Oasis Pavilion Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Casa Grande, Arizona.
- Location
- 161 West Rodeo Road Suite 1, Casa Grande, Arizona 85122
- CMS Provider Number
- 035276
- Inspections on file
- 19
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oasis Pavilion Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with an indwelling catheter had urinary outputs documented in the medical record for days when the resident was not present in the facility, following a hospital transfer. Staff interviews revealed confusion about documentation procedures during resident absences, and the DON confirmed that such documentation should not have occurred, as facility policy requires accurate daily output records.
A resident with multiple complex medical conditions experienced a significant change in condition, including altered mental status, tachycardia, hypotension, and oxygen desaturation. Staff failed to document updated vital signs, the type and timing of hospital transfer, and physician instructions, resulting in incomplete assessment, monitoring, and emergency response. Facility policy for emergency transfers was not followed, and the clinical record lacked necessary progress notes and documentation.
A resident with multiple health conditions developed a stage III sacral pressure ulcer that required specific wound care as ordered by a physician. The wound care orders, including the use of hydrogel and calcium alginate dressings, were not entered into the MAR or TAR, resulting in the treatment not being provided or documented. The LPN responsible for wound care acknowledged the omission, and the DON confirmed that treatments must be entered and documented according to facility policy.
A resident with multiple complex diagnoses experienced a change of condition, but staff failed to document the event, physician notification, physician instructions, and the details of the hospital transfer in the clinical record. Interviews revealed missing or unclear documentation regarding vital signs, the type and timing of the transfer, and the physician's involvement, despite facility policy requiring such records.
A resident with a history of falls and multiple diagnoses was inaccurately assessed as low risk for falls upon admission to an LTC facility. Despite hospital records and care plans indicating a fall risk, the fall risk assessment conducted by an LPN did not reflect this due to a misunderstanding of the assessment criteria. Interviews with staff, including a CNA, RN, and DON, highlighted discrepancies in the assessment process, leading to potential risks in resident care.
The facility failed to protect a resident with severe cognitive impairment from abuse by her newly admitted roommate, resulting in a fall and a new fracture of the resident's left femur. Staff interviews revealed gaps in the screening process for residents with behavioral issues.
Instances of resident-to-resident abuse were reported, highlighting deficiencies in protecting residents from harm. One incident involved a resident throwing a remote control, causing a bruise on another resident's leg. Despite interventions for the resident's impulsive behavior, the altercation occurred. Another case involved a resident being bruised by a motorized wheelchair operated by a resident with a history of impulsive behavior. The facility's documentation and witness statements indicated a lack of effective interventions to prevent these confrontations, despite existing care plans.
The facility failed to ensure the right to personal privacy for two residents. Staff entered rooms without knocking or waiting for a response, and did not introduce themselves, despite facility policy requiring these actions.
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. An RN left an uncapped syringe, a pill cup, and an open EHR displaying resident information unattended. In another instance, the RN walked away from an unlocked EHR revealing residents' names. The ADON confirmed that nurses are expected to lock medication carts and EHR screens when stepping away.
The facility failed to update the care plan for a resident with anxiety disorder, major depressive disorder, and multiple sclerosis after an incident where the resident was mean to her roommate and used a motorized scooter to bump into the roommate. Staff interviews confirmed that the care plan should have been updated to address the resident's behavior and prevent further incidents.
A facility failed to ensure proper catheter care for a resident, leading to the catheter bag dragging on the floor and inconsistent care practices among staff. This put the resident at risk for urinary catheter complications and infections.
The facility failed to keep two of the four medication carts locked and under direct supervision, leaving an uncapped syringe and a pill cup filled with pills unattended. Additionally, two unlocked medication carts with accessible over-the-counter medications were found in an unlit alcove, posing a risk of unauthorized access by residents.
The facility failed to implement proper infection control practices during insulin administration. An LPN did not wipe the needle insertion site with an alcohol swab before administration. The ADON confirmed that nurses are expected to clean the insulin container and injection area with an alcohol swab, as per facility policy.
Inaccurate Documentation of Urinary Output for Absent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one resident regarding urinary output. The resident, who had multiple diagnoses including muscle weakness, mobility issues, and both acute and chronic respiratory failure, was admitted with an indwelling catheter and an order for routine catheter care. Despite being transferred to the hospital and not present in the facility, the resident's Treatment Administration Record (TAR) showed documented catheter outputs for days when the resident was not in the facility. Interviews with staff revealed uncertainty about documentation procedures when a resident is out of the facility. The LPN was unsure if outputs should be recorded during a resident's absence, while the CNA stated that output documentation is only done when the resident is present. The DON confirmed that documentation of outputs should not occur when a resident is not in the facility and verified that incorrect entries were made in the resident's record. Facility policy requires maintaining an accurate record of daily output, which was not followed in this instance.
