Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Maryland Gardens Post Acute during CMS and state inspections, most recent first.
A resident with intact cognition and a history of neurological and mood disorders was physically assaulted by a cognitively impaired roommate who struck him multiple times on the head with a water pitcher after entering his closet and taking his clothes. The injured resident sustained hematomas, a laceration, and bruising, requiring hospital evaluation. Staff and roommate interviews revealed prior behavioral issues that were not reported or addressed, and the facility failed to complete required documentation, including skin assessments and records of supervision or room changes.
A resident with a history of neurological and mood disorders sustained head injuries after being struck multiple times by a roommate during an altercation. The facility failed to document a complete skin assessment, omitted details of a laceration, and did not record 1:1 supervision or a room change for the involved residents, despite policy requiring thorough documentation of such events.
The facility failed to protect residents from abuse, as two residents were involved in a physical altercation. One resident, with cognitive impairment, was found with redness and swelling to the eye, while another resident, with a psychotic disorder, was involved in the confrontation. The facility lacked timely documentation and protective measures, such as one-to-one monitoring or care plan updates, to prevent further harm.
A facility failed to implement abuse prevention policies, leading to inadequate investigation and reporting of an incident involving two residents. One resident, with a history of hemiplegia and aphasia, was found with redness to the eye, while another resident, diagnosed with brain neoplasm, was involved in a confrontation. The facility's investigation revealed conflicting accounts, and staff failed to document and report the incident timely, resulting in a deficiency.
A facility failed to report an abuse allegation within the required timeframe involving two residents. One resident, with cognitive impairment, was found with redness in his eye and gestured he had been hit. Another resident admitted to hitting him during an altercation. The LPN on duty did not notify the ADON promptly, leading to a delay in reporting to authorities.
A facility failed to protect two residents during an abuse investigation. One resident, with a history of hemiplegia and aphasia, was found with redness in his eye and gestured that he had been hit. Another resident, diagnosed with a brain neoplasm and psychotic disorder, admitted to hitting the first resident. Despite the incident, there was no immediate one-to-one monitoring or care plan updates. Staff interviews revealed that the facility's abuse protocol was not followed, and the night nurse was terminated for not reporting the incident timely.
The facility failed to provide accessible bathrooms for residents during room remodeling, requiring them to use other residents' bathrooms. This led to complaints about cleanliness and privacy, as residents with moderate cognitive impairments and various medical conditions were affected. The facility's policy on ADLs was not followed, as residents were not provided with necessary care and services.
Two residents were temporarily housed in a dining room due to renovations, lacking essential amenities like bathrooms and call lights. The dining room was not set up for dining, and privacy was inadequate, compromising the residents' rights to a safe and homelike environment.
Two residents with moderate cognitive impairment were housed in a dining room without a call light system due to ongoing renovations. The residents had to rely on CNAs for assistance, as confirmed by staff interviews. The absence of a call light system compromised the residents' ability to communicate their needs promptly.
During renovations, the facility used the dining room as a temporary bedroom for some residents, leaving no designated dining area. Observations showed the dining room filled with beds and clothing racks, while residents ate outside or in their rooms. Staff confirmed the situation had persisted for about a month, impacting the dining arrangements for 55 residents.
A resident with moderate cognitive impairment and sensory disabilities was involved in altercations with another resident who has a history of physical behaviors. Despite incidents where the first resident was allegedly hit and found on the ground, no changes were made to their care plans. The facility's policy requires care plan updates and documentation after such incidents, but these steps were not taken, resulting in a deficiency.
A resident with schizophrenia and bipolar disorder refused psychotropic medication, specifically Haldol, but the facility failed to honor this refusal. Despite the resident's consistent refusal and lack of signed consent, the medication was administered based on a verbal consent documented by staff, which was not in line with the resident's wishes. The facility's policy required informed consent for psychotropic medications, which was not adhered to, leading to the deficiency.
A registry nurse failed to perform hand hygiene during a medication pass, touching the medication cart and preparing medications without sanitizing her hands. The nurse also did not sanitize her hands after administering medications to each resident, despite having hand sanitizer available. The DON confirmed that staff are expected to perform hand hygiene before and after medication administration.
