Haven Of Scottsdale
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsdale, Arizona.
- Location
- 3293 North Drinkwater Boulevard, Scottsdale, Arizona 85251
- CMS Provider Number
- 035059
- Inspections on file
- 21
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Haven Of Scottsdale during CMS and state inspections, most recent first.
A cognitively impaired, high‑fall‑risk resident with a Foley catheter had a long history of yelling out, agitation, attempts to self‑ambulate, and repeatedly pulling on the catheter, with multiple physician and psychiatry notes stating that the resident needed more supervision and recommending environmental and behavioral interventions. Despite this, the resident was left alone in a gerichair near the nurses’ station without a call light, with the Foley bag attached to the chair, and with no structured activity, while repeatedly yelling for help and requesting toileting; staff intermittently responded but did not provide toileting assistance, often walked past without intervening, and left the resident unsupervised even after he stated he might try to walk and could hurt himself. Video showed the resident attempting to stand from an inadequately secured gerichair, causing the chair to roll and the Foley bag to fall, and later standing and walking unsteadily away from the chair, which pulled the Foley tubing taut and resulted in the catheter and balloon being dislodged, significant bleeding, and transfer to the hospital, demonstrating a failure to provide adequate supervision and prevent accident hazards.
Two residents with significant medical conditions reported abuse-related incidents, including one alleging rough physical treatment by a CNA and another reporting sexually inappropriate comments from another resident while on the smoking patio. Although staff documented the allegations, notified internal leadership, and suspended the implicated CNA, there was no evidence that either allegation was reported to law enforcement or APS, no documentation of a thorough investigation, and no submission of investigation results to the State Agency within required timeframes. The DON and administrator reported that investigations could not be located and referenced a record retention policy, while staff interviews and the written abuse prevention policy described expectations for immediate protection, investigation, and external reporting that were not demonstrated in these cases.
Two residents with significant medical conditions reported separate abuse-related allegations, including rough treatment by a CNA resulting in claims of prior broken bones and threatening behavior, and sexually inappropriate comments from another resident while on the smoking patio. Although initial self-reports were submitted to the SA and one CNA was suspended, there was no documented evidence that these allegations were reported to APS or law enforcement as required, nor that completed investigation results were submitted to the SA within 5 working days for either incident.
Two residents reported separate abuse incidents, including rough treatment by a CNA resulting in alleged injuries and threatening behavior, and sexually inappropriate comments from another resident while on the smoking patio. Both residents had ADL care plans noting self-care deficits and were documented as alert and oriented. The facility submitted initial reports to the SA describing the allegations and suspended the implicated CNA, but later could produce no evidence that thorough investigations were conducted or maintained. Leadership, including the DON and administrator, acknowledged they could not locate investigation records and cited internal record-retention timeframes, despite facility policies requiring identification, investigation, and reporting of all abuse allegations.
A resident with end stage renal disease, type 2 DM, and an ESBL E. coli UTI was on ordered contact isolation with a care plan requiring PPE use, dedicated or disinfected equipment, and adherence to transmission-based precautions. A CNA entered the resident’s isolation room with a vitals cart, did not perform hand hygiene, did not don gown or gloves, took vital signs, then exited without disinfecting the equipment and moved the cart to the therapy gym. The CNA later acknowledged that contact precautions require gown, gloves, and equipment disinfection, but reported missing the isolation sign and not knowing where sanitizing wipes were located or about disposable vital-sign equipment. Other nursing staff and the DON described expectations consistent with facility policies, which require signage, PPE use, hand hygiene, and dedicating or disinfecting non-critical equipment for residents on transmission-based precautions.
A resident with dementia, anxiety, urinary retention, and a Foley catheter had documented moderate to severe cognitive impairment, frequent yelling, confusion, and poor recall, with care plans directing staff to anticipate needs, use calm redirection, and provide positive interaction. Over the course of a morning, the resident was left in a gerichair in front of the nurses’ station without a call light, repeatedly yelled for help, requested to use the bathroom, asked for water, and asked to call his family, while staff intermittently responded without assisting with toileting or changing and sometimes told him there was no reason for his yelling or that it was too early to call his family. With no staff nearby, the resident attempted to stand and walk while still connected to the Foley bag attached to the chair, causing the catheter to be pulled out and prompting loud cries of pain; a CNA then approached, grabbed his arm without reassurance, tried to pull him toward the chair, and repeatedly ordered him in a rude tone to sit, including during toileting, while the resident asked her not to be rude. These actions and inactions, along with the lack of timely implementation or updating of behavior-related care plan interventions, resulted in a failure to honor the resident’s rights to dignity, respect, self-determination, and communication as required by the facility’s resident rights and dignity policy.
Two residents were discharged home after skilled stays, one with metabolic encephalopathy, COPD, and anxiety and the other with speech language deficits and type II diabetes, with documentation showing IDT discharge planning, physician orders for discharge, discharge summaries, and progress notes confirming stable discharge with medications and family support. Despite this, there was no evidence that the Ombudsman was notified or provided copies of the discharge notices for either resident, and the DON reported that while residents and representatives are typically given written discharge information and Ombudsman contact details, the facility’s transfer/discharge policy did not include a requirement to notify the Ombudsman.
A resident admitted with multiple comorbidities and an existing coccyx pressure ulcer was care planned for skin impairment and ordered for weekly skin checks, but the initial wound assessment lacked required details such as measurements, drainage, and surrounding skin condition, and there was no documented wound treatment until two days after admission. When the wound was later documented as unstageable, specific measurements, drainage, necrotic tissue, and a treatment regimen with Medihoney, alginate, foam dressing, and an air mattress were recorded and transcribed to the TAR and wound record. Interviews with the MDS nurse, an RN, and the DON confirmed that facility expectations and policy require immediate provider notification, prompt initiation of ordered wound care, and complete documentation for each treatment, and that the absence of documentation means treatment was not provided, which did not occur as expected in this case.
The facility failed to follow its controlled substance reconciliation protocols, allowing diversion of narcotic medications for two residents. One resident with osteomyelitis and hip pain had an order for PRN oxycodone 5 mg that was not transcribed onto the MAR, while a narcotic audit later showed 58 tablets dispensed with incomplete audit documentation. Another resident with cardiac disease and osteomyelitis had an order for PRN oxycodone‑acetaminophen 10‑325 mg that was transcribed and intermittently administered, but a narcotic audit showed 20 tablets dispensed with the entry highlighted and marked as not applicable. An internal investigation and camera footage showed a registry RN accepting a medication cart with narcotics and count sheets present, later handing off the cart without the oxycodone‑acetaminophen bubble pack or count sheet, and appearing on video to conceal bubble packs in her scrubs. Staff interviews and policy review confirmed that two‑nurse shift‑to‑shift narcotic counts, reconciliation of declining inventory records, and immediate reporting of discrepancies were required but did not prevent or promptly detect the diversion involving these residents’ controlled medications.
