Haven Of Safford
Inspection history, citations, penalties and survey trends for this long-term care facility in Safford, Arizona.
- Location
- 1933 Peppertree Drive, Safford, Arizona 85546
- CMS Provider Number
- 035172
- Inspections on file
- 16
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Haven Of Safford during CMS and state inspections, most recent first.
A resident with a history of behavioral issues and prior attempts to hit staff became agitated after family left the building and later confronted another resident with quadriplegia and intact cognition in a hallway. Witnesses, including staff and another resident, reported that the aggressive resident yelled at and then physically struck the disabled resident, and while being escorted away, also struck a second resident with dementia and moderate cognitive impairment who was seated in a doorway. The second resident was later observed with reddish/grey marks and a documented scratch/abrasion on the forearm, but the clinical records for both victims contained no incident documentation, despite multiple staff and resident accounts and police involvement. The DON and social services staff confirmed that the aggressive behavior constituted abuse under the facility’s abuse-prevention policy and acknowledged that required documentation in the clinical records was not completed, resulting in a failure to protect residents from abuse and to properly document the events and injuries.
A resident with moderate cognitive impairment and multiple comorbidities asked a staff member to help set up a checking account not linked to family, resulting in two $500 transfers intended to establish a new account in the resident’s name. The account was never created, and the funds were instead sent to the staff member, who minimized the issue when the resident repeatedly requested the money back. The resident reported feeling abused, taken advantage of, embarrassed, and betrayed, while the DON and an RN acknowledged that the incident met the definition of financial abuse under the facility’s abuse, neglect, exploitation, and misappropriation prevention policy.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in a bed with one resident’s shirt off and the other hovering over them. Staff acknowledged that both residents were not alert and oriented and could not consent, and one nurse had previously documented kissing behavior between them and recommended separating or moving them. Despite this, the facility did not revise either resident’s care plan to address the sexual behaviors, did not document the incident in progress notes beyond a single behavior entry, did not change room assignments even though their rooms were directly across from each other, and did not submit a facility-reported incident to the state agency, contrary to its abuse, neglect, and exploitation prevention policy requiring investigation, reporting, and protection of residents during investigations.
Two cognitively impaired residents, one with severe Alzheimer’s and one with dementia and a history of sexually inappropriate behavior, were housed in rooms directly across from each other. One day, staff later documented that one resident was found in the other’s bed with her shirt off while the other resident hovered over her, after prior notes had described kissing and the need for close supervision and redirection. Multiple staff acknowledged that the resident in bed could not consent to sexual activity, yet the abuse coordinator and DON concluded there was no abuse and did not report the incident as an allegation of abuse to the State Agency, despite a facility policy requiring investigation and reporting of any allegations within federal timeframes. Care plans for both residents were not revised to address the documented sexual behaviors, and progress notes lacked documentation of the incident and the female resident’s tendency to expose her breasts, leading to a cited deficiency for failure to timely report suspected abuse and the investigation results to proper authorities.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in one resident’s room, with one resident in bed, shirt off, and the other hovering over her after staff briefly lost sight of them. Staff acknowledged that neither resident could consent, but documentation in the clinical record lacked detailed notes about the incident, additional skin assessments around the time of the event, or revisions to either resident’s care plan to address sexual behaviors. The facility’s internal investigation was limited to a few staff statements, did not reflect broader evidence collection as outlined in the SOM, did not result in documented protective measures despite staff concerns about room proximity, and the incident was not reported to the State Agency as required by facility policy and federal guidelines.
Surveyors identified that the facility did not consistently follow procedures for controlled substance reconciliation, as multiple narcotic count sheets and shift change sign-off sheets were missing one or both required nurse signatures over several weeks. Interviews with nursing staff and the DON confirmed that the expected process of dual-nurse counts and signatures was not reliably performed, resulting in incomplete documentation for controlled substances.
Surveyors identified failures in infection control practices, including uncovered soiled laundry, improper handling of dirty linens, and unlabeled medications and insulin pens in medication carts. Staff were observed drawing insulin from multi-dose pens without proper labeling, and home medications were stored in medication carts against policy. Interviews confirmed staff uncertainty and non-compliance with established infection prevention protocols.
A resident with cognitive and communication impairments was repeatedly subjected to loud arguments and profanity by a CNA, including being told to "shut the fuck up." Multiple staff and a student CNA witnessed or overheard these interactions, and the resident reported that such incidents were frequent. Despite facility policies prohibiting such behavior, staff often failed to report or intervene, and the CNA had a history of unprofessional conduct.
