Heritage Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Globe, Arizona.
- Location
- 1300 South Street, Globe, Arizona 85501
- CMS Provider Number
- 035141
- Inspections on file
- 17
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Heritage Health Care Center during CMS and state inspections, most recent first.
A resident with a right heel wound, osteomyelitis, and a history of substance use received PRN Hydrocodone-Acetaminophen and Acetaminophen outside the provider-ordered pain-level parameters. Orders specified Hydrocodone-Acetaminophen only for pain levels 4–10 and Acetaminophen for pain levels 1–3, but MAR review showed both medications were repeatedly administered when documented pain scores were 0, 1, or higher than the ordered range. Facility staff, including an LPN and the DON, acknowledged that medications are required to be administered according to provider orders and that there was no documentation authorizing these out-of-parameter doses.
A resident with multiple chronic conditions and intact cognition repeatedly alleged neglect, racial mistreatment, and mental abuse by staff, including not receiving medications as expected and feeling demeaned by an LPN. These concerns were reported by CNAs and an LPN up the chain of command to the DON, ADON, and Administrator, and the DON acknowledged being aware of at least one allegation and discussing it with others. However, the facility did not document these discussions, did not report several oral allegations of abuse and neglect to the state agency as required, and leadership determined the concerns did not meet their understanding of abuse or neglect despite facility policies mandating immediate reporting of all alleged violations to appropriate authorities.
The facility failed to maintain accurate, consistent, and accessible advance directives and code status orders for multiple residents. One resident had a POLST indicating DNR and selective treatment while an active order listed full code, and the required orange prehospital medical care directive could not be found in the EHR or nursing station binder. Another resident with extensive comorbidities had an Advance Directive Statement Form refusing CPR and defibrillation and specifying other treatment preferences, but the care plan initially lacked any advance directive focus and a later POLST ordered CPR and documented that no advance directive existed. Staff interviews revealed that nurses and CNAs relied on electronic charts and code status books that did not always match, and some staff stated they would proceed with full code when documentation conflicted or was missing, even if this went against resident wishes. Leadership acknowledged that facility policy and state law required correctly completed POLST forms and orange prehospital medical care directives for DNR/DNI status, and that these documents were not consistently completed, updated, or available as required.
Two residents with diabetes on sliding scale insulin orders experienced multiple episodes of blood glucose readings at or above the ordered notification threshold, but staff did not contact the provider as required and did not document any such notifications. For one resident with diabetes, chronic kidney disease, and long-term insulin use, the care plan omitted the specific sliding scale and notification parameters, and MAR reviews over several months showed repeated elevated readings without provider notification. For another resident with diabetes and acute kidney failure, physician orders clearly directed staff to call the medical director for blood sugars of 351 mg/dL or higher, yet MARs and progress notes showed very high readings on multiple occasions with no evidence of provider contact. Staff interviews, including with an LPN and the DON, confirmed that these elevated values were out of ordered parameters and that the provider was not notified, contrary to facility policy and recognized diabetes management guidance.
The facility failed to ensure PASARR screenings were accurate, complete, and updated for two residents with mental health and substance use-related conditions. One resident with diabetes, CKD, malnutrition, and documented substance use disorder and anxiety had a hospital-submitted PASRR Level I that omitted anxiety and substance use, and the facility did not generate its own Level I despite internal care plans and MDS data later reflecting an anxiety diagnosis and antianxiety medication orders. Another resident with an active bipolar disorder diagnosis and antipsychotic use had a PASARR form that omitted the bipolar diagnosis and antipsychotic therapy and was only partially completed, even though the MDS and physician orders documented bipolar disorder, hallucinations, and recent antipsychotic use. Staff interviews revealed that the SSD was new to the PASARR system, had not initiated additional PASARR screenings, and acknowledged that a Level II should have been requested for the resident with bipolar disorder, while the DON confirmed staff were previously unaware of requirements to update Level I when a stay would exceed 30 days and that the facility policy did not address this requirement.