A resident with advanced dementia, severe cognitive impairment, and persistent yelling and agitation had a PRN order for concentrated morphine solution to be given every 4 hours for pain or shortness of breath. On one day, the controlled drug record showed two morphine doses given 2 hours and 10 minutes apart, while the MAR showed no morphine administrations and progress notes did not specify dose times or number of doses. Staff interviews and facility policies confirmed that medications, including controlled substances, must be administered according to prescriber time parameters and documented on the MAR and controlled substance records, but in this case the narcotic was not administered and documented in accordance with the physician’s order.
Surveyors found that the facility failed to properly label and store food items in both the main kitchen and a nourishment refrigerator. An expired container of cooking wine and undated vegetables in a freezer were observed, and the nourishment refrigerator near a nurse station was overcrowded and disorganized, containing multiple unlabeled and undated items such as fruit, bread, prepared meals, soup, and visibly spoiled berries. Staff interviews showed conflicting accounts of who was responsible for labeling and cleaning nourishment refrigerators, and revealed that food brought in by families was not consistently labeled and dated as required. These practices did not align with facility policies mandating that all refrigerated and outside food be covered, labeled, dated, and monitored.
A resident with dementia, anxiety, CHF, cardiomyopathy, and pneumonia had care plans addressing pain and behavioral symptoms, and PRN orders for morphine and lorazepam for pain, SOB, and anxiety-related restlessness. On one day, behavior notes and individual controlled drug records showed that two doses each of morphine and lorazepam were given when the resident was yelling and not responding to redirection. However, the MAR contained no entries showing that these PRN doses were administered, and no anxiety or restlessness episodes were recorded, despite facility policy and staff statements that all administered medications and related symptoms must be documented on the MAR in accordance with professional standards.
A resident with COPD did not receive prescribed doses of Tyvaso DPI as ordered, despite the medication being supplied by the family and available on site. Nursing staff were unaware of the medication's source and failed to administer it consistently, with multiple missed doses documented as 'on order' or unavailable. Facility policy required medications to be given per prescriber orders, but this was not followed, resulting in the deficiency.
Two residents experienced verbal abuse from a CNA, who was loud, intimidating, and disrespectful. Despite multiple grievances, the facility initially failed to recognize these incidents as reportable abuse, leading to a deficiency in protecting residents from harm.
Two residents reported verbal abuse by a CNA, who entered their room abruptly, yelled, and acted intimidating. Despite grievances filed, the facility did not report the incidents to the state agency as required. The facility's abuse policy defines such behavior as abuse, yet prior complaints involving the same CNA were also not reported.
Three residents in an LTC facility reported verbal abuse by a staff member, who was rude and refused assistance. The residents, with no cognitive impairments, filed grievances about the staff's behavior, which included refusing to help and making inappropriate comments. The facility's policy defines such actions as abuse, causing mental anguish.
The facility failed to implement its abuse prevention policy, as evidenced by incidents involving three residents and CNA #42. A resident reported CNA #42's refusal to assist due to her age, while another resident experienced rudeness over bed sheet changes. A third resident, requiring assistance due to a TLSO brace, reported verbal abuse. Despite these grievances, the incidents were not reported or investigated per policy, and the DON did not consider them reportable unless discomfort was explicitly stated.
The facility failed to report alleged abuse involving three residents by a CNA, staff #42. The residents, who had no cognitive impairments, filed grievances against staff #42 for inappropriate comments and refusal to assist with care. Interviews with staff revealed differing views on whether the incidents constituted abuse, but the facility did not report the incidents as required by policy.
The facility failed to investigate and report alleged abuse by a staff member involving three residents. The incidents included inappropriate comments and refusal to assist residents, all of whom had no cognitive impairment. Despite the facility's policy requiring immediate reporting and investigation of abuse, these incidents were not addressed in a timely manner, leading to a deficiency.
Three residents in an LTC facility received pain medication outside of physician-ordered parameters, with no provider notification or post-administration assessments documented. This included a resident with COPD and chronic pain, another with opioid dependence, and a third with acute osteomyelitis. The DON attributed some errors to a nurse's inexperience.
The facility failed to ensure that CNAs maintained valid CPR and first aid certifications, as required by their job descriptions. Personnel file reviews showed that three CNAs lacked evidence of CPR or First Aid certifications. Despite a policy requiring a CPR-certified team, the Director of Nursing confirmed that no CNAs had such certifications. A new job description intended to make CPR certification a preference was not properly implemented, leading to inconsistencies in compliance.
A resident's cell phone went missing, and the facility's investigation was inconclusive. The resident, with intact cognition, reported the missing phone, and a CNA was suspected but could not be contacted due to a false phone number. Another resident also reported missing property during this time. The facility's policy on resident rights was not upheld, and the investigation did not resolve the issue.
A resident's husband reported concerns about care quality, including water damage and inappropriate dressing, to the facility staff and executive director. Despite these concerns, the facility did not document or investigate the grievance as required by policy, citing the husband's refusal to fill out a grievance form and his insistence on discharging the resident. This represents a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Failure to Supervise High‑Risk Resident Leads to Traumatic Foley Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards for a cognitively impaired, high‑fall‑risk resident with a Foley catheter, resulting in accidental catheter dislodgement and transfer to the hospital. The resident had multiple diagnoses including advanced vascular dementia, non‑Alzheimer’s dementia with behavioral disturbance, anxiety, depression, altered mental status, CHF, cardiomyopathy, pneumonia, and urinary retention. From admission onward, clinical documentation repeatedly described the resident as confused, oriented only to self, very forgetful, encephalopathic, and at high risk for falls, with ongoing behaviors of yelling out, agitation, attempts to self‑ambulate, and repeatedly pulling on his Foley catheter. The care plans and multiple physician and psychiatry notes documented that the resident needed more supervision, had impaired safety awareness, and was at risk for catheter‑related trauma, with goals that the resident remain free from such trauma. Despite these documented needs, the record showed that the resident continued to yell out instead of using the call light, frequently requested toileting, and pulled on his Foley catheter on numerous occasions, with notes of bloody urine after pulling on the catheter. Providers and psychiatry repeatedly recommended increased supervision and nonpharmacologic strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for agitation, and a consistent sleep routine. Behavior notes also documented multiple attempts by the resident to self‑ambulate to leave the facility, and staff reports that the resident was constantly yelling, shouting, and difficult to redirect. However, there was no evidence that the facility implemented new or enhanced supervision interventions in response to these escalating behaviors, nor evidence that the recommended nonpharmacologic strategies were put in place. Review of the MAR/TAR further showed that a PRN antianxiety medication ordered for anxiety and restlessness was not documented as administered, and no target behaviors were recorded over several days. On the morning of the incident, observations and video footage showed the resident seated alone in a gerichair across from the nurses’ station with his Foley bag attached to the chair, no call light or call bell within reach, and no television or activity available. Over an extended period, he repeatedly yelled for help, requested water, and requested assistance to use the bathroom. Staff intermittently approached but did not provide toileting assistance, repeatedly left him alone, and at times did not respond at all while he continued to yell loudly. The resident stated he might try to walk and could hurt himself, attempted to stand multiple times, and at one point the unlocked gerichair rolled backward when he partially stood, causing the Foley bag to fall to the floor; staff rehung the bag and again left him seated without continuous supervision. Later, while no staff were in the immediate area, the resident stood and took unsteady steps away from the chair, causing the Foley tubing to pull taut and the catheter with balloon to be dislodged and fall to the floor. The resident yelled in pain and was later found with significant bleeding and clots, leading to his transfer to the emergency department. The surveyors concluded that, despite clear documentation of the resident’s need for increased supervision and his ongoing behaviors of yelling, pulling on the Foley, and attempting to self‑ambulate, the facility failed to implement and maintain adequate supervision and environmental safeguards to prevent this accident. Additional observations and interviews supported the pattern of inadequate supervision and response to the resident’s behaviors. Video review showed prolonged periods during which the resident yelled for help dozens of times without staff response, and instances where staff walked past him while he requested bathroom assistance without intervening. The gerichair was observed with wheels not securely locked when the resident attempted to stand, contributing to instability. Other residents reported that the man’s yelling had been ongoing and affected their sleep. A CNA reported that the resident had gotten up from his chair before and screamed all the time, and that caring for residents with behaviors was very hard because the facility was understaffed. Throughout the record, there was continued documentation that the resident needed more supervision and might not be appropriate for the facility due to agitation, yet no corresponding increase in supervision or implementation of recommended nonpharmacologic safety measures was documented prior to the catheter‑related injury.
