Handmaker Home For The Aging
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 2221 North Rosemont Boulevard, Tucson, Arizona 85712
- CMS Provider Number
- 035016
- Inspections on file
- 23
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Handmaker Home For The Aging during CMS and state inspections, most recent first.
A resident with dementia and a history of verbal and physical aggression toward staff was care planned for behavioral issues, including interventions such as redirection and removal from triggering situations. In the same memory care unit, another cognitively impaired resident without behavioral symptoms was seated at a dining table, asleep and wearing a cowboy hat. The aggressive resident emerged from his room appearing very angry, moved quickly toward the sleeping resident, and struck the back of his head, knocking off the hat, while making statements that the other resident had just gotten out of prison and had denied him a job. A CNA witnessed and reported the event, and both the DON and administrator later characterized the act as physical abuse under the facility’s abuse policy, which defines abuse as physical, verbal, financial, or psychosocial harm and requires investigation of all involved persons.
A resident with multiple comorbidities, left below-knee amputation, morbid obesity, and documented fall risk was care planned as needing assistance with transfers and adherence to fall precautions. Despite this, a CNA left the resident unattended in a shower room after transfer assistance, even though report indicated the resident required a two-person assist and use of a Hoyer lift. The resident fell from the shower chair and sustained an acute intertrochanteric hip fracture, later confirmed by x-ray and requiring ED transfer. Staff interviews, including with the DON, CNA, and an LPN, confirmed that residents are not to be left alone in the shower and that the resident had been left unattended, contrary to facility expectations and the resident’s assessed needs.
A resident with cognitive and behavioral health diagnoses was forcibly removed from bed and given a shower by an RN and a CNA, despite repeated refusals and vocal objections. The incident was witnessed and reported by another CNA, and interviews confirmed that the resident was physically handled against her will. Both staff members involved had prior disciplinary actions and had completed abuse prevention training. The facility substantiated the abuse allegation following an internal investigation.
Two residents experienced substantiated abuse, one by a CNA who was reported to be rough, aggressive, and verbally rude during care, and another through a physical altercation with a fellow resident who had a history of aggression and severe cognitive impairment. The incidents were confirmed by staff and resident interviews, and documentation showed that care plans did not adequately address known behavioral risks, leading to harm.
A resident with severe cognitive impairment was subjected to ongoing verbal and physical abuse by another resident, escalating over several months from threats and yelling to a physical altercation. Despite staff witnessing and reporting these incidents to administration, no effective interventions or increased supervision were implemented, and the events were not consistently documented as abuse. The affected resident experienced psychosocial harm, including increased agitation and fearfulness, as a result of the facility's failure to act.
A resident with severe cognitive impairment was subjected to ongoing verbal and physical abuse by another resident with behavioral health diagnoses. Despite repeated incidents witnessed by staff and documented in clinical records, the facility did not report the abuse to required agencies, failed to conduct timely investigations, and did not implement effective interventions or increased supervision to protect the victim, resulting in continued abuse and distress.
Multiple incidents of verbal and physical abuse occurred between two residents, with staff witnessing and documenting the events, including one resident being slapped and sustaining a visible injury. Despite internal reporting and awareness among management, the incidents were not reported to the State Agency or Adult Protective Services as required by facility policy, and staff were instructed not to escalate the matter externally.
A resident with severe cognitive impairment was subjected to repeated verbal and physical aggression by another resident with a history of behavioral issues. Despite multiple documented incidents, staff observations, and family reports of harm, the facility did not initiate or conduct a thorough investigation or take appropriate actions to protect the victim, contrary to its own abuse prevention policies.
A resident with severe cognitive impairment and multiple psychiatric diagnoses exhibited frequent verbal and physical aggression toward others, as documented in clinical records and MDS assessments. Despite this, the care plan was not updated to include behavioral interventions until much later, and staff interviews confirmed that required updates were not made in accordance with facility policy.
The facility did not ensure the assistant administrator was formally appointed by the governing board, as required. Documentation lacked proper approval, and the individual held the title and responsibilities without evidence of board appointment. Staff reported incidents of abuse to the assistant administrator, who, along with the ADON, instructed staff not to escalate the matter, and no thorough investigation or state reporting was documented.
A resident with multiple chronic conditions had two episodes of elevated respiratory rates that were flagged as abnormal in the electronic health record. Despite facility policy requiring physician notification for such changes, staff did not notify the physician or document any communication, resulting in a failure to monitor and address the resident's change in condition.
A resident with severe cognitive impairment and psychiatric diagnoses, who was fully dependent on staff for bathing, did not consistently receive scheduled showers as required by facility policy. Facility records and staff interviews confirmed that the resident was offered or received showers less frequently than the twice-weekly schedule, due in part to staffing challenges and lack of a dedicated shower aide.
A resident, who was cognitively intact and admitted with multiple fractures, experienced incidents where a family member aggressively sought access to her debit card and was involved in questionable behavior during medication administration. Staff observed and documented these events, discussed concerns among themselves, and reported financial concerns to APS, but failed to report the allegations of abuse and exploitation to the state agency within the required timeframe, as mandated by facility policy.
A resident with cognitive impairment and major depressive disorder was the subject of a financial misappropriation allegation involving a family member. The facility did not complete or submit the required five-day investigative report, as confirmed by the Assistant Administrator, despite facility policy mandating timely reporting and follow-up.
The facility failed to implement its abuse policies in two incidents of resident-to-resident abuse. In one case, a resident with severe cognitive impairment and aggressive behavior hit another resident, while in another, a resident was hit after a verbal exchange. The facility did not adequately prevent the incidents or conduct thorough investigations as required by their policies.
The facility failed to report and investigate incidents of resident abuse in a timely manner. A resident with intact cognitive impairment reported being hit by another resident with severe cognitive impairment, but discrepancies in reporting timelines were found. Additionally, an altercation between two residents was not properly documented or investigated within the required timeframe, indicating a failure to adhere to established procedures.
The facility failed to properly discard expired medications, including a controlled substance, Lyrica, found taped behind a blister pack, and expired Sodium Chloride Injection bags. The RN and DON acknowledged these practices were against facility policies, which require the removal of expired medications from active stock.
The facility failed to store food under sanitary conditions, with several items found beyond their use-by dates and others not properly labeled. This was observed during a kitchen tour, where expired and unlabeled food items were found in the walk-in and nourishment refrigerators. The Food Services Director discarded these items, and interviews revealed inconsistencies in the facility's food labeling and discarding processes.