Surveyors found that kitchen staff failed to follow facility food safety policies requiring proper labeling and dating of stored food items. During a walkthrough of refrigerators, freezers, and dry storage, multiple items—including grapes, pepperoni, vegan burger patties, cod fish patties, potatoes, bananas, and tortilla chips—were observed without required received dates, open dates, or use-by dates. In interviews, the Food Services Director and Dietary Manager confirmed that policy mandates all stored and opened foods be labeled with these dates and, when repackaged, placed in sealed, labeled containers, but the observed practices did not meet these standards.
Two residents with dementia engaged in a physical altercation over a personal item, resulting in one slapping the other and a subsequent shove. Staff intervened and separated the residents, but documentation showed that not all required notifications were made. Despite existing care plans and staff training on abuse prevention, the incident was recognized as abuse and highlighted a failure to fully protect residents from such events.
A resident with cognitive impairment, mobility limitations, and a history of falls was not provided with adequate supervision or timely staff response, leading to two falls. The resident reported long wait times for assistance, resulting in attempts to transfer independently. Staff interviews revealed inconsistent awareness and implementation of fall prevention interventions, contributing to repeated falls and injuries.
Two residents with severe cognitive impairment were physically abused by another resident with a history of agitation and psychotic disorder. In separate incidents, the aggressive resident struck one resident in a common area and slapped another in their shared room, resulting in emotional distress and minor injury. Both events were witnessed by staff and documented, revealing a failure to prevent resident-to-resident abuse despite existing care plans and interventions.
Pain Medications Administered Outside Ordered Parameters for PRN Use
Penalty
Summary
Surveyors identified a deficiency in medication administration in which a resident’s drug regimen was not kept free from unnecessary drugs, specifically pain medications given outside provider-ordered parameters. The cognitively intact resident had diagnoses including Type 2 Diabetes Mellitus without complications, a right heel pressure ulcer, and acute osteomyelitis of the right ankle and foot, and had a care plan addressing pain related to a right heel wound as well as risk for negative health outcomes related to continued substance use while in the facility. Provider orders included PRN Hydrocodone-Acetaminophen 5-325 mg every four hours as needed for pain intensity 4–10, to be held if the resident was drowsy, and PRN Acetaminophen 325 mg, two tablets every six hours as needed for pain intensity 1–3, not to exceed 3 grams in 24 hours. The facility’s Administration of Medications policy required staff to note the resident’s history and any parameters around drug administration and identified opioids as high-alert medications. Record review showed multiple instances in which nursing staff administered these medications outside the ordered pain-level parameters. The January Medication Administration Record (MAR) showed Hydrocodone-Acetaminophen was given once for a documented pain level of 1, and the February MAR showed it was given for pain levels of 0 and 1, despite the order specifying use only for pain levels 4–10. The January MAR also showed Acetaminophen was administered on several dates when the recorded pain levels were 6, 7, 5, 4, or 0, outside the ordered 1–3 pain range, and similar out-of-parameter administrations occurred in February for pain levels 4 and 5. Interviews with an LPN and the DON confirmed that medications are to be given according to provider orders, that these administrations occurred outside the ordered parameters, and that there was no documentation in the record authorizing administration outside the provider’s orders for the identified dates.
