Life Care Center Of Yuma
Inspection history, citations, penalties and survey trends for this long-term care facility in Yuma, Arizona.
- Location
- 2450 South 19th Avenue, Yuma, Arizona 85364
- CMS Provider Number
- 035133
- Inspections on file
- 15
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Life Care Center Of Yuma during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, a history of falls, and anemia was receiving Enoxaparin for DVT prevention, as ordered by a physician and documented on the MAR. Despite this high-risk medication use being identified on the MDS, the facility did not establish a care plan focus area or specific interventions for anticoagulant therapy. Staff, including a CNA, RN, rehab staff, and the DON, reported that they rely on care plans to identify resident-specific risks, that anticoagulant therapy requires individualized care planning and monitoring for bleeding, and that care plans should be updated after incidents and reflect anticoagulant use per facility policy. Review of the clinical record confirmed the absence of anticoagulant-related care plan interventions for this resident, in conflict with the facility’s care planning and anticoagulation management policies.
A resident with multiple chronic conditions and moderate cognitive impairment did not have their controlled medications, including Lorazepam and Morphine, properly recorded, stored, or reconciled. An LPN signed for the medications during a shift change, but there was no physician order for Lorazepam at the time, and the MAR was missing. Staff interviews and document reviews revealed inconsistent completion of controlled substance count sheets, missing signatures, and gaps in documentation, with numerous staff having access to the medication cart.
A resident's controlled medications, including Lorazepam and Morphine, were not securely stored or properly accounted for after delivery by hospice. An LPN received and signed for the medications during a shift change, but later could not determine when the Lorazepam went missing. Both nurses and medication aides had access to the medication cart, and required shift change counts and documentation were incomplete or missing, resulting in the inability to account for the medication.
A resident with multiple chronic conditions was admitted and prescribed anti-anxiety medication, but the facility failed to maintain complete and accurate medication records. An LPN signed for the delivery of controlled medications, but the medication administration record for Lorazepam was missing, and staff could not account for when the medication went missing. Review of controlled substance inventory sheets revealed missing signatures, incomplete documentation, and inconsistent recordkeeping, with multiple staff members having access to the medication cart.
A resident with severe cognitive impairment reported an allegation of sexual abuse to nursing staff. Despite facility policy requiring immediate reporting to authorities within two hours, the DON delayed notification until the following day. Staff interviews and record reviews confirmed that the incident was not reported in accordance with established procedures.
A resident with severe cognitive impairment and multiple health conditions alleged sexual abuse by a staff member. Despite facility policy requiring immediate suspension of the accused, the staff member was only reassigned to a different hall and continued working the shift, allowing potential access to the resident. Multiple staff interviews confirmed this action did not meet facility expectations or policy, and the staff member was not suspended until the following day.
The facility did not follow its policies for investigating and documenting allegations of abuse, neglect, and injuries of unknown origin involving three residents, including those with severe cognitive impairment and one with a recent fracture. Required five-day investigations were not completed, clinical records were not updated, and staff could not provide documentation or recall the incidents, resulting in a lack of evidence regarding the reported events.
The facility did not thoroughly investigate two separate incidents: a resident-to-resident altercation involving a cognitively impaired individual and an injury of unknown origin in a resident with Alzheimer's disease. In both cases, required five-day investigations were not completed, clinical records were not updated, and documentation was lacking, leaving the circumstances of the incidents unclear.
Care plans were not updated for four residents after incidents such as falls, altercations, and reports of pain with physical changes. The clinical records lacked documentation of these events, and interviews with the DON and ADON confirmed that care plans were not revised as required.
The facility did not ensure accurate and complete documentation in the medical records for four residents, including missing records of medication issues, a resident-to-resident altercation, and an allegation of neglect. Staff interviews confirmed that key events and communications were not documented as required by facility policy.
A resident with Alzheimer's disease and osteoporosis was neglected in a facility, as they did not receive regular assistance with bathing, nail clipping, and hair washing. The facility also failed to assess the resident's needs after multiple falls and did not update the care plan with new interventions. Staff interviews revealed a lack of documentation and communication regarding the resident's care, contributing to the neglect and inadequate fall management.
A resident with multiple health issues, including malnutrition and dysphagia, experienced significant weight loss due to the facility's failure to timely develop and implement a nutritional care plan. Despite being on a mechanically altered diet and having specific dietary orders, the resident's nutritional needs were not addressed in a care plan until nearly a month after admission, leading to a deficiency finding.