A resident's privacy was compromised when their personal and medical information was left visible on an unattended medication cart. Despite the facility's policies and staff training on maintaining confidentiality, staff acknowledged the breach, which went against professional standards.
A resident with severe cognitive impairment was subjected to inappropriate behavior by another resident with a history of verbal and sexual misconduct. Despite staff awareness and documentation of the incidents, the facility failed to take adequate action to prevent further occurrences. The facility's policy on abuse prevention was not effectively implemented, leading to a deficiency identified by surveyors.
A resident with severe cognitive impairment was subjected to inappropriate behavior by another resident with a history of verbal and inappropriate sexual behaviors. Despite multiple incidents, the facility failed to report these behaviors to the state agency as required by their abuse prevention policy. Staff were aware of the behaviors and reported them internally, but the Administrator was not informed of a specific incident and acknowledged it should have been reported as abuse.
A resident with severe cognitive impairment was subjected to inappropriate sexual behavior by another resident, also with severe cognitive impairment, in an LTC facility. Despite multiple documented incidents of inappropriate behavior, the facility failed to report these incidents to the state agency. Staff, including LPNs, CNAs, and the DON, were aware of the behavior, but the facility's administration did not adhere to its policy requiring the reporting of abuse allegations.
A facility failed to investigate and report an allegation of abuse involving a resident with severe cognitive impairment and a history of inappropriate sexual behaviors. Despite staff awareness and documentation of the resident's misconduct, the administration did not take appropriate action, leading to a deficiency in abuse prevention and reporting.
The facility failed to administer medications according to physician orders for two residents, leading to potential negative outcomes. One resident received Tramadol outside the prescribed pain scale, while another was given Midodrine despite high blood pressure. Staff interviews and record reviews confirmed these deviations from professional standards and facility policy.
A resident with left-sided paralysis and cognitive impairment was found without access to a call light, despite their care plan requiring it to prevent falls. The call light cord was inaccessible, sandwiched between the mattress and wall, leading to the resident's inability to communicate with staff. Staff confirmed the deficiency, acknowledging the importance of accessible call lights for all residents.
The facility failed to protect residents from abuse, resulting in incidents where a resident with cognitive impairment was hit by another resident, and another resident was inappropriately touched. Despite having care plans and interventions in place, these measures were insufficient to prevent the incidents, highlighting issues such as understaffing and inadequate implementation of preventive measures.
A resident with moderate cognitive impairment physically abused two other residents, resulting in injuries. The aggressive resident's care plan lacked interventions for wandering and physical behaviors, contributing to the incidents. Staff interviews indicated escalating behaviors and challenges in managing the resident's aggression.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident and to properly assess and document the incidents in the clinical records. One victim, Resident #10, had hemiplegia, a history of CVA, dementia, and moderate cognitive impairment (BIMS 10), and was care-planned for behavior problems related to impaired cognition and safety awareness. Another victim, Resident #20, had diagnoses including cerebral ischemia, COPD, quadriplegia, TIA, and depression, with an intact cognition (BIMS 15) and a care plan noting that this resident had previously been the recipient of physical and verbal behaviors from another resident, with interventions to provide for safety and prevent such interactions. Despite these care plans, there were no progress notes in either Resident #10’s or Resident #20’s clinical records documenting any incident involving Resident #50. Resident #50, identified as the perpetrator, had vascular dementia and other medical conditions, with a BIMS score of 15 and a care plan for behavior problems including impaired safety awareness, physical and verbal behaviors, and resistance to care. Prior documentation for Resident #50 included a note that this resident had attempted to hit staff during a separate elopement incident and required 24-hour supervision for safety. On the day of the incident, multiple witnesses, including residents, staff, and the Ombudsman, described escalating behavior by Resident #50 after becoming upset about family leaving the facility. Staff reported that Resident #50 was yelling, pushing a wheelchair with blankets, and verbally agitated. Staff #45 and a nurse initially redirected Resident #50 back to her room, but shortly thereafter, commotion was heard in the hallway where Resident #50 was observed yelling at Resident #20. According to interviews, Resident #50 began physically striking Resident #20 while staff attempted to intervene. Resident #20, who is disabled and unable to walk, reported that Resident #50 grabbed and hit