The facility failed to protect two residents from abuse by peers. One resident with schizophrenia and anxiety was hit by another resident with a history of aggression, resulting in a visible injury. Another resident with bipolar disorder and dementia was struck by a peer with poor impulse control, causing a minor injury. The facility's interventions and abuse prevention policy were insufficient to prevent these incidents.
A resident reported being slapped by a CNA, but the facility failed to report the allegation to the State Agency within the required timeframe. The administrator chose to investigate first, citing the resident's statement of being fine and the belief that residents often made false allegations. This decision violated the facility's policy, which required immediate reporting of abuse allegations.
A facility failed to thoroughly investigate an abuse allegation involving a cognitively intact resident with multiple health conditions. The resident reported being tapped on a painful shoulder by a CNA, but the investigation lacked comprehensive documentation and interviews. The alleged CNA was not suspended, contrary to policy, and the administrator's handling of the situation was inconsistent with established procedures.
A resident with schizoaffective disorder and other mental health conditions did not receive her Aripiprazole injection as ordered due to a transcription error, leading to early administration. Additionally, the medication was unavailable on the next scheduled date, and the nurse did not contact the pharmacy to resolve the issue. The resident was monitored for any adverse effects, but none were immediately observed.
A resident with dementia and other conditions fell during a transfer using a Hoyer lift because a CNA operated the lift alone, against facility policy requiring two staff members. The resident fell from a height of 4-5 feet, reported pain, and was sent to the emergency department for evaluation. The CNA was terminated following the incident.
Failure to Protect Resident from Abuse and Incomplete Documentation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, with a history of intracerebral hemorrhage, hemiplegia, and mood disorders but with intact cognition, was physically assaulted by his roommate, who had severe cognitive impairment and a history of behavioral disturbances. The incident involved the cognitively impaired resident entering the other resident's closet, taking his clothes, and then striking him multiple times on the head with a water pitcher, resulting in visible injuries including hematomas, a laceration, and bruising. The injured resident was sent to the hospital for evaluation, where a CT scan was performed and lacerations were treated with steri-strips. Prior to the incident, there were indications that the aggressive resident had a pattern of entering other residents' spaces and taking their belongings, as reported by both the injured resident and another roommate. Despite these behaviors, there was no documentation of previous interventions or incidents of abuse involving these residents. Staff interviews revealed that some staff were aware of the behavioral issues but did not report them, and there was inconsistency in staff awareness of prior incidents. The care plans for both residents included interventions to monitor and protect residents from behavioral episodes, but these interventions were not effectively implemented to prevent the altercation. Following the incident, documentation was found to be incomplete. There was no skin assessment completed at the time of injury or following, and the laceration on the resident's head was not documented in the facility's records. Additionally, there was no documentation of 1:1 supervision or the room change for the aggressive resident. The Director of Nursing acknowledged these documentation gaps and the risks associated with incomplete records, including delays in treatment and care. The facility's abuse prevention policy states that residents have the right to be free from abuse, neglect, and misappropriation of property, but the failure to prevent and properly document the incident constituted a deficiency.
Failure to Accurately Document Resident Injuries After Altercation
Penalty
Summary
The facility failed to ensure accurate and complete documentation of a resident's injuries following a resident-to-resident altercation. One resident, with a history of intracerebral hemorrhage, hemiplegia, and mood disorders, sustained a hematoma and laceration to the head after being struck multiple times with a water pitcher by his roommate. The incident was witnessed by another roommate, and the injured resident was sent to the hospital for evaluation, where two hematomas and lacerations were treated with steri-strips. The hospital report confirmed the injuries and the resident's desire to press charges. Despite the severity of the incident, the facility's clinical records and documentation were incomplete. There was no skin assessment documented at the time of injury or following the incident, and the laceration on the top left side of the resident's head was not recorded in the facility's records. The Director of Nursing confirmed the absence of a skin evaluation and noted that the progress notes lacked detail regarding the incident and the injuries sustained. Additionally, there was no documentation of the 1:1 supervision provided to the aggressor or the room change that occurred after the incident. Interviews with staff revealed that the expectation was for thorough documentation and immediate assessment following such incidents, including separating residents, reporting, and monitoring. However, these procedures were not fully documented or followed as required. The facility's policy mandates that all services, changes in condition, and progress toward care plan goals be documented in the resident's medical record to facilitate communication among the care team, but this was not adhered to in this case.