Life Care Center Of Tucson
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 6211 North La Cholla Boulevard, Tucson, Arizona 85741
- CMS Provider Number
- 035140
- Inspections on file
- 20
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Life Care Center Of Tucson during CMS and state inspections, most recent first.
Two residents with dementia and severe cognitive impairment, one already care planned for risk of behavioral changes and physical aggression, were seated in a hallway with other residents when an altercation occurred. One resident was heard yelling and striking the other across the chest with a stuffed animal, and the other resident responded by kicking the aggressor in the leg. An ADON heard screaming, directly observed the physical contact between the residents, and later stated she considered the incident to be abuse. Skin assessments showed no injuries, but the event demonstrated that the facility did not effectively protect a resident’s right to be free from abuse by another resident, despite an abuse‑prevention policy requiring identification, assessment, and care planning for residents with verbally or physically aggressive behaviors.
A resident with moderate cognitive impairment and multiple medical conditions was not initially identified as an elopement risk, despite wandering behaviors. After reassessment, the resident was placed on 15-minute checks and listed in the Elopement book, but inconsistencies in risk assessment and care plan updates occurred. The resident was able to exit the facility unsupervised through the front door, with no Wander Guards or security cameras in place, and staff acknowledged that adequate protection was not provided.
A resident with chronic pain was prescribed Dilaudid, but an LPN repeatedly logged out doses on the narcotic count sheet without documenting administration on the MAR. This discrepancy led to the resident experiencing pain and raised concerns about possible medication diversion, as confirmed by staff interviews and facility policy review.
A power outage led to a malfunctioning generator and cooling system, causing uncomfortably high temperatures in a LTC facility. Several residents, including those with chronic conditions, reported discomfort due to the heat. Staff interviews revealed a lack of systematic temperature monitoring and inadequate emergency protocols, contributing to the prolonged discomfort.
The facility failed to maintain safe food storage temperatures in the walk-in refrigerator, with temperatures recorded above the critical limit of 40F. Despite policy requirements, actual temperatures were higher than recorded, posing a risk for food-borne illnesses. Staff interviews revealed the refrigerator was used for storing various food items, and maintenance errors contributed to the issue.
The facility experienced a complete power outage due to a failure in the temporary generator, which had been in use since 2020. This outage affected medical equipment, elevators, and refrigeration units, and required manual intervention to restore power. Residents on oxygen concentrators were switched to O2 tanks, and staff faced challenges due to non-functional elevators and a lack of standard procedures for power outages. The deficiency was confirmed during an exit conference.
The facility failed to maintain a safe and comfortable environment, with observations revealing safety hazards such as peeling paint, sharp handrails, and protruding nails. Staff interviews indicated a lack of proactive maintenance and communication, with issues often going unreported. The Administrator stressed the importance of a safe environment, but the facility's work order report showed no records of the identified issues, highlighting a gap in maintenance practices.
The facility failed to maintain an effective training program, resulting in incomplete or missing documentation for required annual training in areas such as abuse, resident rights, infection control, dementia care, and emergency preparedness for several staff members, including RNs, LPNs, CNAs, the DON, and the Administrator. Interviews confirmed the training program was not effectively managed, despite having a policy in place.
A resident with multiple health issues, including anxiety and malnutrition, did not consistently receive scheduled bathing assistance, as documented in the facility's records from April to July 2024. The Director of Nursing acknowledged that the facility's documentation did not clearly indicate whether bathing tasks were completed, and staff were not consistently reporting or documenting refusals. This failure could lead to poor hygiene and skin infections.
The facility failed to provide accurate Advanced Beneficiary Notices (ABNs) to two residents when Medicare services ended. One resident received a form with conflicting options selected, while another's form had no options selected, leading to ambiguity about their service continuation choices. Staff interviews confirmed the errors, with the Social Services Director taking responsibility.
A resident admitted with multiple health conditions was not weighed upon admission as required by facility policy, leading to a deficiency in monitoring their condition. The weight recorded was taken from hospital transfer records instead of being measured by facility staff. The facility policy mandates weighing residents within 24 hours of admission and regularly thereafter, which was not followed, potentially affecting the resident's health.
The facility did not ensure the daily staff posting was current and accurate, as required by policy. On a specific day, the posting displayed outdated information, including an incorrect census and missing actual hours worked by staff. The DON acknowledged the issue, noting that the staffing coordinator prepares postings, and the weekend receptionist is responsible for updating them.
The facility failed to ensure that the Administrator was free of TB before starting work. Despite being hired in early 2024, the Administrator did not provide a TB test result until July, contrary to facility policy requiring a negative TB test before employment. The Administrator, who walks the facility floors and may contact residents, was only tested after the deficiency was identified.