her, hurt her arm, mocked her, and made her feel afraid and abused. Resident #10, who was nearby, reported seeing Resident #50 return down the hall and hit Resident #20 in the head, prompting Resident #10 to yell for help. Staff #25 (a CNA) placed herself between the residents and reported being hit while acting as a barrier. After staff began escorting Resident #50 away, Resident #50 then approached Resident #10, who was sitting in her doorway, and struck her in the arm and head. Resident #10 later showed reddish/grey marks on her right forearm, which she attributed to the incident, and a skin assessment documented a small scratch/abrasion on that arm without any cause noted. Staff interviews, including with the DON and social services director, confirmed that Resident #50 physically struck both residents and that no documentation of the incident, its details, or the resulting injuries was entered into the victims’ clinical records, despite the DON acknowledging that this conduct met the facility’s definition of abuse and that policy requiring documentation was not followed. The Ombudsman, who was in the building at the time, reported hearing screaming and being told by staff that Resident #50 had struck two residents, and was aware that police came to the facility. Staff #45 confirmed that she saw Resident #50 yelling at and then swinging on Resident #20, and later saw Resident #50 swing at Resident #10 while the DON attempted to block the contact. The CNA corroborated that Resident #50 and Resident #20 had a history of not getting along, that arguments tended to escalate, and that during this incident Resident #50 physically struck both residents. Resident #20 became visibly distraught and tearful when recounting the event to the surveyor and stated ongoing fear of Resident #50. Despite these events and the facility’s written policy stating residents have the right to be free from abuse, neglect, and related mistreatment, the clinical records for Residents #10 and #20 contained no incident documentation, and the single skin assessment for Resident #10 lacked any explanation of the cause of the injury, demonstrating a failure to protect residents from abuse and to document the abusive incidents in accordance with facility policy. A review of the facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program” effective January 1, 2024, stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. The DON acknowledged that the events involving Resident #50 and the two residents constituted abuse under this policy and that the policy was not followed with respect to documentation in the clinical records. The lack of contemporaneous clinical documentation of the incidents, injuries, and assessments for the victims, despite multiple staff and resident witnesses and involvement of law enforcement, was a central factor leading to the cited deficiency. In summary, the facility failed to prevent resident-to-resident physical abuse by a known behaviorally challenging resident and failed to document the incidents and resulting injuries in the victims’ clinical records, contrary to the facility’s own abuse prevention policy and standard documentation practices. This failure was established through clinical record review, interviews with the victims, staff, the Ombudsman, and observation of physical findings on Resident #10’s arm, as well as the absence of any incident-related entries in the clinical records of Residents #10 and #20.
Failure to Protect Resident From Financial Misappropriation by Staff
Penalty
Summary
The facility failed to protect a resident’s right to be free from misappropriation of property when a staff member became involved in the resident’s personal finances and received funds that were never used for their intended purpose. The resident, who had hemiplegia, CVA, dementia, UTI, type 2 DM, and sepsis, had a BIMS score of 10 indicating moderate cognitive impairment and required assistance and supervision with ambulation and various ADLs. According to the resident, she asked a staff member (identified as staff #200) to help her set up a checking account, and two monthly transfers of $500 each were arranged, for a total of $1,000. The resident reported that the account was never set up, that her son discovered the transfers and involved the police, and that she repeatedly asked the staff member for the money back. The resident stated that the staff member minimized the situation by saying it was “only money,” and that she felt abused, taken advantage of, embarrassed, and betrayed. The DON confirmed awareness of the incident and stated that the resident had requested an account not linked to her family and that staff #200 agreed to assist, with the understanding that the payments would be used to establish a new account in the resident’s name. The DON reported that the account was never created and that their investigation confirmed the money had been sent to staff #200. A registered nurse, when interviewed, stated that based on the details, the situation constituted abuse and defined abuse to include financial abuse as a violation of resident rights. The facility’s policy on abuse, neglect, exploitation, and misappropriation states that residents have the right to be free from misappropriation of resident property and exploitation, including financial abuse. Despite this policy, the resident’s funds were misappropriated by a staff member who had agreed to manage the resident’s financial transaction and did not carry out the agreed purpose.