A CNA at the facility was found to lack the necessary CPR certification required for their role, as revealed by a personnel file review. The facility's assessment and policy indicated the responsibility to ensure all staff have the necessary certifications, which was confirmed by the business office manager. This deficiency could affect the facility's ability to meet resident needs during emergencies.
The facility failed to maintain a clean kitchen and ensure food items were dated when opened, risking food-borne illness. Observations revealed undated and improperly stored food, including wilted lettuce, exposed cream cheese, and dusty lamps. Staff interviews highlighted lapses in responsibility for food safety and cleanliness, with the Nutrition Director absent during the inspection.
A facility failed to implement enhanced barrier precautions for a resident with an indwelling catheter and wounds, as required by their care plan and CDC guidelines. Observations showed no EBP signs or PPE outside the resident's room. The DON admitted to misinterpreting CMS guidelines, resulting in the oversight.
Failure to Care Plan for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing anticoagulant therapy for a resident who was receiving Enoxaparin Sodium for DVT prevention. The resident had a history of falling, unspecified dementia, and unspecified anemia, and an MDS assessment showed a BIMS score of 02, indicating severe cognitive impairment. The MDS also documented that the resident was receiving an anticoagulant. A physician order directed daily subcutaneous Enoxaparin Sodium injections for 19 days, and the MAR showed the medication was administered on multiple days in January in the resident’s abdomen. Despite this ongoing anticoagulant therapy, the clinical record and care plan report contained no anticoagulant therapy focus area or anticoagulant-specific interventions, contrary to the facility’s anticoagulation management policy requiring that anticoagulant use be reflected in the care plan. During interviews, a CNA stated that staff rely on the care plan to identify resident-specific needs and that residents on blood thinners require extra caution due to prolonged bleeding and easy bruising, with monitoring for bruising and blood in urine being important. An RN confirmed that staff depend on care plans to identify resident-specific risks and interventions, acknowledged that anticoagulant therapy requires individualized care planning, and verified that there was no anticoagulant-related care planning in the resident’s record. A rehab staff member stated that residents on anticoagulants are at higher risk for bleeding and bruising and that care plans should include monitoring vital signs, symptoms, and blood loss, and coordination among departments to minimize fall risks. The DON stated that care plans are expected to guide staff in implementing fall prevention interventions and to be reviewed and revised after any incident, and confirmed that the resident who experienced a fall while on Enoxaparin had no care plan interventions addressing anticoagulant therapy, which did not meet facility expectations or its care planning and anticoagulation management policies.
Failure to Accurately Record and Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly recorded, stored, and reconciled for a resident with multiple diagnoses, including hypothyroidism, diabetes, anxiety disorder, chronic pain, heart failure, and dementia. The resident had moderate cognitive impairment and was care planned for anxiety, with interventions including administration of anti-anxiety medications as ordered. Documentation showed that controlled medications, specifically Lorazepam and Morphine, were delivered and signed for by an LPN, but there was no physician order for Lorazepam prior to a certain date, despite it being added to the shift count earlier. The medication administration record (MAR) for Lorazepam was also missing. Interviews with staff revealed that the medication delivery occurred during a shift change, and the count verification was completed with the incoming nurse. The LPN who signed for the medications later worked on a different hall and was unaware of when the Lorazepam went missing. It was noted that both nurses and medication aides had access to the medication carts, and approximately 10-15 staff members had access to the cart since the medication was received. Facility policy required that only nurses accept medications and that controlled substances be counted at the end of every shift, but this process was not consistently followed. A review of the controlled substance inventory count sheets revealed multiple deficiencies, including missing second signatures, blank spaces, numbers written over other numbers, and missing pages. There were several instances where both on-coming and off-going staff did not sign the count sheets, and gaps in documentation were observed. The DON confirmed that staff were not consistently filling out the forms as required and that a page was missing and could not be found. The facility's policy required detailed record-keeping and reconciliation of controlled substances, but these procedures were not adhered to, resulting in incomplete and inaccurate records.