Failure to Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident. One resident with dementia and severe cognitive impairment, who had no documented history of verbal or physical behaviors toward others, was care planned for impaired cognitive ability with interventions such as cueing, orienting, and supervision as needed. Another resident, also with dementia and severe cognitive impairment, had a care plan identifying risk for behavioral changes related to dementia and a separate care plan identifying risk for physical aggression during ADL care and showers, including monitoring for behaviors in the dining area and for touching/striking other residents or staff. On the date of the incident, both residents were seated in a hallway surrounded by other residents when an altercation occurred. An event progress note documented that one resident was heard yelling at another, while the other resident was also yelling and hitting the first resident across the chest with a stuffed animal. The note further documented that the first resident then kicked the second resident in the leg. A similar event note for the second resident described the same sequence of events from that resident’s perspective. Skin assessments completed for both residents on the same day showed intact skin with no redness or bruising. The Assistant DON reported hearing screaming outside her office and then witnessing one resident hitting the other across the chest with a stuffed animal and the other resident kicking back. She stated that she was the only staff member to witness the incident and that she would consider the incident to be abuse. The facility’s 5‑day investigation report verified the allegation based on the evidence collected and noted that both residents were unable to recall the incident. The facility’s abuse‑prevention policy stated that procedures include identification, assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict, including verbally and physically aggressive behaviors. Despite this, the altercation occurred between the two residents, constituting a failure to protect one resident’s right to be free from abuse by another resident.
Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for a resident with multiple medical conditions, including moderate cognitive impairment. Upon admission, the resident was not initially assessed as being at risk for elopement, despite having a BIMS score of 4 and exhibiting wandering behavior. The resident was later identified as at risk for elopement after a reassessment, and interventions such as inclusion in the Elopement book and 15-minute checks were implemented. However, there was inconsistency in the risk assessments and care plan updates, as a subsequent assessment overrode the high-risk status without proper reflection in the care plan. The resident was able to exit the facility through the front door after 4 PM, reportedly with the assistance of the receptionist, despite being on 15-minute checks and listed in the Elopement book. At the time, two facility entrances were locked after 4 PM, while the others required a security code, but there were no Wander Guards or security cameras in place. Staff interviews revealed that monitoring relied primarily on 15-minute checks and staff awareness, with no electronic monitoring devices used for residents at risk of elopement. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices to prevent accidents. Despite these policies, the resident was able to leave the facility unsupervised, and staff acknowledged that adequate protection was not provided after the resident's elopement risk was identified.
Failure to Administer and Document Pain Medication per Physician Orders
Penalty
Summary
A resident with dementia, cervical spine fusion, and a right humerus fracture was admitted to the facility and placed on pain medication therapy for chronic pain syndrome. The care plan required administration of analgesic medications as ordered by the physician and monitoring for side effects and effectiveness. A physician's order specified Dilaudid (Hydro-morphine HCI) 2 mg oral tablets, with 0.5 mg to be given every 4 hours as needed for pain. Review of the narcotic count sheet showed that an LPN logged out doses on multiple occasions, but the Medication Administration Record (MAR) did not reflect administration of the medication on several dates when the narcotic count sheet indicated it had been dispensed. Further review revealed that the resident complained of pain, and the nurse on duty was unable to administer pain medication due to discrepancies in the narcotic count sheet and medication cart key handoff times. Staff interviews indicated that the LPN may have either failed to document administration on the MAR or possibly diverted the medication, as it was not reasonable for documentation to occur on the narcotic count sheet but not on the MAR multiple times in a short period. Facility policy required medications to be administered and documented per physician orders, and defined misappropriation to include missing or diverted prescription medications.
Failure to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain adequate and comfortable temperature levels for 14 residents, resulting in an environment that was not homelike or comfortable. On the morning of July 15, 2024, surveyors noted a significant temperature difference upon entering the facility, which felt uncomfortably warm. Interviews with staff revealed that a power outage the previous evening had caused the generator to malfunction, preventing the cooling system from activating. This led to elevated temperatures in residents' rooms, with some rooms registering temperatures as high as 87.1 degrees Fahrenheit. Several residents, including those with conditions such as dementia, chronic obstructive pulmonary disease, and heart failure, reported discomfort due to the heat. Observations confirmed that air conditioning units in many rooms were either not functioning or blowing only room temperature air. Residents expressed their discomfort, with some stating they were unable to sleep well due to the heat. Staff interviews indicated that there was no systematic approach to monitoring room temperatures or relocating residents to cooler areas during the outage. The maintenance staff acknowledged the issues with the generator and cooling system, noting that the chiller took several hours to cool the facility. Despite weekly tests on the generator, there was no alarm system to alert staff of malfunctions. The facility lacked a clear protocol for managing such situations, and staff were not adequately trained in emergency procedures, such as evacuating non-ambulatory residents from the second floor. The absence of a documented plan for addressing temperature control during power outages contributed to the prolonged discomfort experienced by the residents.
