Mi Casa Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mesa, Arizona.
- Location
- 330 South Pinnule Circle, Mesa, Arizona 85206
- CMS Provider Number
- 035120
- Inspections on file
- 23
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mi Casa Nursing Center during CMS and state inspections, most recent first.
A resident with multiple neurologic and functional impairments, but intact cognition, reported feeling neglected after being left in a wet brief and requested that law enforcement be called. The resident’s spouse alleged that an RN and CNA provided rough care during a brief change, ignored the resident after he asked them to stop, and left his bed remote out of reach, and she filed police reports for abuse and neglect on two occasions. The ED documented the concern, briefly interviewed the resident and spouse, concluded that care had been provided, and decided not to report the later allegation to the State Survey Agency, APS, or other required entities because the resident’s account differed from his wife’s, despite facility policy requiring that all alleged violations of abuse or neglect be reported within specified timeframes regardless of how the allegation is characterized.
A resident with multiple neurologic and medical conditions, but intact cognition, reported feeling neglected after being left in a wet brief for several hours and requested that law enforcement be called. The resident’s wife alleged that an RN and CNA provided rough incontinence care after a urinal spill, ignored the resident’s pleas to stop, then ignored him for the rest of the night and left his bed remote out of reach; she stated that police reports were filed for two separate incidents and that the later allegation was not reported to any state agency. The Executive Director documented the concern, interviewed the resident and his wife, obtained staff statements, and concluded that care had been provided, deciding not to report the later allegation to the State Survey Agency, APS, or other required officials. This decision conflicted with facility policy, which required that all alleged violations of abuse or neglect, whether or not explicitly labeled as such and regardless of conflicting accounts, be reported within specified timeframes to the administrator and appropriate state authorities.
A resident with a PEG tube and intact cognition, dependent on staff for nutrition, repeatedly refused a bolus feeding and water flush, verbally saying no and physically pushing the tube away. An LPN, assisted by two CNAs, proceeded with the midnight bolus and flush while the resident attempted to kick and push the feeding away, and the CNAs held the resident’s hands and knees down so the LPN could continue the treatment. Facility documentation and staff records show that the staff forcefully administered the tube feeding flush against the resident’s expressed wishes, in violation of the resident’s rights to be free from abuse and to refuse treatment.
A resident with complex medical needs did not receive a required wound dressing change as ordered, and the LPN on duty charted the treatment as completed despite not performing it. The DON confirmed the omission after the resident reported the missed care, and facility policy requires accurate documentation of all treatments provided.
Two residents experienced deficiencies in bowel and bladder care, including a resident with severe cognitive impairment who did not receive timely intervention for constipation, resulting in hospitalization for severe fecal impaction, and another resident with an indwelling catheter who did not receive catheter care as ordered, with inconsistent documentation and no evidence of physician notification regarding missed care.
Staff were observed delivering and transporting uncovered beverages, such as coffee, water, and juice, to residents' rooms and bedside tables, including in areas with Enhanced Barrier Precautions. These actions did not follow facility expectations or infection control policies, as confirmed by interviews with dietary and nursing staff.
A resident with significant physical and cognitive impairments was found with a severely torn fall mat next to their bed, exposing internal materials and creating an infection control concern. Staff confirmed the mat could not be properly cleaned and should have been removed according to facility policy, which requires the removal of compromised equipment to prevent infection risks.
A resident with multiple health conditions and a recent fracture was not allowed to make an informed choice about continuing specialized rehab services, despite being cognitively intact and expressing a desire to continue therapy. The care plan did not reflect the resident's wishes, and staff communication failures led to the discontinuation of therapy, even though insurance coverage was still active.
A resident with a documented DNR advance directive did not have their code status entered into the electronic clinical record or incorporated into the care plan, as required by facility policy. The DNR order was only present in the hard chart, making it inaccessible to staff using electronic records, and the process for entering such directives was not consistently followed.
A resident admitted for orthopedic aftercare with multiple comorbidities did not receive ordered PT and OT services for an extended period, despite ongoing insurance coverage and medical necessity. Miscommunication among staff led to a gap in therapy, with no physician order for discharge and no documentation of the resident's rehab goals in the care plan. The resident was not included in care planning discussions and reported not understanding why therapy was stopped, resulting in unmet rehabilitation needs.
