Haven Of Cottonwood
Inspection history, citations, penalties and survey trends for this long-term care facility in Cottonwood, Arizona.
- Location
- 197 South Willard Street, Cottonwood, Arizona 86326
- CMS Provider Number
- 035093
- Inspections on file
- 22
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Haven Of Cottonwood during CMS and state inspections, most recent first.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
Surveyors observed unsanitary conditions in shared resident restrooms and shower rooms, including feces on surfaces, dust, calcification, and a used urinal. An unlabeled chemical was found within resident reach, and vents and drains were unclean. A resident reported ongoing issues with restroom cleanliness and lack of staff response. The facility lacked an official housekeeping manager, and cleaning responsibilities were not adequately fulfilled according to policy.
The facility did not ensure that an RN was present for at least eight consecutive hours each day, as required. On several occasions, there was no RN coverage, and when an RN was unavailable, the DON or LPNs would cover shifts, which did not meet regulatory standards. Staff interviews confirmed awareness of the requirement and acknowledged that the facility's RN coverage was insufficient, particularly on weekends.
Surveyors found that the facility did not maintain accurate reconciliation and documentation of controlled substances, with missed and duplicate staff signatures, count inconsistencies, and incorrect dates in the narcotic logbook. Interviews with the DON, clinical resource staff, and an RN confirmed that these practices did not meet facility expectations for shift-to-shift narcotic counts.
Surveyors observed multiple failures in food safety and hygiene, including expired and improperly stored food, lack of hand hygiene by staff, and unsanitary kitchen equipment and surfaces. Staff interviews confirmed inconsistent cleaning practices and lack of oversight, with facility policies not being consistently followed.
A CNA failed to perform hand hygiene before and after obtaining a resident's vital signs and did not disinfect equipment as required. The CNA then entered another resident's room without sanitizing hands. Interviews with staff and review of facility policy confirmed that hand hygiene and device disinfection are expected before and after resident care to prevent infection transmission.
A resident with moderate cognitive impairment was subjected to inappropriate language by a nurse after a startling interaction. Although the incident was documented and the resident did not report feeling mistreated, the facility did not report the allegation of verbal abuse to the required authorities within the timeframe specified by policy, resulting in a deficiency related to timely reporting of suspected abuse.
The facility did not conduct comprehensive investigations into allegations of abuse and neglect involving three residents, including cases of verbal abuse by a staff member and a family member, and an allegation of neglect. Investigation reports lacked required interviews, witness statements, and documentation, failing to meet the facility's own policy standards.
A resident with multiple medical and mental health diagnoses did not have their participation in activities properly assessed or documented, despite having an activities care plan in place. The Activities Manager was unaware of the need for individual documentation and relied on memory to complete records, while the facility's system only tracked group attendance. Leadership confirmed that individual tracking was expected, and the resident was not informed about available activities, with no activity calendar present in their room.
Two residents with cognitive impairment and mobility issues were not adequately supervised or assessed, leading to one resident eloping from the facility on multiple occasions and another experiencing repeated falls without timely care plan updates or consistent neuro checks. Staff interviews and record reviews revealed missing assessments, incomplete documentation, and a lack of appropriate interventions, in violation of facility policies.
A resident with cognitive impairment and multiple diagnoses was administered Bupropion, a psychotropic medication, for several days before informed consent was obtained. The resident's representative later declined consent, and staff interviews confirmed that facility policy requires psychotropic consent prior to administration, which was not followed in this instance.
A resident with hepatic encephalopathy and alcoholic cirrhosis received Morphine Sulfate for pain levels below the prescribed threshold, as documented on the MAR. Both nursing staff and the DON confirmed that the medication was given outside the ordered pain scale, in violation of facility policy and prescriber instructions.
A resident with moderate cognitive impairment received Bupropion HCL ER for anxiety without documented informed consent from their representative. The medication was administered for three days before the representative declined consent, and facility staff confirmed that this was not in accordance with policy requiring consent for psychotropic use.
Surveyors found that two medication carts contained improperly stored and labeled medications, including unrefrigerated Lorazepam, bottles with crusted residue, missing open dates, and medications not in original containers. Staff interviews confirmed these practices were against facility policy, and both staff and residents expected medications to be stored and prepared in a clean, safe manner.
A resident with moderate cognitive impairment and multiple medical conditions was spoken to disrespectfully by a staff member, who told the resident to "please settle down and stop acting like a a**" after being startled during an interaction. Staff interviews and policy review confirmed that this language was inappropriate and not in accordance with professional conduct or resident rights standards.
The facility did not follow its policies for investigating abuse and neglect allegations, failing to conduct thorough investigations or adequately protect two residents from further harm. In both cases, required interviews and documentation were incomplete or missing, and actions to separate alleged perpetrators from residents were not consistently documented. Staff interviews confirmed awareness of policy requirements, but the necessary steps were not followed in these incidents.