Failure to Assess, Monitor, and Document Emergency Response for Resident with Change in Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed, monitored, and provided with an appropriate emergency response during a change in condition. The resident, who had multiple complex diagnoses including altered mental status, COPD, brain neoplasm, diabetes, hemiplegia, and slurred speech, was admitted with orders for oxygen therapy and regular monitoring of oxygen saturation. On the day of the incident, the last recorded oxygen saturation was 93% in the morning, but there was no documentation of further vital signs or oxygen levels in the afternoon when the resident's condition changed. Despite the resident exhibiting altered mental status, tachycardia, hypotension, and oxygen desaturation into the 80s, there was a lack of clear documentation regarding the assessment of the resident's condition, the timing and type of transfer to the hospital, and whether the transfer was emergent or non-emergent. Interviews with nursing staff and the DON revealed confusion and inconsistent accounts about who ordered the transfer, the resident's status at the time, and the communication with the medical provider. The hospital transfer form did not specify the time of transfer, the type of transfer, or provide updated vital signs at the time of transfer. Facility policy required that in the event of an emergency transfer, staff should call 911 if clinical criteria are met, document the resident's condition, and notify the attending physician. However, the clinical record lacked progress notes detailing the change in condition, updated vitals, and physician instructions. The deficiency was identified due to these omissions in assessment, monitoring, documentation, and emergency response for the resident experiencing a significant change in condition.
Failure to Provide Physician-Ordered Wound Care for Pressure Ulcer
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, malnutrition, dementia, and chronic kidney disease, was admitted and identified as being at risk for skin breakdown. Upon admission, the resident had a stage I pressure ulcer on the sacrum/coccyx and a stage II closed blister on the left foot. The care plan included interventions such as incontinence care, regular repositioning, and wound care as ordered by the physician. Orders were in place for wound cleansing, use of a low airloss mattress, application of barrier cream, and specific wound treatments for the left heel and buttocks. On December 24, a physician upgraded the sacral wound from stage I to stage III, noting the presence of eschar and necrotic tissue, and provided new wound care orders, including cleansing with wound cleanser, application of hydrogel ointment, and use of calcium alginate dressings. However, these new orders were not entered into the order summary, Medication Administration Record (MAR), or Treatment Administration Record (TAR). As a result, there was no documentation that the prescribed wound care was provided. The wound nurse acknowledged that the order for hydragel calcium alginate was not entered, and therefore, the treatment was not documented or performed as required. Interviews with the wound nurse and the Director of Nursing confirmed that the omission of the physician's wound care orders led to the failure to provide the necessary treatment. The facility's policy and the wound nurse's job description require that all physician orders be entered and carried out, and that treatments be documented. The lack of order entry and documentation resulted in the resident not receiving wound care in accordance with professional standards of practice.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to properly document a resident's change of condition, the notification of the physician, the physician's instructions, and the details of the hospital transfer in the clinical record. The resident in question had multiple significant diagnoses, including altered mental status, COPD, malignant neoplasm of the brain, type II diabetes, hemiplegia, and slurred speech, and was noted to have moderate cognitive impairment. On the day of the incident, the resident's oxygen saturation was last recorded in the morning, but there was no documentation of vital signs or oxygen levels at the time of the change of condition in the afternoon, when the resident was transferred to the hospital. Staff interviews revealed confusion and lack of clarity regarding the events leading up to the transfer. The DON acknowledged that there was no documentation of the resident's change of condition, vitals, or whether the physician had been notified or had ordered the transfer as emergent or non-emergent. The hospital transfer form did not specify the time or type of transfer, and staff were unable to confirm these details during interviews. The nurse practitioner later entered a late note indicating the resident was exhibiting altered mental status, tachycardia, hypotension, and oxygen desaturation, and that the resident was sent out via 911 for a higher level of care, but this was not contemporaneously documented. Facility policy requires prompt notification and documentation of changes in a resident's condition, including physician notification and recording of relevant information in the medical record. However, in this case, the required documentation was incomplete or missing, including the resident's condition at the time of transfer, the physician's instructions, and the specifics of the hospital transfer. This failure to document key aspects of the resident's care and transfer process constitutes the deficiency identified in the report.