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving two residents. Resident #1, who has a history of hemiplegia, aphasia, and cognitive impairment, was found with redness and mild swelling to the left eye. The facility's documentation did not provide evidence of an incident report or progress notes detailing the event on January 4, 2025. Despite a physician order noting a change in condition, there was no documentation of one-to-one staff monitoring for Resident #1, nor was there an update to the care plan following the incident. Resident #3, admitted with diagnoses including malignant neoplasm of the brain and psychotic disorder, was involved in a physical confrontation with Resident #1. The facility's records lacked progress notes documenting the altercation on January 4, 2025. A physician's note indicated that Resident #3 had been in a physical confrontation, and behavioral health was to be consulted. However, there was no evidence of a care plan update to address Resident #3's aggressive behavior, nor was there a physician order for one-to-one staff monitoring. Interviews and observations revealed that staff failed to document the incident adequately and did not report it within the required timeframe. The facility's investigation report, submitted five days after the incident, included interviews with staff and residents, indicating that Resident #1 was struck by Resident #3. However, the facility's initial response lacked timely documentation and protective measures, such as one-to-one monitoring or room changes, to prevent further harm.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse for two residents, leading to a deficiency in the investigation and reporting of alleged abuse incidents. Resident #1, who has a history of hemiplegia, aphasia, and other conditions, was found with redness and mild edema to the left eye orbital. Despite a physician order noting the change in condition, there was no evidence of progress notes or an incident report documenting the event. The facility's self-report to the state health department indicated uncertainty about whether the redness was self-inflicted or caused by another resident, and no care plan update was made. Resident #3, diagnosed with malignant neoplasm of the brain and other conditions, was involved in a physical confrontation with Resident #1. A physician progress note mentioned the altercation, but there was no evidence of progress notes or a care plan update addressing the resident's aggressive behavior. The facility's investigation report included interviews with staff and residents, revealing conflicting accounts of the incident. Staff interviews indicated that Resident #1 accused Resident #3 of hitting him, while Resident #3 claimed that Resident #1 had kicked him. The facility's policies on abuse prevention and reporting were not followed, as evidenced by the lack of timely documentation and reporting of the incident. The facility's Director of Nursing and Assistant Director of Nursing acknowledged the failure to meet expectations for documentation and incident reporting. The night nurse was terminated for not reporting the incident within the mandated timeframe, and the facility's investigation report was submitted late, further highlighting the deficiency in handling the situation according to established policies.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse to mandatory reporting agencies within the required timeframe for two residents. Resident #1, who has moderate cognitive impairment and communication difficulties due to aphasia, was found with redness in his eye and gestured that he had been hit. The incident was reported to the facility administration, but the report to the state health department was delayed beyond the mandated 2-hour window. Resident #3, who has a history of brain neoplasm and psychotic disorder, was involved in a resident-to-resident altercation with Resident #1. The altercation occurred when Resident #3 was found in Resident #1's room wearing his clothes. Resident #3 admitted to hitting Resident #1, claiming it was in retaliation. The incident was not reported to the appropriate authorities within the required timeframe, as the LPN on duty failed to notify the ADON promptly. Interviews with facility staff revealed a breakdown in communication and adherence to the facility's policy on reporting abuse. The LPN, who was new to the facility, did not report the incident within the 2-hour timeframe, leading to her termination. The ADON and DON acknowledged the failure to report the incident promptly, citing uncertainty about the occurrence of the abuse and a lack of immediate notification from the night nurse.
Failure to Protect Residents During Abuse Investigation
Penalty
Summary
The facility failed to protect residents from further abuse during an ongoing investigation of an alleged abuse incident involving two residents. Resident #1, who has a history of hemiplegia, aphasia, and major depressive disorder, was found with redness in his eye and was gesturing that he had been hit. Despite the incident being reported, there was no immediate physician order for one-to-one staff monitoring, and the care plan was not updated to reflect the incident. The facility's report indicated uncertainty about whether the redness was self-inflicted or caused by another resident. Resident #3, diagnosed with malignant neoplasm of the brain and brief psychotic disorder, was involved in a physical confrontation with Resident #1. A physician's note confirmed the confrontation and recommended a behavioral health consultation. However, there was no evidence of a care plan update or a physician order for one-to-one monitoring. The CNA on duty at the time of the incident reported that Resident #3 admitted to hitting Resident #1, and the residents were not separated immediately after the incident. Interviews with facility staff revealed that the facility's protocol for handling abuse allegations was not followed. The night nurse failed to report the incident timely, resulting in her termination. The DON confirmed that a risk management report was not completed, and one-to-one monitoring was not implemented until later in the morning. The facility's policy requires protecting residents from further harm during investigations, which was not adequately executed in this case.