A resident with severe cognitive impairment and behavioral issues assaulted another resident, leading to a deficiency in the facility's ability to prevent abuse. Despite interventions in place, the aggressive resident was not adequately monitored, resulting in an altercation. The facility's policy required timely reporting and prevention of abuse, which was not fully adhered to.
A facility failed to develop a comprehensive care plan for a resident on anticoagulants, despite a physician's order for Lovenox for DVT prophylaxis. The resident later showed symptoms of a possible GI bleed, but the Treatment Administration Record lacked documentation of bleeding symptoms. The DON expected staff to monitor for bleeding, but it was unclear if facility policy required care-planning for anticoagulants.
The facility failed to ensure that a Registered Nurse and a Certified Nursing Assistant had completed necessary training on abuse, neglect, and exploitation, as well as gift-giving policies. Despite facility policies requiring annual training and removal from the schedule for non-compliance, these staff members' records lacked evidence of such training, highlighting a deficiency in the facility's training implementation.
A resident with rheumatoid arthritis and muscle weakness expressed multiple grievances, including medication issues and lack of showers, but did not receive necessary behavioral health services. Despite documented concerns and a desire to return home, the facility failed to follow up with social services. Staff interviews revealed a lack of adherence to reporting and documentation processes, highlighting deficiencies in addressing the resident's needs.
A facility failed to ensure a resident was informed of the risks and benefits of, and had consented to, the use of Sertraline, a psychotropic medication. The resident, with no cognitive impairment, was prescribed the medication without documented consent. The interim DON confirmed that consents should be signed upon admission and when new medications are added, but no such consent was found. The facility's policy requires education on psychotropic drug use, which was not followed.
A facility failed to ensure a timely PASARR screening for a resident with serious mental illness, including Schizoaffective Disorder and Bipolar Disorder. The resident's chart lacked evidence of a completed PASARR Level 1 screening, which could result in not receiving necessary specialized services. The interim DON acknowledged inconsistencies in PASARR completion and admitted the screening could have been done sooner, posing potential risks for inappropriate monitoring of medication and behavior.
A facility failed to monitor a resident's nutritional status according to its policy. The resident, admitted with conditions including depression and hypertension, was identified as malnourished. Despite orders for regular weight checks, no weights were recorded after the initial readings, and the resident reported significant weight loss. Staff interviews confirmed the lack of adherence to the facility's weight monitoring policy.
A facility failed to provide dialysis care consistent with professional standards for a resident with chronic kidney disease. The resident's care plan required dialysis, but there were no physician orders or evidence of dialysis treatment. Post-dialysis care instructions were not followed, and the facility lacked a policy on dialysis care, leading to the deficiency.
The facility failed to maintain accurate medication records, with missing signatures on the Narcotic Count Sheet for several dates. An LPN confirmed that medications were not recorded properly, which did not meet facility expectations. The DON stated that both nurses should sign and count medications together, as per policy.
A resident with a history of GI bleeding continued to receive Apixaban despite reporting dark stools, indicating potential bleeding. The facility failed to follow protocols for notifying the provider and documenting medication changes, leading to a deficiency in medication management.
A LTC facility reported a medication error rate of 6.9%, exceeding the acceptable 5%. One resident with diabetes received an incorrect insulin dose, and another resident was given a higher dose of Carvedilol than prescribed. Both errors were due to staff not following physician orders, highlighting a failure in medication administration protocols.
A resident with type 1 diabetes received an incorrect dose of insulin Lispro due to a nurse administering 3 units instead of the prescribed 8 units based on the resident's blood sugar level. The nurse documented inaccurately and did not inform the physician of the deviation from the order, contrary to facility policy.
The facility failed to consistently complete glucometer controls, as observed and confirmed by staff interviews. The Quality Control Record sheet showed non-compliance on multiple days in August, September, and October 2024. Staff acknowledged the risk of inaccurate readings due to this deficiency, despite the glucometers having a 24-hour quality control reminder feature.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents upon admission, despite their medical conditions requiring such measures. Observations showed a lack of EBP signage and PPE availability near the residents' rooms. Interviews with the IP and DON confirmed that EBP orders should have been initiated at admission, but were not, due to oversight during weekend admissions.
The facility failed to prevent falls for three residents, leading to serious injuries. Despite being high risk, care plans were not updated with new interventions after falls. Observations showed missing fall mats, and staff interviews revealed inconsistencies in identifying fall risks. The DON acknowledged the lack of new interventions, highlighting a deficiency in the fall prevention program.
A resident with significant cognitive impairment and multiple diagnoses was not allowed to return to the facility after hospitalization, despite being ready for discharge. The facility cited family issues and safety concerns as reasons for refusal, leading to a deficiency in their care practices.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident with dementia, major depressive disorder, and anxiety disorder had a documented history of behavioral problems, including sexually inappropriate comments to female staff, persistent yelling out, and verbal and physical aggression toward staff during care. His care plan, initiated in early October, identified these behaviors and included interventions such as administering medications as ordered, anticipating and meeting needs, intervening to protect the rights and safety of others, using calm approaches, diverting attention, and removing him from situations as needed. Behavior notes from late December documented that this resident was up and down all night, was restless, was looking for a family member, and expressed dislike and suspicion toward another male resident, stating he did not like the other resident looking at him and questioning why he was there. Staff attempted redirection several times, which was ineffective, and administered anti-anxiety medication for increased restlessness. The alleged victim was another resident on the same memory care unit, also with dementia and anxiety disorder, and with a BIMS score indicating severely impaired cognition. This resident did not exhibit behavioral symptoms or wandering. Both residents had been on the same unit since mid-December. On a day after lunch, the cognitively impaired victim was sitting at a dining room table, asleep and wearing a cowboy hat, with his back facing the other resident. The resident with behavioral issues was observed by staff coming out of his room looking very angry and moving quickly toward the sleeping resident. He then hit the back of the other resident’s head, knocking the cowboy hat off. Staff documented that the aggressive resident repeatedly stated that the other resident had just gotten out of prison and had denied him a job. A CNA witness described seeing the resident smack the back of the sleeping resident’s head, and considered this to be physical abuse. The facility’s own investigation and leadership interviews confirmed that the incident constituted abuse. The 5-day investigation report documented that the CNA saw the aggressive resident smack the cowboy hat off the other resident and that both residents were unable to recall the event. The DON stated that the aggressive resident went straight to the other resident and smacked his hat off, and that this action was not allowed and was considered physical abuse, even if the DON believed the hat rim was struck. The administrator also stated that the aggressive resident hit the back of the other resident’s head and considered it abuse. The facility’s abuse policy defined abuse broadly and required identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, and witnesses. Despite prior documentation of the aggressive resident’s behavioral issues and recent agitation directed toward another male resident, the incident occurred, demonstrating that the facility did not effectively protect the victim resident from physical abuse by another resident.