Failure to Implement Abuse Prohibition Policy After Alleged Sexual Incident Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prohibition policy and to investigate and report an allegation of possible sexual abuse between two cognitively impaired residents. One resident had early onset Alzheimer’s disease, aphasia, depression, a BIMS score of 00 indicating severe cognitive impairment, and a care plan noting behavior problems including poor safety awareness, wandering, exit seeking, and later, lifting her shirt and exposing her breasts. Despite this, the care plan interventions were not revised when the behavior of lifting her shirt was added, and there were no progress notes documenting this behavior or the alleged incident. The second resident had dementia with behavioral disturbances, type 2 diabetes, depression, a BIMS score of 09 indicating moderate cognitive impairment, and a care plan that identified sexually inappropriate behavior, but the care plan was not revised after the incident to reflect modified interventions related to sexual behaviors. Progress notes for the second resident showed that he was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note documented that he was observed kissing the first resident and that the first resident was reciprocating, but no additional progress notes were found related to this alleged incident. An observation showed that the two residents’ rooms were directly across the hallway from each other. Review of the state agency complaint portal revealed that no facility-reported incident had been submitted regarding these two residents, despite the facility’s policy requiring investigation and reporting of allegations of abuse within required timeframes and protection of residents from further harm during investigations. Multiple staff interviews revealed inconsistent and incomplete responses to the incident and a failure to treat it as a reportable allegation of abuse. A CNA stated that suspected abuse should be reported to the administrator, described the first resident as nonverbal and unable to give consent due to cognitive impairment, and expressed concern that having the residents’ rooms across from each other was not safe. An RN reported being told at shift change that there had been inappropriate behavior between the two residents but was unsure what occurred and noted that the residents should be moved. Another RN stated she had been told that the male resident was kissing the female resident on the cheek and that she had recommended moving them but was told only to keep them separated. The DON reported that both residents were found in the male resident’s room with the female resident’s shirt up, that they were separated, and that the facility concluded no sexual abuse had occurred; she acknowledged the incident was not reported to the state and could not say with 100% certainty that nothing had happened. The administrator, serving as abuse coordinator, confirmed that staff reported the residents were in bed together, fully clothed, and that the female resident could not consent, yet he did not consider the situation abuse and did not report it. The written statement from the witnessing RN described the female resident in bed with her shirt off and the male resident hovering over her; this RN stated she separated them and reported the incident because both residents were not alert and oriented and could not consent, but she personally did not label it as sexual abuse. Despite the facility’s policy defining abuse to include sexual abuse and requiring investigation and reporting of allegations, the incident was not reported to the state, the residents were not clearly protected through care plan revisions or room changes, and the facility did not fully implement its abuse prohibition policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Agency as required by its own policy and federal requirements. One resident, identified as Resident #5, had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00, indicating severe cognitive impairment. Her care plan, initiated in August 2025, documented behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, the care plan was updated to note that she lifted her shirt and exposed her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to this behavior or to the alleged incident. Another resident, identified as Resident #8, had dementia with behavioral disturbances, type 2 diabetes, and depression, and a BIMS score of 09, indicating moderate cognitive impairment. His care plan, revised in August 2025, documented behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to protect the rights and safety of others. Behavior notes from early January 2026 showed that he was placed on 1:1 activity for increased supervision and required redirection and supervision around other residents. A behavior note documented that he was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this incident, and his care plan was not revised after the incident to reflect modified interventions for sexual behaviors. Staff interviews and the facility’s internal investigation revealed that a nurse (Staff #9) found Resident #5 in Resident #8’s room, in his bed, with her shirt off and Resident #8 hovering over her after she had briefly lost sight of them. Staff #9 separated the residents and reported the incident to the DON (Staff #17). Multiple staff, including a CNA and RNs, stated that Resident #5 was not able to give consent due to cognitive impairment, and the abuse coordinator (Staff #2) confirmed that Resident #5 could not consent to being in bed with another person because she was not alert and oriented. Despite this, the abuse coordinator and DON concluded, based on staff statements and their belief that there was insufficient time for sexual contact, that no sexual abuse had occurred and therefore did not report the incident as an allegation of abuse to the State Agency. The abuse coordinator stated he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse, even though Resident #5 could not consent. Review of the State Agency complaint portal showed no facility-reported incident related to these residents, and the facility’s policy required investigation and reporting of any allegations within required federal timeframes. Resident room placement was also relevant to the events leading to the deficiency. Observations showed that the rooms of Resident #5 and Resident #8 were directly across the hallway from each other. Staff interviews indicated concerns about this proximity, with a CNA stating that this arrangement was not safe for Resident #5 because Resident #8 could easily access her, and RNs reporting that they had raised concerns and suggested moving the residents to different rooms. Nonetheless, the residents remained in close proximity. The combination of documented cognitive impairment, inability to consent, prior sexually inappropriate behavior, the observed incident of one resident in bed with clothing removed and another hovering over her, and the facility’s decision not to treat this as a reportable allegation of abuse led to the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities, contrary to the facility’s abuse prevention policy. The facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” effective January 1, 2024, required the facility to investigate and report any allegations within timeframes required by federal requirements. Despite this policy, the DON acknowledged that she could not say with 100% certainty that nothing took place between the two residents during the time they were unsupervised. The abuse coordinator described the situation as merely a nurse reporting an incident and maintained that there was no allegation of abuse, even though he acknowledged that Resident #5 could not consent. The investigative report, which documented that Resident #5 was in bed with her shirt up and Resident #8 hovering or leaning over her, was not part of the clinical record and was initially characterized as a quality measurement document. These facts demonstrate that an allegation of potential sexual abuse involving a resident who could not consent was not reported to the State Agency as required, constituting the deficiency. Review of the State Agency’s complaint portal confirmed that no facility-reported incident related to these residents had been submitted. Staff interviews consistently described the internal reporting chain, with suspected abuse to be reported to the administrator/abuse coordinator or the DON, who would then determine whether to report to external agencies. In this case, although staff recognized that both residents were not alert and oriented and that Resident #5 could not consent, the leadership determined that the situation did not constitute abuse and did not submit a report. This failure to report an allegation of sexual abuse, despite the circumstances and the facility’s own policy requiring reporting of any allegations, is the central deficiency identified by the surveyors.
