Haven Of Show Low
Inspection history, citations, penalties and survey trends for this long-term care facility in Show Low, Arizona.
- Location
- 2401 East Hunt Street, Show Low, Arizona 85901
- CMS Provider Number
- 035139
- Inspections on file
- 23
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Haven Of Show Low during CMS and state inspections, most recent first.
A resident with paraplegia and multiple pressure ulcers did not receive wound care and assessments as ordered, including missed treatments, incomplete documentation, and lack of physician notification for a new facility-acquired scrotal ulcer. Nursing staff and leadership confirmed gaps in care and documentation, and the resident was later hospitalized for sepsis related to a sacral wound.
A resident with cognitive impairment and a history of wandering ingested bleach after confusing a bleach wipe container for a water cup, as cleaning wipe containers were left accessible in the room. Staff interviews and observations confirmed that hazardous chemicals were not consistently secured, and there was no specific facility policy for chemical storage, contributing to the incident.
A resident with multiple diagnoses did not receive physician-ordered treatments, including catheter care, Nystatin powder application, and oxygen saturation checks. Interviews with an LPN and the DON confirmed the missed treatments and the associated risks, highlighting a deficiency in documentation and adherence to physician orders.
A resident with multiple medical conditions and a Foley catheter experienced inadequate wound care management, resulting in a necrotic wound and hospitalization. Despite complaints and a physician's order, there was no documented care plan or timely referral to a wound clinic. Staff interviews revealed systemic issues, including the absence of a wound care nurse and inadequate documentation practices.
The facility failed to ensure proper labeling and storage of medications, with several opened bottles found without open dates and expired medications not discarded. A resident's phosphorus binder was left unattended, and a bag of IV Ceftriaxone was left on a medication cart. Staff interviews revealed unfamiliarity with policies, and the DON confirmed the need for proper dating and discarding of medications.
The facility failed to follow proper food safety and hand hygiene practices. Observations revealed expired food items in the refrigerator and improper glove use during food preparation and serving. Staff did not change gloves or wash hands between handling different food items, leading to potential cross-contamination. Interviews with management confirmed these practices did not meet facility expectations.
A resident with moderate cognitive impairment was found to be self-administering medication without a documented assessment for safety, contrary to facility policy. The resident's medication was left unattended at the bedside, which staff interviews confirmed was against policy. The DON stated there was no self-administration determination in the resident's clinical record.
Two residents were not given advance written notice of room changes, violating their rights. Despite having intact cognition, they were moved without proper notification, leading to dissatisfaction and distress. The facility's policy requires advance written notice, which was not adhered to, as confirmed by the administrator and DON.
A facility failed to complete a required PASRR Level I screening for a resident with multiple mental health diagnoses who stayed longer than 30 days. The initial screening was done, but no follow-up was conducted despite new diagnoses and an extended stay. Staff interviews confirmed the oversight, which did not meet facility expectations.
A resident with severe cognitive impairment and their representative were not involved in care planning despite documentation indicating their participation. Interviews revealed that neither the resident nor the representative were aware of or attended care conferences. Facility staff admitted to documentation errors, highlighting a failure to ensure proper involvement in care decisions.
A resident with cognitive impairments and safety awareness issues was observed smoking without supervision, despite the care plan requiring it. Staff interviews revealed a lack of adherence to the facility's smoking policy, as the resident was allowed to keep smoking materials in her room and smoke unsupervised. The facility's acting DON and MDS Coordinator confirmed the need for supervision, which was not implemented, leading to the deficiency.
A resident with a PICC line for antibiotic therapy due to a knee infection did not have their dressing changed as ordered by the physician. Despite documentation indicating site checks were completed, observations revealed the dressing was soiled and lacked proper labeling. Interviews with an LPN and the DON confirmed the dressing needed immediate replacement, highlighting a failure to adhere to the facility's policy.
A resident with hypotension and other conditions received Midodrine hydrochloride outside of physician-ordered parameters, as documented in the MAR for June and July. The facility's LPN and DON confirmed the medication was given despite the resident's SBP exceeding the specified limit, contrary to the facility's policy requiring adherence to physician orders and pre-administration assessments.