Resident Left Unattended in Shower Resulting in Fall With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and interventions to prevent a fall for one resident identified as being at risk for falls. The resident had multiple diagnoses, including type 2 diabetes mellitus, osteomyelitis of the right ankle and foot, cervical spinal stenosis, major depressive disorder, bipolar disorder, left below-knee amputation, and morbid obesity. The resident’s BIMS score was 15, indicating intact cognition, and the care plan identified the resident as high risk for falls due to deconditioning, with interventions such as prompt response to requests for assistance, ensuring the call light was within reach, following the facility fall protocol, and ensuring non-skid footwear when ambulating or mobilizing in a wheelchair. A Morse Fall Scale score of 40 indicated a moderate fall risk. On the date of the incident, documentation initially described the event as an unwitnessed fall in the shower room, with the resident reportedly stating she slipped off from her bed, and an x-ray was ordered for left hip pain. A subsequent nursing note documented that the x-ray showed an acute fracture of the left hip at the intertrochanteric region, and the resident was sent to the ED. A later incident note clarified that the resident had sustained a fall inside the shower room after being left alone by a CNA, despite report that the resident required a two-person assist for transfers and use of a Hoyer lift. The CNA left the resident alone twice to get assistance to stand the resident, and the resident was found on the floor complaining of left hip pain. Interviews with staff confirmed that residents should never be left unattended in the shower. The DON stated that residents should not be left alone in the shower and acknowledged that the resident was left alone, even if only for a brief period, and that the resident was typically able to ambulate with little assistance but was feeling weak that day. A CNA with over twenty years of experience stated that shower procedures include positioning the wheelchair and shower chair for stability and that, while ideally two staff assist, it can be done with one; she also stated it was never permissible to leave a resident unattended in the shower. An LPN reported assisting the CNA with pulling up the resident’s pants and brief and helping get the resident back on the shower chair; after being told by the CNA that she could leave, the LPN departed and later learned the resident had been left unattended. The facility’s shower policy required assisting residents with bathing, helping them into the shower, ensuring the shower chair is locked if the resident remains seated, and encouraging use of safety rails, but the resident was left alone in the shower room contrary to these expectations and the resident’s assessed need for assistance.
Resident Forced to Shower Against Will by Staff
Penalty
Summary
A deficiency occurred when staff members failed to protect a resident from abuse. The resident, who had a history of dementia, bipolar disorder, major depressive disorder, and anxiety disorder, was care planned for behavioral issues and a tendency to refuse assistance with transfers and showers. On the day of the incident, the resident refused multiple offers for a shower from a CNA, who then notified the assigned RN. The RN instructed the CNA not to ask for consent but to proceed with the shower regardless of the resident's wishes. Subsequently, the RN and another CNA physically removed the resident from bed and forced her into the shower, despite her vocal objections and resistance. The resident expressed distress during the incident, stating she was cold and did not want her hair wet, and was described as angry afterward. Interviews and documentation confirmed that the resident was pulled out of bed by her arms while she was yelling to stop. A bruise on the resident's arm was investigated but determined to have been present prior to the incident. Staff interviews revealed that it was not standard practice for nurses to perform showers and that refusals were typically respected, with documentation of the refusal if the resident continued to decline after being approached by both CNA and nurse. Personnel records for the involved staff showed prior disciplinary actions for discourtesy, insubordination, and failure to follow procedures. Both staff members involved in the incident had completed abuse prevention training earlier in the year. The facility's investigation substantiated the abuse allegation, confirming that the staff members forced the resident to shower against her will, in violation of facility policy and resident rights.
Failure to Protect Residents from Abuse by Staff and Other Residents
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in substantiated incidents involving both staff-to-resident and resident-to-resident abuse. One resident, who had multiple diagnoses including hypertensive heart and chronic kidney disease, morbid obesity, major depressive disorder, anxiety disorder, and unspecified dementia, was dependent on staff for activities of daily living and had moderate cognitive impairment. This resident reported that a CNA was angry, aggressive, and rough during care, and that the CNA threw a snack at her. Multiple residents confirmed that the CNA was physically aggressive and displayed an angry demeanor toward them. Documentation and interviews revealed that the resident did not feel safe when cared for by this staff member, and the CNA was described as verbally rude and rough with care by several residents and staff members. Another incident involved a resident with metabolic encephalopathy, anxiety disorder, and muscle weakness, who exhibited wandering behaviors and attempted to help other residents, making her difficult to redirect. This resident entered another resident's room, leading to a physical altercation where the second resident, who had severe cognitive impairment and a history of behavioral problems including aggression, grabbed the first resident's arm and would not let go, causing a scratch and bruise. Staff witnessed the incident and confirmed that the resident who initiated the physical contact had a history of aggression and was difficult to redirect. The care plan for the wandering resident did not address her wandering behavior, despite repeated documentation of her entering other residents' rooms and interacting with them in ways that led to conflict. Facility documentation, including care plans, nursing notes, and staff interviews, confirmed that both incidents were substantiated as abuse. The facility's policy defined abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and included both staff-to-resident and resident-to-resident altercations. The failure to prevent these incidents demonstrated a lack of effective measures to protect residents from abuse by staff and other residents.