Improper Food Storage Temperatures in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure that multiple food items were stored at safe temperatures in accordance with professional standards, potentially placing residents at risk for food-borne illnesses. During observations of the kitchen's walk-in refrigerator, temperatures were consistently recorded above the critical limit of 40 degrees Fahrenheit, with readings of 45F, 42F, and 50F on different occasions. Despite the facility's policy requiring temperatures to be under 40F, the temperature logs inaccurately recorded temperatures within the acceptable range, suggesting a discrepancy between actual and recorded temperatures. Interviews with kitchen staff and the Registered Dietician revealed that the walk-in refrigerator was used to store various food items, including dairy, meat, and leftovers, all of which require safe storage temperatures to prevent bacterial growth. The Maintenance Director admitted that the refrigerator was mistakenly set to 40F during maintenance, and the external thermometer was broken, leading to incorrect temperature readings. The Executive Director acknowledged the issue and stated that corrective measures were being implemented. The facility's policy emphasized the importance of maintaining food storage temperatures to prevent foodborne illnesses, highlighting the deficiency in adhering to these standards.
Emergency Power System Failure
Penalty
Summary
The facility failed to ensure that its emergency and standby power systems were functioning properly, which led to a complete power outage on July 14, 2024. The facility had been relying on a rental generator since March 2, 2020, and during the power failure, the temporary generator did not activate, leaving the facility without power. This outage affected critical systems, including medical equipment, elevators, and refrigeration units. Staff interviews revealed that the maintenance director was notified of the outage and arrived at the facility to find it in darkness, with staff panicking. It took approximately one hour to troubleshoot and manually start the generator, but the chillers remained inactive due to high voltage requirements. Additionally, the circular pumps were bypassed, and alarms were turned off, which contributed to the delay in addressing the issue. The power outage had significant implications for resident care, as those on oxygen concentrators had to be switched to O2 tanks. The lack of power also raised concerns about resident safety, as the elevators were non-functional, preventing the movement of residents if necessary. Staff interviews indicated a lack of standard procedures for handling power outages, and no mock disaster drills had been conducted. The absence of red plugs in resident rooms further complicated the situation, as extension cords had to be used. The deficiency was confirmed during the exit conference on July 18, 2024, highlighting the facility's prolonged reliance on a temporary generator without a permanent solution in place.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for residents, as observed during a walk-through on July 14, 2024. Several safety hazards were identified, including missing doorway frames with peeling paint, rough and sharp handrails, and doorframes with gouges. Additionally, a nail was found sticking out at the nurse's station, and screws were protruding from a handrail by the stairway. These conditions posed potential risks for injury to residents and staff. Interviews with staff revealed a lack of proactive maintenance and communication regarding the facility's condition. A Registered Nurse noted that maintenance had not sought input from staff or residents about necessary repairs, and the overall appearance of the facility was accepted as it was. The Maintenance Director acknowledged that while priority work orders related to resident safety were addressed promptly, other issues like painting took longer to resolve. The Director also mentioned that maintenance walk-throughs were conducted weekly, but issues not reported by staff or residents might go unnoticed. The Administrator emphasized the importance of maintaining a clean and safe environment to ensure residents' quality of life. However, a review of the facility's work order report showed no records of the identified issues, indicating a gap in the reporting and addressing of maintenance needs. The facility's policies on preventive maintenance and resident rights highlighted the requirement for a safe and homelike environment, which was not upheld in this instance.
Deficient Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the lack of completion of required annual training in key areas such as abuse, resident rights, infection control, dementia care, and emergency preparedness. Employee records revealed that several staff members, including registered nurses, licensed practical nurses, certified nursing assistants, the Director of Nursing, the Maintenance Director, and the Administrator, had incomplete or missing documentation for these mandatory trainings. For instance, some staff members had not completed emergency preparedness training, while others lacked documentation for abuse or infection control training. Interviews with facility staff, including the human resources accounting clerk and the Director of Nursing, confirmed that the training program was not effectively managed. The human resources accounting clerk indicated that training notifications were typically sent via email from the corporate office, and all staff were required to complete the training annually based on their hire date. However, the Director of Nursing acknowledged that not all staff had completed the necessary training, despite having a policy in place that outlined the annual training requirements. The facility's policy on yearly required training did not include dementia care, further contributing to the deficiency.