A resident with a history of diabetes, traumatic brain injury, and dementia did not have follow-up dental appointments scheduled after a consultation recommended further extractions. Despite documentation and staff acknowledgment of the need, the facility failed to ensure the appointments were made, as confirmed by interviews with the RN, transportation manager, and DON. This oversight did not meet facility standards and could risk the resident's health.
The facility failed to prevent elopement for two residents, one with dementia and another with encephalopathy, due to inadequate supervision and lack of alarms on certain exits. Additionally, a resident sustained a skin tear during wheelchair transport due to improper safety measures. These incidents highlight deficiencies in supervision and safety protocols.
An altercation between two residents with severe cognitive impairments occurred when one resident attempted to use a shared bathroom, resulting in a skin tear. The facility failed to document the incident promptly and did not check for potential causes of the injury. The investigation was delayed, and communication barriers were not addressed, highlighting deficiencies in resident safety and documentation.
A facility failed to report and investigate an abuse allegation within the required timeframe. A CNA documented a resident's claim of being overpowered and hit by staff, but the LPN did not report it to the Administrator or state agency. The Administrator discovered the issue during another investigation, noting the delay in reporting. Staff interviews confirmed awareness of the reporting protocol, which was not followed, risking potential abuse.
A facility failed to investigate and report an abuse allegation timely when a resident reported being overpowered and hit by staff. A CNA documented the claim but did not report it to the Administrator as required, and the alleged perpetrator, an LPN, was not suspended during the investigation. The Administrator discovered the allegation days later, delaying the report to the state agency and the five-day investigation submission. Interviews revealed communication lapses among staff, and the facility's abuse policy was not followed.
A resident with a UTI did not receive the prescribed antibiotic, Cefpodoxime Proxetil, due to unavailability from March 27 to March 30. Despite staff awareness and facility policies requiring medication administration, the antibiotic was not provided, leading to a deficiency in care.
The facility failed to meet professional standards during a call light system outage, falsely documenting visual checks for five residents. Despite using hand-held bells and implementing 15-minute Fire Watch checks, staff did not enter all required rooms, and documentation inaccurately indicated that visual checks were performed.
Failure to Provide Pressure Ulcer Care and Prevent New Ulcers
Penalty
Summary
A resident with multiple comorbidities, including paraplegia, chronic kidney disease, and a history of pressure ulcers, was not provided with care and services in accordance with professional standards and physician orders to prevent new pressure ulcers and the worsening of existing ones. The resident was dependent on staff for bed mobility and had a care plan identifying the risk for skin impairment, with interventions for weekly wound monitoring, measurement, and physician notification of changes. However, there was no evidence that the care plan was updated to address a newly developed, facility-acquired pressure ulcer on the scrotum, nor was there documentation of physician notification or treatment orders for this new wound. There were significant lapses in wound care management, including a lack of wound care orders or treatment for the left ischium wound for nearly two months, and missed or incomplete documentation of weekly wound assessments, measurements, and wound descriptors for several pressure ulcers. The clinical record showed gaps in weekly wound assessments, with no evidence of assessments or measurements between certain dates, and missing documentation regarding the presence of tunneling in wounds. Additionally, wound care treatments for the right ischium and sacral wounds were not completed as ordered on multiple occasions, with no documentation of resident refusal or coordination of alternative care times as outlined in the care plan. Interviews with nursing staff and facility leadership confirmed awareness of the missed wound care treatments and assessments, as well as the lack of documentation and physician notification for the new scrotal pressure ulcer. Facility policies required prompt notification of changes in resident condition, systematic and comprehensive assessments, and completion of physician-ordered treatments, but these were not followed. The resident was later transferred to the hospital and treated for sepsis secondary to a sacral wound, with wound cultures positive for infection.
