used as storage, missing floor tiles at the entrance/exit, and a wet area under the sink with a brown unknown material spot. Interviews with additional staff confirmed that the shower rooms were dated and needed work, with concerns about mold and the safety hazards posed by the cracked tiles. Review of the facility's Shower Room Cleaning Log indicated that the shower rooms were cleaned weekly, including sweeping, mopping, and deep cleaning of walls and tiles with bleach. However, a review of work orders from September 24, 2023, to January 23, 2024, did not show any work orders related to the shower room issues. The facility's policy on Facility Maintenance stated that procedures should be established for routine and non-routine care to ensure the facility remains in good working order for resident and staff safety. Despite this policy, the facility failed to address the deficiencies in the shower rooms, leading to an unsafe and unsanitary environment for residents and staff.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered by the provider. Resident #350, who has diagnoses including urinary tract infection, chronic obstructive pulmonary disease, depression, gastro-esophageal reflux disease, hypertension, and convulsions, was prescribed oxyCODONE HCI oral tablet 5mg to be taken every 4 hours for pain. However, the Medication Administration Record (MAR) revealed that the medication was not administered on multiple occasions, with the reason coded as the resident was sleeping. There was no documentation in the eMAR progress notes indicating that attempts were made to wake the resident or that the medication was attempted to be administered as required by the facility's policy. Further review of the MAR indicated that the prescribed oxyCODONE was held multiple times, with progress notes stating that the medication was either on order or awaiting delivery from the pharmacy. An investigation report revealed that the resident had raised concerns about not receiving the medication, but the facility's review concluded that all medications had been administered per physician's orders, which was unsubstantiated. Interviews with staff confirmed that the proper procedure was not followed, as there were no corresponding notes to justify the coding on the MAR, and the medication should have been administered as scheduled or the resident should have been woken up. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires medications to be administered as prescribed and documented accurately. The ADON also noted that the mismatched codes and progress notes were unacceptable and that the resident not receiving the prescribed medication could lead to pain and loss of trust in the staff. The facility's policy on the administration of drugs emphasizes the importance of administering medications within the scheduled time frame and documenting any deviations accurately in the clinical record.
Latest citations in Arizona
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
