Immanuel Campus Of Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Peoria, Arizona.
- Location
- 11301 North 99th Avenue, Peoria, Arizona 85345
- CMS Provider Number
- 035250
- Inspections on file
- 38
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Immanuel Campus Of Care during CMS and state inspections, most recent first.
A resident with PTSD, depression, speech disturbance, and moderate cognitive impairment, who had a documented history of prior sexual and physical trauma, was participating in karaoke with two other residents when another cognitively intact resident with mental health and substance abuse history became upset over the resident’s phone use. According to staff and resident interviews, the upset resident yelled profanities, grabbed the resident around the neck, pulled her from her wheelchair so that her head struck a table, and both fell to the floor, while making threats and derogatory statements. The resident was found on the floor crying, reported head pain and fear, and a witness described the event as physical and verbal abuse. Staff, including an LPN and the DON, identified the incident as resident-to-resident physical abuse, demonstrating a failure to protect the resident from abuse despite facility policies requiring residents be free from abuse and re‑traumatization avoided.
A resident with severe cognitive impairment experienced an unwitnessed fall and was later observed with multiple bruises, but the family was not promptly notified by facility staff as required. Documentation and staff interviews confirmed that the incident and injuries were recorded, but the resident's representative only learned of the situation from hospice staff days later, indicating a lapse in timely communication and adherence to notification policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective or consistently enforced policies and procedures to prevent abuse, neglect, and theft. Surveyors found gaps in staff training and unclear guidance on reporting and responding to such incidents, leaving residents inadequately protected.
The facility did not report an alleged incident of resident-to-resident abuse to the State Agency and APS within the required two-hour timeframe. A resident with intact cognition reported being struck and choked by another resident, and a staff member witnessed the event. However, the facility's investigation did not include a statement from the witnessing staff, and the incident was not promptly reported as required by facility policy.
A resident with severe cognitive impairment was physically struck in the face by another cognitively impaired resident during a smoke break in a common area, resulting in mild facial redness. Staff and facility documentation confirmed the incident as physical abuse under the facility's abuse policy.
A resident with severe cognitive impairment and a history of psychiatric disorders became physically aggressive, pulling another cognitively impaired resident to the ground in a common area. The incident was witnessed by staff, who separated the residents and assessed the victim for injuries. Facility records and care plans did not previously document aggressive behaviors for the aggressor, and the facility's investigation substantiated the occurrence of resident-to-resident abuse.
A resident with a history of substance abuse was found unresponsive and later hospitalized after overdosing on fentanyl, which was obtained from outside the facility and provided by another resident. Staff interviews revealed a lack of clear interventions to prevent residents from accessing non-prescribed or illicit substances, and the resident's care plan did not address substance abuse risks. Facility policy emphasized safety and supervision, but these measures were not effectively implemented, leading to the overdose event.
Two residents experienced physical and verbal abuse from CNAs, including rough handling, aggressive language, and threats to withhold privileges. Staff interviews confirmed the abusive behaviors, and facility documentation lacked records of the incidents. The DON acknowledged that the facility did not document staff-to-resident abuse allegations, contrary to policy.
During a COVID-19 outbreak, two residents were kept in quarantine for 18 days despite being asymptomatic and eligible to leave their rooms after seven days. The residents expressed distress over being confined, and a CNA was observed instructing a resident to return to her room in an unwelcoming manner. The Nursing Administrator and Infection Control Preventionist confirmed that the residents should have been allowed out, and the facility's policy guarantees treatment with respect and prohibits involuntary seclusion. However, a miscommunication led to the residents' rights being violated.
The facility failed to provide activities for two residents who tested positive for COVID-19, keeping them isolated beyond the required quarantine period. Despite being asymptomatic, they were not offered activities, impacting their psychosocial well-being. Staff interviews revealed miscommunication and misunderstanding about quarantine duration and activity provision, leading to a failure to follow the activity care plan.
A resident with a history of self-harm and suicidal ideation was left unsupervised when the staff member assigned to her one-to-one care was called away to assist with another emergency. During this time, the resident attempted to harm herself by wrapping a sheet around her neck. She was found by staff and transported to the hospital. The deficiency occurred due to the failure to maintain the required supervision as per the resident's care plan.
A resident with a history of behavioral issues was verbally abused by a staff member, who used unprofessional language and threatened physical harm. The staff member had not attended recent abuse training, and the facility failed to document the resident's behavior in the MAR, highlighting a deficiency in protecting residents from abuse.