Failure to Prevent Resident Access to Hazardous Chemicals Resulting in Bleach Ingestion
Penalty
Summary
A resident with a history of Parkinson's disease, anxiety disorder, hypertension, obesity, and liver abscess was admitted to the facility and exhibited signs of cognitive impairment, including wandering, attempts to leave the facility, and confusion regarding orientation. Despite these behaviors and documentation of impaired cognition, there was no care plan addressing cognitive impairment until more than two years after admission. The resident was known to wander into other residents' rooms and had difficulty with redirection, sometimes becoming combative with staff. On one occasion, the resident ingested bleach after filling a container that previously held bleach wipes with water and drinking from it, mistaking it for his water cup. The incident was discovered after the resident's roommate reported the behavior, and the resident himself indicated confusion between the bleach container and his water cup. The bleach wipe container was found accessible in the resident's room, and staff interviews confirmed that such containers should not be left within reach of residents, especially those with cognitive impairment. Further review revealed that the facility did not have a specific policy for chemical storage, relying instead on a general safety and supervision policy. Observations confirmed that cleaning wipe containers were accessible in resident rooms, and staff acknowledged that hazardous chemicals should be stored securely and not left in areas accessible to residents. The facility's policy emphasized the importance of identifying and mitigating accident hazards, but in practice, hazardous materials were not consistently secured, leading to the resident's accidental ingestion of bleach.
Failure to Administer Physician-Ordered Treatments
Penalty
Summary
The facility failed to ensure that a resident received medical care treatments as ordered by the physician, which could result in residents not improving. The resident was admitted with diagnoses including enterocolitis due to Clostridium Difficile, urinary tract infection, neuromuscular dysfunction of the bladder, and Parkinson's Disease. The care plans included interventions for infections, enhanced barrier precautions, risk for skin impairment, and oxygen therapy. However, the Treatment Administration Record (TAR) revealed that several treatments were not administered as ordered, including catheter care, Nystatin powder application, and oxygen saturation checks. Interviews with staff revealed that the licensed practical nurse (LPN) and the Director of Nursing (DON) acknowledged the missed treatments and the associated risks. The LPN stated that treatments should be documented in the TAR, and if not documented, it indicates the treatment was not done. The DON confirmed that the catheter was not cleaned multiple times, increasing the risk of infection, and that the Nystatin powder was not applied as ordered, which could lead to the spread of infection. Both staff members emphasized the importance of documentation and adherence to physician orders. The facility's policy on administering medications and treatments requires that medications be administered safely, timely, and as prescribed, with documentation in the Medication Administration Record (MAR) or TAR. The failure to document and administer treatments as ordered represents a deficiency in meeting professional standards of quality care, as outlined in the facility's policies and procedures.
Failure in Wound Care Management Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate care and services related to wound management for a resident, leading to a necrotic wound and subsequent hospitalization. The resident, who had multiple medical conditions including atrial fibrillation, acute kidney failure, type II diabetes mellitus, and bilateral lower extremity amputations, was admitted with a Foley catheter. Despite complaints of discomfort and a physician's order to monitor urination and potentially replace the catheter, there was no documented care plan or interventions related to the catheter use. The resident's clinical records showed a lack of consistent documentation and follow-up on the condition of the resident's penis, which developed slough and inflammation. Despite the presence of a Foley catheter and recommendations for wound clinic referral, there was no evidence of timely action or proper catheter care. The resident's condition worsened, with significant necrosis noted by the wound clinic, which led to an emergency room referral. Interviews with staff revealed systemic issues, including the absence of a wound care nurse and inadequate documentation practices. The Director of Nursing acknowledged the problem, noting the delay in referring the resident to the wound clinic and the lack of individualized assessment notes. A CNA reported notifying the administration about the resident's condition, but the issue persisted, with some staff uncomfortable performing necessary care procedures.