Failure to Secure and Account for Controlled Medications
Penalty
Summary
The facility failed to ensure the safe and secure storage of controlled medications for one resident, resulting in a deficiency related to the handling of controlled substances. On a specific date, an LPN received and signed for a delivery of Lorazepam and Morphine from hospice, with the transaction documented on a receipt. The LPN reported that the medication delivery occurred during a shift change and that the count verification was completed with the incoming nurse. However, the LPN later stated they were unsure when the Lorazepam went missing, as they were assigned to a different hall after a few days. It was also revealed that both nurses and medication aides had access to the medication carts, and that approximately 10-15 staff members had access to the cart containing the controlled substances since the date of delivery. Further review showed that there was no physician order for Lorazepam for the resident prior to a certain date, despite the medication being added to the shift count. Additionally, the medication administration record (MAR) sheet for the Lorazepam was missing, and staff were not consistently or completely filling out the required shift change controlled substance inventory count sheets. The facility's policy required a count of controlled substances at each shift change, but documentation was incomplete and a page was missing from the records. The DON confirmed that the lack of accurate recordkeeping and the number of staff with access to the medication cart contributed to the inability to account for the missing Lorazepam.
Failure to Safeguard and Accurately Document Controlled Medications
Penalty
Summary
The facility failed to ensure that medication records were properly completed and safeguarded, resulting in incomplete medical records that do not meet accepted professional standards. A resident with multiple diagnoses, including hypothyroidism, type 2 diabetes mellitus, anxiety disorder, chronic pain, heart failure, and dementia, was admitted and had a care plan addressing anxiety with interventions for anti-anxiety medication administration. However, there was no physician order for Lorazepam prior to a certain date, despite the medication being added to the shift count and signed for by an LPN. The medication administration record (MAR) sheet for Lorazepam was missing, and the facility was unable to account for when the medication went missing. Interviews with staff revealed that the medication delivery occurred during a shift change, and the count verification was completed with the incoming nurse. The LPN responsible for accepting the medication stated that documentation was completed and a MAR sheet was created, but could not specify when the Lorazepam went missing due to being assigned to a different hall. The DON confirmed that multiple staff members, including 10-15 nurses and medication aides, had access to the medication cart, and that policy required staff to count controlled substances at the end of every shift. However, review of the controlled substance inventory count sheets showed numerous deficiencies, including missing signatures, blank spaces, numbers written over each other, and gaps in documentation. Facility documentation and policy review further revealed that the process for medication orders from hospice involved faxing orders to the nursing station, with the responsible nurse documenting the medications. Despite this, the required documentation for Lorazepam was not present, and the controlled substance sheets were not consistently or accurately completed. The facility's abuse and neglect policy emphasized the need to prevent misappropriation of resident property, but the lack of accurate recordkeeping and control over medication access led to the deficiency.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident with severe cognitive impairment was reported to the State Agency within the required two-hour timeframe. The resident, who had diagnoses including unspecified dementia and depression, communicated an allegation of sexual abuse to a nurse during medication pass. The nurse, after calming the resident, discussed the allegation with the accused CNA and decided not to move forward with reporting at that time, citing the resident's mental capacity. The CNA continued working the remainder of the shift, and the incident was not immediately escalated. Multiple staff interviews revealed that the facility's policy and annual training require immediate reporting of abuse allegations to the designated abuse coordinator, who is then responsible for notifying the appropriate authorities within two hours. Despite this, the Director of Nursing, who was the designated abuse coordinator, was informed of the allegation but did not report it to the State Agency until the following day. The DON acknowledged awareness of the two-hour reporting requirement but could not provide a reason for the delay. Further review of facility records and staff statements confirmed that the delay in reporting was not in accordance with facility expectations or policy. Staff members, including the Social Services Director and other department heads, reiterated that timely reporting is essential and that the delay could compromise the investigation. The facility's policies clearly define the types of abuse and the required reporting procedures, which were not followed in this instance.
Failure to Immediately Restrict Staff Access Following Abuse Allegation
Penalty
Summary
The facility failed to implement its policy regarding the immediate restriction of staff access to residents following an allegation of abuse. A resident with severe cognitive impairment, multiple comorbidities including COPD, dementia, depression, and CHF, and who was dependent on staff for all activities of daily living, made an allegation of sexual abuse against a staff member. The allegation was reported to the LPN and subsequently to the DON, who instructed that the accused staff member be removed from the resident's assignment and reassigned to another hall, rather than being immediately suspended and sent home as required by facility policy. Despite the policy requiring immediate suspension of the alleged perpetrator to prevent further interaction with the resident, the staff member continued to work the remainder of the shift on a different hall, which still allowed potential access to the resident. Multiple interviews with facility staff, including the Staff Coordinator, Social Services Director, and the DON's proxy, confirmed that the expectation was for immediate suspension and removal from the premises, which did not occur. Documentation showed that the staff member was not suspended until the following morning, several hours after the initial allegation was reported. The resident expressed feeling safer after learning that the staff member was no longer employed at the facility and reported previous pain during peri-care provided by the accused staff member. The facility's own policies on abuse prevention and resident rights were not followed, as the alleged perpetrator was not immediately removed from the facility, thereby placing the resident at continued risk during the investigation period.