Deficiency in Providing Accessible Bathrooms for Residents
Penalty
Summary
The facility failed to provide accessible bathrooms for residents, leading to a deficiency in accommodating the needs and preferences of residents. Specifically, two residents were observed to lack readily available bathroom facilities, as their rooms were sealed off for remodeling. As a result, these residents were required to use the bathrooms of other residents, which were not intended for their use. This situation was confirmed through interviews with the residents and staff, including the Director of Nursing, who acknowledged the arrangement due to the ongoing remodeling. The deficiency involved residents with moderate cognitive impairments and various medical conditions, such as hypertension, cerebrovascular accident, depression, bipolar disorder, major depressive disorder, and chronic heart failure. The lack of accessible bathrooms forced residents to use facilities that were not their own, leading to complaints about cleanliness and privacy. One resident expressed dissatisfaction with having to clean feces off the toilet seat after other residents used his bathroom. The facility's policy on Activities of Daily Living (ADLs) was not adhered to, as it mandates that residents be provided with care and services to maintain or improve their ability to carry out ADLs.
Deficiency in Providing Homelike Environment During Renovations
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, resulting in a deficiency. Resident #34, with a history of hypertension, cerebrovascular accident, depression, and bipolar disorder, was found living in the dining room due to ongoing renovations. The resident had moderate cognitive impairment and expressed concerns about privacy and the lack of a call light system. Resident #46, with major depressive disorder and a history of traumatic brain injury, was also residing in the dining room. Both residents were using the dining room as their bedroom, which lacked essential amenities such as bathrooms and call lights. Observations revealed that the dining room was not set up for dining, with tables and chairs removed and replaced by hospital-type beds for the residents. Privacy screens were inadequately placed, and residents had to rely on other residents' bathrooms due to the absence of facilities in the dining area. Interviews with staff and residents confirmed that the dining room was being used as a temporary living space for residents affected by room renovations, with no alternative arrangements for dining or personal care needs. The facility's policy on resident rights emphasizes the importance of providing a dignified existence, respect, and privacy for all residents. However, the current living arrangements for residents #34 and #46, along with others affected by the renovations, did not align with these policies. The lack of appropriate facilities and privacy measures in the dining room compromised the residents' rights to a safe and homelike environment, as outlined in the facility's policies.
Deficiency in Call Light System for Residents
Penalty
Summary
The facility failed to ensure an accessible, working call light system was available for two residents, leading to a deficiency in resident care. Resident #34, who has moderate cognitive impairment and a history of cerebrovascular accident, depression, and bipolar disorder, was observed living in the dining room without access to a call light. The resident reported having to wait for staff to pass by or snap fingers to get attention, which could take from a few minutes to an hour. Similarly, Resident #46, with moderate cognitive impairment and a history of major depressive disorder and traumatic brain injury, was also housed in the dining room without a call light system. The dining room, used as a temporary housing area due to ongoing renovations, lacked a call light system, and residents had to rely on the presence of CNAs for assistance. Interviews with staff, including the Maintenance Director, staffing coordinator, and CNAs, confirmed the absence of call lights in the dining room. The Director of Nursing acknowledged the situation, stating that CNAs were stationed in the dining room to monitor and assist residents, using radios to communicate with nurses if needed. Despite these measures, the lack of a call light system compromised the residents' ability to communicate their needs promptly.
