Maryland Gardens Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 31 West Maryland Avenue, Phoenix, Arizona 85013
- CMS Provider Number
- 035247
- Inspections on file
- 14
- Latest survey
- January 23, 2025
- Citations (last 12 mo.)
- 0
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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A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
Trusted data from CMS and state health departments
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