Failure to Report and Investigate Abuse Allegations per Policy
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse reporting and investigation policy for two residents who made abuse-related allegations. For one resident with a history of a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain, documentation showed that the resident was alert, oriented, and able to verbalize events. After admission following a ground-level fall at home, the resident experienced a fall in the facility and later expressed dissatisfaction with the facility without initially providing details. A late entry incident note documented that the resident reported being treated roughly and refused further care from a CNA who had worked the morning shift, prompting notification of the ED, DON, physician, and family. The initial facility report to the State Agency stated that this resident told an unnamed therapist that he did not want care from a CNA assigned to him and alleged that this CNA had caused multiple broken bones, was going to kill him, and was out to get him. The resident provided a physical description of the CNA, and facility documentation indicated that there was a CNA who best fit that description. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that he hit his face on the wall while being turned during care. The report noted that the CNA was immediately suspended and that the facility was contacting other agencies. However, there was no evidence in the clinical record or facility documentation that this allegation was reported to law enforcement or APS, that a thorough investigation was conducted, or that the results of the investigation were submitted to the State Agency within five working days. For a second resident with diagnoses including chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, care plans and notes indicated the resident was encouraged to participate in ADLs and was documented as alert and oriented. Psychology notes referenced an “incident last week” and stated there was no evidence of psychological harm and no further conflicts, but did not describe the incident. An initial facility report to the State Agency later documented that this resident reported to the ED that another resident made sexual comments toward her while she was sitting on the smoking patio. As with the first case, there was no evidence that this allegation was reported to law enforcement, that a thorough investigation was completed, or that the results of the investigation were submitted to the State Agency within five working days. Interviews with the DON, administrator, RNs, and the social services director confirmed that investigations related to these two residents were not available and that the facility followed a record retention policy under which incident reports and self-reports were only kept for 12 months and grievances for three years. The DON and administrator stated they could not locate any evidence of the investigations for these incidents, and the DON referenced that the requested investigations were “outside the guidelines” for document retention. Staff interviews described the facility’s general procedures for responding to abuse allegations, including ensuring resident safety, separating alleged perpetrators, suspending staff when implicated, and reporting to the ED, DON, Ombudsman, police, physician, family, and State Agency. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program required identification, investigation, and reporting of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property within required federal timeframes and protection of residents from further harm during investigations, but the documentation for these two residents did not demonstrate that these policy requirements were carried out.
Failure to Report and Complete Abuse Investigations Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse to Adult Protective Services (APS) and law enforcement, and failure to submit the results of abuse investigations to the State Agency (SA) within 5 working days for two residents. For one resident with a history of a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain, the care plan identified risk for ADL self-care performance deficit and encouraged participation in care. This resident was admitted after a ground level fall at home and later sustained a fall in the facility, after which he was found on the floor by the toilet, alert and oriented, and able to describe the event. On the same day, documentation showed the resident expressed unhappiness with the facility and, in a late entry incident note, reported being treated roughly and refusing further care from a specific CNA. The initial facility report to the SA for this resident stated that he told an unnamed therapist he did not want care from a CNA assigned that day, alleging that this CNA had caused at least three broken bones, was going to kill him, and was out to get him. He provided a physical description of the CNA, and the facility identified a CNA who best fit that description. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that he hit his face on the wall while being turned during care. The CNA was immediately suspended, and the report indicated the facility was contacting other agencies. However, review of the clinical record and facility documentation revealed no evidence that this allegation was reported to law enforcement or APS, and no evidence that the results of the investigation of the alleged abuse were submitted to the SA within 5 working days of the incident. For the second resident, admitted with chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, the ADL care plan also identified risk for ADL self-care performance deficit and included interventions to praise self-care efforts and encourage participation. Documentation showed the resident was alert and oriented, with psychology notes indicating no evidence of psychological harm related to an unspecified incident the prior week and no concerns or changes since that occurrence. An initial facility report to the SA later documented that this resident reported to the executive director that another resident made sexual comments toward her while she was sitting on the smoking patio. Despite this allegation of sexual comments by another resident, review of the clinical record and facility documentation showed no evidence that the allegation was reported to law enforcement, and no evidence that the results of the investigation of the alleged abuse were submitted to the SA within 5 working days of the incident.
Failure to Maintain and Document Thorough Investigations of Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of abuse. For the first resident, an individual admitted with a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain had an ADL care plan indicating risk for self-care performance deficits and encouragement to participate in care. This resident experienced a fall in the facility bathroom, was found on the floor by the toilet, and was documented as alert and oriented and able to verbalize what happened. Later that same day, documentation showed the resident expressed unhappiness with the facility without elaborating. A late entry incident note then recorded that the resident reported being treated roughly and refused further care from a CNA who had worked the morning shift, with a skin assessment showing no new findings. The facility’s initial report to the State Agency documented that the resident told an unnamed therapist he did not want care from a CNA assigned that day and alleged that this CNA had caused at least three broken bones, was going to kill him, and was out to get him. The resident provided a physical description of the CNA, including age range, hair color, glasses, tattoos, and clothing, and later clarified the clothing color and tattoo location, which the facility noted matched a specific CNA. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that during turning for care he hit his face on the wall. The CNA was immediately suspended, and the facility reported that it was contacting other agencies. Despite these detailed allegations, review of the clinical record and facility documentation revealed no evidence that the facility conducted or maintained a thorough investigation into this abuse allegation. The second resident involved was admitted with diagnoses including chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, and had an ADL care plan noting risk for self-care performance deficits with interventions to praise self-care efforts and encourage participation. A health status note documented that this resident was alert and oriented, and a late entry NP note indicated a long history of daily smoking. Psychology progress notes on two consecutive days stated that observations and conversations with the resident showed no evidence of psychological harm related to an incident the prior week, but did not describe the incident itself, only noting no concerns or changes and no further conflicts. The facility’s initial report to the State Agency later specified that the resident had reported to the ED that another resident made sexual comments toward her while she was sitting on the smoking patio. As with the first case, review of the clinical record and facility documentation showed no evidence that this allegation of abuse was thoroughly investigated. Interviews with facility leadership and review of facility policies further clarified the deficiency. The DON stated she did not know where the investigations related to these two residents were and referred to them as being "outside the guideline," explaining that this meant outside the facility’s document retention timeframes. The administrator similarly stated he could not find any evidence of investigations for these incidents and cited a facility memo on record retention that limited how long incident reports, self-reports, and grievances were kept. The DON also described the facility’s abuse policy and the expected process for responding to abuse allegations, including ensuring resident safety, suspending involved staff, reporting to the abuse coordinator and external agencies within required timeframes, and conducting interviews with the victim, alleged perpetrator, and witnesses. However, despite these stated procedures and policies emphasizing identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation, there was no documentation available to demonstrate that thorough investigations were completed or maintained for the abuse allegations involving these two residents.