Failure to Investigate and Document Abuse and Neglect Allegations
Penalty
Summary
The facility failed to follow its own policies and procedures regarding the prevention and investigation of abuse, neglect, and injuries of unknown origin for three residents. For one resident with dementia and severe cognitive impairment, and another resident who was cognitively intact, the facility did not complete a thorough five-day investigation or update clinical records following a reported resident-to-resident altercation. Documentation was lacking, and staff interviews were inconclusive or unavailable, leaving no evidence of what occurred during the incident. In a separate incident involving a resident with a periprosthetic fracture and Alzheimer's disease, the facility again failed to conduct a thorough five-day investigation or update the clinical record after an allegation of neglect was reported when a therapist discovered a leg length discrepancy and pain. The facility did not follow its policy, and there was no documentation or recollection from staff regarding the incident. In both cases, the facility did not provide evidence that all alleged violations were thoroughly investigated or that results were reported as required by federal regulations.
Failure to Investigate Alleged Abuse and Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents involving three residents, as required by their own policy and federal regulations. In the first incident, a resident with dementia and severe cognitive impairment was involved in a resident-to-resident altercation, where it was alleged that this resident punched another cognitively intact resident in the back. The facility reported the incident to the State Agency, but did not complete a thorough five-day investigation, failed to update the clinical record, and could not provide documentation or reliable interviews regarding the event. In the second incident, a resident with a periprosthetic fracture and Alzheimer's disease reported hip and groin pain, and a therapist observed a leg length discrepancy. This was reported up the chain of command, but again, the facility did not complete a thorough five-day investigation, did not update the clinical record, and failed to follow their own policy. Attempts to gather information were unsuccessful due to lack of documentation and unavailable or uncooperative staff. In both cases, the facility did not have evidence of a complete investigation or documentation to determine what happened to the residents.
Failure to Update Care Plans After Resident Incidents
Penalty
Summary
The facility failed to update and revise care plans for four residents following significant incidents, as required by regulation. For one resident with Parkinson's Disease and a history of falls, the care plan was not updated after a witnessed fall where the resident reported vertigo. Another resident with dementia and severe cognitive impairment was involved in a resident-to-resident altercation, but there was no documentation of the incident or any updates to the care plan. Additionally, a resident with sepsis and chronic pain was involved in the same altercation, yet the care plan remained unchanged and lacked documentation regarding the event. A fourth resident, diagnosed with a periprosthetic fracture and Alzheimer's disease, reported hip and groin pain with a noted leg length discrepancy, but there was no evidence in the clinical record to explain the incident or any care plan updates. Interviews with the DON and ADON confirmed that care plans for these residents were not updated after the incidents, and there was a lack of documentation and follow-up as per facility policy.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to ensure accurate and complete medical documentation for four residents, resulting in incomplete clinical records. For one resident with chronic pain, there was no documentation in the medical record regarding the lack of a required handwritten prescription for a controlled substance upon admission, the communication with the discharging facility, or the resident's subsequent request to go to the emergency room for pain management. Interviews with staff confirmed that these events occurred, but none were recorded in the resident's clinical record. Additionally, the facility did not document incidents involving other residents, including a resident-to-resident altercation and an allegation of neglect related to pain and a possible injury. In both cases, the facility reported the incidents to the State Agency, but there was no evidence in the clinical records to indicate what happened to the residents involved. Attempts to gather further information through interviews were unsuccessful due to lack of recollection or staff turnover. The facility's own policy requires thorough record review and documentation of such incidents, but this was not followed.
Neglect of Resident's Basic Needs and Inadequate Fall Management
Penalty
Summary
The facility failed to ensure that a resident's basic needs were met, resulting in neglect. The resident, who had Alzheimer's disease, depression, and osteoporosis, was dependent on staff assistance for activities of daily living (ADLs) such as bathing, nail clipping, and hair washing. Documentation revealed that the resident did not receive assistance with bathing for extended periods, and there was no record of nail clipping or hair washing. The facility's shower lists did not document the condition of the resident's skin, and there was no evidence that the resident refused care. Additionally, the facility did not adequately assess the resident's needs after falls or update the care plan with new interventions. The resident experienced multiple falls, some of which were unwitnessed, and there was a lack of documentation regarding interdisciplinary team meetings or care plan updates following these incidents. The facility's policy required fall risk assessments and care plan updates after each fall, but these were not consistently completed. Interviews with staff revealed that there was an expectation for showers twice a week and for skin issues to be reported and documented. However, there was a lack of communication and documentation regarding the resident's care, including the absence of interdisciplinary meetings and care plan updates after falls. The facility's failure to adhere to its policies and procedures contributed to the neglect of the resident's needs and the lack of appropriate interventions following falls.