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as observed during a survey. On one occasion, a white pill was found unattended on a resident's bedside table, which the resident identified as a phosphorus binder that he self-administers daily. Additionally, during an inspection of medication carts, several opened bottles of medications, including Vitamin C, Vitamin B12, and aspirin, were found without open dates. The aspirin bottle was also expired. Staff interviews revealed a lack of familiarity with the facility's policy on dating opened medication bottles and checking for expired medications. Further observations revealed a bag of IV Ceftriaxone left unattended on a medication cart, with the LPN admitting to leaving IV medications unattended on several occasions. Additional opened medication bottles without open dates and expired medications were found on another medication cart. In the medication storage room, expired bottles of Nutricia Pro-Stat and an opened bottle of 8-Hour Arthritis Pain Relief without an open date were discovered. The Director of Nursing confirmed that medications should be dated upon opening and expired medications should be discarded immediately, but there was uncertainty about the 28-day time limit policy. The facility's policies on medication labeling and storage, as well as discarding medications, were reviewed, highlighting the deficiencies in practice.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, as observed during a survey. An unlabeled container with a purple liquid, identified as grape Kool-Aid, was found in the unit nourishment refrigerator/freezer with an expired date. The kitchen manager acknowledged that the container should have been removed, recognizing the risk of using expired food items. Additionally, during food preparation, a cook was observed using the same pair of gloves to handle various food items and touch personal items, such as a marker and refrigerator door, without changing gloves or washing hands. This included handling salad mix, boiled eggs, tomatoes, and cottage cheese, all without proper hand hygiene. Further observations during breakfast service revealed that a serving line cook removed gloves, adjusted clean stacks of plates and plate covers with bare hands, and then donned new gloves without washing hands. The cook then proceeded to handle food items, such as bananas, and served them without changing gloves. Interviews with the kitchen and dietary managers confirmed that these practices did not meet the facility's expectations for hand hygiene and food safety. The facility's policies on food storage, date marking, and general food preparation emphasize the importance of proper hand hygiene and the use of gloves to prevent cross-contamination, which were not followed in these instances.
Failure to Assess Resident for Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for the safety of self-administering medication, which is a requirement for allowing residents to self-administer drugs. Resident #145, who was admitted with multiple diagnoses including clostridium difficile, enterocolitis, end-stage renal disease (ESRD), ankylosing spondylitis, and atherosclerotic heart disease, was found to have a moderate cognitive impairment with a BIMS score of 8. Despite this, there was no evidence in the clinical record that an assessment for self-administration was conducted or that it was deemed clinically appropriate for the resident to self-administer medication. During an observation, a white pill was found unattended on the bedside table of Resident #145, which the resident identified as his phosphorus binder taken before meals. The resident reported that he self-administers this medication daily, as allowed by the nursing staff. Interviews with nursing staff revealed that facility policy requires nurses to remain at the bedside until medications are taken and prohibits leaving medications unattended. The Director of Nursing confirmed that there was no self-administration determination in the clinical record for the resident, and the facility policy mandates that any unauthorized medications found at the bedside should be collected and reported.
Failure to Provide Advance Written Notice for Room Changes
Penalty
Summary
The facility failed to provide advance written notice to two residents regarding room changes, which is a violation of resident rights. Resident #24 experienced multiple room changes without proper notification. The clinical records lacked evidence of advance notice for room changes on several occasions, including June 22, 2023, December 4, 2023, February 9, 2024, and August 1, 2024. Despite having intact cognition, as indicated by a BIMS score of 15, Resident #24 did not recall being informed or signing any room change notices. The facility's documentation was incomplete, with missing resident signatures and reasons for room changes not adequately explained. Similarly, Resident #37, who also had a BIMS score of 15 indicating cognitive intactness, was not given advance written notice of a room change on August 1, 2024. The resident expressed dissatisfaction and distress over the room change, stating that they were informed verbally and moved on the same day without prior written notice. Interviews with the facility's administrator and DON confirmed that the required written notices were not provided to the residents, and the facility's policy mandates advance written notice for room changes, including the reasons for such changes.