A resident with multiple medical and psychiatric diagnoses was transferred to the hospital for COVID-19-related symptoms and remained hospitalized for an extended period. The facility failed to document or provide required notification to the resident's public fiduciary regarding the transfer and hospital admission, despite policy and staff statements indicating this is standard procedure. The deficiency was identified through record review, staff interviews, and a complaint from the responsible party.
A resident with documented cognitive impairment and a history of being unable to make decisions was admitted with multiple diagnoses, including severe protein-calorie deficit. Despite clear evidence of cognitive issues from hospital records and facility staff observations, the MDS admission assessment was incomplete, lacking both a BIMS score and staff assessment for mental status. Staff interviews confirmed the resident's confusion and wandering behavior, but required cognitive assessments were not performed as outlined in facility policy and the RAI manual.
A resident with cognitive impairment and communication deficits was admitted with multiple complex diagnoses. Despite documentation of cognitive issues and a history of confusion, the care plan only addressed communication challenges related to jaw carcinoma and did not include interventions for cognitive impairment. The omission was evident when the resident was found outside the facility on two occasions after becoming confused, and staff interviews confirmed the lack of appropriate care planning for cognitive deficits.
A resident with multiple diagnoses and a history of falls experienced repeated falls and behavioral changes over several weeks. Despite ongoing incidents and interventions such as 1:1 supervision and environmental modifications, the care plan was not updated to reflect these changes. Staff interviews and record review confirmed that the care plan was not revised as required after each fall or significant change in condition.
A resident with multiple complex diagnoses experienced several falls and changes in condition, but the facility failed to maintain complete and accurate medical records. Documentation was missing for neuro checks, progress notes, and notifications to the provider and family after several incidents, despite facility policy and staff interviews confirming these actions were required.
A resident with multiple medical conditions experienced a fall resulting in right arm discomfort and limited mobility. Although a provider ordered a right arm x-ray to rule out fracture, the x-ray was never completed due to a documentation error by nursing staff. The order was not followed, and the omission was only discovered later during a review of the clinical record and staff interviews.
A resident with complex medical and mental health needs exhibited significant behavioral changes after readmission. Although a psychiatric consultation was ordered and a telehealth visit occurred, the psychiatric provider's notes were not present in the medical record at the time of review. Staff confirmed the visit took place and that records were requested, but the absence of timely documentation resulted in an incomplete medical record, contrary to facility policy and federal requirements.
A resident with significant medical needs and a physician order for weekly weight monitoring did not have weights taken or documented as required. Only a single weight, entered by a dietary consultant using prior hospital data, was found in the record. Staff interviews confirmed that the expected process for obtaining and recording weights was not followed, and there was no documentation of refusal by the resident.
Two residents in the facility did not receive wound care as ordered by their physicians, leading to a deficiency in care. One resident, who was cognitively intact, had her wound care neglected, with the last bandage change noted several days past the scheduled time. Another resident with osteomyelitis and cellulitis had a blood-soaked bandage that was overdue for changing. Staff admitted to signing off on care that was not provided, violating the facility's documentation policy and potentially risking wound infections.
The facility failed to provide adequate nail care and shower assistance to two residents, leading to concerns about poor hygiene and potential infection. A resident with chronic conditions was observed with long, dirty fingernails, and received only one shower per week, contrary to the facility's policy. Staff interviews revealed inconsistencies in documentation and monitoring, with missing shower sheet forms and lapses in record-keeping.
The facility failed to implement enhanced barrier precautions for two residents with indwelling catheters, as staff did not wear gowns during high-contact care activities. Despite following hand hygiene and glove protocols, the lack of gown use during catheter care was observed. Interviews revealed that staff had not been trained on the new EBP guidelines, which require gowns and gloves for high-contact activities, regardless of MDRO status.
A facility failed to obtain a physician order for an indwelling catheter for a resident admitted with acute cystitis and acute kidney failure. Despite the care plan indicating the catheter's use for bladder outlet obstruction, no physician order was documented from admission until several days later. Observations and staff interviews confirmed the catheter's presence without an order, contrary to facility policy requiring documentation of clinical indications and ongoing assessment.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Maintain Clean and Sanitary Resident Restrooms and Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and safe environment in the residents' shower rooms and a shared bathroom on the 200-Hall. During a walkthrough with the Maintenance Supervisor and Maintenance Manager, surveyors observed feces on the inside of the commode, on the handrail, and on the floor, as well as dust and calcification in the toilet bowl and a used, stained urinal in a shared restroom used by female residents. In the 200-Hall shower room, an unlabeled blue chemical was found within reach of residents, and the shower drains contained soap scum and hair. The shower room vent was covered in a thick layer of black and grayish substance. These conditions were directly observed by staff and surveyors. A resident expressed dissatisfaction with the cleanliness of the shared restroom, stating that feces were present on the floor and that staff had been alerted but took no action to resolve the issue. Interviews with the Maintenance Supervisor and Maintenance Manager revealed that there was no official housekeeping manager at the time, and the maintenance manager was covering the position. Facility documentation and policies indicated that maintaining a clean and safe environment is the responsibility of the Environmental Services Manager and Housekeeper, and that cleaning and disinfection should occur regularly and when surfaces are visibly soiled.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Review of facility documentation, including the facility assessment and RN punch detail records, revealed multiple dates where there was no evidence of RN coverage for the required period. The facility assessment indicated that staffing should include at least one RN per 24-hour period, with assignments based on patient care needs. However, on specific dates, there was no RN coverage documented, and the staffing coordinator confirmed that RN coverage was not consistently met. When an RN was unavailable, the Director of Nursing (DON) would occasionally cover the RN floor nurse role, and at other times, LPNs or the staffing coordinator would fill in, despite being aware that this did not meet the facility's expectations or regulatory requirements. Interviews with the staffing coordinator and DON confirmed awareness of the requirement for RN coverage and acknowledged that the facility did not always meet this standard. The clinical resource staff also noted that the facility had lower RN hours, particularly on weekends, compared to competitors, and that this issue would be addressed in future quality performance discussions. The census during the review period ranged from 38 to 67 residents, with a sample of 20 residents reviewed. The lack of consistent RN coverage could result in residents not receiving advanced care activities to meet their needs, as stated in the report.