Failure to Report Resident’s Abuse and Neglect Allegations to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse and neglect reporting policies and to timely report allegations of neglect to the state agency for one resident. The resident had multiple medical diagnoses, including type 2 diabetes mellitus, depression, urinary retention, benign prostatic hyperplasia, muscle spasm, and morbid obesity due to excess calories. A care plan initiated in February 2024 identified a risk for change in mood or behavior related to medical conditions, with interventions including medications as ordered. A quarterly MDS assessment documented intact cognition with a BIMS score of 15/15 and noted that the resident experienced depressed mood and behavioral symptoms in the days preceding the assessment. The resident’s care plan for risk of change in mood and behavior was revised in February 2025 to note that the resident made untrue statements about receiving medications on time. On a date in February 2026, a behavior progress note documented that the resident told a medication technician he was being neglected and wanted to speak to a nurse immediately. The note indicated the allegation was reported to the DON, who spoke with the resident and instructed staff to provide care with two staff present in the room; however, there was no evidence that this allegation was reported to the state agency. The care plan was later revised to include interventions for two-person care and medication pass. Another behavior progress note in February 2026 recorded that the resident complained of not receiving nighttime medications and accused staff of abusing and neglecting him, and the nurse documented that the ADON was notified and that medications were being administered per physician orders. A separate note the same day indicated that care in pairs was continuing. During interviews, the resident stated that an LPN had inflicted mental abuse on him through prior interactions that made him feel less than a man, and that he experienced increased anxiety and anxiety attacks when aware that this LPN would be on shift. He also reported feeling abused and neglected due to his race and said he had informed the DON but felt nothing was done. CNAs reported that the resident had shared allegations of abuse and neglect with them and that they relayed these concerns to nurses, who responded that they were already aware and would handle the matter; the CNAs were unsure what actions were taken. An LPN stated that allegations of abuse and neglect, including verbal and physical abuse and withholding care, must be reported to the state agency within two hours and that she had reported the resident’s allegations about water restrictions and medications to the ADON, DON, and Administrator, but she was not informed of any subsequent facility actions. The DON stated that all allegations of abuse and neglect, including verbal abuse, were to be reported to the abuse coordinator, and acknowledged that a prior allegation of neglect documented in a June 2024 progress note had not been reported to her, and therefore was not reported to the state agency as required by policy and regulation. Regarding the February 13, 2026 progress note, the DON confirmed that the allegation of neglect had been reported to her but that she did not document any discussion with the resident. The DON, ADON, and Social Services confirmed that a conversation about the allegations occurred but was not documented and that they determined the allegation did not meet their understanding of abuse or neglect and did not require further action, including reporting to the state agency, contrary to facility policy and regulatory requirements. Social Services noted the resident had increased depression and anxiety and did not connect these behaviors with the abuse and neglect allegations. The facility’s policies on abuse identification and on reporting and response required staff to report suspected abuse, neglect, or exploitation to leadership and mandated that all alleged violations, whether oral or written, be reported to the facility and appropriate officials within prescribed timeframes, which did not occur in this case. An LPN identified as the alleged perpetrator stated that whether she would report an allegation depended on who made it and the rapport she had with the resident, indicating she would decide what to report based on that relationship. She also stated she could not recall the resident disclosing allegations of abuse or neglect to her or against her and denied that any such allegations would be true based on her character. She did not describe specific actions or behaviors that would constitute abuse or neglect. Overall, the documented allegations by the resident, the staff interviews, and the policy review show that multiple allegations of abuse and neglect were not reported to the state agency and were not handled in accordance with the facility’s written abuse and neglect reporting policies and regulatory requirements.
Failure to Maintain Accurate and Accessible Advance Directives and Code Status Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that valid, consistent, and readily accessible advance directives and medical orders were in place and accurately reflected for multiple residents, resulting in conflicting code status information and missing documentation. For one resident with diagnoses including malignant neoplasm of the prostate, acute kidney failure, hypothyroidism, glaucoma, benign prostatic hyperplasia, and muscle weakness, a POLST form documented a choice of no CPR and selective treatment to avoid intensive care and resuscitation efforts. Despite this, an active order in the clinical record listed the resident as full code, and staff were unable to locate the required prehospital medical care directive (orange advance directive form) in either the electronic health record or the nursing station binder at the time of review. The DON later acknowledged that staff were expected to follow the most recent POLST indicating DNR, but this conflicted with the active full code order and the absence of the required orange directive form. Another resident, with a complex medical history including traumatic brain injury, hypertension, GERD, tremor, long-term anticoagulant and insulin use, schizoaffective disorder, Guillain-Barré syndrome, generalized anxiety disorder, bipolar disorder, dementia with behavioral disturbance, neoplasm, protein-calorie malnutrition, dyspnea, and type 