Failure to Follow Contact Isolation and Equipment Disinfection for ESBL-Positive Resident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility’s infection prevention and control program and contact isolation policies for a resident with an active ESBL E. coli urinary tract infection. The resident was admitted from a short-term general hospital for IV infusions with contact isolation and had diagnoses including end stage renal disease and type 2 diabetes mellitus. Physician orders documented contact isolation due to ESBL for a defined period, and the care plan identified an active ESBL infection with interventions such as contact/droplet isolation precautions, staff and resident education on infection containment, use of disposable or dedicated equipment, appropriate cleaning and disinfection of non-disposable equipment, and provision of independent or 1:1 activities. On the day of the survey observation, a CNA entered the resident’s room, which had a contact isolation sign posted on the right side of the doorway and an isolation cart with PPE outside the room. The CNA pushed a vitals cart into the room without performing hand hygiene and without donning a gown or gloves, despite the posted contact isolation precautions. The CNA proceeded to take the resident’s vital signs using the blood pressure cuff on the resident’s ankle while the resident was in bed, then closed the door and later exited the room without sanitizing the vitals cart. The CNA then pushed the unsanitized vitals cart down the hallway to the therapy gym and left it there. In a subsequent interview, the CNA stated that staff identify isolation rooms by signs on the door indicating the type of precautions and required PPE, and that for contact precautions, staff are required to wear a gown and gloves. The CNA also stated that equipment brought into an isolation room and then used for other residents should be sanitized with sanitizing wipes, but she did not sanitize the vitals cart because she did not know where wipes were located and none were present in the isolation cart. She reported she had not received verbal report at shift change about which rooms were on isolation, did not initially realize the room was an isolation room because the sign was posted to the side of the door rather than in the center, and was unfamiliar with disposable or single-use blood pressure cuffs or stethoscopes. When the room was re-observed with the CNA, she acknowledged the contact isolation sign. Other nursing staff, including an RN/unit manager, an LPN, and the DON, described expectations consistent with facility policy: observing isolation signage, donning required PPE before entry, performing hand hygiene before leaving the room, dedicating or disinfecting equipment with sanitizing wipes before reuse, and maintaining PPE and supplies in or near the room, and they stated that failure to follow these practices could result in spread of infection. Review of facility policies on "Managing Infections: Isolation - Categories of Transmission-Based Precautions" and "Managing Infections: Isolation - Initiating Transmission-Based Precautions" showed that transmission-based precautions are to be initiated for residents with transmissible infections or laboratory-confirmed infections at risk of transmission. Policies require appropriate signage on the room entrance door and chart, use of standard precautions at all times, and additional contact precautions for residents known or suspected to be infected with organisms transmitted by direct or indirect contact. The policies specify that non-critical resident-care equipment such as stethoscopes, sphygmomanometers, and thermometers should be dedicated to a single resident when possible, or cleaned and disinfected before use with another resident if reuse is necessary. They also require gloves and disposable gowns upon entering the room, removal of PPE and performance of hand hygiene before leaving the room, and ensuring that PPE and necessary supplies, including appropriate waste and linen containers, are maintained in or near the resident’s room. The observed staff actions did not align with these written requirements.
Failure to Treat Cognitively Impaired Resident With Dignity and Respond to Repeated Requests for Help
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively impaired resident with dignity and respect and to respond appropriately to his repeated requests for assistance. The resident had acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention, and was admitted with a Foley catheter. Assessments and therapy notes documented moderate to severe cognitive impairment, poor orientation, poor recall, confusion, and frequent yelling out for help or for his wife. Care plans identified behavior problems related to impaired cognition, including yelling out instead of using the call light, and directed staff to anticipate and meet needs, provide positive interaction, explain procedures, identify triggers, and use calm approaches and redirection. Multiple clinical notes from nursing, therapy, psychiatry, neurology, and pulmonary providers documented ongoing confusion, anxiety, constant yelling, inability to verbalize needs, and repeated pulling on the Foley catheter. On the morning of the incident, video footage and surveyor observations showed the resident seated in a gerichair in front of the nurses’ station with a Foley catheter bag attached to the chair and no call light or call bell available. From shortly after 6:00 a.m. onward, the resident repeatedly yelled for help, requested to use the bathroom, and asked for water and to call his family. Staff responses were intermittent and did not address his toileting requests; one staff member told him he had a catheter and did not assist him to the bathroom, another told him to remain reclined until breakfast, and others walked past without responding while he continued to call out loudly dozens of times. When he reported having had a bowel movement, he was told to wait until staff could be found, and no one assisted him with toileting or changing for an extended period. Staff also told him there was no reason for his yelling, that he was waking everybody up, and that it was too early to call his family, without addressing his expressed needs. Later that same morning, with no staff nearby, the resident attempted to stand and walk unassisted while still connected to the Foley catheter bag attached to the gerichair. As he took small, unsteady steps, the catheter tubing became taut and ultimately the catheter balloon and tubing were observed on the floor after being pulled out, and the resident yelled out loudly in pain. A CNA then approached and, without reassuring the resident or explaining her actions, grabbed his arm with both hands and attempted to pull him back toward the chair while he said “No” and tried to walk in the opposite direction. The CNA then positioned the gerichair in front of him and repeatedly ordered him in a rude, firm tone to “sit down here” and “sit in there,” without explanation, while the resident questioned what the chair was. During toileting assistance in the bathroom, the CNA’s firm and rude tone continued, and the resident was overheard asking her not to be rude. Interviews with staff and leadership confirmed awareness of the resident’s ongoing yelling behaviors and confusion, and the facility’s own policy required that residents be treated with kindness, respect, and dignity and be free from abuse and neglect, which was not followed in this case. The facility’s care plans and provider recommendations called for consistent routines, environmental modifications, structured activities, task segmentation, frequent redirection, and calm, respectful communication to address the resident’s impaired cognition and behaviors. Despite this, there