The facility failed to provide adequate staffing, resulting in delayed care for residents. A resident at risk for skin breakdown did not receive timely continence care, while another resident requiring assistance with transfers reported long wait times for call-light responses. Staff interviews confirmed the challenges posed by staffing shortages, with the facility's management acknowledging the issue but failing to resolve it effectively.
The facility failed to maintain adequate staffing levels, resulting in prolonged call light response times and unmet resident needs. Observations and interviews revealed that residents often waited over 30 minutes for assistance, with staffing levels falling short of the facility's requirements. The DON and Staffing Coordinator acknowledged the challenges in hiring sufficient CNAs, impacting the quality of care and posing risks to residents.
A resident with multiple health issues reported that a CNA was mean and disrespectful, turning off the call light without providing care. The CNA rudely told the resident to watch her tone and refused to let another CNA take over care. The DON confirmed the incident and noted the CNA's history of attitude concerns.
A facility failed to protect a resident from verbal abuse by a CNA, who had a history of inappropriate behavior. Additionally, the facility did not prevent physical and emotional abuse between two residents, one of whom used a backscratcher to hit the other. Interviews revealed a lack of staff intervention and inadequate implementation of abuse prevention policies, leading to an unsafe environment.
The facility failed to provide consistent showers to three residents, leading to hygiene issues and skin conditions. A resident who is completely dependent on staff for showers missed numerous scheduled showers, resulting in a rash. Another resident required extensive assistance and missed several showers, leading to untreated skin conditions. A third resident experienced long periods without showers, contributing to a recurring yeast rash. Interviews revealed ongoing staffing issues and unaddressed concerns despite repeated discussions.
A facility failed to protect residents from abuse, resulting in two incidents. In one case, a resident reported an LPN threw a remote at him, which the LPN denied, but another LPN corroborated the resident's account. The facility deemed the abuse unsubstantiated but terminated the LPN for poor service. In another case, a cognitively impaired resident gripped another resident's shoulders, causing pain. The facility substantiated this abuse. The facility's abuse prevention policy was not effectively implemented.
A resident with multiple chronic conditions experienced inadequate wound care management, leading to hospitalization. Despite treatment orders for cellulitis and blisters, the facility failed to consistently administer care, and the resident's noncompliance was not addressed in the care plan. Maggots were later found in the wound, prompting another hospital transfer. Interviews revealed that staff nurses were responsible for wound treatments, but documentation was lacking.
Failure to Report and Investigate Allegation of Staff-to-Resident Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse and neglect reporting policy after an allegation of staff-to-resident abuse and neglect involving Resident #70. Resident #70 had multiple significant diagnoses, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors. A care plan initiated in late December identified the resident as being at risk for alteration in psychosocial well-being due to staff failure to honor resident choices during care. On December 27, 2025, the Executive Director (ED) documented a Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The form noted that the concern was reported to the ED and that the ED spoke with the resident and his wife that afternoon. The resident and his wife reported that he did not receive care upon arrival from the hospital. The ED’s handwritten investigation notes concluded the same day that the resident had received care throughout the night, including at arrival, at midnight, and when the nurse checked his feeding pump. The ED documented that the concern was resolved at the time it was shared and that the investigation findings were concluded within about 40 minutes. In a later interview, the resident’s wife reported that during the night in question, an RN and a CNA responded to the resident’s call light for a brief change after he spilled his bedside urinal, and that they turned him back and forth aggressively during the brief change despite his request for them to stop. She stated that the RN made a comment to the assisting staff that they needed to get out of the room or else the resident would get them fired, and that staff then ignored the resident for the rest of the night and left his bed remote out of reach. She also stated that two police reports had been filed regarding abuse and neglect during his stay, and that the incident from December 27, 2025, was not reported by the facility to any state agency except the police. The ED confirmed in interview that he was informed of the wife’s allegation of neglect on December 27, that he spoke with both the wife and the resident, and that because the resident contradicted the wife’s allegation, he decided not to report the incident to the State Survey Agency, APS, or other required entities, despite facility policy requiring that all alleged violations be reported. Staff interviews further described the events and the facility’s handling of the allegation. The RN identified as being involved stated