2 diabetes with polyneuropathy, had an order indicating DNR and no feeding tube. An Advance Directive Statement Form documented that this resident did not want CPR or defibrillation in the event of cardiac arrest, did not want a feeding tube, did want IV hydration, wanted adequate pain medication even if it risked depressing respiration, wanted transfer to the hospital if their condition became terminal or irreversible, and would accept blood transfusions but not mechanical ventilation. However, the resident’s care plan initially contained no focus or interventions related to advance directives after admission, and only later was revised to state that the resident had an advance directive for CPR, do not shock, and DNI. A POLST completed later documented “Yes, CPR, attempt resuscitation” and stated that no advance directive existed, directly conflicting with the previously completed Advance Directive Statement Form. Staff interviews further demonstrated inconsistent understanding and implementation of the facility’s advance directive process. Nursing staff reported that code status information should be available in the electronic chart and in a code status book at each nursing station, and that changes in code status should be reflected in both locations. One LPN stated that if an advance directive was incorrect, staff could go against the resident’s wishes, and a CNA reported that if forms and lists did not match the health record, they would proceed with full code until the correct status was confirmed, even though this could result in care against the resident’s wishes. The ADON and DON described a process requiring both a correctly completed POLST and a prehospital medical care directive on orange paper for DNR/DNI status, in accordance with state law and facility policy, and acknowledged that incomplete, conflicting, or inaccessible documents could lead to treatment being performed against a resident’s wishes. The facility’s own policy required review and updating of advance directives at admission, quarterly, and with changes in condition, and required social services to ensure copies were in the medical record with corresponding physician orders, but these expectations were not met for the residents reviewed. Additional findings showed that for another resident, staff could not locate any advance directive or POLST in the electronic record or nursing station binder, despite an active order indicating DNI and do not shock status. The DON confirmed that, given this active order, both a POLST and an orange prehospital medical care directive should have been completed and present in the record, but they were not. The state prehospital medical care directive requirements specified that the DNR document must be on orange paper, signed by the patient, health care provider, and a witness or notary, and displayed visibly for first responders, yet such a valid document was not consistently available for the residents in question. Overall, the facility did not follow its own policy and state requirements to ensure that advance directives and related medical orders were accurately completed, consistently documented, and readily accessible, leading to conflicting and incomplete information regarding residents’ code status and treatment preferences.
Failure to Notify Provider of Critically Elevated Blood Glucose Levels per Insulin Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders requiring provider notification for abnormal blood glucose levels for two residents with diabetes who were receiving insulin on sliding scale orders. For one resident with Type 2 Diabetes Mellitus, Stage 4 chronic kidney disease, long-term insulin use, a right heel pressure ulcer, and acute osteomyelitis of the right ankle and foot, a provider order dated October 20, 2025 directed staff to notify the provider and administer 12 units of Humalog for glucose levels of 351 mg/dL or greater. The resident’s diabetes care plan, initiated October 21, 2025, instructed staff to obtain blood sugar checks and administer medications as ordered, but did not include the specific sliding scale insulin parameters or the requirement to contact the provider when glucose exceeded 351 mg/dL. Review of the December 2025 MAR showed multiple blood glucose readings at or above 351 mg/dL on several dates, with no documentation that the provider was notified as ordered. Further review of the same resident’s records showed that in January 2026 and February 2026, blood glucose levels again reached 351 mg/dL or greater on multiple dates, triggering the order to administer 12 units of Humalog and notify the provider. However, the clinical record contained no documentation that the provider was contacted for any of these elevated readings. The admission MDS indicated the resident was cognitively intact with a BIMS score of 15 and received daily insulin therapy. Interviews with facility staff, including a CNA, the RD, an LPN, and the DON, confirmed that staff understood that elevated blood glucose levels and sliding scale orders requiring provider notification must be reported to the provider, and the DON acknowledged that the provider should have been contacted for each instance and that no documentation of such notifications could be found. For a second resident re-admitted with diagnoses including type 2 diabetes mellitus, long-term insulin use, and acute kidney failure, a physician order dated November 28, 2025, and again on December 5, 2025, specified Humalog insulin to be given subcutaneously before meals and at bedtime per a sliding scale, with instructions that for blood glucose levels of 351 mg/dL or greater, 10 units of insulin should be administered and the medical director called. Review of the December 2025 MAR showed multiple blood glucose readings above 351 mg/dL on several dates, and a February 2026 MAR entry showed a blood sugar of 449 mg/dL, with no evidence that the physician was notified on any of these occasions. Progress notes from December 2025 through January 2026 also lacked documentation of provider notification when blood sugars exceeded 351 mg/dL. Interviews with an LPN and the DON confirmed that the resident’s blood sugars were very high on the identified dates and that the provider was not notified, despite facility policy requiring orders to be followed and documentation to be consistent with professional standards and guidance indicating that persistent elevated readings above the ordered sliding scale should be communicated to the provider.