A resident with severe cognitive impairment and risk for skin breakdown had multiple instances of bruising and discoloration that were not documented in weekly skin assessments. Despite progress notes indicating these issues, the assessments consistently reported no skin concerns. Interviews with staff confirmed the discrepancies, highlighting a failure to accurately document the resident's skin condition as per facility policy.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse in Activity Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident with a documented history of multiple past traumas from physical and verbal abuse by another resident. The alleged victim had anoxic brain damage, mood disorder, depression, PTSD, and speech disturbance, and had been care planned as positive for adult sexual abuse, child physical abuse, domestic violence, and vehicular victimization, with interventions to avoid re‑traumatization. A quarterly MDS showed moderately impaired cognition with a BIMS score of 9. On the date of the incident, a nursing note documented that the resident was found on the floor crying, non‑verbal but able to indicate that another resident had pushed her, and that she had pain in her head and knee after hitting her head. The alleged perpetrator had anoxic brain damage, bipolar disorder, anxiety, seizures, and a cognitive communication deficit, with a care plan noting a history of substance abuse and mental health disorder and interventions to monitor for depression. A quarterly MDS showed intact cognition with a BIMS score of 15. Staff and resident interviews consistently described an altercation in the activity room involving three residents who had been doing karaoke. Witness accounts indicated that the alleged perpetrator became upset when the alleged victim was using her phone, believed she was communicating with someone else, and attempted to take the phone. When the alleged victim refused, the alleged perpetrator began yelling profanities, grabbed her around the neck area, and pulled or dragged her from her wheelchair, causing her head to strike a table before both residents fell to the floor. The alleged victim was observed on the floor crying and later reported feeling scared and hurt on the left side of her head. A witness resident reported that the alleged perpetrator yelled threats, including “I will kill you,” and called the alleged victim derogatory names, while the victim asked not to be left alone. Staff interviews, including an LPN, a life enrichment associate, and the DON, characterized the event as resident‑to‑resident physical abuse, with some also identifying verbal and emotional abuse. Facility policies on resident rights and abuse defined residents’ right to be free from abuse and described physical abuse as including hitting and controlling behavior through corporal punishment. Despite these policies and the known trauma history and vulnerabilities of the alleged victim, the incident occurred in a supervised activity setting, resulting in the resident being physically assaulted and verbally threatened by another resident.
Failure to Notify Resident Representative of Injury and Fall
Penalty
Summary
The facility failed to notify a resident's representative of an injury and an unwitnessed fall, as required by policy. The resident, who had severe cognitive impairment and required maximum assistance, was observed with multiple bruises and discoloration on her body over several days. Progress notes and staff interviews confirmed that these injuries were documented, and an unwitnessed fall occurred, but there was no documentation or evidence that the family was notified promptly after these incidents. Staff interviews revealed that the nurse responsible did not notify the family or supervisors immediately after the fall, citing the end of shift and being off over the weekend as reasons for the delay. The resident's representative confirmed that notification was only received from hospice staff several days later, not from the facility. Facility policy requires immediate notification of the resident's physician and family following incidents such as falls or injuries, and documentation of such notifications in the medical record. Despite this, the required notifications were not made in a timely manner, and the incident was not properly documented according to policy. The deficiency was identified through closed record review, staff interviews, and review of facility documentation, which all indicated a lapse in communication and adherence to established procedures for reporting resident injuries and incidents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility records and interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and responding to incidents of abuse, neglect, or theft. The absence of these measures contributed to an environment where residents were not adequately protected from potential harm.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving two residents was reported to the State Agency and Adult Protective Services within the required two-hour timeframe. One resident, who had diagnoses including anoxic brain damage and paraplegia but was cognitively intact, reported to his insurance case manager that he was struck in the face and choked by another resident. The incident was said to have occurred in a hallway while staff were present, and a Life Enrichment Associate confirmed witnessing the event. However, the facility's self-report investigation did not include an interview or statement from this staff member, and staff working at the time denied witnessing the altercation. The Executive Director, who serves as the facility's abuse officer, confirmed that staff are trained to report suspected abuse immediately to management, who are then responsible for notifying the appropriate agencies within two hours. Despite this policy, the Executive Director only became aware of the incident through the resident's insurance case manager and was unable to confirm the date of the incident or identify witnesses during the investigation. The facility's policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, but this process was not followed in this case.