that she did not recall any allegation of abuse, neglect, or rough care being made to her or against her, and denied ignoring the resident or making the statement about staff being fired. A CNA who assisted with care that night reported that the resident had a history of making allegations and that he received two-person care at all times; she described assisting with a full bed change after the resident spilled his urinal and later being contacted by the previous DON to write a statement after the resident reported that night shift had neglected him. Another CNA stated she was instructed to provide care in pairs because the resident was having issues with staff and reporting that no care was being given. Despite these multiple accounts and the wife’s explicit allegation of neglect, the ED acknowledged that he did not report the December 27 allegation to state agencies, relying instead on his own assessment that the incident was not abuse or neglect. Review of the facility’s policies showed that abuse included the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and that neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The reporting policy required that all alleged violations be reported immediately, but no later than 2 hours if abuse or serious bodily injury was involved, or within 24 hours if not, to the administrator and to other officials, including the State Survey Agency and APS. The policy also specified that an individual reporting an alleged violation did not need to label it as abuse or neglect for it to trigger a facility investigation and reporting, and that all alleged violations, whether oral or written, must be reported to the administrator and other officials in accordance with state law. Despite this, the ED stated that he did not report the December 27 allegation to any state agency because he did not deem it necessary after the resident contradicted his wife’s account, thereby failing to follow the facility’s abuse and neglect reporting policy for this allegation.
Failure to Report Alleged Staff-to-Resident Abuse and Neglect to Required Agencies
Penalty
Summary
The facility failed to report an incident involving alleged staff-to-resident abuse and neglect to the required state agencies after a resident and his wife reported concerns about his care. The resident had multiple significant medical conditions, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors for 1–3 days. A care plan focus was initiated for risk of alteration in psychosocial well-being related to staff failure to honor resident choices during care on a prior date. On a later date, the Executive Director (ED) completed a handwritten Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The ED documented that the resident and his wife reported that he did not receive care upon arrival from the hospital, and the ED’s investigation concluded that the resident had received care throughout the night, including at midnight and when his feeding pump was checked. The ED recorded that the concern was resolved at the time it was shared and that the resident was informed that a specific RN would no longer provide his care, as requested. The facility’s internal investigation included obtaining written statements from staff about the incident. In a subsequent interview, the resident’s wife stated that during the night in question, an RN and a CNA responded to the resident’s call light after he spilled his bedside urinal and that they turned him aggressively during a brief change, ignored his requests to stop, and then ignored him for the rest of the night, leaving his bed remote out of reach. She reported that two police reports were filed during his stay, one for an earlier incident and another for this night, and asserted that the later incident was not reported by the facility to any state agency except the police. The ED confirmed that he was aware of the allegation of neglect made by the wife, that he spoke with both the wife and the resident, and that the resident contradicted the wife’s allegation. The ED stated that, because he had conflicting statements and did not deem the later incident to be abuse, he did not report it to the State Survey Agency, APS, or other required state entities, despite facility policy requiring that all alleged violations be reported within specified timeframes regardless of how they are characterized. Additional staff interviews showed that staff were aware of the requirement to report allegations of abuse and neglect promptly to facility leadership. The RN identified as involved denied that any allegation of rough care or neglect had been made to or about her and denied ignoring the resident or making threatening statements. Other CNAs and an LPN recalled that the resident had a history of making allegations, that he was to receive two-person care, and that there had been prior incidents involving staff being fired. One CNA reported being contacted by the previous DON and asked to provide a written statement after the resident alleged that night-shift staff had neglected him. The facility’s abuse and neglect policies defined abuse and neglect broadly and required that all alleged violations, whether oral or written, be reported immediately (within 2 hours if abuse or serious bodily injury was involved, or within 24 hours otherwise) to the administrator and appropriate state officials, and that staff did not need to explicitly label an event as abuse or neglect for it to be considered reportable. Despite these policy requirements, the ED acknowledged that the later allegation of neglect was not reported to the required state agencies.