Failure to Thoroughly Investigate and Respond to Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an allegation of possible sexual abuse between two cognitively impaired residents and to take steps to correct the situation. Resident #5, who had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00 indicating severe cognitive impairment, had a care plan initiated in August 2025 for behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, this care plan was updated to note that Resident #5 lifted her shirt exposing her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to the alleged incident or to Resident #5’s tendency to lift her shirt and expose her breasts. Resident #8 had dementia with behavioral disturbances, type 2 diabetes, depression, and a BIMS score of 09 indicating moderate cognitive impairment. His care plan, revised in August 2025, identified behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to intervene as necessary to protect the rights and safety of others. After the incident involving Resident #5, there was no indication that his care plan was revised to reflect modified interventions related to sexual behaviors. Behavior notes documented that Resident #8 was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note on January 2, 2026, documented that Resident #8 was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this alleged incident. Interviews and the facility’s investigative documentation revealed inconsistencies and gaps in the investigation of the incident. Staff reported that Resident #5 and Resident #8 resided in rooms directly across from each other, and multiple staff expressed concern that this proximity was not safe for Resident #5. The DON stated that both residents were found in Resident #8’s room with Resident #5’s shirt up and that the residents were separated, and she reported that they concluded no sexual abuse had occurred, though she could not say with 100% certainty that nothing took place. The abuse coordinator stated that he was told the residents were in bed together with clothes on and that they liked to flirt, and he did not consider Resident #5 having her shirt up with Resident #8 hovering over her to be abuse, even though he acknowledged Resident #5 could not consent. The written investigation consisted only of statements from the witnessing RN, a CNA who did not witness the event, and the DON, with no evidence of broader interviews, additional observations, or further record review around the time of the incident, including no additional skin assessments beyond those dated December 22, 2025 and January 5, 2026. The incident was not reported to the State Agency’s complaint portal, despite facility policy and the State Operations Manual requiring investigation and reporting of allegations within required timeframes and the collection of evidence through observations, interviews, and record reviews, as well as immediate measures to protect residents from further abuse during the investigation. Further, the RN who witnessed the incident later described finding Resident #5 in Resident #8’s room, in bed with her shirt off and Resident #8 hovering over her, after hearing giggling and having lost sight of them for a few minutes. She separated the residents and reported the situation to the DON, acknowledging that both residents were not alert and oriented and could not consent, which was why she intervened. She stated that she did not personally consider it sexual abuse because she believed they were two consenting adults and that there was not enough time for anything to happen, but she recognized that determining whether it was abuse and whether to report it was the responsibility of leadership. Review of the State Agency’s complaint portal showed no facility-reported incident related to these residents, and the facility’s own policy on abuse, neglect, exploitation, and misappropriation prevention required investigation and reporting of any allegations within federal timeframes. The combination of incomplete documentation, limited investigative steps, lack of care plan revisions, and failure to report the allegation to the State constituted the deficient practice identified by surveyors. The facility also did not document any additional protective measures or environmental changes in the clinical record related to the proximity of the residents’ rooms, despite staff concerns that having the two residents directly across from each other was unsafe for Resident #5. CNA and RN staff interviews indicated that suspected abuse was to be reported to the administrator or DON, and that this process was followed in terms of initial reporting, but the subsequent investigation did not include comprehensive evidence collection as outlined in the State Operations Manual. The investigative report was treated as a quality measurement document and not part of the clinical record, and it did not demonstrate that the facility had thoroughly collected evidence through broader staff interviews, resident observations, or expanded record review around the time of the incident. These actions and omissions led to the finding that the facility failed to thoroughly investigate the allegation of abuse and to take steps to correct it.