Resident-to-Resident Physical Abuse in Common Area
Penalty
Summary
A resident with severe cognitive impairment and a history of unspecified intracranial injury was sitting outside during a smoke break when another resident, also severely cognitively impaired and diagnosed with schizoaffective disorder, bipolar type, stood up and hit the first resident in the face. Clinical documentation confirmed that the incident resulted in mild redness to the face of the assaulted resident. The event was witnessed and documented in progress notes and a skin assessment, which verified the physical evidence of the altercation. Staff interviews confirmed that the incident occurred in a common area designated for smoking and that such resident-to-resident altercations are recognized as abuse under facility policy. The facility's abuse policy defines abuse as the willful infliction of injury, including physical acts such as hitting. The report details that the incident was identified as abuse by staff and that the facility's policy recognizes this type of event as a violation of residents' rights to be free from abuse.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident. One resident with severe cognitive impairment and a history of psychiatric and behavioral diagnoses, including schizoaffective disorder and traumatic brain injury, exhibited physical and verbal aggression. On the day of the incident, this resident became aggressive with staff and attempted to hit them while trying to leave, ultimately requiring intervention by three staff members and the police. During this episode, the resident physically assaulted another resident by grabbing the individual's leg and pulling them to the ground. Prior to this event, the resident's care plan and assessments did not document any physical behaviors or incidents involving aggression toward other residents. The resident who was assaulted also had severe cognitive impairment and multiple psychiatric and medical diagnoses, including dementia with agitation and psychosis. At the time of the incident, this resident was attempting to ambulate in a common area when the aggressor pulled him down, resulting in a fall to his knees. Staff immediately separated the residents and assessed the assaulted resident for injuries, finding none. The facility's investigation substantiated that resident-to-resident abuse had occurred. Policy reviews confirmed that the facility was required to prevent all forms of abuse, including those perpetrated by other residents.
Failure to Prevent Non-Prescribed Medication Overdose Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a non-prescribed medication overdose for a resident. One resident with a history of substance abuse and opioid use was found unresponsive in bed, exhibiting symptoms consistent with an overdose, including mouth foaming and residual powder at the nose. Hospital records confirmed the presence of fentanyl, oxycodone, and benzodiazepines in the resident's system, despite no physician order for fentanyl. The resident later confirmed that the overdose was due to fentanyl obtained from outside the facility, and that another resident had provided it, though the source was not affiliated with the facility. Interviews with staff revealed gaps in interventions to prevent residents from obtaining or using non-prescribed medications or illicit substances. Staff members stated that residents were not allowed to keep medications in their rooms unless specifically indicated, and that they would alert supervisors if illicit drugs or unprescribed medications were observed. However, staff were not aware of specific interventions in place to prevent residents from bringing in or accessing such substances, aside from searching rooms if drug use was suspected and obtaining consent for drug screenings or searches. The facility's policy emphasized resident safety and supervision to prevent accidents, including targeting interventions to reduce individual risks related to environmental hazards. Despite this, the care plan for the resident with a known history of substance abuse did not include specific interventions related to substance abuse or dependency. The lack of targeted supervision and preventive measures contributed to the resident's ability to obtain and use non-prescribed fentanyl, resulting in an avoidable overdose event.
Failure to Protect Residents from Staff Abuse
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by staff, as evidenced by multiple documented incidents and corroborated staff interviews. One resident with severe cognitive impairment and a history of traumatic brain injury was subjected to rough handling and physical aggression by a CNA, who pushed the resident's wheelchair and used a chair to strike the resident's upper back. The LPN on duty witnessed these actions and noted that the CNA had previously exhibited aggressive behavior toward the same resident, including forcefully pulling the resident back using a bib. Despite witnessing these actions, the LPN did not report the prior incident, believing that a verbal warning would suffice. Another resident with moderate cognitive impairment and a history of depression and physical aggression was subjected to verbal abuse by a CNA. The resident reported being spoken to in a demeaning and profane manner by the CNA after requesting assistance with shaving. Multiple staff interviews confirmed that the CNA raised her voice, used inappropriate language, and threatened to withhold privileges, such as a smoke break, as a response to the resident's behavior. Staff interviews also indicated that the CNA had a pattern of using an aggressive tone with both residents and other staff members. Facility documentation and interviews revealed that there was no documentation in the progress notes regarding the alleged abuse incidents for either resident. The facility's Director of Nursing confirmed that it was not the facility's practice to record allegations of staff-to-resident abuse, only resident-to-resident abuse. The facility's abuse policy states that residents have the right to be free from abuse, neglect, and corporal punishment, and that the facility does not condone any form of resident abuse.
Violation of Resident Rights During COVID-19 Quarantine
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination during a COVID-19 outbreak. Two residents, one with moderate cognitive impairment and another who was cognitively intact, were kept in quarantine for 18 days despite being asymptomatic and testing positive for COVID-19 on December 2, 2024. According to the facility's COVID-19 line listing, they should have been allowed to leave their rooms by December 10, 2024. However, they were not permitted to do so, which led to distress and complaints from the residents. During interviews, one resident expressed frustration about not being allowed to leave his room for a cigarette, while another resident was told by a CNA to return to her room in an unwelcoming tone. The CNA explained that the residents were not allowed out due to the COVID-19 outbreak. The Nursing Administrator and the Infection Control Preventionist both confirmed that the residents should have been allowed out of their rooms after seven days of quarantine, and that keeping them confined was a violation of their rights. The facility's policy on resident rights guarantees treatment with respect, kindness, and dignity, and prohibits involuntary seclusion. Despite this, a licensed practical nurse reported being instructed by the Nursing Administrator and the QAPI nurse that no residents were allowed out of their rooms due to the ongoing spread of COVID-19. This miscommunication and failure to adhere to the facility's policy resulted in the residents being unnecessarily confined, violating their rights to dignity and self-determination.