Failure to Protect Resident from Repeated Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from repeated verbal and physical abuse by another resident, despite ongoing incidents and staff awareness. Documentation shows that the abusive behavior began as verbal aggression and threats, escalating over several months to physical abuse, including a witnessed incident where one resident slapped another. Multiple staff members, including CNAs and an LPN, observed and reported these behaviors to administration, but there was no evidence that effective interventions were implemented to prevent further abuse or to separate the residents consistently. The clinical records and staff interviews reveal a pattern of inaction by facility management. Staff reported that incidents were treated as behavioral issues rather than abuse, and management did not respond to staff concerns or implement protective measures. The care plans for the residents involved did not reflect the ongoing aggression, and there was a lack of documentation or follow-up on reported incidents. Additionally, the facility failed to document a physical altercation until several days after it occurred, despite staff and family being aware of the event. The affected resident, who had severe cognitive impairment and was dependent on staff for care, exhibited signs of psychosocial harm following the abuse, including increased agitation and fearfulness, particularly at night. The abusive resident had a documented history of paranoia and aggression toward the victim, but no effective interventions or increased supervision were put in place prior to the escalation to physical abuse. The facility's own policy defined such behaviors as abuse and required protective actions, but these were not followed, resulting in harm to the resident and a failure to uphold resident rights.
Removal Plan
- Resident #2 was assigned a 1:1 sitter and relocated to a different unit, with behavior monitoring
- Resident #1 was assessed for injuries, including possible psychosocial harm. Clinical documentation was reviewed, and behavior was tracked
- Individualized care plans were updated
- Ongoing staff training was implemented on how to identify abuse
- Ongoing staff training was provided on how to intervene and stop abuse
- Ongoing staff training was conducted on the proper protocol for reporting abuse
- All residents were interviewed to identify any potential abuse. For residents unable to be interviewed, the MDS nurse completed an assessment for signs or symptoms of abuse
- Quality Assurance and Performance Improvement (QAPI) meetings were scheduled to review any incidents or concerns related to abuse
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding resident protection, abuse reporting, and investigation following multiple incidents of verbal and physical abuse by one resident toward another. Despite repeated documentation of aggressive behaviors, including yelling, threats, and physical altercations, there was no evidence that these incidents were reported to the State Agency (SA) or Adult Protective Services (APS), nor that a thorough investigation was conducted. Staff and witness interviews confirmed that the abusive behaviors were ongoing and known to staff, yet no effective interventions or increased supervision were implemented to prevent further incidents. The residents involved had significant cognitive impairments, with one resident having a documented history of dementia, muscle weakness, and severe cognitive impairment, as indicated by a BIMS score of 00. The alleged perpetrator also had dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder, and exhibited paranoid and possessive behaviors toward another resident. Multiple behavior notes detailed a pattern of verbal aggression, threats, and physical altercations, including slapping and pushing, which were witnessed by staff and other residents. Despite these documented incidents, the facility did not take timely or adequate steps to separate the residents or provide increased monitoring to ensure safety. Interviews with staff revealed confusion and inconsistency regarding the reporting process for abuse, with some staff being instructed not to escalate or report incidents involving residents with cognitive impairment. The facility's own policy required immediate reporting and investigation of abuse allegations, regardless of the cognitive status of those involved, but this was not followed. Documentation showed delays in recording incidents and a lack of protective measures for the victim, resulting in continued exposure to abuse and psychological distress.
Failure to Report Resident-to-Resident Abuse to Authorities
Penalty
Summary
The facility failed to ensure that multiple incidents of verbal and physical abuse between residents were reported to the State Agency (SA) and Adult Protective Services (APS) as required by both regulation and facility policy. Documentation and interviews revealed that one resident with severe cognitive impairment was repeatedly subjected to verbal aggression, threats, and physical abuse by another resident with a history of behavioral disturbances, including paranoia and anger. Despite staff witnessing these incidents and documenting them in clinical records, there was no evidence that the required reports were made to the appropriate authorities. Staff interviews indicated that several team members, including CNAs and LPNs, observed or were informed of incidents where one resident yelled at, threatened, and physically assaulted another resident. In one instance, staff witnessed a resident being slapped, resulting in visible injury, and this was reported internally to facility management. However, management instructed staff not to escalate or report the incident externally, citing the cognitive status of the residents involved. The facility's Assistant Director of Nursing and other staff confirmed that they did not report the abuse to the SA or APS, believing it was the responsibility of the administrator, who in turn determined the incident was not reportable if the victim could not recall the event. The facility's own policy required immediate reporting of all alleged violations to the administrator, state agency, and APS, with specific timeframes for reporting based on the severity of the incident. Despite this, there was a consistent pattern of internal reporting without external notification, even in cases involving physical harm and repeated verbal abuse. Documentation also showed that family members were informed of some incidents, and staff were later provided with abuse education, but the required notifications to authorities were not made as stipulated by policy and regulation.
Failure to Investigate and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse of one resident by another were thoroughly investigated and that appropriate corrective actions were taken. Multiple documented incidents showed a pattern of verbal and physical aggression by one resident towards another, including yelling, threats, and physical altercations such as slapping and punching. Despite staff witnessing these events and documenting them in behavior notes, there was no evidence that the facility initiated or conducted a thorough investigation into these incidents. The clinical records and staff interviews revealed that the resident who was the victim had severe cognitive impairment, as indicated by a BIMS score of 00, and a history of dementia and muscle weakness. The alleged perpetrator also had dementia, along with major depressive disorder, anxiety disorder, and schizoaffective disorder, and exhibited repeated aggressive behaviors, particularly when the victim was near another resident. Staff documented multiple episodes where the aggressor yelled at, threatened, and physically confronted the victim, sometimes in the presence of other residents and staff. Family members of the victim also reported noticing physical signs of harm, such as a bruise on the victim's face, after being informed by staff of an altercation. Despite these repeated incidents and staff awareness, the facility did not document any initiation of an investigation or protective measures in response to the abuse allegations. Staff interviews indicated that management was informed of the incidents, but no substantial action was taken to address the behaviors or protect the victim. The facility's own policy defined such behaviors as abuse and required investigation and protection, but there was no evidence that these procedures were followed in this case.
Failure to Timely Update Care Plan for Resident Aggression
Penalty
Summary
The facility failed to ensure that the care plan for a resident with multiple psychiatric and neurological diagnoses, including unspecified dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder-bipolar type, was revised to address the resident's verbal and physical aggression towards others. The resident was admitted with severe cognitive impairment, as indicated by a BIMS score of 5, and exhibited verbal behavioral symptoms directed toward others 4 to 6 days a week, as documented in the quarterly MDS assessment. Despite this, the care plan dated October 17, 2024, did not include interventions for these behaviors, focusing instead on social and emotional needs. Clinical record review and staff interviews revealed that the resident had documented incidents of verbal aggression, including yelling at and threatening another resident. However, there was no evidence that the interdisciplinary team (IDT) had reviewed the quarterly MDS assessment for behaviors or updated the care plan accordingly at that time. The care plan was not revised to include behavioral interventions until September 11, 2025, despite ongoing documentation of aggressive behaviors in the clinical record. Interviews with nursing staff, the MDS nurse, the assistant director of nursing, and administrative staff confirmed that the behavioral symptoms were identified in the MDS and clinical records but were not transferred to the care plan in a timely manner. Staff acknowledged that the lack of behavioral interventions in the care plan could impede behavior identification, de-escalation, and communication among staff. Facility policy required the comprehensive care plan to be reviewed and revised by the IDT after each comprehensive and quarterly MDS assessment, which was not followed in this case.