Failure to Ensure Accurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to ensure proper safeguards and systems for the accurate reconciliation and accounting of controlled substances on one of three medication carts. During an observation of a medication cart with an LPN, surveyors reviewed narcotic count reconciliation sheets and shift change sign-off sheets for several months. Multiple entries were found to be missing one or both required nurse signatures, with some days having no entries at all. The facility was unable to provide all requested medication cart logs, submitting only the shift change sign-off sheets. Interviews with nursing staff and the DON confirmed that the established procedure requires two nurses to count and sign for controlled substances at each shift change, but this was not consistently followed as evidenced by the missing signatures and incomplete documentation. The facility's policy requires that both the nurse receiving and the person delivering controlled substances count and sign together, and that the consultant pharmacist routinely monitors these records. Despite this, the review of documentation revealed repeated failures to obtain the necessary signatures and maintain complete records for controlled substances over multiple weeks. Staff interviews acknowledged that these omissions did not meet facility expectations and that the dual-nurse count is intended to ensure accuracy and accountability for narcotic medications.
Infection Control Deficiencies in Laundry and Medication Management
Penalty
Summary
The facility failed to adhere to infection control guidelines in multiple areas, including laundry services, medication preparation, and medication storage. In the laundry area, surveyors observed several deficiencies: dirty linen carts and storage containers were left uncovered or improperly covered, soiled blankets with visible debris were found under machines, and trash containers were not properly lidded. Additionally, a leaking washing machine was managed by placing blankets on the floor, which were replaced only when visibly soiled. Staff interviews revealed uncertainty and inconsistency regarding the requirement to keep dirty laundry covered and the proper handling of soiled items, with some staff unaware of the facility's expectations. In the area of medication preparation and storage, surveyors found open multi-dose insulin vials and insulin pens in medication carts without resident identifiers. Some insulin pens were being used as a substitute for unavailable insulin vials, with staff drawing insulin from the pens using syringes after swabbing the cartridge tops. This practice was described as common by nursing staff, despite facility policy prohibiting the use of multi-dose pens for more than one resident and requiring clear labeling with resident identifiers. Additionally, a cluttered medication cart contained a pill organizer and various medication bottles without proper labeling, and home medications were stored in the cart due to renovations, contrary to policy. Interviews with staff, including the DON and Infection Preventionist, confirmed that these practices did not meet infection control expectations. The DON acknowledged that dirty laundry should be bagged and tied at the source, kept covered, and separated from clean laundry, and that trash cans should be lidded. The DON also stated that insulin pens must be labeled and used only for the assigned resident, and that the observed medication storage practices were not compliant with facility policy. The facility's own policies require strict labeling and storage procedures for medications and biologicals, and prohibit transferring medications between containers or using multi-dose pens for multiple residents.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with multiple medical and cognitive conditions, including cerebral infarction, legal blindness, chronic pain syndrome, and moderate cognitive impairment, was not protected from verbal abuse by a staff member. The resident had a documented history of communication impairment and behavioral challenges, including agitation, use of profane language, and making false accusations. Despite these challenges, the care plans in place directed staff to anticipate and meet the resident's needs, maintain effective communication, and support the resident's comfort and dignity. On several occasions, staff and witnesses reported that a CNA engaged in loud arguments and used profanity toward the resident, including telling the resident to "shut the fuck up." Multiple interviews with staff, a student CNA, and the resident confirmed that such interactions were not isolated incidents but rather frequent occurrences. The resident consistently reported that CNAs yelled and used profanity, and a student CNA and other staff corroborated hearing the CNA argue and use inappropriate language. Facility documentation and interviews revealed that staff often did not report these incidents, considering them unprofessional but not necessarily abuse, and some staff justified the loud tone due to the resident's hearing deficit. The facility's own policies strictly prohibited demeaning, intimidating, or harassing behavior, including swearing and shouting, and required staff to treat residents with kindness, respect, and dignity. Despite these policies, the CNA in question had a documented history of unprofessional conduct, including previous incidents of arguing with residents and staff. The facility's investigation into the verbal abuse allegations was ultimately inconclusive, but firsthand accounts and interviews indicated that the resident was subjected to repeated verbal abuse, and staff failed to consistently recognize, report, or intervene in these situations as required by policy.