Failure to Provide Activities for COVID-19 Positive Residents
Penalty
Summary
The facility failed to provide appropriate activities for residents who tested positive for COVID-19, specifically residents #55 and #33, during their quarantine period. Both residents were asymptomatic and should have been allowed to leave their rooms after seven days of quarantine, as per the facility's policy. However, they remained isolated for 18 days, during which they were not offered any activities, impacting their psychosocial well-being. Resident #55 expressed frustration about being confined to his room, while resident #33 was similarly restricted and expressed feelings of being disliked by staff. Interviews with staff revealed a lack of clarity and communication regarding the quarantine duration and the provision of activities. The Nursing Administrator and the Infection Control Preventionist confirmed that the quarantine period was seven days, and residents should have been allowed to participate in activities after this period. However, the Life Enrichment Associate did not offer activities to COVID-19 positive residents due to a misunderstanding of the quarantine duration and a reluctance to use personal protective equipment. This resulted in a failure to follow the activity care plan, leaving residents without engagement or stimulation. The Director of Nursing expected that activities be documented and tailored to each resident's needs, but this was not adhered to during the COVID-19 outbreak. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance. The lack of activities and prolonged isolation could lead to negative psychosocial outcomes for the residents, as noted by the staff interviews.
Failure to Maintain One-to-One Supervision Leads to Resident Self-Harm Attempt
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a history of self-harm and suicidal ideation, leading to a serious incident. The resident, who was cognitively intact but had a history of borderline personality disorder, schizoaffective disorder, major depression, and generalized anxiety, was admitted with suicidal thoughts. The care plan required one-to-one supervision due to the resident's risk of self-harm. However, on the day of the incident, the staff member assigned to supervise the resident left to assist with an emergency involving another resident, leaving the resident unsupervised. During the period of unsupervised time, the resident attempted to harm herself by wrapping a sheet around her neck. She was found by staff standing on her bed with the sheet around her neck, but was responsive and subsequently assessed for injuries. The incident was reported to the necessary authorities, and emergency services were called to transport the resident to the hospital. The deficiency arose from the failure to maintain the required one-to-one supervision, as outlined in the resident's care plan, due to staff being redirected to another emergency situation.
Verbal Abuse Incident Involving Staff and Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, which constitutes a deficiency in ensuring resident safety and dignity. The incident involved a resident who was cognitively intact, as indicated by a BIMS score of 15, and had a history of behavioral issues such as verbal and physical aggression. On the specified date, the resident became argumentative with a staff member, who responded with unprofessional and abusive language, threatening physical harm. This interaction was reported to the facility administrator, and the staff member admitted to the unprofessional conduct. The facility's investigation revealed that the staff member involved had not attended a recent in-service abuse training, although they had completed orientation training earlier in the year. The facility's policy on identifying types of abuse clearly defines verbal abuse as a form of mental abuse, which includes the use of inappropriate language or gestures towards residents. Despite having interventions in place to manage the resident's behavior, the facility failed to document any behavioral issues in the resident's Medication Administration Record on the days surrounding the incident, indicating a lapse in monitoring and addressing the resident's needs effectively.
Inaccurate Skin Assessment Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of skin assessments for a resident with severe cognitive impairment and multiple diagnoses, including dementia and chronic kidney disease. The resident was at risk for skin breakdown, as noted in their care plan, and had interventions in place such as padded bedrails. Despite this, weekly skin checks repeatedly documented no skin breakdown or areas of concern, even though progress notes indicated the presence of discolorations and bruises on the resident's arms. These discrepancies were observed over several weeks, with specific instances of bruising noted in progress notes but not reflected in the weekly skin assessments. Interviews with staff, including a CNA and an LPN, revealed that the resident had been observed with bruises and discolorations, which were not documented in the weekly skin assessments. The LPN acknowledged that the assessments should have noted the bruising, and the DON confirmed that skin assessments should accurately document any alterations in the skin, including bruises. The facility's policy on skin assessment frequency emphasizes the importance of full body assessments to prevent and manage pressure injuries, yet the documentation failed to reflect the resident's actual skin condition.
Latest citations in Arizona
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