Assistant Administrator Not Duly Appointed by Governing Board
Penalty
Summary
The facility failed to ensure that the assistant administrator was duly appointed by the governing board, as required by regulation. Review of the assistant administrator's personnel file showed a job description signed by the individual but lacking CEO approval, and a handwritten HR approval signed by the same individual. The resume did not document any licenses or certifications, and the staff list, business card, and facility documentation all identified the individual as the assistant administrator. A letter designated the assistant administrator as the responsible party in the administrator's absence, but there was no evidence of a formal appointment by the governing board. The administrator confirmed there was no policy for assistant administrator appointment and was unaware of the requirement for board appointment. Interviews with staff revealed that incidents of abuse were reported to the assistant administrator, who, along with the ADON, instructed staff to let the incident go and not escalate it, particularly as it involved residents in the behavioral unit. Despite continued reports of verbal abuse and intimidation, there was no evidence of a thorough investigation or reporting to the state agency. Staff interviews confirmed the assistant administrator's role in handling such incidents, but the lack of proper appointment and oversight contributed to the deficient practice.
Failure to Notify Physician of Abnormal Respiratory Rates
Penalty
Summary
The facility failed to monitor and communicate abnormal respiratory rates for a resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, heart failure, and morbid obesity. The resident was admitted following hospitalization for shortness of breath, sepsis, pneumonia, and heart failure. During the resident's stay, vital sign records showed two instances of elevated respiratory rates (28 breaths per minute), which triggered warnings in the electronic health record for exceeding the normal threshold. Despite these abnormal findings, there was no evidence that the physician was notified, as required by facility policy. Interviews with staff confirmed that respiratory rates outside the normal range should prompt re-checks and physician notification, and that such notifications should be documented in the electronic health record. The director of nursing and other staff acknowledged that the abnormal respiratory rates were not communicated to the physician and that this was not documented. Facility policy requires prompt notification of significant changes in a resident's condition, and the failure to notify the physician and monitor the abnormal vital signs constituted neglect as defined by the facility's own policies.
Failure to Provide Scheduled ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically personal hygiene, for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, Bipolar disorder, and Major Depressive Disorder. The resident was documented as being dependent on staff for showering and bathing, as reflected in both the Minimum Data Set and the care plan, which specified that all ADLs should be met with staff assistance daily. However, facility records showed that the resident received or was offered a shower only six times in November and three times in December, which is less frequent than the facility's stated policy of showers twice a week. Staff interviews revealed that CNAs are assigned shower duties based on a schedule, but staffing shortages sometimes make it difficult to complete all showers as planned. When showers cannot be completed, CNAs are expected to notify the nurse and request that the evening shift provide the service. Both CNA and nursing staff confirmed that showers are scheduled twice a week, and there is a protocol for which rooms receive showers on which days. The facility's policy, updated in October 2024, requires that residents be assisted with bathing according to the facility schedule to maintain hygiene and prevent skin issues. Despite these protocols, the resident did not consistently receive the required assistance, resulting in a deficiency.
Failure to Timely Report Alleged Abuse and Exploitation
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving a resident who was cognitively intact and admitted with multiple fractures. Documentation shows that a family member was aggressively attempting to obtain the resident's debit card, claiming it was to pay rent, and later took the resident's phone, debit card, and keys with the resident's permission. Staff noted concerns about the family member's behavior, including aggressive demands for money and a chemically odor, and conveyed these concerns to nursing staff. The social worker documented the events and indicated ongoing monitoring for potential abuse. Further incidents included the family member being aggressive with nursing staff, demanding pain medication for the resident, and being present during medication administration. Staff observed unusual behavior during medication administration, such as the resident holding a pill in her mouth and the family member making remarks about medication being crushed. These incidents were discussed among staff, and a safety plan was put in place, but there was no documentation that these events were reported to the Long Term Care Licensing authority as required by facility policy. Interviews with staff confirmed awareness of the family member's actions and the expectation to report abuse allegations immediately to management and appropriate authorities. However, the Assistant Administrator acknowledged that not every suspicion of abuse is reported and that, in this case, the social worker reported the financial concerns to Adult Protective Services (APS) but did not report the incidents to the state agency as required. The facility's policy mandates immediate reporting of all alleged violations to the Administrator, state agency, and other required agencies within two hours, but this was not followed in these instances.
Failure to Investigate Alleged Financial Misappropriation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of financial misappropriation involving a resident with mild cognitive impairment and major depressive disorder. The resident required extensive assistance with daily activities and was reported to be cognitively intact at the time of the incident. A complaint was received by Long Term Care Licensing indicating that a family member was misappropriating the resident's finances and not paying for bills or equipment repairs. Despite this, the required five-day report documenting the investigation was not completed or submitted. During staff interviews, the Assistant Administrator confirmed that there was no five-day report for the incident and was unaware of the specific details of the complaint. The facility's policy on abuse, neglect, and exploitation requires that the Administrator follow up with government agencies and submit the results of the investigation within five working days of the incident. This policy was not followed in this case, resulting in a failure to appropriately respond to the alleged violation.
Failure to Implement Abuse Policies in Resident Altercations
Penalty
Summary
The facility failed to implement its abuse policies in two separate incidents of resident-to-resident abuse. In the first incident, Resident #222, who had intact cognitive function but exhibited behavioral symptoms, reported being hit multiple times in the stomach by Resident #169, who had severe cognitive impairment and a history of aggressive behavior. Despite the aggressive behavior exhibited by Resident #169, including threatening staff and other residents, the facility did not adequately intervene to prevent the altercation. The incident was reported to the state agency, but the facility's investigation revealed that staff were not fully aware of the abuse as it occurred. In the second incident, Resident #223, with intact cognition, was involved in an altercation with Resident #49, who also had no cognitive impairment. A CNA observed Resident #49 hitting Resident #223 after a verbal exchange about coughing at the dining table. Although the incident was reported to the state agency, the facility failed to provide a 5-day report or conduct a thorough internal investigation as required by their policies. The facility's policy on abuse, neglect, and exploitation mandates the prevention and reporting of abuse within two hours, as well as a follow-up investigation within five days. However, in both incidents, the facility did not adhere to these policies, failing to prevent the abuse and to conduct comprehensive investigations. This lack of adherence to established protocols could lead to further instances of resident-to-resident abuse.