Failure to Assist Resident with Bathing
Penalty
Summary
The facility failed to ensure that a resident received assistance with bathing, which could result in poor hygiene and skin infections. The resident, who was admitted with diagnoses including anxiety, depression, malnutrition, and a history of venous thrombosis, had a care plan indicating a need for assistance with bathing due to weakness and decreased mobility. Despite being scheduled for baths twice a week, the resident's shower/bathing task sheets from April to July 2024 showed multiple instances where bathing did not occur, and refusals were not consistently documented. Interviews with the Director of Nursing revealed that the facility's skin care alert form was being used to document various tasks, but it did not specify whether a shower, hair washing, or nail care was completed. The DON acknowledged that staff were not identifying which specific task was being done and emphasized the expectation that CNAs should report refusals to the nurse, who should then document the refusal and have the resident sign it. The facility's policy stated that residents would receive assistance as needed for ADLs, and any changes in ability should be reported to the nurse.
Inaccurate Completion of Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide accurate and complete Advanced Beneficiary Notices (ABNs) to two residents when their Medicare services were terminated. Resident #222, who was admitted with multiple diagnoses including severe cognitive impairment, received an ABN that incorrectly had both option 1 and option 3 selected, which are conflicting choices. This error in the form could lead to confusion about the resident's decision regarding the continuation of services and their financial liability. Resident #223, who was cognitively intact, received an ABN form where no options were selected, leaving ambiguity about the resident's choice to continue or discontinue services. Interviews with staff revealed that the Social Services Director acknowledged the errors in completing the ABNs and took responsibility for the inaccuracies. The administrator confirmed that the ABNs were not completed accurately, which could impact reimbursement and resident rights.
Failure to Conduct Initial and Ongoing Weights for Resident
Penalty
Summary
The facility failed to ensure that initial and ongoing weights were conducted for a resident, leading to a deficiency in monitoring the resident's condition. The resident, who was admitted with diagnoses including anoxic brain damage, Parkinson's disease, and chronic respiratory disease, was not weighed upon admission as required by the facility's policy. Instead, the weight recorded in the clinical record was taken from the hospital transfer records. This oversight was confirmed during an interview with a Registered Dietician, who stated that the resident should have been weighed monthly to assess and monitor weight loss, fluctuations, and fluid shifts. The Director of Nursing confirmed that the facility policy mandates all residents be weighed within 24 hours of admission, weekly for the first four weeks, and then monthly. The failure to weigh the resident as per policy could result in significant weight changes going unrecognized, potentially affecting the resident's health. The facility's policy and procedures emphasize the importance of accurate weight measurement for various clinical assessments and interventions, highlighting the deficiency in adhering to these standards.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting included the correct and up-to-date information as required by their policy. On July 14, 2024, the daily staff posting was observed to be outdated, displaying information from July 12, 2024, with a census of 60, while the actual census on July 14, 2024, was 58. Additionally, the posting did not include the actual hours worked by staff, which is a requirement according to the facility's policy. The Director of Nursing (DON) acknowledged the outdated posting and indicated that the Central Supply Director/staffing coordinator is responsible for preparing the postings, with the weekend receptionist tasked with updating them. The facility's policy, revised on December 13, 2023, mandates that nurse staffing information be posted daily in a prominent location, accessible to residents and visitors, and must include the facility name, current date, resident census, and total number of staff and actual hours worked per shift. The policy also requires that any staff absences due to callouts or illness be reflected in the posting. The failure to update the staff posting as per the policy resulted in incorrect information being displayed, which was not in compliance with the facility's procedures.
Failure to Ensure TB Testing for Administrator
Penalty
Summary
The facility failed to ensure that a staff member, specifically the Administrator, was free of tuberculosis (TB) prior to commencing work. The Administrator was hired on January 8, 2024, but did not provide a current TB test result before starting her duties. This oversight was confirmed during an interview with the accounting clerk/human resources personnel, who acknowledged that the Executive Director is supposed to have a TB test before working in the building to prevent the risk of TB spreading. Further interviews revealed that the Administrator herself admitted to not having a TB test prior to working at the facility, although she was tested on July 16, 2024, with results pending. The Director of Nursing confirmed that all new hires are required to show a negative TB test result before working. Despite not interacting directly with residents, the Administrator walks the floors and can come into contact with residents, increasing the risk of TB exposure. The facility's policy, revised in June 2024, mandates TB testing in accordance with CDC guidelines, which was not adhered to in this case.
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.
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