Abusive Administration of Tube Feeding Flush Despite Resident Refusal
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to honor the resident’s right to refuse treatment during enteral feeding care. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, malnutrition, facial weakness, and dysarthria, and had a PEG tube due to dysphagia and dependence on staff for eating. A care plan and enteral feeding order directed Jevity 1.5 bolus feeds every four hours with a 50 mL purified water flush after each feeding. Documentation showed the resident occasionally became confused and resistive with care, including PEG tube care, and had been known to reject care. On one occasion, a behavior note documented that during a bolus feeding the resident became combative, pushed the nurse’s hands away, and said “no more food and water,” after which the LPN explained the need for the water flush and the resident agreed to the flush. A subsequent behavior note recorded that at a midnight bolus feeding, the LPN, assisted by two CNAs, proceeded with the bolus and water flush while the resident tried to kick staff and push the food away, repeatedly saying “no more food, no more water.” During this episode, the two CNAs held the resident’s hands and knees down while the LPN administered the bolus and flush. A later note the same night documented that the resident refused food and the bolus was not given. The resident’s admission MDS showed a BIMS score of 14, indicating cognitively intact status, and confirmed dependence on staff for eating and use of a PEG tube, with a history of rejecting care. In an interview, the resident reported refusing multiple times by pushing the tube away and verbally stating he did not want the treatment or the flush because it caused him to go to the bathroom, and stated that when he tried to push it away, the nurse brought more staff to hold him down while she flushed against his wishes. Personnel and termination documents for the LPN and both CNAs indicated that they participated in resident abuse by forcefully administering treatment and physically holding the resident’s extremities so that the tube feeding flush could be given despite the resident’s clear refusals. Facility policies in effect at the time stated that residents have the right to be free from abuse, including physical restraint not required to treat medical symptoms, and the right to request, refuse, and discontinue treatment.
Failure to Accurately Document and Perform Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to accurately document and perform wound treatment for a resident with multiple complex medical conditions, including surgical aftercare, diabetes, infection, and an abdominal surgical wound. The resident was admitted with an order for specific wound care, including cleansing with normal saline, application of Adaptic on biological mesh, packing with acetic acid-soaked gauze, and covering with a dry dressing, to be performed every shift. Documentation showed that the wound care was charted as completed on both the day and night shifts of a specific date. However, during an interview, the LPN assigned to the night shift admitted that she did not perform the wound care due to a busy shift and was unaware of a change in the wound care order. She also stated that she mistakenly charted the treatment as completed. The DON confirmed that the wound care was missed on the night shift, as reported by both the resident and the LPN, despite documentation indicating otherwise. The facility's policy requires that nursing documentation accurately reflect the care provided and the resident's progress. The inaccurate documentation and failure to perform the ordered wound care resulted in a deficiency, as the medical record did not provide an accurate representation of the resident's experience or care received.
Deficient Bowel and Catheter Care for Two Residents
Penalty
Summary
A deficiency was identified regarding the care and services provided to two residents with bowel and bladder management needs. One resident with a history of intracranial injury, full fecal incontinence, and severe cognitive impairment did not have a documented bowel movement for more than three days, as evidenced by CNA task documentation. Despite facility protocols and staff interviews indicating that lack of bowel movement should trigger nursing intervention and physician notification, there was no evidence that the resident received any medication or intervention for constipation until after the resident was hospitalized for severe constipation. The clinical record showed no physician order for stool softeners or laxatives until after the hospital admission, and the resident was ultimately diagnosed with a large, retained stool mass requiring medical intervention. Another resident with an indwelling catheter for neurogenic bladder and severe cognitive impairment did not receive catheter care as ordered by the physician. The care plan and physician orders required catheter care and securing the catheter with an anchoring device every shift, as well as regular monitoring of the catheter tubing and bag. However, review of the CNA Bowel and Bladder Elimination Report revealed inconsistent and infrequent documentation of catheter care, with several days showing only a single check or no documentation at all. There was no evidence that the physician was notified about the missed catheter care, nor any documentation explaining the lapses. Staff interviews confirmed that both CNAs and nurses were responsible for monitoring and documenting bowel movements and catheter care, and that the facility's electronic medical record system was designed to alert staff to issues such as missed bowel movements. Despite these systems and protocols, the required care was not consistently provided or documented for the two residents, resulting in deficiencies related to the management of constipation and catheter care.