was no evidence of updates or revisions to the behavior-related care plan interventions after mid-December, even as documentation showed escalating yelling, anxiety, and inability to be redirected. On the day of the incident, staff did not implement the planned interventions such as anticipating and meeting needs, providing one-to-one interaction, or promptly assisting with toileting, and instead left the resident unattended in the hallway for prolonged periods while he loudly and repeatedly called for help, the bathroom, water, and his family. The combination of failing to respond to his expressed needs, leaving him without a call system or supervision despite known impulsivity and unsteady gait, and interacting with him in a rude and non-reassuring manner constituted a failure to honor his rights to dignity, respect, self-determination, and communication as outlined in the facility’s resident rights and dignity policy. Other residents and staff interviews corroborated that the resident frequently screamed and that he likely wanted someone to talk to or an activity to calm him. CNAs and nurses described appropriate approaches they would generally use for confused, yelling, or restless residents, such as sitting with them, holding their hand, providing activities, or placing them near the nurses’ station with close supervision. However, on the morning in question, these approaches were not consistently applied to this resident. The Director of Nursing acknowledged awareness of his yelling and impulsivity and stated expectations for calm approaches, redirection, and offering comfort measures, while the Administrator acknowledged that staff could have done a better job addressing his requests to use the bathroom. The documented events, observations, and interviews collectively show that the resident’s rights to be treated with dignity and respect and to have his needs assessed and addressed were not upheld. The facility’s written policy on Resident Rights/Dignity required employees to treat all residents with kindness, respect, and dignity and guaranteed residents the right to a dignified existence, to be treated with respect, kindness, and dignity, to be free from abuse and neglect, and to exercise self-determination and communication with people and services. The observed failure to respond to the resident’s repeated requests for toileting and assistance, the lack of a call light, the prolonged periods without staff attending to him while he yelled for help, and the CNA’s rude tone and physical handling of his arm were inconsistent with these policy requirements. These actions and inactions formed the basis of the cited deficiency for failure to ensure the resident was treated with dignity and respect.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide the Ombudsman with a copy of the written notice of discharge for two residents who were discharged from skilled care. For the first resident, admitted with metabolic encephalopathy, COPD, and anxiety for post‑operative rehabilitation, the clinical record showed ongoing discharge planning toward return to home, later updated to discharge to home with hospice services. Multiple documents, including skilled needs reviews, IDT care plan conference notes, therapy notes, a discharge summary, a discharge transfer evaluation, physician orders, and a discharge MDS, confirmed that the resident was discharged home on a specified date. However, there was no evidence in the clinical record that the Ombudsman was notified or provided a copy of the discharge notice for this resident. For the second resident, admitted with speech language deficits and type II diabetes, the record contained physician orders indicating completion of the skilled inpatient stay and discharge to home, an IDT care plan conference note documenting a plan to discharge home with family, a discharge summary confirming the discharge date and that the resident would be discharged with medications, and a progress note stating the resident was discharged home in stable condition with family and belongings. Despite this documentation of discharge, there was no evidence that the Ombudsman was notified or given a copy of the discharge notice for this resident. In an interview, the DON explained the usual process for notifying residents and/or representatives in writing about discharge, including appeal rights, bed‑hold policy, and Ombudsman contact information, but the facility’s written policy on transfer or discharge notice did not include a requirement to notify the Ombudsman.
Failure to Initiate and Document Timely Pressure Ulcer Treatment on Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and complete pressure ulcer care and assessment for a resident admitted with an existing coccyx wound. The resident was admitted with multiple comorbidities, including a left tibia fracture, type II diabetes with hyperglycemia, pulmonary fibrosis, shortness of breath requiring oxygen, and bowel and bladder incontinence. An admission Braden scale showed a score of 15, and a progress note on the admission date documented a stage 4 coccyx ulcer with foul odor. The care plan identified existing and at-risk skin areas, including the coccyx, and called for treatments as ordered, weekly skin assessments, and adherence to facility policies for prevention and treatment of skin breakdown. A physician order for weekly skin checks was also in place. Despite the identification of a stage 4 coccyx ulcer on admission, the weekly skin check and wound assessment note for that date did not include required wound descriptors such as measurements, odor, drainage, tunneling, or description of surrounding skin and wound edges/bed. The clinical record showed no evidence that any wound treatment was initiated on the admission date, and there was no documentation of wound care being provided until two days later. On the subsequent weekly skin check, the coccyx wound was documented as an unstageable pressure ulcer present on admission, with specific measurements, drainage, odor, necrotic tissue, and surrounding slough, and treatment orders including Medihoney, alginate, and foam dressing were documented at that time. A low air loss mattress was requested, and an order for an air mattress and specific wound care regimen was entered and transcribed onto the treatment and wound administration records on that later date. Interviews with facility staff confirmed that the documented practice did not align with facility expectations and policy. The MDS nurse and an RN stated that upon admission, a head-to-toe skin assessment is performed, the provider is notified for orders if a wound is identified, and treatment is expected to begin as soon as orders are received, with each treatment documented; they both indicated that if there is no documentation, the treatment is considered not done, and that a delay of two to three days in treatment would not meet expectations. The DON stated that nurses are expected to assess and document wound characteristics on admission, transcribe any existing wound orders, and notify the provider if no orders exist, and that wound care documentation must include details of the care provided and resident response. The DON and corporate resource both acknowledged that they found no documentation that wound treatment was provided to this resident prior to the later date. The facility’s written policy required full assessment and documentation of pressure ulcers, including location, stage, size, exudate, necrotic tissue, pain, mobility status, current treatments, and support surfaces, and required that newly admitted residents be examined for existing pressure ulcers so that the physician could order appropriate wound treatments and pressure reduction surfaces, which was not fully carried out for this resident on admission.