Failure to Ensure Accurate Narcotic Reconciliation and Documentation
Penalty
Summary
The facility failed to maintain proper safeguards and systems for the accurate reconciliation and accounting of controlled substances. During an observation of Medication Cart #1's narcotic logbook, surveyors identified several discrepancies in the Shift to Shift Narcotic Sheet & Card Verification for a period in May. These included count inconsistencies over multiple days, six missed staff signature entries, duplicate signature entries, and an incorrect year written on the log sheet. Interviews with the DON, clinical resource staff, and an RN confirmed that the facility's expectation is for two licensed nurses to sign off on narcotic counts at each shift change, and that the missing or duplicate signatures did not meet facility standards. Facility policy requires the DON to supervise all personnel administering medications and mandates that medication-related issues be reviewed as part of the quality assurance and performance improvement process. Despite these policies, the observed documentation failures and inconsistencies in narcotic counts indicate that the required procedures were not consistently followed, leading to a deficiency in the facility's pharmaceutical services.
Deficient Food Safety, Storage, and Hygiene Practices in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety, storage, and hygiene practices in the kitchen, as evidenced by multiple observations of expired, improperly sealed, and undated food items. During a kitchen inspection, surveyors found cooked bacon wrapped in tinfoil without date labeling, strawberries with visible mold, and bags of lettuce and green onions that were either unsealed, undated, or past their use-by dates. Additionally, a staff member was observed discarding and then retrieving bacon from the trash, then handling food without washing hands or wearing gloves, and failing to perform hand hygiene between tasks. Further inspection revealed that kitchen equipment and surfaces were not maintained in a sanitary condition. The interior and exterior of the ice machine had visible dirt and dust buildup, and the large mixer and gas range were found with food splatter, grease, and dust. Cleaning logs indicated that some equipment, such as refrigerators and the ice machine, had not been cleaned for several weeks. Ceilings, vents, and lights in the kitchen and freezer room were also covered in dust, dirt, and cobwebs, with no documented cleaning schedule for these areas. Interviews with staff, including the cook, dietary aide, maintenance manager, DON, dietary manager, and executive director, confirmed inconsistent cleaning responsibilities and a lack of supervisory oversight or documentation for food checks and cleaning tasks. Facility policies required proper food storage, dating, and regular cleaning of equipment, but these were not consistently followed. The facility was unable to provide a policy for cleaning kitchen ceilings and lights, further contributing to the deficiency.
Failure to Follow Hand Hygiene and Infection Control Practices During Resident Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed failing to perform hand hygiene before and after obtaining a resident's vital signs near the nursing station. The CNA did not sanitize or wash his hands prior to or after providing care, and after recording the vital signs, proceeded to enter another resident's room without sanitizing his hands. The CNA acknowledged during an interview that he did not follow the facility's hand hygiene expectations, which require handwashing before and after resident contact and when obtaining vital signs, as well as disinfecting the equipment used. Another CNA confirmed the facility's expectations for hand hygiene and device disinfection when providing care or obtaining labs. The Director of Nursing/Infection Preventionist (DON/IP) and a Clinical Resource staff member reiterated that hand hygiene is required before and after all patient care activities, including obtaining vital signs, and that equipment disinfection is equally important. The facility's infection control policy also outlines specific situations requiring hand hygiene, emphasizing its role in preventing the spread of infection.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of verbal abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including dementia and nervous system degeneration. On the evening of November 8, 2021, a registered nurse used inappropriate language toward the resident after being startled by the resident's actions. The incident was documented in a health status note, and the resident did not express offense or dissatisfaction with care during subsequent interviews. However, the facility did not report the allegation to the required authorities until November 16, 2021, several days after the incident occurred. Interviews with facility staff confirmed that the policy requires immediate reporting of suspected abuse, with some staff specifying a two-hour timeframe for such reports. The facility's abuse policy outlines the need for prompt reporting and investigation to protect residents. Despite these policies, the delay in reporting the incident to the appropriate entities constituted a failure to follow established procedures for handling allegations of abuse.