Inaccurate Fall Risk Assessment in Resident's Health Record
Penalty
Summary
The facility failed to ensure that the electronic health record for a resident was complete and accurately documented, which could result in incomplete and/or inaccurate clinical records and potentially impact resident care. The resident was admitted with multiple diagnoses, including malignant neoplasm of the kidney, secondary malignant neoplasm of the brain, and a history of repeated falls. Despite this, the fall risk assessment conducted upon admission incorrectly indicated that the resident was at low risk for falls, with a score of '0'. This was inconsistent with the resident's documented history of falls in the hospital records, MDS, and care plan. Interviews with staff revealed discrepancies in the understanding and execution of the fall risk assessment process. A CNA mentioned that fall risk information is shared during shift changes and documented in the electronic health record. An RN stated that the fall risk assessment should include a review of the resident's fall history, interviews with the resident or family, and a review of hospital documentation. However, the LPN who conducted the assessment admitted to considering only the resident's fall history within the facility, not prior to admission, leading to the inaccurate assessment. The Director of Nursing acknowledged that the fall risk assessment should have identified the resident as a fall risk, as it should capture both current and historical information. The facility's policy on falls and fall risk management emphasizes the importance of identifying interventions based on previous evaluations and data to prevent falls. The failure to accurately assess the resident's fall risk could lead to staff confusion and inadequate precautions being put in place, as noted by the MDS nurse and the Director of Nursing.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to ensure the right of one resident to be free from abuse by another resident. Resident #2, who has severe cognitive impairment and uses a walker for mobility, was admitted with a history of hypertension, strokes, and falls. On April 5, 2024, a nurse responded to calls for help and found Resident #2 on the floor, reporting that her roommate, Resident #1, had pulled her off the bed and pushed her to the floor. An x-ray taken the following day revealed a new fracture of Resident #2's left femur. Interviews with Resident #2 confirmed the incident, and the resident reported soreness and pain in the left hip area where the fracture was identified. Resident #1, admitted for palliative care with severe cognitive impairment, had no documented history of behavioral issues prior to the incident. The facility's investigative report noted that Resident #1 had been admitted only an hour before the incident occurred. Interviews with staff revealed that the facility typically does not admit residents with dementia and behavioral issues due to inadequate training. The Director of Nursing (DON) confirmed that the screening process for prospective residents is conducted by the Admissions Coordinator and herself, and that Resident #1's case manager had reported no behavioral issues. Despite this, the incident occurred, resulting in physical harm to Resident #2.
Resident-to-Resident Abuse Due to Impulsive Behaviors
Penalty
Summary
The report details instances where residents in the facility were subjected to abuse by other residents, leading to deficiencies in protecting residents from harm. In the case of resident #1 and resident #149, resident #149 threw a remote control at resident #1, resulting in a large bruise on her leg. Resident #149 exhibited impulsive behavior and outburst behaviors, leading to the altercation. Despite interventions in place for resident #149's behavioral symptoms, the incident still occurred, indicating a failure to adequately prevent resident-to-resident abuse. Similarly, resident #63 reported that resident #15 had bumped into her with a motorized wheelchair, causing a bruise on her knee. Resident #15 had a history of impulsive behavior, and the incident with resident #63 was not an isolated event, as similar behaviors had been displayed with previous roommates. The facility's failure to address resident #15's tendency to intimidate roommates or use the wheelchair to harm others contributed to the deficiency in protecting resident #63 from abuse. The facility's investigation reports, witness statements, and documentation highlighted the confrontations between the residents, indicating a lack of effective interventions to prevent resident-to-resident abuse. Despite the residents' cognitive statuses and care plans being in place, the incidents occurred, underscoring the need for improved monitoring, supervision, and intervention strategies to ensure the safety and well-being of all residents in the facility.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure the right to personal privacy for two residents. Resident #6, who was admitted with diagnoses including unspecified injury of the head and generalized muscle weakness, reported that staff were either not knocking or not waiting for a reply before entering her room. An observation confirmed that a CNA entered Resident #6's room without knocking or waiting for a response, and did not introduce herself. The CNA admitted to not following the correct process of knocking and waiting for permission to enter the room. Similarly, Resident #79, who was admitted with cardiorespiratory conditions and coronary artery disease, reported that staff entered her room without knocking or waiting for her response. An observation confirmed that a CNA knocked once and entered Resident #79's room without waiting for a response. The CNA acknowledged that she did not wait for the resident's response before entering. The assistant Director of Nursing stated that staff are expected to knock, wait for a response, and introduce themselves before entering a resident's room. The facility's policy on Residents Rights emphasizes the right to personal privacy and respectful treatment.