Failure to Reconcile and Safeguard Controlled Medications Resulting in Narcotic Diversion
Penalty
Summary
The deficiency involves the facility’s failure to follow its own protocols for reconciliation and control of narcotic medications, resulting in undetected diversion of controlled substances for two residents. For one resident with acute osteomyelitis of the right ankle and foot, infection and inflammatory reaction due to an internal left hip prosthesis, and left hip pain, the admission evaluation and care plan documented high‑risk medications and pain management needs. A physician order was in place for oxycodone 5 mg by mouth every 6 hours as needed for pain rated 4–10, along with an order for pain evaluation using a 1–10 pain scale every shift. However, this oxycodone order was not transcribed onto the February MAR. A narcotic card audit conducted by the DON showed that 58 oxycodone 5 mg tablets had been dispensed for this resident, and the audit documentation for this medication was highlighted and incomplete, with no indication that the medication was in the cart or scanned. For another resident admitted with atherosclerotic heart disease, muscle weakness, and acute hematogenous osteomyelitis of the right ankle and foot, there was a physician order for oxycodone‑acetaminophen 10‑325 mg, one tablet by mouth every 6 hours as needed for pain level 1–10. The care plan documented that the resident was on an opiate and required medications to be administered as ordered, and there was also an order for pain evaluation using a 1–10 pain scale every shift. The MAR for February showed that the oxycodone‑acetaminophen order was transcribed and documented as administered on two dates. Provider notes indicated that the resident complained of leg pain and that pain control was adequate, with a plan to continue the current pain regimen. Despite this, the narcotic card audit revealed that 20 tablets of oxycodone‑acetaminophen 10‑325 mg had been dispensed, but the audit entry was highlighted, lacked a check mark, and was marked as not applicable. The facility’s internal investigation documented that two nurses on consecutive shifts completed medication reconciliation for the second resident’s oxycodone‑acetaminophen and that both the bubble pack and narcotic count sheet were present at that time. The following day, a registry RN accepted the cart from the night shift nurse and identified that the narcotics and count sheet were present, but when that RN later passed the cart to the next nurse, the narcotic sheet and bubble pack for the oxycodone‑acetaminophen were no longer present. The investigation stated that the registry RN concealed this information and did not properly report it during handoff. Camera footage reviewed by the facility showed the registry RN entering the medication room, pretending to place medications into a cabinet, and instead stuffing medication bubble packs down the front of her scrubs. During an audit of all residents on controlled medications, the facility determined that this RN had removed the first resident’s oxycodone 5 mg, totaling 58 tablets, which were from a discontinued order set for destruction. The facility substantiated misappropriation of medications based on this evidence. Interviews with nursing staff and review of the facility’s controlled substances policy confirmed that the established process required two‑nurse narcotic counts each shift, reconciliation of declining inventory records with MARs and access records, and immediate reporting and investigation of discrepancies, but these controls did not prevent or timely detect the diversion involving these two residents’ narcotics. Additional staff interviews further described the expected practices that were not effectively implemented in this incident. An RN stated that it was never acceptable to use one resident’s controlled medication for another and that two nurses were to conduct narcotic counts at shift change, with any discrepancies immediately reported to the DON. An LPN explained that the oncoming nurse was to count all controlled medication cards, bottles, and syringes for every resident, with two nurses verifying that all medications were accounted for, and that any discrepancy would prompt review of the previous three shifts and notification of the DON. The DON described the reconciliation process in which the oncoming and outgoing nurses compare the narcotic sheet with the physical bubble packs, first by card count and then by pill count, and notify her of any mismatch for investigation and possible notification of the administrator and consultant pharmacy. Despite these written policies and described procedures, the documented diversion of oxycodone and oxycodone‑acetaminophen for the two residents occurred, and the missing narcotics and associated documentation were not identified and addressed at the time of shift‑to‑shift reconciliation.
Failure to Administer and Document PRN Morphine per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer and document narcotic medication according to a physician’s order for a resident with dementia and significant behavioral symptoms. The resident had multiple diagnoses including acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention. Assessments and provider notes over time documented moderate to severe cognitive impairment, advanced dementia with behaviors, and near constant yelling, screaming, and agitation that were difficult to redirect. Care plans identified pain, behavior problems, and impaired cognitive function, with interventions that included administering medications as ordered, monitoring for side effects and effectiveness, and using non-pharmacological interventions prior to PRN medications. On a specified date, a physician ordered Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, to give 0.25 ml every 4 hours as needed for pain or shortness of breath. A behavior note from that same date documented that the resident continued to yell throughout the day, that redirection had no effect, and that PRN lorazepam and morphine were administered into the resident’s cheek pocket, pending effectiveness. The Individual Control Drug Record for the resident’s morphine 5 mg pre-filled syringe (0.25 ml/5 mg) showed that two doses were administered that day, one at 10:00 a.m. and another at 12:10 p.m., which was 2 hours and 10 minutes after the first dose, rather than at or after the ordered 4-hour interval. Despite the controlled drug record indicating two morphine doses, the January Medication Administration Record (MAR) contained no evidence that any doses of morphine sulfate oral solution were administered. Progress notes referenced that morphine was given but did not specify how many doses or the exact times of administration. Interviews with nursing staff and the DON confirmed that facility practice and policy require medications to be administered in accordance with prescriber orders, including required time frames, and to be documented on the MAR, with controlled substances also documented on individual controlled substance records. The DON reviewed the morphine order and narcotic reconciliation sheet and stated that administering morphine at 10:00 a.m. and again at 12:10 p.m. did not meet her expectations for following the physician’s order, and staff interviews emphasized that failure to document on the MAR creates a risk of not knowing when a medication was given and of administering another dose too soon. Facility policies on administering medications and controlled substances required that medications be administered as prescribed, that medication errors be documented and reported, and that the individual administering the medication record the date, time, dosage, route, indications, results, and their signature in the medical record or EMAR. The controlled substances policy required accurate individual controlled substance records and reconciliation using MARs and declining inventory records. In this case, the discrepancy between the controlled drug record, the MAR, and the physician’s order, along with incomplete documentation in progress notes, demonstrates that the resident’s narcotic medication was not administered and documented according to the physician’s order and facility policy.
Failure to Properly Label and Store Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure food was labeled and stored in accordance with professional standards. During a kitchen observation, a container of cooking wine was found in the walk-in dry storage with a use-by date of August 25, 2025, indicating it was past its use-by date at the time of the survey. In the large three-door freezer, peas and sliced carrots were stored in a blue plastic bag without any date labeling. Further observations of a nourishment refrigerator near a nurse station showed it was almost full and unorganized, with multiple food items that were unlabeled and undated. These included a plastic container with diced fruit in liquid, individual snacks and two triangle-shaped pieces of bread, a rectangular container with two round yellow substances on a white substance with dark speckles, a black container with pancakes and bacon, a styrofoam cup with what appeared to be vegetable soup with ice formation on top, and a large fruit cup with grapes, watermelon, and cantaloupe that had a past sell-through date but no facility-applied label. Additional items included a light blue container with what appeared to be meatballs and pasta with only “August 26” on the container and no complete date, and a black container with raspberries covered with light brownish fuzz mixed with blueberries that was also unlabeled and undated. Interviews with staff revealed inconsistent understanding and practices regarding responsibility for labeling and cleaning nourishment refrigerators. One cook stated the expired cooking wine was no longer good and acknowledged using the undated peas and carrots from the blue bag to prepare food the previous night. The cook also stated that CNAs were responsible for cleaning and discarding expired food from the nourishment refrigerator, while the Kitchen Dietary Director stated that specific kitchen staff were responsible for cleaning nourishment refrigerators on designated days. A dietary aide reported that she and the Dietary Director were responsible for cleaning all refrigerators and that food brought in by families should be labeled, dated, and used within 5 to 7 days. A CNA, however, stated that maintenance staff were responsible for cleaning nourishment refrigerators and that staff or families would label and date food brought in for residents. Facility policies reviewed by surveyors required that all refrigerated food be covered, labeled, dated, and monitored, and that foods brought from outside sources be labeled with the resident’s name and date and stored separately from facility food, which was not consistently followed in these observations.