Failure to Implement Nutritional Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan to meet the assessed nutritional needs of a resident who was admitted with multiple diagnoses, including hemiplegia, type 2 diabetes mellitus, dysphagia, and malnutrition. Upon admission, the resident was identified as malnourished with a mini nutritional assessment score of 6. Despite being on a mechanically altered diet and having a physician's order for fortified foods and 1:1 supervision during meals, the resident experienced significant weight loss of approximately 20 pounds within a short period. The deficiency was identified when it was found that no care plan addressing the resident's nutritional risk was developed or implemented until nearly a month after admission, despite the resident triggering for weight loss. Interviews with the registered dietitian and the director of nursing revealed that the nutritional status of the resident was not care-planned in a timely manner, which was acknowledged as an oversight by the staff involved.
CNA Lacked Required CPR Certification
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as staff #64, possessed the necessary cardiopulmonary resuscitation (CPR) certification required to provide nursing and related services. This deficiency was identified through a review of the personnel file, which showed no evidence of current CPR certification for the CNA, despite being hired on a specific date. The facility's assessment indicated a staffing plan that included 13 licensed nurses and 27 CNAs to care for an average of 86 residents daily, including during emergencies. The lack of CPR certification for staff #64 could potentially impact the facility's ability to meet resident needs during emergencies. An interview with the business office manager (BOM/staff #12) confirmed that it was the facility's responsibility to ensure that all staff and contracted individuals have the necessary licenses and certifications as outlined in their job descriptions. The facility's policy on License and CPR Certification Verifications further emphasized this responsibility, stating that the facility must ensure all associates requiring a license or certification have the necessary credentials to fulfill their roles. The Compliance department assists in monitoring professional licensure, including the licenses and certifications of nurses and CNAs employed by the facility.
Kitchen Cleanliness and Food Dating Deficiencies
Penalty
Summary
The facility failed to maintain a clean kitchen and ensure food items were dated when opened, which could result in residents having food-borne illness. During an observation of the kitchen, a large walk-in refrigerator was found to contain a 5lb opened and undated bag of green leaf lettuce with wilted and discolored lettuce heads. Inside the bag was a white plate with turkey, chicken, and potato salad, which staff could not account for. Additionally, an opened and exposed three-pound box of cream cheese was found with dried-out ends, and the refrigerator floor had spilled milk. The walk-in freezer had frozen corn kernels on the floor and an opened bucket of frozen mashed potatoes. Other observations included opened loaves of bread and dinner rolls without open or use-by dates, and a cooking area with stringy particles and dust-covered lamps. Further observations revealed an open container of butter and a bag of shredded cheese without open or use-by dates. Another inspection found a partially open container of strawberries, wilted cucumbers, and a mix of lemons and soft tomatoes in the refrigerator. The same bag of green leaf lettuce and dusty lamps were still present. Staff interviews indicated that it was the cook's responsibility to clean the lamps and manage food storage to prevent contamination. The administrator expected the Nutrition Director to ensure daily quality checks, but the director was on vacation at the time. The facility's policy on food safety requires food to be stored in a clean and sanitary manner to minimize contamination and bacterial growth.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards related to enhanced barrier precautions (EBP) for a resident with an indwelling catheter and wounds, potentially leading to the transmission of multi-drug resistant organisms. The resident, who was admitted with multiple diagnoses including obstructive uropathy, type 2 diabetes, and dementia, had an indwelling catheter and open lesions on the coccyx and buttocks. Despite the care plan indicating the need for EBP, observations on two separate days revealed the absence of EBP signs and readily available personal protective equipment (PPE) outside the resident's room. Interviews with the Director of Nursing (DON) revealed a misunderstanding of the Centers for Medicare & Medicaid Services (CMS) guidelines regarding EBP, resulting in the resident not being placed on the necessary precautions. The facility's policy, which was revised shortly before the observations, indicated that EBP should be implemented for residents with wounds and indwelling medical devices, even if they are not known to be infected or colonized with multi-drug resistant organisms. The CDC guidelines emphasize the importance of gown and glove use during high-contact care activities for such residents.
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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