Failure to Complete and Update Accurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure PASARR (Preadmission Screening and Resident Review) screenings and referrals were accurate, complete, and submitted according to professional standards for two residents. For one resident with diagnoses including long-term insulin use, Type 2 diabetes, stage 4 chronic kidney disease, and malnutrition, the hospital-submitted PASRR Level I did not reflect the resident’s history of anxiety or substance use disorder. The facility did not generate its own PASRR Level I, despite internal documentation identifying substance use disorder and elopement risk, and a mood/behavior care plan that referenced risk for mood or behavior changes. The admission MDS showed moderately impaired cognition but no history of anxiety or antianxiety medication use, even though the resident later had an order for an antianxiety medication and a quarterly MDS listed an active anxiety disorder diagnosis. For the second resident, who had an active diagnosis of bipolar disorder, the care plan documented the use of antipsychotic medications related to this diagnosis. However, the PASARR form completed for this resident did not include the bipolar disorder diagnosis or any evidence of ordered antipsychotic medication, and only three of the five PASARR review pages were completed. Subsequent clinical documentation, including a physician’s order for olanzapine for bipolar disorder and behaviors such as hallucinations and repeated requests for assistance, as well as a quarterly MDS indicating bipolar disorder and recent antipsychotic use, demonstrated that the PASARR information was incomplete and inconsistent with the resident’s actual condition and treatment. Interviews with facility staff further demonstrated gaps in the PASARR process. The Activities Director stated that a correct PASARR helps staff develop appropriate interventions but acknowledged reliance on her own assessment when the PASARR is inaccurate. The Social Services Director reported being new to the PASARR portal, lacking access for a period, and not having completed additional PASARR level screenings since assuming the role, despite acknowledging that a Level II should have been submitted for the resident with bipolar disorder once it was clear the stay would exceed 30 days. The DON confirmed that social services is responsible for PASARR completion, that staff were previously unaware of requirements such as updating Level I when a stay is expected to exceed 30 days, and that the diagnoses, care plans, and PASARR information for the residents did not match. The facility’s PASARR policy also lacked language addressing the requirement to update a Level I when an individual’s stay will exceed 30 days, as specified in the state Medicaid policy manual.
Failure to Label and Date Stored Food Items per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices based on observations in the kitchen refrigerators, freezers, and dry storage areas. During an inspection of Refrigerator #1, an original package of grapes was found without any received date, opened date, or use-by date. In Freezer #1, an original package of pepperoni was labeled only with a received date of September 5, 2025, but lacked an opened date and use-by date. In the same freezer, an opened original package of vegan burger patties, received on January 7, 2026, had no open date or use-by date, and an opened original package of cod fish patties had no received date, opened date, or use-by date. In the dry storage area, an original box of potatoes, a box of bananas, and an original bag of tortilla chips were all found without any received dates, and the tortilla chips also lacked an opened date and use-by date. In interviews following these observations, the Food Services Director and the Dietary Manager & Director confirmed that facility policy requires all items stored in the refrigerator, freezer, and dry storage to be labeled with a received date, open date, and, when applicable, a use-by date, in a manner accessible to staff. They stated that opened items kept in original packaging are expected to be placed in sealable containers or packages and labeled with the required dates, and that fresh produce boxes must retain the received date and be checked daily for wholesomeness. The facility’s written “Food Safety” policy, last reviewed May 1, 2025, further documented that pre-packaged food transferred to new containers must be labeled with contents and date, that received food must be dated if not already indicated, that each item in multi-item boxes must be individually dated, and that opened packages must be resealed tightly and labeled with a use-by date when applicable. The observed lack of required labeling and dating on multiple food items demonstrated noncompliance with these established policies and professional standards for food storage.