Failure to Accurately Document PRN Controlled Medications on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident. The resident was re-admitted with multiple diagnoses, including acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention. An admission MDS showed moderate cognitive impairment. The resident’s care plan included a focus on pain management, with interventions such as administering analgesics per orders, anticipating pain needs, monitoring for non-verbal signs of pain, and using non-pharmacological interventions before PRN medications. Another care plan focus addressed behavior problems related to impaired cognition and impaired safety awareness, including verbal behaviors such as yelling out and banging on the table, with interventions to administer medications as ordered and monitor and document side effects and effectiveness. Physician orders dated January 2, 2026, included PRN Morphine Sulfate oral solution (20 mg/ml, 0.25 ml every 4 hours for pain/shortness of breath) and PRN Lorazepam Intensol oral concentrate (2 mg/ml, 1 ml every 2 hours for anxiety evidenced by restlessness/agitation). A behavior note on the same date documented that the resident continued to yell throughout the day, that redirection was ineffective, and that PRN doses of lorazepam and morphine were administered into the resident’s cheek pocket, pending effectiveness. The Individual Control Drug Records showed that two doses of morphine and two doses of lorazepam were administered on that date, at 10:00 a.m. and again at 12:10 p.m. Despite these entries on the narcotic control records and in the behavior note, the Medication Administration Record (MAR) for January 2026 contained no documentation that any doses of morphine sulfate oral solution or 2 mg/ml lorazepam were administered to the resident. The MAR also showed no recorded episodes of anxiety or restlessness for any shift in January 2026 under target symptoms/behavior tracking. Interviews with an RN, an LPN, and the DON confirmed that facility practice and policy require nurses to document all administered medications on the MAR, including date, time, dosage, route, symptoms, and results, and that controlled substances must also be recorded on narcotic reconciliation sheets. The DON reviewed the records and acknowledged that, although the narcotic sheets showed administration of morphine and lorazepam at 10:00 a.m. and 12:10 p.m., the MAR did not reflect these administrations, which did not meet the facility’s documentation expectations and policies.
Failure to Administer Prescribed Inhalation Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) received the prescribed Tyvaso Dry Powder Inhaler (DPI) as ordered by the physician. The resident was admitted with multiple diagnoses, including COPD and acute respiratory failure, and had a care plan that required administration of aerosol or bronchodilators as ordered. Physician orders were in place for Tyvaso DPI at varying dosages over several weeks. However, clinical record review and medication administration records (MAR) revealed multiple missed doses of Tyvaso DPI, with documentation indicating the medication was 'on order' or unavailable, despite the resident's family having provided the medication to the facility and it being stored on site. Staff interviews revealed confusion among nursing staff regarding the source and administration of the medication. An LPN stated that medications were always ordered through the pharmacy and was unaware that the family had supplied the Tyvaso DPI. The Assistant Director of Nursing confirmed that the medication was never ordered through the pharmacy and that the family had brought it in, but due to confusion over titration and dosage, the administration was inconsistent and not all doses were given as ordered. The facility's policy required medications to be administered according to prescriber orders, but this was not followed in this case, resulting in missed doses and a failure to comply with physician instructions.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a Certified Nursing Assistant (CNA), identified as staff #67. Resident #5, who was admitted with a diagnosis of traumatic subdural hemorrhage and other conditions, reported an incident where CNA #67 entered the room abruptly, was loud, and threw items on the floor. The resident felt afraid and unsafe due to the CNA's behavior, which included yelling and calling the residents troublemakers. The resident's call light was also thrown under the bed by the CNA, further exacerbating the situation. Resident #30, who shared the room with Resident #5, corroborated the account of verbal abuse. This resident, admitted with a fracture and other health issues, reported that CNA #67 was loud and inconsiderate, waking them up and arguing with them. The CNA was described as being out of control, flailing her arms, and towering over Resident #5 in an intimidating manner. Both residents expressed a desire for the CNA not to return to their room due to her behavior. Interviews with other staff members revealed a pattern of complaints against CNA #67, including her reluctance to assist residents and her tendency to speak loudly and disrespectfully. Despite multiple grievances and reports of verbal abuse, the facility's administration initially treated these incidents as grievances rather than reportable abuse. The facility's policy defines verbal abuse as actions that cause mental anguish, which aligns with the residents' experiences. However, the administration failed to recognize and report these incidents as abuse, leading to a deficiency in protecting residents from verbal harm.
Failure to Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report alleged abuse involving two residents, which could lead to continued abuse. Resident #5, admitted with a diagnosis of traumatic subdural hemorrhage and other conditions, filed a grievance report on November 8, 2024, stating that a CNA entered her room abruptly, was loud, and threw items on the floor. The resident reported feeling afraid and unsafe due to the CNA's behavior, which included yelling and throwing the call light under the bed. The resident's care plan indicated she was at risk for falls and required assistance, which was not adequately provided. Resident #30, admitted with a fracture and other conditions, also filed a grievance report regarding the same CNA on November 8, 2024. The resident reported that the CNA was loud and verbally abusive, arguing with both residents and blaming them for using the call light. The resident described the CNA as being out of control, flailing her arms, and intimidating her roommate. Despite these reports, the facility did not report the allegations of verbal abuse to the state agency within the required timeframe. The facility's Executive Director and Director of Nursing were informed of the allegations but did not consider the incidents as reportable verbal abuse. The facility's abuse policy defines abuse as the willful infliction of injury or intimidation causing mental anguish, including verbal abuse. The facility had prior complaints involving the same CNA for verbal abuse, which were also not reported as required. This failure to report alleged abuse constitutes a deficiency in the facility's compliance with regulatory requirements.
Verbal Abuse by Staff Member in LTC Facility
Penalty
Summary
The facility failed to protect three residents from verbal abuse by a staff member, identified as staff #42. Resident #456, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture and anxiety disorder, filed a grievance on May 22, 2024, reporting that staff #42 refused to assist him, stating, 'I am 55 and I am not picking you up.' This resident had a BIMS score of 15, indicating no cognitive impairment, and was dependent on staff for care. Resident #457, admitted with acute cystitis and anxiety disorder, reported an incident on July 16, 2024, where staff #42 was rude and upset about having to replace bed sheets after urine spilled. The resident had a BIMS score of 13, also indicating no cognitive impairment, and was dependent on staff for care. Staff #42 was subsequently not assigned to this resident again. Resident #458, with a diagnosis of a wedge compression fracture and other conditions, filed a grievance on July 30, 2024, stating that staff #42 was rude when asked for assistance with hygiene due to the resident's physical limitations. The resident had a BIMS score of 14, indicating no cognitive impairment, and required assistance due to a TLSO brace and orthostatic hypotension. The facility's abuse policy defines abuse as actions causing mental anguish, which was corroborated by interviews with other staff members who confirmed the verbal abuse by staff #42.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy for abuse prevention and reporting, as evidenced by incidents involving three residents and a staff member, CNA #42. Resident #456, who had no cognitive impairment, filed a grievance after CNA #42 refused to assist him, citing her age as a reason for not providing care. This incident was not reported or investigated according to the facility's policy. Resident #457, also cognitively intact, reported an incident where CNA #42 was rude and upset about having to change bed sheets. Although CNA #42 was not assigned to this resident again, the incident was not reported or investigated as required by the facility's abuse policy. The care plan for this resident indicated dependency on staff for care, highlighting the importance of staff support. Resident #458, who required assistance due to a TLSO brace and orthostatic hypotension, reported verbal abuse from CNA #42. The resident felt uncomfortable with the staff member's comments, yet the incident was not reported or investigated. Interviews with other staff members confirmed that the comments made by CNA #42 constituted verbal abuse, but the Director of Nursing did not consider it reportable unless the resident explicitly stated discomfort. The facility's documentation revealed a lack of thorough investigation and reporting of these incidents, contrary to their stated policy.