Failure to Complete Required PASRR Screening
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASRR) Level I screening was completed as required for a resident who was admitted with multiple mental health diagnoses, including major depressive disorder, bipolar disorder, post-traumatic stress disorder, and anxiety disorder. The initial PASRR Level I screening was conducted on November 8, 2022, and indicated that the resident's admission met the criteria for 30-day convalescent care. However, the resident remained in the facility for longer than 30 days, and new diagnoses were documented, including post-traumatic stress disorder and bipolar disorder with psychotic features. Despite these changes and the extended stay, there was no evidence of a subsequent PASRR Level I screening being completed after the initial assessment. Interviews with facility staff, including a social worker and the Director of Nursing (DON), confirmed that the last PASRR Level I screening was conducted on November 8, 2022, and acknowledged that another screening should have been completed after the resident's stay exceeded 30 days. The facility's policy requires a new PASRR Level I screening to be completed within 40 calendar days if the resident's stay extends beyond the initial 30-day convalescent period. The DON stated that the lack of a follow-up PASRR screening did not meet facility expectations and could have resulted in the resident not receiving appropriate specialized services for their diagnoses.
Failure to Involve Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and their representative were involved in the development of the care plan and in making decisions about the resident's care. The resident, who was admitted with chronic kidney disease, adult failure to thrive, tremor, chronic pain, depression, and mobility issues, had a severe cognitive impairment as indicated by a BIMS score of 6. Despite documentation suggesting that the resident and their representative attended care plan conferences, interviews revealed that they were not aware of or involved in these meetings. The resident and their representative expressed concerns about not being informed or involved in care planning. They reported that no staff member had met with them to discuss the care plan, and the representative had unsuccessfully attempted to contact the resident relations manager multiple times. The resident stated that they were unaware of any care conference meetings and had not participated in discussions about their care. The representative also denied attending any care conferences. Interviews with facility staff, including the Director of Nursing and the resident relations manager, revealed discrepancies in the documentation of care conferences. The resident relations manager admitted to an error in the documentation and stated that the care conference was held in the office with the activities director, with the representative attending via telephone. However, the Director of Nursing indicated that care conferences should be documented in the clinical record, contradicting the resident relations manager's understanding.
Inadequate Supervision of Resident Smoking
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with impaired safety awareness who wished to smoke. The resident, who had a history of cerebral infarction, monoplegia, aphasia, and cognitive impairments, was assessed as needing supervision while smoking. Despite this, the resident was observed with a lighter and cigarettes in her room and was seen smoking without supervision in the designated smoking area. Observations revealed that the resident was not wearing a smoking apron and was not supervised while smoking, contrary to the care plan and smoking assessment requirements. Interviews with staff indicated a lack of awareness and adherence to the facility's smoking policy. The CNA and nurse were unaware of the resident's need for supervision and the requirement to store smoking materials at the front desk. The facility's acting DON and MDS Coordinator confirmed that the resident's care plan and smoking assessment indicated the need for supervision, but these were not implemented. The facility's policy required direct supervision for residents needing monitoring while smoking, which was not followed, leading to the deficiency.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that the PICC line dressing for a resident was changed as ordered by the physician, which could result in complications such as infection. The resident, who was admitted with diagnoses including left knee staphylococcal arthritis and immunodeficiency, had a physician order for PICC line dressing changes every 7 days and as needed using sterile technique. However, during an observation, it was found that the PICC line dressing was not initialed, dated, or timed, and appeared dirty, indicating it had not been changed as required. The resident, who was cognitively intact, reported that the dressing was hardly changed and had not been changed that week, despite becoming dirtier each day. The resident was unaware of the required frequency for dressing changes but noted that the nurses continued to use the PICC line. This suggests a lack of adherence to the facility's policy and physician orders regarding PICC line care. Interviews with staff, including an LPN and the DON, revealed that the facility's policy required PICC line dressings to be changed at least once a week or if soiled, and the site to be checked every shift for signs of infection. Despite documentation indicating that site checks were completed, both the LPN and DON confirmed that the dressing was soiled and needed immediate replacement. They also acknowledged the absence of documentation indicating when the dressing was last changed, which was not in accordance with the facility's policy.