Failure to Timely Report and Investigate Resident Abuse Incidents
Penalty
Summary
The facility failed to report an incident of abuse between two residents accurately and in a timely manner. Resident #222, who had intact cognitive impairment, reported being hit in the stomach by Resident #169, who had severe cognitive impairment and exhibited aggressive behavior. The incident was reported to a registered nurse, but discrepancies were found in the timeline of the incident's reporting to the state agency. The facility's documentation did not align with the state agency's incident reporting system, leading to a delay in the proper reporting of the event. Additionally, the facility did not conduct a thorough investigation of the incident involving Resident #222 and Resident #169. The facility's policy required that abuse be reported to the state agency within two hours, but the investigation revealed that the incident was not reported until several hours later. Interviews with staff members, including the Director of Nursing and the Administrator, indicated a lack of clarity regarding the timeframe for reporting such incidents, which contributed to the delay. In another incident, the facility failed to report and investigate an altercation between Resident #223 and Resident #49 within the required timeframe. A Certified Nursing Assistant observed Resident #49 hitting Resident #223, but the facility did not have a 5-day report or additional investigation notes for the incident. The facility's policy required a follow-up with government agencies within five working days to report the investigation of the incident, but this was not completed, indicating a failure to adhere to established procedures for handling abuse allegations.
Expired Medication Mismanagement
Penalty
Summary
The facility failed to properly manage and discard expired medications, which could lead to the administration of expired drugs to residents, contrary to professional standards. During a medication administration observation, a controlled substance, Lyrica, was found with an unsealed capsule taped behind the medication blister pack. The Registered Nurse (RN) involved acknowledged that this practice was not part of the facility's best practices and could potentially contaminate the medication. Additionally, in the Unit Rich medication room, four expired 0.9% Sodium Chloride Injection USP 100ml bags were observed, with one bag having a used-by date that had already passed. The RN confirmed that these medications should have been discarded. The Director of Nursing (DON) stated that the controlled substance should have been wasted and that it was against facility expectations to have medication taped to the back of blister packs. The DON also mentioned that expired medications should be removed from active stock and discarded according to facility policy. The facility's policy on the storage of medication requiring refrigeration emphasizes the importance of monitoring temperature daily and removing expired medications from active stock. However, the facility failed to adhere to these policies, resulting in the presence of expired medications in the medication room.
Deficient Food Storage Practices
Penalty
Summary
The facility failed to ensure that food was stored under sanitary conditions, which could potentially lead to foodborne illness. During an initial tour of the kitchen, surveyors observed several food items in the large walk-in refrigerator and secondary walk-in fridge that were beyond their use-by dates, including six Gold's Horseradish sauces and a block of Swiss cheese. Additionally, several opened food items, such as a salsa container, apple juice package, and sour cream container, were not dated or labeled according to when they were opened or expected to be discarded. Further observations in the nourishment refrigerators on the units revealed additional expired items, including sugar-free, fat-free ice cream and milk cartons, as well as opened items that were not labeled with dates, such as salsa, sour cream, various loaves of bread, oat milk, soy milk, butter, orange pineapple juice, and rainbow sherbet ice creams. The Food Services Director discarded all expired, unlabeled, and undated foods. Interviews with the Food Services Director and the Administrator revealed that the facility's process for food labeling and discarding expired foods was not consistently followed, posing a risk of residents consuming expired food.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #222, who had a history of behavior problems and was placed in a secured memory care unit, reported being hit several times in the stomach by Resident #169. Despite the altercation, there was no immediate evidence of injury, and the facility did not conduct a timely skin assessment following the incident. Resident #222's medical history included unspecified dementia, bipolar disorder, and major depressive disorder, among other conditions. Resident #169, who had severe cognitive impairment and exhibited frequent behavioral symptoms, was involved in multiple aggressive incidents leading up to the altercation. The resident's care plan included interventions for behavioral problems and wandering, but these measures were insufficient to prevent the incident. On the day of the altercation, Resident #169 displayed aggressive behavior, including threatening staff and other residents, and was eventually sent to the hospital for evaluation. The facility's policy on abuse, neglect, and exploitation required the prevention and reporting of abuse within two hours, but the incident was not reported until later. The facility's investigation revealed that staff were aware of Resident #169's aggressive behavior but failed to prevent the altercation. The RN on duty did not witness the physical abuse but was informed by Resident #222 afterward. The facility's failure to adequately monitor and intervene in Resident #169's behavior led to the deficiency.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was readmitted with diagnoses including COPD, acute and chronic respiratory failure with hypoxia, and a history of falling. The resident had a BIMS score indicating intact cognition and was taking an anticoagulant medication. However, the care plan initiated did not include any focus or interventions regarding the use of anticoagulants, despite a physician's order for Lovenox for DVT prophylaxis. On a specific date, the resident began vomiting coffee-ground emesis, indicating a possible upper GI bleed. The physician ordered the anticoagulants to be held, but the Treatment Administration Record did not document any symptoms of bleeding. Interviews with staff revealed that the RN on duty alerted the doctor and administered Zofran, which was effective in preventing further vomiting. The Director of Nursing acknowledged that anticoagulants are high-risk medications and expected staff to monitor for bleeding symptoms, although it was unclear if the facility policy required these medications to be care-planned.
Deficiency in Staff Competency Training
Penalty
Summary
The facility failed to ensure that two out of six sampled nursing staff members, a Registered Nurse and a Certified Nursing Assistant, possessed the necessary competencies and skills to care for residents' needs. The personnel records for these staff members, hired in June and July 2023 respectively, lacked evidence of training on freedom from abuse, neglect, and exploitation, as well as gift-giving policies. This deficiency was identified through a review of personnel records, facility assessments, and interviews with facility staff. Interviews with the Human Resource Coordinator and the interim Director of Nursing revealed that the facility's expectation is for all staff to complete required training annually. Staff who have not completed the training are to be removed from the schedule until they do so. The facility's policies on Continuing Education and Abuse, Neglect, and Exploitation emphasize the importance of timely completion of training, with disciplinary actions outlined for non-compliance. Despite these policies, the lack of documented training for the two staff members indicates a failure in the facility's implementation of its training requirements.