Resident Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the privacy of a resident during medication administration, which was observed during a survey. Resident #23, who has a history of Non-St Elevation Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Atherosclerotic Heart Disease, and Gastrointestinal Hemorrhage, was affected by this deficiency. The resident's information, including their name, date of birth, photo, and medications, was left visible on a device atop an unattended medication cart. This incident occurred despite the facility's policy and staff training emphasizing the importance of resident privacy and confidentiality. Interviews with staff, including a Registered Nurse and Unit Manager, a Licensed Practical Nurse, and the Director of Nursing, revealed that the facility's expectations were not met. Staff acknowledged that leaving resident information exposed and unattended was against professional standards. The facility's policy on resident rights and dignity clearly states that residents have the right to privacy and confidentiality regarding their medical records, and any breach of this policy could lead to further violations of resident privacy.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #128, who has severe cognitive impairment and depression, was subjected to inappropriate behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. On July 7, 2024, Resident #128 was found yelling for Resident #66 to stop touching her, as staff witnessed Resident #66 reaching for her and attempting to expose himself. This incident was documented in progress notes, indicating that Resident #66 frequently engaged in inappropriate behavior towards female residents. Despite being aware of Resident #66's behavior, the facility's staff, including CNAs, LPNs, and the DON, failed to adequately address the situation. Interviews with staff revealed that Resident #66 had a history of touching female residents inappropriately and making sexual comments. Staff reported these incidents to their supervisors, but the facility did not take sufficient action to prevent further occurrences. The facility's policy on abuse prevention was not effectively implemented, as the administrator was unaware of the July 7 incident until it was brought to his attention during the survey. The facility's response to Resident #66's behavior was inadequate, as evidenced by the continued inappropriate conduct documented in subsequent progress notes. Staff interviews indicated that Resident #66's behavior persisted, with reports of him touching other female residents and making inappropriate comments. The facility's failure to report the July 7 incident to the state agency and to implement effective interventions to prevent further abuse contributed to the deficiency identified by the surveyors.
Failure to Report and Address Inappropriate Resident Behavior
Penalty
Summary
The facility failed to follow its abuse policy for a resident, leading to a deficiency. Resident #128, who has severe cognitive impairment due to dementia, was subjected to inappropriate behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. Despite multiple incidents of Resident #66 attempting to touch female residents inappropriately, including Resident #128, the facility did not adequately address or report these behaviors as required by their abuse prevention policy. Resident #66 was admitted to the facility with a history of dementia and depression and exhibited inappropriate sexual behaviors towards staff and residents. The facility's care plan for Resident #66 included interventions such as anticipating needs, identifying behavior triggers, and referring to a psychiatric provider. However, despite these measures, Resident #66 continued to engage in inappropriate behaviors, including touching female residents' private areas and making inappropriate comments. These incidents were documented in progress notes, but the facility failed to report them to the state agency as required. Interviews with staff revealed that they were aware of Resident #66's behaviors and had reported them to supervisors, including the Director of Nursing and the Administrator. However, the Administrator admitted to not being aware of the July incident involving Resident #128 and acknowledged that it should have been reported as abuse. The facility's policy requires immediate reporting of suspected abuse to the state agency, but this was not done, resulting in a deficiency in following the abuse prevention policy.
Failure to Report Resident Abuse
Penalty
Summary
The facility failed to report an incident of abuse involving two residents to the state agency, as required by professional standards. Resident #128, who has severe cognitive impairment due to dementia, was subjected to inappropriate sexual behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. Despite multiple documented incidents of Resident #66's inappropriate behavior towards female residents, including touching and groping, the facility did not report these incidents to the state agency. The deficiency was identified through clinical record reviews, staff and resident interviews, and facility documentation. Staff members, including LPNs, CNAs, and the DON, were aware of Resident #66's behavior, which included touching female residents inappropriately and making sexual advances. Despite being aware of these behaviors, the facility's administration, including the DON and the administrator, failed to report the incidents to the state agency. The administrator acknowledged that the incident involving Resident #66 and Resident #128 should have been reported as abuse but was not. The facility's policy requires the identification, investigation, and reporting of any allegations of abuse within the timeframes required by federal requirements. However, the facility did not adhere to this policy, as evidenced by the lack of reporting of Resident #66's behavior. The failure to report these incidents could result in further unreported incidents of abuse, neglect, or exploitation, as the facility did not follow its own protocols for preventing and identifying abuse.