Failure to Administer Blood Pressure Medication per Physician Orders
Penalty
Summary
The facility failed to ensure that blood pressure medications were administered according to physician-ordered parameters for a resident diagnosed with hypotension, major depressive disorder, bipolar disorder, and post-traumatic stress disorder. The resident's care plan included interventions to obtain blood pressure readings as ordered and under consistent conditions. A physician order specified that Midodrine hydrochloride should be held if the systolic blood pressure (SBP) was greater than 130. However, the Medication Administration Record (MAR) for June and July 2024 showed that Midodrine was administered on several occasions when the resident's SBP exceeded the ordered parameters, specifically on June 6, June 7, June 30, and July 3, 2024. Interviews with facility staff, including an LPN and the Director of Nursing (DON), confirmed that the medication was administered outside of the physician's parameters, which did not align with the facility's expectations or policy. The LPN acknowledged that the medication administration did not follow the physician's orders, and the DON stated that the provider should have been notified if the medication was administered outside the ordered parameters. The facility's policy on administering oral medications required verification of a physician's order and pre-administration assessments, which were not adhered to in this case.
Failure to Schedule Follow-Up Dental Appointments
Penalty
Summary
The facility failed to ensure that recommended follow-up dental appointments were scheduled for a resident, leading to a deficiency in providing necessary dental care. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, a history of traumatic brain injury, and unspecified dementia, had oral health problems documented in their care plan. A dental consultation on August 16, 2023, resulted in the extraction of three teeth and a recommendation for further extractions. Despite this recommendation being noted by a registered nurse, there was no evidence that a follow-up appointment was scheduled. Interviews with facility staff, including a registered nurse, the transportation manager, and the Director of Nursing, revealed that the process for scheduling follow-up appointments was not followed. The transportation manager confirmed that no follow-up dental appointments were scheduled after the initial consultation. The facility's policy indicated that nursing services should notify social services of a resident's need for dental services, but this process was not completed, resulting in a failure to meet facility standards and potentially putting the resident at risk for infection.
Inadequate Supervision and Safety Measures Lead to Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision and prevent elopement for two residents, leading to multiple incidents of elopement. One resident, diagnosed with dementia and severe cognitive impairment, was identified as a flight risk. Despite wearing a Wanderguard, the resident managed to elope multiple times, including an incident where the resident was found outside the facility near a Home Depot. The facility's lack of sensors on certain doors contributed to the resident's ability to leave the premises undetected. Another resident with a history of encephalopathy and alcohol dependence also eloped from the facility. This resident was observed exiting through a window and was later found by police at a nearby establishment. The facility's failure to have alarms on windows and inadequate monitoring of residents on isolation contributed to this incident. The resident's care plan included interventions such as hourly checks and distraction with activities, but these measures were insufficient to prevent the elopement. Additionally, the facility failed to prevent an accident involving a resident who sustained a skin tear while being transported in a wheelchair by a physical therapist. The therapist did not ensure the resident's arms were safely positioned within the wheelchair, resulting in the resident's arm making contact with a doorframe. This incident highlights a lack of adherence to safety protocols during resident transport, leading to injury.
Resident Altercation and Inadequate Documentation
Penalty
Summary
The facility failed to prevent an altercation between two residents, resulting in a deficiency related to resident safety and protection from abuse. Resident #14, who has severe cognitive impairment due to Alzheimer's disease and unspecified dementia, was involved in an incident with Resident #33, who also has similar cognitive impairments and communication barriers. The altercation occurred when Resident #33 attempted to use the shared bathroom while Resident #14 was already inside, leading to Resident #14 sustaining a skin tear on his right hand. The facility's documentation and staff interviews revealed that there was no immediate documentation of the incident in the progress notes, and the investigation into the altercation was delayed. The residents were not interviewed until three days after the incident, and by that time, they could not recall the details. Additionally, there was no documentation indicating that staff checked Resident #33's fingernails for sharpness, which could have caused the skin tear. The facility's response included moving Resident #33 to another part of the facility, but the initial handling of the situation lacked thoroughness and timely documentation. The facility's policy on abuse prevention acknowledges the challenges of caring for residents with dementia and other mental illnesses, yet the incident highlights a failure to adequately protect residents from harm. The lack of an interpreter for Resident #33, whose first language is not English, further complicated the investigation and communication. The deficiency report underscores the need for improved measures to prevent resident-to-resident altercations and ensure timely and comprehensive documentation of such incidents.