Failure to Provide Behavioral Health Services for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary behavioral health services despite the resident expressing multiple concerns and grievances. The resident, who was admitted with diagnoses including rheumatoid arthritis and muscle weakness, had a BIMS score indicating no cognitive impairment. Despite being described as pleasant and cooperative, the resident reported issues such as not receiving the correct medication, not having a shower since admission, and feeling frustrated and distrustful of the aides. These concerns were documented in various progress notes, yet there was no evidence of a referral for behavioral health or social services. The resident expressed a desire to return home, citing dissatisfaction with the care received, including issues with medication and therapy. The resident also reported feeling upset about the lack of attention from staff, such as an aide being on the phone during meal service. Additionally, the resident was worried about housing issues and the potential theft of a walker. Despite these documented grievances, the facility did not follow up with social services or behavioral health services to address the resident's concerns. Interviews with facility staff revealed a lack of action in response to the resident's grievances. Staff members described processes for reporting abuse and psychological impacts of isolation, but there was no indication that these processes were followed in this case. The facility's policies on abuse, neglect, and promoting resident dignity were not adhered to, as there was no documentation of interviews or care plan revisions. The medical director acknowledged the need for better documentation and follow-up on complaints, indicating a gap in the facility's response to the resident's needs.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was informed of the risks and benefits of, and had consented to, the usage of a psychotropic medication, specifically Sertraline. The resident, who was admitted with multiple psychiatric diagnoses including Schizoaffective Disorder and Bipolar Disorder, had a BIMS score indicating no cognitive impairment. Despite this, the clinical record lacked evidence that the resident was informed about the medication's risks and benefits. A consent form dated several months after the medication was prescribed was found, but it was incomplete as the boxes indicating consent were left unchecked. Interviews with the interim Director of Nursing revealed that medication consents should be signed upon admission and again if a new medication is added to the treatment regime. However, no signed consent for the use of psychotropic medications prior to the administration of Sertraline could be located for the resident. The facility's policy mandates that residents or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments, which was not adhered to in this case.
Failure to Complete Timely PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. This deficiency was identified through clinical record review and staff interviews. The resident, who was admitted with multiple mental health diagnoses including Schizoaffective Disorder, Major Depressive Disorder, and Bipolar Disorder with Psychotic Features, did not have evidence of a completed Pre-Admission Screening and Resident Review (PASARR) Level 1 screening in their chart. The absence of this screening could result in the resident not receiving necessary specialized services in accordance with professional standards. During an interview, the interim Director of Nursing acknowledged that PASARR screenings should be completed at the time of admission and expressed that there was inconsistency in their completion. The facility's policy requires that any resident not previously screened should be evaluated within 40 days of admission. However, the PASARR screening for this resident was only signed on the day of the interview, indicating a delay in the process. The interim DON admitted that the screening could have been completed sooner, and the lack of timely screening posed potential risks for inappropriate monitoring of the resident's medication and behavior.
Failure to Monitor Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure the nutritional status of a resident was assessed and managed according to its policy. Resident #60, who was admitted with diagnoses including major depressive disorder, muscle weakness, and hypertension, was identified as malnourished with a mini nutritional assessment score of 7. Despite physician orders to weigh the resident weekly for four weeks and then monthly, the facility did not obtain any weight readings after July 7, 2024, when the resident weighed 145 pounds. This lack of follow-up on the resident's weight was confirmed during a multidisciplinary conference and through interviews with the resident and staff. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that weights are supposed to be recorded in the electronic health record by Certified Nursing Assistants. However, the facility's policy on weight monitoring, which requires weekly weights for newly admitted residents and those with weight loss, was not adhered to. The resident reported a belief of significant weight loss during their stay, but this was not documented due to the absence of regular weight monitoring, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Failure to Provide Appropriate Dialysis Care
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident with stage 4 chronic kidney disease and dependence on renal dialysis. The resident's care plan indicated the need for dialysis and included interventions such as monitoring for signs of infection at the access site. However, there was no evidence of physician orders for dialysis care and treatment, including the name of the dialysis facility and the days for receiving dialysis. Additionally, the Minimum Data Set (MDS) assessment did not show evidence that the resident received hemodialysis upon admission or while at the facility. The facility also failed to follow post-dialysis care instructions. A post-dialysis form indicated that the dialysis access site should be observed every 30 minutes for 4 hours, and palpation for thrill and bruit should occur every 8 hours. However, the clinical records lacked evidence of these assessments. Interviews with the RN and DON confirmed the absence of physician orders for dialysis and documentation of access site assessments. The facility did not have a policy regarding dialysis care and treatment, which contributed to the deficiency.
Medication Recordkeeping Deficiency
Penalty
Summary
The facility failed to ensure that medication records were accurately maintained according to professional standards of care. During an observation, it was found that the Narcotic Count Sheet on a medication cart had missing signatures for both the Out-Going and In-Coming nurses on several occasions. Specifically, the records were not properly documented on multiple dates in September and October 2024. An interview with an LPN revealed that the expected procedure is for one nurse to sign as the Out-Going nurse and another as the In-Coming nurse, with both nurses counting the medication together. The LPN acknowledged that the medications were not recorded properly on the specified days, which did not meet the facility's expectations. The Director of Nursing (DON) confirmed that the lack of accurate recording poses a risk as there would be no proof that the medication was counted, aligning with the facility's policy that requires controlled substances to be signed in the narcotic book.