Dining Room Used as Bedroom During Renovations
Penalty
Summary
The facility failed to provide a designated dining room for residents during ongoing renovations, which led to the dining room being used as a temporary bedroom for some residents. Observations revealed that tables and chairs were not set up for dining, and instead, hospital-type beds and clothing racks were placed in the dining room. Interviews with residents and staff confirmed that the dining room had been used as a bedroom for about a month, affecting the dining arrangements for the 55 residents in the skilled and long-term care units. Residents were redirected to eat outside on the patio or in their rooms, as the dining room was occupied by residents due to the renovations. The Director of Nursing stated that the renovations could take from one to three weeks, depending on the need for plumbing replacement. The facility's policies on resident rights and activities of daily living emphasize the importance of providing a dignified existence and appropriate care, which were not upheld due to the lack of a designated dining area.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #4, who has moderate cognitive impairment, legal blindness, and extreme hard of hearing, was involved in altercations with Resident #5, who is cognitively intact but has a history of physical behaviors. On two occasions, Resident #4 was allegedly hit by Resident #5, with the second incident resulting in Resident #4 being found on the ground in a fetal position. Despite these incidents, there were no changes made to Resident #4's care plan to address the situation. Resident #5, who has diagnoses including schizophrenia and bipolar disorder, was observed holding a cane and allegedly trying to hit Resident #4 during the second altercation. Although Resident #5 admitted to intentionally trying to harm Resident #4, no interventions were added to his care plan following either incident. The facility's policy requires changes to care plans and documentation of interventions after altercations, but these steps were not taken, leading to the deficiency.
Failure to Honor Resident's Right to Refuse Psychotropic Medication
Penalty
Summary
The facility failed to honor a resident's right to refuse psychotropic medication, specifically Haldol, despite the resident's clear refusal to consent. The resident, who was admitted with diagnoses including schizophrenia and bipolar disorder, had a moderate cognitive impairment as indicated by a BIMS score of 12. The resident consistently refused medications, including Haldol, stating that they did not work, and did not sign a consent form for its administration. Despite this, a verbal consent was documented by two staff members, which was not in line with the resident's expressed wishes. The facility's documentation showed that the Haldol order was discontinued on April 11, 2024, yet it continued to be transcribed and administered in May 2024 without proper consent. Interviews with staff, including an LPN and the DON, revealed that there was no signed consent for the Haldol, and the medication was administered based on a verbal consent that was not properly documented or aligned with the resident's refusal. The facility's policy required informed consent for psychotropic medications, which was not adhered to in this case. The resident's refusal of medications was a repetitive pattern since their arrival at the facility, and despite this, the plan was to continue administering Haldol. The facility's failure to obtain proper consent and respect the resident's right to refuse treatment led to the deficiency. Interviews with staff highlighted a lack of proper documentation and adherence to policy regarding psychotropic medication consent.
Failure in Hand Hygiene During Medication Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration, as observed during a medication pass with a registry nurse. The nurse was seen touching the medication cart with bare hands and preparing medications without performing hand hygiene. Furthermore, the nurse administered the medications to residents without sanitizing her hands after each resident interaction. During an interview, the nurse acknowledged not sanitizing her hands after giving medication to each resident, despite having hand sanitizer available on her medication cart. The Director of Nursing confirmed that staff are expected to perform hand hygiene before and after medication administration and any time hands could potentially be contaminated.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect the rights of two residents, identified as #11 and #205, from abuse by other residents, identified as #160 and #18, respectively. Resident #11, who has diagnoses of paranoid schizophrenia and anxiety disorder, reported being hit by another resident while sitting outside. The incident was documented as unprovoked, and there was visible redness on the resident's cheek. The care plan for resident #11 included monitoring for agitation and aggression, but the facility did not effectively intervene to prevent the altercation. Resident #160, who has schizophrenia, depression, and antisocial personality disorder, was identified as the aggressor in the incident involving resident #11. The resident had a history of verbal and physical aggression, as well as refusal of medications. Despite these known behaviors, the facility's interventions, such as medication administration and behavior monitoring, were insufficient to prevent the altercation. The facility's investigation concluded that the allegation could not be verified due to conflicting accounts and cognitive impairments of the involved residents. In a separate incident, resident #205, with diagnoses of bipolar disorder, major depressive disorder, and dementia, was hit by another resident, identified as #18, resulting in a minor injury. Resident #18, who has schizophrenia and vascular dementia, exhibited poor impulse control and physical aggression. The care plan for resident #18 included interventions to manage these behaviors, but the facility failed to prevent the altercation. The facility's policy on abuse prevention was not effectively implemented to protect residents from peer aggression.