Uncovered Beverage Delivery During Meal Service
Penalty
Summary
Staff failed to follow proper food handling practices during the distribution of beverages to residents, as observed on multiple occasions. Beverages, including coffee, water, juice, and dairy, were repeatedly transported and delivered to resident rooms and bedside tables without covers. These uncovered beverages were observed being carried through hallways, placed on bedside tables, and retrieved from food trolleys, including in areas where residents were on Enhanced Barrier Precautions (EBP). Staff members, including nursing and dietary staff, were seen handling and delivering these uncovered drinks over varying distances within the facility. Interviews with facility staff, including the Kitchen Manager and Registered Dietitian, confirmed that the expectation was for all beverages to be covered during delivery to prevent contamination. However, the observed practice did not align with this expectation, as staff distributed uncovered beverages to residents. Facility policies on infection prevention and control, as well as surveillance of infection-related practices, were referenced, but the observed actions did not adhere to these standards.
Failure to Remove Damaged Fall Mat Creates Infection Control Deficiency
Penalty
Summary
A resident with quadriplegia, legal blindness, and aphasia was admitted to the facility and identified as being at risk for falls, with a fall mat care plan in place. During an observation, a blue fall mat next to the resident's bed was found to be ripped apart approximately three-quarters of the way, exposing the internal sponge-like material. This condition was noted in the presence of the resident and their representatives. The resident's clinical records indicated severely impaired decision-making abilities. Staff, including a Registered Nurse and the Infection Preventionist, confirmed that the torn mat could not be properly cleaned and posed an infection control concern, as it could harbor potentially infectious organisms. The facility's policies required removal of products with compromised integrity and identified proper cleaning, disinfection, and disposal of equipment as essential to infection prevention. The presence of the damaged fall mat in the resident's environment demonstrated a failure to implement effective infection control measures as outlined in facility policy.
Failure to Honor Resident Choice in Continuation of Therapy Services
Penalty
Summary
A resident admitted for orthopedic aftercare with multiple comorbidities, including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking, was found to have been denied the right to make choices regarding the continuation of specialized rehabilitative services. Despite being cognitively intact and expressing a clear desire to continue therapy to meet personal mobility goals, the resident's care plan did not reflect this preference. The resident reported confusion about the discontinuation of therapy services and stated that therapy sessions were only missed due to illness. The resident also indicated a lack of communication regarding therapy options, insurance coverage, and care plan meetings, and did not recall any discussions with the insurance company or staff about the continuation of therapy. Interviews with facility staff, including the case manager and a panel of leadership, confirmed that the resident was eligible for continued therapy services and that insurance coverage was still active. However, a breakdown in communication among staff resulted in the resident not receiving the requested therapy services. Facility policies require that residents be informed of changes to their care plan and be allowed to make informed choices about their treatment, but these procedures were not followed in this case.
Failure to Enter and Care Plan DNR Order in Clinical Record
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Non-Hodgkin lymphoma, muscle weakness, and an indwelling urinary catheter, had a documented advance directive indicating Do Not Resuscitate (DNR) status. Despite this, the resident's DNR order was not entered into the electronic clinical record upon admission or readmission, nor was it incorporated into the resident's care plan as required by facility policy. The advance directive was only found in the hard chart at the nursing station and not reflected in the electronic system, making it inaccessible to staff relying on electronic records for code status information. Interviews with nursing staff revealed that the process for entering advance directives into the electronic record was not consistently followed, and there was no centralized system, such as a code book, to alert staff to residents' code statuses. The responsible nurse was unable to locate the code status in the electronic record until after the deficiency was identified, at which point the order was entered. Facility policy requires a physician's order for DNR status and mandates that it be flagged in the chart and included in the care plan, but these steps were not completed for this resident.