Failure to Manage Anticoagulant Therapy
Penalty
Summary
The facility failed to appropriately manage the anticoagulant therapy for a resident, leading to a deficiency in medication administration. The resident, who was admitted with atrial fibrillation and a history of gastrointestinal bleeding, reported dark stools, a potential sign of bleeding, on October 19, 2024. Despite this, the resident continued to receive doses of Apixaban, an anticoagulant, on October 20, 2024. It was not until October 21, 2024, that the provider ordered the medication to be held and a consultation with a gastroenterologist was requested. The resident had been experiencing dark stools for several days and expressed concern about a possible GI bleed, which was confirmed by a positive hemoccult test. Interviews with staff revealed a lack of timely communication and documentation regarding the resident's condition and the continuation of Apixaban. The Director of Nursing acknowledged the failure to follow protocol by not contacting the provider on October 19, 2024, when the dark stools were first noted. Additionally, there was no documentation to confirm that the provider was aware or approved the restart of Apixaban on October 23, 2024. The facility's policies on high-risk medications and notification of changes were not adhered to, contributing to the deficiency.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 6.9%. One incident involved a resident with type 1 diabetes who was supposed to receive 8 units of insulin Lispro based on a sliding scale for a blood sugar level of 389. However, the RN administered only 3 units and did not notify the provider, contrary to the physician's orders. The RN acknowledged the error and the potential risk of increased blood sugar due to the incorrect dosage. Another incident involved a resident with a diagnosis of idiopathic gout, hypothyroidism, and major depressive disorder. The LPN administered a 12.5 mg dose of Carvedilol instead of the prescribed 6.25 mg. The LPN admitted to not checking the updated physician's order and acknowledged the risk of overdose. The facility's policy requires adherence to the right resident, dosage, drug, route, documentation, and time, which was not followed in these cases.
Significant Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The resident, who was admitted with diagnoses including stage 4 chronic kidney disease, respiratory failure, and type 1 diabetes, had a physician's order for insulin Lispro to be administered according to a sliding scale. On a particular day, a registered nurse administered 3 units of insulin Lispro instead of the 8 units prescribed for the resident's blood sugar level of 398. The nurse documented inaccurately in the medication administration record, indicating that 8 units were given, and did not inform the physician of the deviation from the prescribed dosage. The nurse stated that the resident requested only 3 units, and she complied, believing it was the resident's decision. However, the physician clarified that while residents can refuse medication, they cannot decide the dosage. The facility's policy requires following physician orders as written and notifying the physician if a medication is administered outside of the order. The Director of Nursing confirmed that the facility's process was not followed, as the physician was not notified, and the incorrect dose was administered, which did not align with the facility's policy.
Inconsistent Glucometer Control Checks
Penalty
Summary
The facility failed to ensure that glucometer controls were consistently completed, as revealed during an observation on October 23, 2024. The Quality Control Record sheet on Unit Rich with medication Cart 2 showed that glucometer controls were not consistently completed. Interviews with various staff members, including the Assistant Director of Nursing (ADON), a Registered Nurse (RN), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that glucometer controls were not consistently completed on multiple days in August, September, and October 2024. The facility's manual for the glucometers indicated that there is a 24-hour quality control reminder feature, which was not adhered to, as evidenced by the flashing icon on the glucometers when quality control was not tested. The RN provided specific dates in August, September, and October 2024 when glucometer controls were not completed, highlighting a pattern of non-compliance with the facility's expectations. The LPN and DON both acknowledged the risk of not completing glucometer controls, which could lead to inaccurate readings. The DON stated that the night staff is responsible for checking glucometer controls, but the failure to do so was evident from the records and staff interviews. This deficiency in completing glucometer controls poses a risk of inaccurate glucose readings for residents, which could impact their care and treatment.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to appropriately implement their Enhanced Barrier Precaution (EBP) program for two residents, leading to a deficiency in infection prevention and control. Resident #38, who was admitted with paroxysmal atrial fibrillation, Type 2 Diabetes, and an open wound infection of the right artificial knee, did not have EBP orders initiated upon admission despite having a PICC line and receiving wound care. Similarly, Resident #64, admitted with Type 2 Diabetes, ulcers, dementia, and an indwelling catheter, also did not have EBP orders initiated at admission. Observations revealed that there were no EBP signs or PPE carts near the residents' rooms until several days after admission. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that EBP orders should have been initiated at admission for both residents due to their medical conditions. The IP acknowledged that EBP orders can be overlooked during weekend admissions, as she does not work on weekends. The facility's policy on Transmission-Based Precautions requires signage and PPE to be readily available for residents known or suspected to be infected or colonized with certain infectious agents, which was not adhered to in these cases.
Deficiency in Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure that three residents were free from preventable falls, leading to increased risks for serious injury and harm. Resident #5, who was admitted with severe cognitive impairment and a history of falls, experienced multiple unwitnessed falls resulting in major injuries, including a concussion and fractures. Despite being identified as high risk for falls, the care plan interventions were not updated following these incidents, and no new measures were implemented to prevent further falls. The resident continued to exhibit restlessness and a lack of safety awareness, yet the recommended intervention of a private sitter was not documented as being implemented. Resident #40, with a history of dementia and falls, also experienced multiple unwitnessed falls, including one resulting in a major injury with a mid-shaft fracture to the right leg. Although the resident was assessed as high risk for falls, the care plan did not reflect the fall with major injury, and no new interventions were added to address the increased risk. The resident's absence from the facility during a shift was not documented, and upon return, the resident required substantial assistance for transfers, indicating a lack of adequate supervision and fall prevention measures. Resident #24, diagnosed with dementia and Parkinson's disease, was identified as high risk for falls but experienced an unwitnessed fall with minor injury. The care plan included monitoring for 72 hours but did not incorporate further interventions post-monitoring. Observations revealed the absence of a fall mat in the resident's room, contrary to the care plan. Interviews with staff indicated inconsistencies in identifying and communicating fall risks, with some residents lacking visible indicators such as signs or wristbands. The Director of Nursing acknowledged the lack of new interventions following repeated falls, highlighting a deficiency in the facility's fall prevention program.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return after hospitalization, which constitutes a deficiency in their care practices. The resident, who had significant cognitive impairment and multiple diagnoses including dementia and bipolar disorder, was sent to the hospital due to altered mental status and labored breathing. The hospital case manager confirmed that the resident was ready to return to the facility, with no change in the level of care required. However, the facility refused to readmit the resident, citing ongoing issues with the family as the reason. Interviews with facility staff revealed differing perspectives on the decision not to readmit the resident. The Director of Nursing expressed concerns about the safety of bringing the resident back, referencing the resident's distress and emergency hospitalization. Meanwhile, the facility administrator cited threatening behavior from the resident's family towards staff and the building as the reason for their decision. This refusal to readmit the resident after hospitalization, despite the hospital's assessment that the resident was ready to return, highlights a failure in the facility's discharge and readmission practices.
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A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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