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency within the required timeframe. The resident, who was cognitively intact and had a history of hemiplegia, hemiparesis, type II diabetes, depression, and psychotic disorder, reported that a CNA slapped his shoulder while he was in the bathroom. The resident's care plan noted behavior problems related to his psychiatric diagnoses, including false accusations and verbal aggression. Despite the resident's report of abuse, the facility administrator decided not to report the incident immediately, citing the resident's statement that he was fine and the belief that the resident population often made false allegations. The administrator conducted an investigation, interviewing the alleged CNA and another staff member, and concluded that the alleged CNA did not interact with the resident. The facility's policy required immediate reporting of abuse allegations to the state agency, defined as within two hours, but the administrator chose to investigate first and report only if the allegation was confirmed. This decision led to a failure to comply with the facility's policy and state regulations, potentially leaving residents unprotected from further abuse.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was cognitively intact and had a history of hemiplegia, hemiparesis, type II diabetes, depression, and a psychotic disorder. The resident reported that a CNA tapped him on his bad shoulder, causing pain, while he was in the bathroom. The facility's investigation did not include observations, interviews with other residents, staff, or witnesses, nor was there evidence of reporting the incident to appropriate agencies. Additionally, the alleged CNA was not suspended during the investigation, contrary to the facility's policy. The administrator stated that he conducted an investigation and reassigned a different staff to the resident. However, the investigation lacked thoroughness as it did not follow the facility's policy, which requires comprehensive documentation and interviews with all relevant parties. The alleged CNA was not informed of the allegation until after the fact and was not placed on leave, which is a requirement according to the facility's policy. The administrator's approach to handling the allegation was inconsistent with the established procedures, leading to a deficiency in addressing the abuse claim properly.
Medication Administration Error and Unavailability
Penalty
Summary
The facility failed to ensure that medication was administered as ordered by the physician for a resident diagnosed with schizoaffective disorder, schizophrenia, generalized anxiety disorder, and depression. The resident was supposed to receive an Aripiprazole injection every 28 days, but due to a transcription error, the injection was administered approximately 8-9 days early. This error was documented in the medication administration record (MAR) and noted in the eINTERACT note. Despite the early administration, there were no immediate adverse effects reported, although the resident was placed on change of condition status for monitoring. Further issues arose when the resident did not receive the scheduled Aripiprazole injection on the due date because the medication was unavailable. The Licensed Practical Nurse (LPN) involved stated that the medication was not administered as it was not available, and the Director of Nursing (DON) confirmed that the registry night nurse did not call the pharmacist to resolve the issue. The resident's care plan included monitoring for behavior problems related to her conditions, and the failure to administer the medication as ordered could potentially impact her treatment. The facility's documentation and interviews with staff highlighted the sequence of events leading to the deficiency.
Failure to Implement Fall Interventions Leads to Resident Fall
Penalty
Summary
The facility failed to ensure proper implementation of fall interventions for a resident, leading to a fall incident. The resident, who had a history of dementia, neuralgia, schizophrenia, and anxiety, was identified as being at risk for falls due to gait and balance problems, incontinence, and psychoactive drug use. The care plan included interventions such as keeping the call light within reach and using a bed bolster mattress. However, during a transfer using a Hoyer lift, the resident fell because the certified nurse assistant (CNA) operated the lift alone, contrary to the facility's policy requiring two staff members for such transfers. The incident occurred when the Hoyer lift tipped over, causing the resident to fall from a height of 4-5 feet, landing on her right shoulder. The resident reported hitting her head and experiencing pain in her chest and shoulder, although no bruising or loss of consciousness was noted. The resident was sent to the emergency department for evaluation, where CT scans showed no injuries. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the CNA's failure to follow the two-person policy for operating the Hoyer lift led to the incident, resulting in the CNA's termination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Phoenix
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Terraces Of Phoenix | 1.6 mi | ★★★★★ | 0 | 0 |
| The Rehabilitation Center At The Palazzo | 1.7 mi | ★★★★★ | 1 | 0 |
| Beatitudes Campus | 1.8 mi | ★★★★★ | 5 | 0 |
| Camelback Post Acute Care And Rehabilitation | 2.2 mi | ★★★★★ | 1 | 0 |
| North Mountain Medical And Rehabilitation Center | 2.7 mi | ★★★★★ | 2 | 0 |
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