Failure to Provide Ordered Rehabilitative Services Due to Communication Breakdown
Penalty
Summary
A resident was admitted for orthopedic aftercare following a right fibula fracture, with additional diagnoses including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking. Upon admission, orders were written for both physical therapy (PT) and occupational therapy (OT) evaluations and treatments, with plans specifying services five times a week for several weeks. The resident was cognitively intact and expressed a desire to participate in therapy to regain strength and mobility, specifically aiming to reduce fall risk and improve ability to use a bedside commode. Despite having insurance coverage for the entire stay, the resident experienced a discontinuation of both PT and OT services after March 20, even though the treatment plans and insurance authorizations extended beyond that date. The clinical record did not reflect a physician order to discharge rehabilitative services, nor did the nursing care plan document the resident's goals for specialized rehab services. The resident reported not receiving therapy for approximately two weeks prior to discharge and was unclear about the reason, despite inquiring with staff. Interviews with facility staff confirmed that there was a miscommunication regarding the resident's coverage and discharge status, resulting in the resident not being re-evaluated or transitioned to restorative or continued rehabilitative services during the gap period. The resident expressed frustration and discouragement about not receiving therapy, feeling weaker, and not achieving her rehabilitation goals. She was not included in care plan meetings or discussions about her therapy, and staff interviews confirmed that the extension of her stay and continued eligibility for services were not effectively communicated to the rehabilitation department. Facility policies required individualized, person-centered care planning and the provision of specialized rehabilitative services as assessed, but these were not followed in this case.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, resulting in several instances where residents did not receive timely care. Resident #22, who was at risk for skin breakdown, did not receive continence care on a specific day, leading a family member to provide care due to unresponsive staff. The facility's records confirmed that staff did not attend to the resident during the day shift, highlighting a lapse in care provision. Resident #77, who required substantial assistance with transfers, reported waiting over two hours for call-light responses and experiencing delays in receiving necessary care. The resident's care plan lacked specific instructions for assistance with activities of daily living, such as transfers, further complicating the situation. Interviews with other residents revealed similar issues, with reports of long wait times for assistance, particularly during peak hours like lunch. Staff interviews corroborated the residents' complaints, with CNAs acknowledging the challenges posed by staffing shortages. The facility's staffing coordinator and DON admitted to being aware of the staffing issues, which were exacerbated by call-offs and inadequate scheduling adjustments. Despite attempts to manage the situation, the facility's staffing levels were insufficient to meet the residents' needs, as evidenced by the numerous complaints and documented instances of delayed care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by multiple instances of prolonged call light response times and insufficient staff coverage. Resident Council meeting minutes and grievance logs highlighted ongoing concerns about staffing, particularly on weekends and during night shifts. Residents reported waiting excessively long for assistance, with some call lights remaining unanswered for over 30 minutes. Observations confirmed these delays, with staff often unavailable or occupied with other tasks, leaving residents without timely care. On specific dates, the facility was notably understaffed, with insufficient numbers of CNAs and nurses to cover the resident census. For instance, on March 16, 2023, the facility had only 3 RNs, 2 LPNs, and 4 CNAs during the day for 116 residents, which did not meet the facility's own staffing requirements. Interviews with staff, including the DON and Staffing Coordinator, acknowledged the staffing shortages and the challenges in hiring and retaining sufficient staff, particularly CNAs. The facility's staffing assessment indicated a need for more staff than were present, leading to compromised resident care. The deficiency was further highlighted by specific incidents where residents' needs were not promptly addressed. For example, a resident reported waiting over an hour for assistance off a bedside commode, and another resident's call light was on for over two hours before receiving medication. These incidents, along with staff interviews, revealed systemic issues in staffing that affected the quality of care provided to residents, with risks of falls, skin issues, and unmet care needs being directly linked to the understaffing problem.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident who was readmitted with multiple diagnoses, including acute and chronic respiratory failure, Type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease. The resident was alert and oriented, with no documented behavior or mood issues. An incident occurred where the resident reported that a CNA was mean, turned off the call light without providing care, and was disrespectful during an interaction. The resident expressed upset feelings about the delayed care, and the CNA responded rudely, telling the resident to watch her tone and insisting on continuing care despite another CNA offering to take over. The incident was documented in a facility investigation report, and a corrective action form was issued to the CNA involved. The Director of Nursing confirmed that staff are trained on dignity and respect and expressed that the incident was not conducive to the resident's health. The DON also noted that the CNA had previous attitude concerns and had been written up for insubordination in the past. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity.