Failure to Protect Residents from Abuse During Roommate Altercation
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse, as evidenced by an altercation between two roommates. One resident, who had diagnoses including dementia and severely impaired cognition, was involved in a physical altercation with her roommate over a plastic flower. During the incident, one resident slapped the other on the face, and the other responded by shoving her roommate's shoulder. Staff intervened and separated the residents, and a skin assessment was completed with no injuries noted. Clinical documentation and staff interviews confirmed that the altercation was witnessed by staff, who heard a commotion and observed the physical exchange. The residents were separated, and notifications were made to the DON, administrator, and provider. However, the behavioral progress note indicated that the resident's representative and case manager were not notified of the incident. Both residents had care plans indicating a potential for verbal aggression related to dementia, with interventions to assess and anticipate needs, but the altercation still occurred. Staff interviews revealed that the incident was recognized as a form of abuse, with both the LPN and Medication Technician stating that physical contact such as slapping or pushing constitutes abuse. The facility's policies on abuse prevention and resident rights were reviewed, confirming the expectation to prevent all types of abuse. Despite these policies and staff training, the incident occurred, resulting in a failure to fully protect residents from abuse as required.
Failure to Provide Adequate Supervision Resulting in Resident Falls
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including moderate cognitive impairment, osteoporosis, and dementia, was not provided with adequate supervision to prevent falls. The resident had a documented history of falls, impaired mobility, and required assistance with activities of daily living (ADLs) and transfers. Despite these needs, the care plan interventions prior to the falls primarily included having the call light within reach, staff assistance for transfers and toileting, and the use of non-slip socks or shoes during mobility. However, the resident experienced two falls within a short period, one in the bathroom while attempting to transfer from the wheelchair without assistance and another after falling asleep in the wheelchair and sliding to the floor. Documentation and staff interviews revealed that the resident had reported using the call light for assistance but experienced significant delays in staff response, sometimes waiting an hour or more. The resident stated that due to these delays, he attempted to perform tasks independently, leading to falls. Staff interviews indicated inconsistent awareness of the resident's fall risk status and interventions, with one CNA unaware that the resident was a fall risk prior to the incidents and noting the absence of a yellow armband, which was supposed to indicate fall risk. The care plan and interventions were not consistently communicated or implemented among staff, and there was a lack of timely and effective supervision tailored to the resident's needs. The facility's policy required providing an environment free from accident hazards and adequate supervision to prevent avoidable accidents. Despite this, the resident's increased weakness, cognitive impairment, and history of falls were not sufficiently addressed through effective supervision or timely staff response. The lack of prompt assistance and inconsistent implementation of fall prevention interventions contributed to the resident's repeated falls and subsequent injuries, including compression fractures and increased back pain.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with severe cognitive impairment and a history of agitation and psychotic disorder initiated a verbal altercation with another cognitively impaired resident in a common area. Despite staff presence, the aggressive resident struck the other on the back of the head, an act witnessed by staff. The victim was left teary-eyed but did not sustain physical injuries. The aggressive resident had a recent reduction in antipsychotic medication, which was later increased after the incident due to a return of behavioral issues. In the second incident, the same aggressive resident was involved in a physical altercation with a different roommate, also diagnosed with severe dementia and behavioral disturbances. The altercation occurred in their shared room, where the aggressive resident slapped the roommate on the face, resulting in visible redness and emotional distress. The aggressive resident claimed provocation, but the victim denied any physical aggression. Staff responded to the incident after hearing a scream and found the victim holding her face and visibly upset. The incident was documented, and the residents were separated immediately after. Both incidents were substantiated or under investigation by the facility, with staff interviews confirming the aggressive resident's history of agitation, confrontational behavior, and recent emotional distress related to personal matters. The facility's policy prohibits all forms of abuse, including resident-to-resident abuse, but the interventions in place failed to prevent these incidents. The events were witnessed by staff, and the facility's documentation confirmed the occurrence of physical abuse between residents.
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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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