Failure to Timely Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse and complete a 5-day written investigation regarding a resident in the required timeframe. A certified nursing assistant (CNA) documented that a resident expressed feeling overpowered and hit by staff, which was reported to a licensed practical nurse (LPN). However, the LPN instructed the CNA to document it in a progress note and did not report the allegation to the Administrator or state agency as required. The resident was cognitively intact, as indicated by a BIMS score of 15, and had diagnoses including urinary tract infection, obesity, chronic kidney disease, and muscle weakness. The Administrator discovered the allegation while reviewing progress notes for another investigation, realizing the report was not made within the required two-hour timeframe. Interviews with staff revealed that both the CNA and the LPN were aware of the reporting protocol but failed to follow it. The facility's policy mandates immediate notification of the Executive Director and state survey agency, with an investigation to be completed within five working days. The delay in reporting and investigation could result in residents being abused.
Failure to Investigate and Report Abuse Allegation Timely
Penalty
Summary
The facility failed to conduct a thorough investigation into an abuse allegation involving a resident who reported being overpowered and hit by staff. The incident was initially reported by a CNA who documented the resident's claim in a progress note. However, the CNA did not follow the facility's policy of reporting the allegation to the Administrator within two hours, and the alleged perpetrator, an LPN, was not immediately suspended pending investigation. The Administrator only became aware of the allegation several days later while reviewing progress notes, leading to a delay in reporting the incident to the state agency and in submitting the required five-day investigation. Interviews conducted during the investigation revealed inconsistencies and a lack of communication among staff. The resident, who was cognitively intact, reported that the LPN squeezed her leg, but the LPN denied the allegation and claimed the resident frequently made false accusations. The CNA stated she reported the incident to the LPN, who instructed her to document it but did not take further action. Additionally, a physical therapist was informed by the resident of issues with the LPN but did not report this to a supervisor. The facility's policy on abuse requires immediate reporting and investigation of suspected abuse, with the alleged perpetrator being suspended during the investigation. However, these procedures were not followed, resulting in a delayed response to the abuse allegation. The Administrator acknowledged the failure to report the incident in a timely manner and the lack of immediate action to protect the resident from potential further abuse.
Failure to Administer Prescribed Antibiotic for UTI
Penalty
Summary
The facility failed to administer medication as prescribed for a resident with a urinary tract infection (UTI). The resident was admitted with diagnoses including UTI, obesity, chronic kidney disease, and muscle weakness. An order was placed for Cefpodoxime Proxetil, an antibiotic, to be administered twice daily for seven days. However, progress notes from March 27 to March 30 revealed that the medication was not available and remained on order, resulting in the resident not receiving the prescribed treatment. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed that the medication was not administered as prescribed. The staff acknowledged that the lack of medication could lead to worsening of the UTI and potential complications. The facility's policy required compliance with professional standards, but the failure to ensure the availability and administration of the prescribed antibiotic led to a deficiency in care for the resident.
Failure to Ensure Professional Standards During Call Light System Outage
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a period when the call light system was inoperable. Staff falsely documented that visual checks were conducted for five residents. The call light system had been down for almost two weeks, and residents were provided with hand-held bells as an alternative. Despite the implementation of 15-minute Fire Watch resident checks, observations revealed that staff did not enter certain resident rooms as required, and documentation inaccurately indicated that visual checks were performed. Interviews with staff, including a CNA, the Administrator, an RN, and the VP of Clinical Operations, confirmed the inoperability of the call light system and the use of hand-held bells. The RN and VP of Clinical Operations stated that the 15-minute checks should include visual confirmation of each resident's status. However, observations on two separate occasions showed that staff did not enter all rooms, and the Fire Watch checklists were inaccurately completed, indicating that visual checks were performed when they were not.
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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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