Failure to Prevent Resident Abuse and Inadequate Staff Intervention
Penalty
Summary
The facility failed to protect Resident #47 from verbal abuse by an employee, identified as a certified nursing assistant (CNA). The resident, who had moderate cognitive impairment and required maximal assistance for certain activities, was subjected to inappropriate language by the CNA. The incident was reported by another staff member, and interviews with various staff members revealed a pattern of intimidating and inappropriate behavior by the CNA, who had previously received a second written warning for refusing assignments and making coworkers uncomfortable. Despite these warnings, there was no documentation of a first written warning or a complete investigation into the CNA's behavior. In another incident, the facility failed to prevent physical and emotional abuse between two residents, Resident #39 and Resident #41. Resident #39, who had severe cognitive impairment and was dependent on a wheelchair, was involved in an altercation with Resident #41, who was cognitively intact but had a history of behavioral disturbances. The altercation occurred when Resident #41 used a backscratcher to hit Resident #39's hand to stop him from moving a table. Interviews with other residents and staff indicated that such incidents were becoming more common, with residents often feeling the need to intervene due to a lack of staff presence. The facility's policies on abuse prevention and investigation were not effectively implemented, as evidenced by the lack of immediate staff intervention during the altercation and the absence of a thorough investigation into the verbal abuse incident. The Director of Nursing and Executive Director were aware of the incidents but did not take sufficient steps to prevent recurrence, such as separating the involved residents or ensuring adequate supervision in common areas. The facility's failure to address these issues created an unsafe environment for residents, as highlighted by the repeated instances of abuse and the residents' concerns about their safety.
Inconsistent Showering Practices in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents received consistent showers, which is a deficiency in providing care and assistance for activities of daily living. Resident #3, who is cognitively intact and completely dependent on staff for showers, missed numerous scheduled showers over several months. Despite the resident's preference for a female CNA, the facility did not accommodate this request, leading to missed showers and a rash on the resident's arms and groin. Resident #8, also cognitively intact, required extensive assistance for showers due to paralysis and other health conditions. The resident missed several scheduled showers, and a rash in the skin folds required treatment with anti-fungal powder. The resident expressed concerns about insufficient staffing and the inability to receive showers during the day shift, which contributed to the missed showers. Resident #11, who needs partial assistance with showering, also experienced missed showers, leading to a recurrence of a yeast rash. The resident reported long periods without showers and poor call light response, resulting in prolonged exposure to wet briefs. Interviews with staff and residents highlighted ongoing issues with staffing and the facility's failure to address these concerns, despite repeated discussions in resident council meetings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse, resulting in a deficiency. In the first incident, a resident with moderate cognitive impairment reported that an LPN threw his television remote at him and removed the batteries because the TV volume was too high. The LPN denied throwing the remote and stated that she underhand tossed it into the resident's lap. Another LPN corroborated the resident's account, stating that the accused LPN admitted to taking the remote and removing the batteries. The facility's investigation concluded that the allegation of abuse was unsubstantiated, but the LPN was terminated for failing to provide good customer service. In the second incident, a resident with cognitive impairments and a history of aggressive behavior was involved in an altercation with another resident. The aggressor resident, who had moderately impaired cognitive skills, approached the victim from behind and gripped his shoulders, causing pain and a bruise. The victim was unable to free himself and called for help. Staff intervened and separated the residents. The facility's investigation substantiated the allegation of abuse, confirming that the aggressor resident's actions caused harm to the victim. The facility's policy on abuse prevention, which includes preventing physical abuse by any individual, was not effectively implemented in these cases. The policy outlines steps to prevent abuse, including monitoring residents identified as aggressors and separating involved residents. However, the incidents involving the two residents highlight a failure to adhere to these preventive measures, resulting in harm to the residents involved.
Failure to Administer Wound Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide care and treatment for a resident according to professional standards of practice, resulting in the resident's hospitalization. The resident, who had chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end-stage renal disease, and hyperkalemia, was admitted with a nutrition care plan goal for skin improvement. Despite documentation of cellulitis and blisters on the resident's lower extremities, treatment orders were inconsistently administered, and the resident's wounds were not care planned with interventions. The Treatment Administration Record (TAR) showed missed or refused treatments on several occasions, and the resident was eventually transferred to the hospital. Upon return from the hospital, new treatment orders were documented as administered, but the resident's refusal and noncompliance with wound care were not addressed in the care plan. The resident remained non-compliant with wound care, and maggots were found in the wound upon bandage removal, leading to another hospital transfer. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that wound care documentation was expected in the TAR, and staff nurses were responsible for the resident's wound treatments. The CDC notes that untreated or open wounds increase the risk of myiasis, a parasitic infection, which was a concern in this case.
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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.
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