Failure to Conduct Thorough Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and neglect involving three residents. For one resident with hypotension, chronic kidney disease, and nocturia, an allegation of neglect was reported to the State Agency, but the facility did not submit a comprehensive investigation. The 5-day investigation report lacked interviews with residents and staff, did not include witness statements, and failed to specify when interviews were conducted or identify witnesses. In another case, a resident with monoplegia, chronic heart failure, and depression experienced a family-to-resident verbal abuse incident. The clinical record documented the resident's depression and suicidal ideation but did not reference the incident with the family member or indicate any monitoring or visitation restrictions. The facility's investigation report was undated, did not include interviews with witnesses, the alleged perpetrator, or staff, and lacked witness statements and interview details. A third incident involved a resident with hypotension, unsteadiness, nervous system degeneration, and dementia, who was verbally abused by a staff member. The facility reported the incident but the investigation report did not include witness statements or interviews with other residents to determine if there was a trend. The staff member involved was suspended and educated, but the investigation did not meet the facility's policy requirements for thoroughness, as outlined in their abuse policy.
Failure to Assess and Document Resident Activity Participation
Penalty
Summary
The facility failed to properly assess and monitor the activities program for one resident with multiple diagnoses, including chronic obstructive pulmonary disease, above-knee amputation, depression, and anxiety disorder. The resident was cognitively intact and had an activities care plan that included providing leisure supplies, introducing the resident to others with similar interests, modifying schedules as needed, offering a variety of activities, and reassessing preferences. However, documentation of the resident's participation in activities was lacking, with task sheets for various activities showing no entries for the past thirty days, and activity tracking only indicating limited participation in movies/TV and occasional group activities. Interviews with the Activities Manager revealed that she was unaware of the requirement to document each resident's participation in activities and that the documentation system had only recently become operational. The Activities Manager admitted to not having documentation for any residents and relied on memory to complete activity records retroactively. The activities list provided only showed aggregate attendance numbers without identifying individual residents, making it impossible to monitor or evaluate specific residents' engagement or changes in participation. Further interviews with facility leadership confirmed that there was an expectation for the Activities Manager to track and review individual resident participation in activities, as this information is necessary to identify trends or concerns such as depression. The resident in question expressed interest in attending group activities depending on the type but was unaware of the current activity offerings, and no activity calendar was present in the resident's room. The facility's policy required monitoring and evaluating residents' responses to activities and revising approaches as appropriate, which was not followed in this case.
Failure to Prevent Elopement and Repeated Falls Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to ensure adequate supervision and accident prevention for two residents, resulting in deficiencies related to elopement and repeated falls. One resident with a history of cognitive impairment, communication deficits, and a public fiduciary was admitted without a completed cognitive assessment or care plan addressing his impaired cognition. Despite documentation from hospital records and therapy evaluations indicating cognitive impairment and the need for a guardian, the facility did not initiate interventions to mitigate risks associated with his condition. The resident was found ambulating alone on the street on two separate occasions, with staff only implementing a wander guard and behavioral care plan after these incidents. There was no evidence of a timely wandering risk evaluation, supervision/monitoring logs, or an investigation file for the elopement events, contrary to facility policy requirements. Another resident, re-admitted with diagnoses including Parkinson's disease, traumatic brain injury, dementia, and abnormal gait, experienced multiple falls shortly after admission. The resident's care plan was not updated with new interventions for an extended period despite repeated falls, and there was no evidence of neuro check logs during the admission period. Documentation revealed the resident was highly confused, unable to use the call light, and required frequent monitoring and 1:1 supervision at times, but the facility did not consistently implement or document these interventions. Staff interviews confirmed that care plan updates and supervision were lacking during a period of repeated falls, and that the facility did not employ 1:1 supervision due to staffing limitations, even when it was indicated as necessary. Facility policies required prompt assessment, documentation, and investigation of accidents and incidents, as well as individualized fall prevention plans and immediate safety strategies for residents with cognitive or behavioral risks. However, the facility did not follow these protocols for the residents in question, as evidenced by missing assessments, incomplete care plans, lack of documentation, and failure to implement or document appropriate interventions after repeated incidents. These actions and omissions resulted in residents being exposed to preventable accidents and inadequate supervision.
Psychotropic Medication Administered Without Prior Consent
Penalty
Summary
A resident with diagnoses including atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit was admitted to the facility. The resident had impaired cognition as indicated by a BIMS score of 10 and no recent depressive symptoms per the Resident Mood Interview. The care plan included administration of antidepressant medication for depression. An order for Bupropion HCL Extended Release for anxiety was initiated, and the medication was administered to the resident over a three-day period. However, the required informed consent for the psychotropic medication was not obtained prior to administration. The resident's representative declined consent for Bupropion after the medication had already been given. Interviews with facility staff, including an LPN, the clinical resource, and the DON, confirmed that facility policy mandates obtaining psychotropic medication consent before administration, and this expectation was not met in this case. Facility policies also state that residents have the right to be informed and to decline treatment with psychotropic medications.