Failure to Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to report alleged violations of abuse involving three residents, which could lead to further abuse. Resident #456, who had no cognitive impairment, filed a grievance against a CNA, staff #42, for being unqualified and refusing to assist him. Resident #457, also cognitively intact, reported an incident where staff #42 was rude and upset about changing bed sheets. Resident #458, who required assistance due to a back injury and orthostatic hypotension, reported that staff #42 made a racially insensitive and inappropriate comment when asked for help with toileting. Interviews with staff members revealed differing opinions on whether the incidents constituted abuse. Staff #43 and staff #40 considered the comments made by staff #42 as verbal abuse, while the DON, staff #28, viewed it as poor communication and customer service, stating it was only abuse if the resident felt uncomfortable. Despite the grievances and staff opinions, the incidents were not reported to the appropriate authorities as required by the facility's policy. The facility's policy mandates that any suspected or witnessed abuse be reported to the Executive Director and other relevant entities, including Adult Protective Services and the State Survey Agency. The policy also requires an immediate investigation and suspension of the alleged perpetrator pending results. However, the facility did not adhere to these procedures, as the incidents involving staff #42 were not reported, and the required investigation and notifications were not conducted.
Failure to Investigate and Report Alleged Abuse by Staff Member
Penalty
Summary
The facility failed to investigate and correct alleged violations of abuse involving three residents by a staff member, identified as staff #42. Resident #456, who had no cognitive impairment, filed a grievance stating that staff #42 was not qualified for her job and refused to assist him, citing her age as a reason. Resident #457, also cognitively intact, reported an incident where staff #42 was rude and upset about having to replace bed sheets after a urine spill. Resident #458, who required assistance due to a back injury and orthostatic hypotension, reported that staff #42 made a racially insensitive and inappropriate comment when he requested help with toileting. Interviews with staff members, including the Resident Relations Manager and the Director of Nursing (DON), revealed that these incidents were brought to the attention of the DON, but staff #42 was only written up much later, on October 1, 2024. The facility's documentation showed that the incidents were not reported or investigated at the time they occurred, contrary to the facility's policy on abuse. The policy mandates immediate reporting and investigation of suspected abuse, including notifying various entities and conducting interviews to determine if there is a trend. The facility's failure to adhere to its abuse policy was further highlighted by interviews with other staff members, who confirmed that the comments made by staff #42 constituted verbal abuse. Despite this, the DON did not consider the incidents reportable unless the residents explicitly stated they felt uncomfortable. This lack of action and failure to follow established procedures for handling abuse allegations led to the deficiency noted in the report.
Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to administer scheduled pain medication in accordance with physician orders for three residents, leading to potential inadequate pain control. Resident #14, who was admitted with conditions including COPD and chronic pain, received Oxycodone outside of the prescribed parameters on multiple occasions. The medication was administered for pain levels of 0, contrary to the physician's order for administration at pain levels 4-10. There was no evidence that the provider was notified of these deviations, nor were post-administration pain assessments documented. Resident #4, with a history of opioid dependence and other significant health issues, also received pain medication outside of the prescribed parameters. Roxicodone was administered for a pain level of 0 on numerous occasions, and the provider was not notified in most instances. The resident's orders were for administration at higher pain levels, and the lack of adherence to these orders was not documented or communicated to the provider. Resident #40, who had diagnoses including acute osteomyelitis and heart failure, was given Oxycodone for a pain level of 0, which was outside the ordered parameters. The facility's policy required pre-administration assessments and adherence to medication orders, which were not followed. The DON acknowledged the errors and attributed them to the nurse's inexperience, indicating a failure in ensuring proper medication administration training and oversight.
Deficiency in CNA CPR Certification Compliance
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) maintained valid CPR and first aid certifications, as required by their job descriptions. Personnel file reviews revealed that CNAs Staff #48, #61, and #42 did not have evidence of obtaining CPR or First Aid certifications. The job description for CNAs, revised in September 2016, listed an active CPR certification as a minimum requirement. However, a new job description, which was undated and not signed by any CNAs, indicated that CPR certification was preferred but not required. Interviews with the Director of Nursing and the Corporate HR Operations Manager revealed inconsistencies in the understanding and implementation of the CPR certification requirement. The facility's policy on emergency procedures required that the CPR team include at least one nurse, one LPN/LVN, and two CNAs, all certified in CPR/BLS. Despite this, the Director of Nursing acknowledged that no CNAs, including Staff #48 and #61, had CPR certifications. The Corporate HR Operations Manager confirmed that a new policy and job description were intended to remove the CPR requirement for CNAs, but the transition was not properly executed, as evidenced by CNAs signing the incorrect job description. This oversight could potentially result in harm to residents due to staff not being knowledgeable about providing emergency care as part of the CPR team.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, specifically a cell phone, which went missing during the night. The resident, who had intact cognition as indicated by a BIMS score of 12, reported the missing phone to the facility. The facility's investigative report noted that the phone was reported missing on the morning following the incident, and attempts to contact a registry-contracted CNA, who was suspected of involvement, were unsuccessful due to the use of a false phone number. The facility's documentation also revealed that another resident reported missing property during the same period. The facility's policy on resident rights emphasizes protection from misappropriation of property, yet the investigation into the missing phone was inconclusive. The Executive Director noted discrepancies in the report to the Arizona State Board of Nursing, suggesting that the allegation against the CNA could not be substantiated. Despite the facility's process for handling missing items, which includes searching and reporting, the missing phone was not recovered, and the investigation did not lead to a resolution.
Failure to Document and Investigate Grievance
Penalty
Summary
The facility failed to file and investigate a grievance according to its policy for a resident who was admitted with diagnoses including hypertension, shoulder pain, delirium, hallucinations, and the presence of a pacemaker. The resident's husband reported concerns to the nursing staff, resident relations, and the executive director, including issues such as water damage in the room and the resident being left inappropriately dressed. Despite these concerns being communicated verbally, the facility did not document or investigate the grievance as required by their policy. The executive director acknowledged the concerns as a quality of care issue but did not initiate a formal grievance process, citing the husband's refusal to fill out a grievance form and his insistence on discharging the resident. The resident relations manager also failed to document the grievance, and the facility's grievance log showed no record of the incident. This lack of documentation and investigation represents a failure to honor the resident's right to voice grievances without discrimination or reprisal.
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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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