Failure to Ensure Privacy and Security of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. During an observation, an uncapped syringe and a pill cup filled with an assortment of pills were left unattended on a medication cart. Additionally, the electronic health record (EHR) was left open and uncovered, displaying a resident's picture and list of medications. The registered nurse responsible for the medication cart and EHR was found in an alcove with another patient, leaving the medication and EHR screen out of her line of sight. In another instance, the same registered nurse walked away from the medication cart with an unlocked EHR that revealed a list of residents' names. The nurse was about to enter a resident's room for medication administration before being stopped to lock the EHR screen. The Assistant Director of Nursing confirmed that nurses are expected to lock the medication carts and EHR screens when stepping away. Facility policies reviewed indicated that unauthorized release, access, or disclosure of resident information is prohibited and that medication carts must be securely locked when not in the nurse's view.
Failure to Update Care Plan Following Resident Altercation
Penalty
Summary
The facility failed to ensure that the care plan for a resident was updated and revised as needed. Resident #15, who was admitted with diagnoses of anxiety disorder, major depressive disorder, and multiple sclerosis, was involved in an incident where she was reported to have been mean to her roommate, bumped into the roommate with a motorized scooter, and claimed control over the room. Despite this behavior, the care plan was not updated to address these issues or include interventions to manage the resident's behavior towards her roommates. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that the care plan should have been updated following the incident to mitigate further occurrences. The ADON acknowledged that the lack of an updated care plan could lead to repeated incidents and emphasized the importance of updating care plans to inform staff about the resident's needs. The facility's policies on care plans and abuse and neglect also support the need for timely updates and revisions to care plans based on changes in a resident's condition or behavior.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care and services related to an indwelling urinary catheter for a resident. The resident was observed with the catheter tubing exposed and the catheter bag dragging on the floor while being wheeled through the hallway. The Licensed Practical Nurse (LPN) acknowledged the incorrect placement and the associated risks of contamination and urinary tract infection (UTI). The resident also reported that catheter care was provided only once a day or when it itched, and during an interview, the catheter bag was again observed touching the floor while the resident was in bed. Further interviews with staff revealed inconsistencies in catheter care practices. A Certified Nursing Assistant (CNA) stated that catheter care was provided during each brief change and documented in the resident's electronic record. However, the CNA also acknowledged that the catheter bag should not touch the floor and should be placed below the resident's waist. The Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed that the correct placement of the catheter bag was below the patient for easy flow and that the catheter tubing should not touch the floor. They also mentioned that catheter care training was provided regularly to staff. The facility's policy on urinary catheters and incontinence, reviewed and revised in January 2024, emphasized the importance of keeping the catheter tubing and drainage bag off the floor to prevent UTIs. Despite these policies, the observations and staff interviews indicated a failure to adhere to proper catheter care protocols, putting the resident at risk for urinary catheter complications and infections.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to keep two of the four medication carts locked and under the direct supervision of authorized staff. During an observation on March 6, 2024, an uncapped syringe and a pill cup filled with an assortment of pills were left unattended on a medication cart. Additionally, two unlocked and unsupervised medication carts were found in an unlit alcove of Hall B, with over-the-counter medications easily accessible in the top drawer of both carts. These observations were made in areas where residents could potentially access the medications, posing a risk of unauthorized ingestion. In interviews conducted with staff, the LPN acknowledged that a resident could take and ingest medications that were not theirs. The ADON confirmed that nurses were expected to lock the medication carts and the facility's EHR when stepping away. The facility's policy on Medication Administration, reviewed in October 2023, mandates that nurses must ensure the medication cart is securely locked at all times when not in the nurse's view. The failure to adhere to this policy was evident in the observations made during the survey.
Failure to Implement Infection Control Practices During Insulin Administration
Penalty
Summary
The facility failed to implement proper infection control practices during insulin medication administration. During an observation, an LPN did not wipe the single-resident use needle insertion site with an alcohol swab before placing the needle for administration. In an interview, the ADON confirmed that nurses are expected to clean the top of the insulin container and the skin injection area with an alcohol swab prior to administration. The facility's policy on Medication Administration also mandates the use of proper administration techniques, including maintaining sterility.
Latest citations in Arizona
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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