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents, one of whom was identified as having severe cognitive impairment and a history of inappropriate sexual behaviors. The incident involved a resident with dementia and depression, who was observed reaching for another resident and attempting to expose himself. Despite being aware of the behavior, the facility did not report the incident to the state agency as required. The resident with inappropriate behaviors had a documented history of verbal and physical sexual misconduct towards female residents and staff. Multiple staff members reported witnessing these behaviors and had informed their supervisors, including the Director of Nursing and the Executive Director. However, the facility's administration did not take appropriate action to investigate or report these incidents, as evidenced by the lack of documentation and acknowledgment of the July incident involving the two residents. Interviews with staff revealed that the resident's behaviors were known and had been ongoing, yet the facility's response was inadequate. The Director of Nursing and the Administrator were not fully aware of the extent of the resident's behaviors, and the facility's policy on abuse prevention and reporting was not followed. This failure to act and report the abuse allegations could lead to further incidents of resident abuse.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, leading to potential negative outcomes. For one resident, who was admitted with conditions including surgical aftercare and end-stage renal disease, the facility administered Tramadol 50mg for a pain level of 4, which was outside the prescribed parameters of a pain scale of 6-10. This was confirmed through a review of the Medication Administration Record and staff interviews, where it was acknowledged that the medication was given out of order parameters, contrary to professional standards and facility policy. Another resident, admitted with diagnoses including hypotension and rheumatoid arthritis, received Midodrine 5mg despite having a systolic blood pressure greater than 130, which was against the physician's order. The Medication Administration Record showed multiple instances of this medication being administered outside the prescribed parameters. Interviews with staff, including a pharmacist and a unit manager, confirmed that the medication should have been given only within the specified parameters unless cleared by the provider. The facility's policies on medication administration and resident assessment emphasize adherence to physician orders and the importance of notifying the physician of any abnormal vital signs.
Resident Lacks Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident had access to a call light, which is crucial for communication with staff. The resident, who was admitted with diagnoses including left-sided paralysis, stroke, Type-2 Diabetes, repeated falls, and depression, was observed without access to a call light on multiple occasions. The resident's care plan specifically noted the need for the call light to be within reach to prevent falls and ensure prompt assistance. However, the call light cord was found sandwiched between the mattress and the wall, making it inaccessible to the resident. During interviews, the resident expressed concerns about not having a call light and mentioned previous falls. The resident's cognitive impairment and physical limitations further exacerbated the issue, as they were unable to reach the call light. Staff interviews confirmed that the call light was not easily accessible, and it was acknowledged that all residents should have easy access to their call lights. The deficiency was identified through observations, interviews, and a review of facility policies and resident records.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in injuries. Resident #15, who has moderate cognitive impairment, was hit in the head with a hairbrush by resident #50, who also has moderate cognitive impairment and a history of abusive behaviors. The incident was confirmed by staff interviews, but there were no detailed progress notes in resident #15's clinical record about the incident. Resident #50's behavioral care plan included interventions to prevent escalation of agitation, but these were not effectively implemented to prevent the incident. In another incident, resident #50 was inappropriately touched by resident #75, who has significant cognitive impairment and a history of inappropriate sexual behaviors. This incident was witnessed by staff and reported, but resident #50 expressed feeling abused by the encounter. Staff interviews revealed that resident #75 has a pattern of inappropriate behaviors, and there were interventions in place to identify behavior triggers and meet the resident's needs, but these measures were insufficient to prevent the incident. The facility's abuse policy acknowledges the challenges of preventing abuse among residents with dementia and mental illnesses, but the incidents indicate a failure to adequately protect residents from abuse. Staff interviews highlighted issues such as understaffing, which may have contributed to the inability to prevent these incidents. The Director of Nursing confirmed the incidents and noted that interventions were in place, but the incidents were considered outliers, suggesting a lack of consistent implementation of preventive measures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to injuries. Resident #30, who has significant cognitive impairment, was hit in the face by resident #90 after an incident involving a wheelchair. Resident #30 was admitted with diagnoses including gout, alcohol dependence, and hypertension, and had a care plan to maintain a consistent routine to reduce confusion. Despite these measures, resident #30 suffered a bruise to the right eye after being struck by resident #90. Resident #90, who has moderate cognitive impairment and a history of physical behaviors, was involved in multiple incidents of aggression. The resident's care plan noted risks of wandering and physical behaviors but lacked specific interventions to address these issues. Progress notes indicated that resident #90 had several angry outbursts and was difficult to redirect, culminating in the physical altercation with resident #30. Additionally, resident #90 was reported to have caused an abrasion on the face of resident #60, another resident with significant cognitive impairment. Interviews with staff revealed that resident #90's behavior had escalated over time, with incidents of physical aggression towards other residents. The facility's abuse policy acknowledges the challenges of preventing abuse among residents with dementia and other mental illnesses. However, the lack of effective interventions for resident #90's behaviors contributed to the incidents of abuse, highlighting a deficiency in ensuring resident safety.
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A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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