Pain Medication Administered Outside of Prescribed Parameters
Penalty
Summary
Staff failed to administer pain medication according to the prescribed parameters for a resident with hepatic encephalopathy and alcoholic cirrhosis of the liver with ascites. The physician's order specified Morphine Sulfate 5 mg by mouth every 3 hours as needed for pain levels between 7 and 10. However, documentation on the medication administration record (MAR) showed that the medication was given three times for pain levels of 6, 3, and 6, which were outside the ordered pain scale parameters. Interviews with the registered nurse and the Director of Nursing confirmed that the medication was administered outside of the specified pain scale, contrary to facility policy and prescriber orders. Both staff members acknowledged that PRN pain medication orders require adherence to dosage, frequency, and pain scale, and that the MAR should reflect the pain level and effectiveness of the medication. The facility's policy requires medications to be administered in accordance with prescriber orders, including any required time frame.
Psychotropic Medication Administered Without Consent
Penalty
Summary
A resident with diagnoses including atrial fibrillation, dementia with mood disturbance, anxiety, muscle weakness, and cognitive communication deficit was admitted to the facility. The resident had a BIMS score indicating moderate cognitive impairment. An order for Bupropion HCL Extended Release was written for anxiety, and the medication was administered to the resident over three days. The clinical record did not show that consent was obtained from the resident or their representative prior to starting the medication. On the third day of administration, the resident's representative declined informed consent for the psychotropic medication, after which the medication was discontinued. Interviews with the resident's representative, an RN, the Clinical Resource, and the DON confirmed that the medication was given without proper consent, which was against the family's wishes and contrary to facility policy. The facility's policy stated that residents have the right to decline treatment with psychotropic medications.
Improper Medication Storage and Labeling in Medication Carts
Penalty
Summary
Surveyors observed that two of four medication carts contained medications that were not stored according to professional standards and facility policy. Specifically, an unrefrigerated vial of Lorazepam labeled to be kept refrigerated was found in the narcotic storage area, and several medication bottles, including Geri-Tussin, Milk of Magnesia, Wild Cherry Pro-Stat, Geri-Lanta, and Pepto Bismol Ultra, were found with crusted residue, missing labels, or missing open dates. Additionally, a medicine cup containing two Zofran tablets was found in a cart drawer, not in its original container. These findings were confirmed during interviews with the DON and staff, who acknowledged that these practices were against facility policy and expectations. Further interviews with staff and residents indicated an expectation that medications are prepared and stored in a clean and safe environment. The facility's own policy requires medications to be stored in their original containers, with proper labeling and dating, and for medication storage areas to be kept clean and sanitary. The observed deficiencies demonstrated a failure to adhere to these standards, as evidenced by improper storage, lack of labeling, and unsanitary conditions in the medication carts.
Failure to Treat Resident with Respect and Dignity
Penalty
Summary
A resident with diagnoses including hypotension, unsteadiness, nervous system degeneration due to alcohol, and unspecified dementia was involved in an incident where a staff member used disrespectful language. During an interaction, the resident, who had a moderate cognitive impairment as indicated by a BIMS score of 12, expressed frustration and raised his hand at a nurse. The nurse, startled by the resident's actions, responded by telling the resident to "please settle down and stop acting like a a**." This exchange was documented in the resident's health status note and was later reported as a facility event. Interviews with staff and review of facility policies confirmed that such language is considered inappropriate and not in line with the expected standards of professional conduct or resident rights, which require all residents to be treated with kindness, respect, and dignity. The incident was acknowledged by the staff member involved, and other staff interviewed agreed that the language used was disrespectful and not acceptable according to facility policy.
Failure to Implement Abuse and Neglect Investigation Policies
Penalty
Summary
The facility failed to implement its policy regarding the thorough investigation of abuse and neglect allegations and did not adequately protect residents from further abuse in two separate cases. In the first case, a resident with hypotension, chronic kidney disease, and nocturia was the subject of a neglect allegation involving a CNA who reportedly told the resident not to use the call light for at least an hour. The facility's self-report lacked details about the incident and the alleged perpetrator, and there was no documentation in the clinical record regarding the incident, assessment, or required notifications. The subsequent investigation did not include interviews with other residents or staff, lacked witness statements, and failed to specify when interviews were conducted or who the witnesses were. The investigation concluded no neglect occurred, but the CNA involved had a documented history of poor performance and was later terminated for a separate incident. In the second case, a resident with monoplegia, chronic heart failure, and depression was involved in an incident of alleged verbal abuse by a family member. The facility's self-report did not indicate whether the family member was separated from the resident during the investigation. While progress notes showed the resident was separated from the spouse and the incident was reported to the physician, administrator, and DON, there was no documentation of follow-up regarding the resident's interaction with the spouse or any limitations on visitation. The investigation report did not include interviews with the alleged perpetrator or potential witnesses, and summaries of interviews lacked details about timing and witness identity. Staff interviews revealed an understanding of the importance of following policies to ensure resident safety and thorough investigations, but staff were unfamiliar with the specific incidents. The facility's policy required immediate suspension of alleged employee perpetrators and interviews with a minimum of three residents to identify trends, but these steps were not consistently documented or followed in the cases reviewed.
Failure to Notify Responsible Party of Resident Transfer and Hospital Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that all required notifications regarding a resident's transfer and discharge were made. The resident in question had multiple diagnoses, including hyperlipidemia, bipolar disorder, anxiety disorder, and gastro-esophageal reflux disease, and had a public fiduciary listed as the responsible party, guardian, and emergency contact. Documentation reviewed showed that while a discharge assessment indicated the responsible party was notified, it did not specify who was notified or when. There was no documentation in the order summary report or progress notes indicating that the responsible party was informed of the resident's transfer to the hospital or subsequent admission. Further review revealed that the resident was transferred to the emergency room due to COVID-19 symptoms and low oxygen saturation, and was admitted to the hospital for a prolonged stay. The resident did not return to the facility until over two weeks later. During this period, there was no evidence in the medical record that the public fiduciary was notified of the transfer or hospital admission. A complaint was submitted to the State Agency by the responsible party, stating that they were not informed of the resident's transfer until a care conference, and that the facility did not accurately communicate the resident's status. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the standard practice is to notify the responsible party or public fiduciary prior to a resident's transfer and to document this notification in the medical record. The staff acknowledged the importance of this communication and indicated that failure to notify is inappropriate. Facility policy also requires documentation of notification to the resident and/or legal representative when a transfer or discharge occurs, including in emergency situations. However, in this case, the required notifications and documentation were not completed.
Failure to Complete Comprehensive MDS Assessment for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for a resident who was admitted with significant cognitive impairment and a history of being unable to make his own decisions. Hospital records prior to admission documented the resident's incompetence and need for a public fiduciary, as well as a history of cognitive impairment. Upon admission, the resident was noted to have diagnoses including malignant neoplasm of the mandible, temporomandibular joint disorder, and severe protein-calorie deficit. Facility documentation, including a speech therapy evaluation and progress notes, further confirmed the resident's cognitive impairment and poor ability to provide his own history. Despite this, the MDS admission assessment did not include a Brief Interview for Mental Status (BIMS) score, and both the cognitive patterns section and the staff assessment for mental status were left blank. Interviews with facility staff, including a CNA, LPN, and the DON, confirmed that the resident exhibited confusion and had episodes of wandering, with one incident involving the resident leaving the facility and being found a mile away. Facility policy and the RAI manual require comprehensive assessment of cognition and behavior to identify care needs and risks, but these were not completed as required for this resident.
Failure to Address Cognitive Impairment in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan addressing a resident's cognitive communication deficit. The resident was admitted with multiple diagnoses, including malignant neoplasm of the mandible, temporomandibular joint disorder, and severe protein-calorie deficit. Hospital records and a speech therapy evaluation documented the resident's cognitive impairment and the presence of a guardian or public fiduciary. Progress notes and the Minimum Data Set (MDS) assessment further indicated cognitive and communication difficulties, but the MDS lacked a Brief Interview for Mental Status (BIMS) score and omitted staff assessment for mental status. Although a communication care plan was initiated, it only addressed the resident's jaw carcinoma and related communication challenges, without incorporating interventions for the cognitive impairment. There was no evidence in the care plan or clinical record that the resident's cognitive deficits were specifically addressed or that interventions were implemented to mitigate associated risks. This omission was contrary to facility policy, which requires comprehensive, person-centered care plans with measurable objectives and timetables based on ongoing assessments. The lack of appropriate care planning for cognitive impairment was highlighted by two incidents where the resident was found outside the facility, having become confused and lost while ambulating. Staff interviews confirmed the importance of care planning for known deficits and the potential for negative outcomes when such plans are not in place. Facility policies also emphasized the need for behavioral assessment and immediate safety strategies for residents with impaired cognition, which were not reflected in the resident's care plan.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised in response to ongoing falls and changes in condition. The resident, who was re-admitted with multiple complex diagnoses including Parkinson's disease, dementia, traumatic brain injury, and a history of falls, experienced repeated falls and behavioral issues over a period of several weeks. Despite multiple documented incidents of falls, changes in mental status, and recommendations for increased supervision and interventions, the care plan was not updated to reflect these events between February 9 and March 4. Documentation shows that the resident was highly confused, unable to use the call light, and exhibited behaviors such as wandering, attempting to self-transfer, and removing medical devices. The resident had several falls, some resulting in injury or requiring hospital evaluation, and staff implemented various interventions such as 1:1 supervision, use of a wander guard, and environmental modifications. However, these interventions and the resident's changing needs were not consistently reflected in the care plan during the identified period. Interviews with staff confirmed that the expectation was to update the care plan after each fall or significant change, and the Director of Nursing acknowledged that the care plan lacked necessary updates during the period of repeated falls. Review of facility policy also indicated that care plans should be revised as residents' conditions change, but this was not done for the resident in question, resulting in a deficiency related to care planning and resident safety.
Incomplete and Inaccurate Medical Record Documentation After Multiple Falls
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, as required by accepted professional standards. The resident, who had a history of Parkinson's disease, traumatic brain injury, dementia, abnormal gait, cognitive communication deficit, anxiety disorder, and required assistance with personal care, experienced multiple falls and changes in condition during their admission. Despite these incidents, there were significant gaps in the documentation, including missing neuro check logs, incomplete progress notes, and lack of evidence that notifications to the medical provider and family were made after several falls and changes in condition. Specific events included the resident being found on the floor multiple times, attempting to ambulate without assistance, and exhibiting confusion and forgetfulness. On several occasions, the resident was observed to have fallen or attempted to get out of bed or a wheelchair, sometimes resulting in injuries such as a skin tear or the removal of a Foley catheter with the balloon still inflated. Despite these incidents, the medical record often lacked documentation of assessments, neuro checks, and notifications to the provider and family, as required by facility policy and standard practice. Interviews with nursing staff and the Director of Nursing confirmed that the expected protocol after a fall includes assessment, documentation in the medical record, completion of an incident report, and notification of the provider and family. Review of the facility's documentation policy further emphasized the need for complete and accurate records, including details of care provided, assessments, and notifications. However, the review of the resident's clinical record revealed multiple instances where these requirements were not met, leading to incomplete and inaccurate documentation of the resident's care and condition.
Failure to Complete Ordered Post-Fall X-ray Assessment
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not following a physician's order for an x-ray assessment after a resident experienced a fall. The resident, who had a history of pneumonia, end-stage renal disease, acute pulmonary edema, hemiplegia, hemiparesis, and dysarthria, was noted to have rolled out of bed, resulting in discomfort and difficulty moving his right arm. A physician was notified and ordered an x-ray of the right arm to rule out a fracture. However, there was no evidence in the clinical record that the x-ray was completed, and documentation in the electronic medication administration record did not indicate that the x-ray was performed. Interviews with facility staff revealed that the process for obtaining an x-ray involved sending the order to a mobile x-ray company and scheduling the procedure. A nurse acknowledged that the x-ray was not completed and attributed the oversight to a documentation error, noting that once an order is charted on, it disappears from the system. The Director of Nursing confirmed that the x-ray was not done and that the issue was related to documentation by the floor nurse. Facility policy requires that a current list of orders be maintained in the clinical record and that all medication administration be documented immediately after administration.
Incomplete Medical Record for Resident Following Psychiatric Consultation
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurate, and readily accessible, as required by federal regulations and facility policy. The resident in question had a complex medical history, including surgical aftercare, urinary tract infection, functional quadriplegia, and multiple mental health diagnoses. Upon readmission, the resident exhibited significant behavioral and cognitive changes, including self-transferring, unusual behaviors with personal and facility items, and emotional distress. The care plan included a referral to a mental health professional for trauma assessment and treatment. Despite documentation indicating that a psychiatric consultation was ordered and a telehealth appointment was conducted, there was no evidence in the clinical record that the psychiatric provider was consulted, evaluated the resident, or made any recommendations. Progress notes from staff confirmed that the telehealth visit occurred and that multiple attempts were made to obtain the visit notes from the contracted psychiatric provider. However, the psychiatric consultation records were not present in the resident's medical record at the time of review. Interviews with staff, including the CNA responsible for scheduling appointments, the Medical Records Manager, and the DON, confirmed that the psychiatric visit notes had not been received or uploaded into the electronic medical record in a timely manner. The facility did not have a policy specifying a required timeframe for uploading consult and visit notes. The absence of these records meant that the medical record was incomplete and did not fully document the services provided or the resident's response to care, as required by facility policy and federal regulation.
Failure to Monitor Resident Weight per Physician Orders
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including hemiplegia, dysphagia, acute respiratory failure, and malnutrition risk, did not receive weight monitoring as ordered by the physician. The care plan and physician orders specified that the resident was to be weighed upon admission and then weekly for four weeks, in accordance with facility protocol. However, a review of the clinical record, medication and treatment administration records, and weight logs revealed that only one weight was documented, which was entered by a dietary consultant using a previous hospital record rather than an actual weight taken at the facility. Interviews with staff, including CNAs, a registered dietician, and the dietary consultant, confirmed that the expected process was for CNAs or nurses to obtain and document resident weights in the electronic medical record. The dietary consultant clarified that her entry was a placeholder based on hospital data, not a current assessment. There was no documentation of the resident refusing weight assessments, and staff acknowledged that the required weekly weights were not performed as ordered. The facility's policy required monitoring and recording of resident weights to detect undesirable or unintended weight changes. Both the current and former DONs confirmed that the resident's weight monitoring order was not followed, and that the omission did not meet facility expectations. The lack of documented weights meant that the resident's nutritional status and response to enteral feeding could not be properly monitored during the relevant period.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered by a physician for two residents, leading to a deficiency in care. Resident #1, who was cognitively intact, was supposed to have wound care on her right surgical area every three days. However, records showed that between November 19, 2024, and December 4, 2024, the wound care was not provided as frequently as ordered. Interviews with the resident and staff confirmed that the bandage had not been changed according to the schedule, with the last change noted on November 29, 2024. Staff admitted to signing off on care that was not provided, indicating a lapse in following the prescribed wound care regimen. Resident #2, diagnosed with osteomyelitis and cellulitis, also did not receive wound care as ordered. The physician's orders required wound care to the right ankle every three days, but observations on December 4, 2024, revealed a blood-soaked bandage dated November 28, 2024. This indicated that the wound care was overdue. Staff acknowledged the oversight, noting that the bandage needed changing and that the outgoing nurse had not completed the task during her shift. The facility's policy on wound care documentation was not adhered to, as staff documented care that was not provided. The policy required that wound care be documented after it was given, ensuring accuracy and completeness in the medical records. The failure to follow these procedures could lead to potential wound infections, as noted by staff during interviews.
Deficient Shower and Nail Care Documentation
Penalty
Summary
The facility failed to provide adequate nail care and shower assistance to two residents, leading to concerns about poor hygiene and potential infection. Resident #41, who has chronic kidney disease, Type II diabetes, and an acquired absence of the left leg below the knee, was observed to have long, stained fingernails with dirt underneath. The resident's care plan indicated a need for substantial assistance with bathing, yet the shower task sheets for March and April 2024 showed that the resident received only one shower per week, contrary to the facility's policy of two showers per week. There was no documentation of showers or nail care being offered or refused during this period. Interviews with staff revealed inconsistencies in documentation and monitoring of shower and nail care. A CNA stated that showers, which include nail care, were scheduled twice a week, and any refusals should be documented. However, the Medical Records Manager could not find any shower sheet forms for the last two weeks for Resident #41. The DON acknowledged the issue with documentation and stated that both task sheets and shower sheet forms were being used to ensure proper record-keeping. Despite these measures, the Direct Care Coordinator responsible for reviewing these forms was occupied with other duties, leading to lapses in monitoring and documentation.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff used appropriate enhanced barrier precautions (EBP) for two residents, which could result in the transmission of infections. Resident #172, who was admitted with acute cystitis and acute kidney failure, had an indwelling catheter for bladder outlet obstruction. During an observation, a certified nursing assistant (CNA) performed catheter care without wearing a gown, despite handling the catheter and performing high-contact care activities. The CNA washed her hands and donned gloves but did not follow the EBP guidelines that require wearing a gown during such procedures. Similarly, Resident #23, admitted with generalized muscle weakness and urinary incontinence, also received catheter care without the CNA wearing a gown. The CNA followed hand hygiene protocols and used gloves but did not adhere to the EBP guidelines. There were no signs posted to indicate the necessary personal protective equipment (PPE) for catheter care, and the CNA confirmed that gowns were only worn when a resident was on isolation. Interviews with the Director of Nursing (DON) and the President of Clinical Operations revealed a lack of training on PPE requirements for high-contact care activities involving residents with indwelling medical devices. The facility's infection control policy required staff education on infection control and isolation precautions, but the DON admitted that training on the new EBP guidelines had not been provided. The CMS guidance on EBP, updated in March 2024, emphasized the need for gowns and gloves during high-contact care activities, regardless of the resident's multidrug-resistant organism status.
Lack of Physician Order for Indwelling Catheter
Penalty
Summary
The facility failed to ensure there was a physician order for the use of an indwelling catheter for a resident, which could result in inappropriate use of the catheter for residents who do not need them. The resident was admitted with diagnoses of acute cystitis without hematuria and acute kidney failure. Despite the care plan indicating the presence of an indwelling catheter for bladder outlet obstruction, there was no physician order for the catheter from the time of admission until several days later. The Minimum Data Set (MDS) assessment did not code for an indwelling catheter, and the history and physical progress note did not document the presence of the catheter. Observations and interviews with staff revealed that the resident had an indwelling catheter, but the clinical record lacked a physician order for its use. A CNA was observed performing catheter care, and an LPN confirmed the absence of a physician order during a review of the electronic record. The Director of Nursing stated that a physician order was necessary for the use of an indwelling catheter and that staff should verify admission orders and contact the physician if needed. The facility's policy required documentation of clinical indications for catheter use prior to insertion and ongoing assessment of the need for the catheter.
Latest citations in Arizona
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
