Palm Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Goodyear, Arizona.
- Location
- 13575 West Mcdowell Road, Goodyear, Arizona 85395
- CMS Provider Number
- 035255
- Inspections on file
- 33
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Palm Valley Post Acute during CMS and state inspections, most recent first.
A nurse left an EHR open and visible on a medication cart computer while administering medications to a resident, resulting in the resident’s medical information being exposed on the unattended screen. Upon return, the RN confirmed the EHR was still visible. Other staff, including a CNA, an LPN, and the DON, acknowledged that unsecured computer screens can allow unauthorized viewing of HIPAA-protected information and that screens can and should be locked. Facility policy prohibits unauthorized access or disclosure of resident information and requires compliance with privacy laws.
A resident with a history of traumatic brain injury, opioid use, schizophrenia, and severe cognitive impairment remained in the facility after an initially exempt stay without a new PASRR Level I or any Level II being completed when the stay converted from skilled to LTC. Despite documented schizophrenia with hallucinations and delusions and ongoing antipsychotic use, no updated PASRR documentation was found in the record at the time of the status change, contrary to facility policy requiring evaluation of applicants for serious mental disorder and/or intellectual disability.
Surveyors found that the dumpster area was not maintained in a sanitary condition, with accumulated refuse, including a clear bag of trash containing clinical-type waste, miscellaneous trash, yard waste, and a dead bird around and behind the dumpsters. The Maintenance Director reported that daily inspections and shared maintenance responsibility were expected but acknowledged the area did not meet expectations and posed an infection control risk. The Housekeeping Supervisor noted the potential for contamination and germ spread from refuse outside the dumpsters, and the Administrator stated that the protocol required closed lids and a refuse-free area, recognizing that the observed conditions could attract pests, cause foul odors, reduce a homelike environment, and create an infection control issue.
A resident with multiple comorbidities and a neurogenic bladder requiring an indwelling Foley catheter was observed twice with the catheter drainage bag placed under the bed on the floor, with tubing lying on the floor, despite a care plan and physician orders for proper catheter management. Staff, including a CNA, an RN, and the DON, all described facility practices and expectations that catheter bags be hung below bladder level, covered with a privacy/dignity bag, and never placed on the floor. Facility catheter care and infection prevention policies, as well as CDC CAUTI prevention guidance, also specified that collection bags should not rest on the floor, but these standards were not followed for this resident.
The facility was found to have a medication error rate of 30.77%, significantly above the acceptable threshold, due to failures such as administering an incorrect dose of Vitamin D3 to a resident and delayed administration of multiple scheduled medications to another resident. Staff interviews and policy review confirmed that medications were not given as ordered or within the required timeframe.
Surveyors found that single-dose Omeprazole packets were stored in a medication cart without visible expiration dates or original packaging, and expired blood culture collection kits were present in a medication storage room. Staff were unable to verify expiration dates or ensure proper labeling, contrary to facility policy.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe cognitive impairment was physically abused by another resident with a history of aggression, resulting in skin discoloration. Staff intervened to separate the individuals and reported the incident, but the event showed a failure to fully protect residents from abuse as required by facility policy.
A resident reported a missing wallet to staff, and the social services director attempted to submit a misappropriation complaint to the state agency. However, the required email verification step was not completed, and no follow-up was made to confirm the report was received, resulting in the incident not being documented by the state agency as required.
A resident with severe cognitive impairment and a history of falls experienced multiple falls despite care plan interventions, ultimately sustaining a significant injury that required surgical intervention. Staff and documentation confirmed that supervision and fall prevention measures were not adequate to prevent further injury.
The facility failed to notify physicians and resident representatives about missed or rescheduled dialysis treatments for three residents, did not consistently complete required pre- and post-dialysis assessments for a resident receiving outpatient dialysis, and maintained a dialysis policy lacking essential procedures and documentation requirements. These deficiencies were confirmed through record reviews, staff interviews, and policy examination.
A resident with dementia and a history of wandering was physically pushed by another cognitively impaired resident with a pattern of aggression, resulting in a fall and injury. The incident was witnessed by an LPN and substantiated through facility investigation, highlighting a failure to protect a resident from physical abuse.
A facility failed to thoroughly investigate a resident-to-resident altercation where one resident struck another in the face. Despite a staff member witnessing the incident and a skin assessment showing redness, the investigation did not include interviews with other residents present, leading to an incomplete and inaccurate conclusion.
A resident with severe cognitive impairment was physically abused by another resident with mild cognitive impairment and a history of aggression. The incident occurred in the dayroom during dinner tray distribution, resulting in a minor injury to the victim. Staff intervened quickly, but the facility failed to prevent the altercation, highlighting a deficiency in ensuring resident safety.
A resident with dementia was allegedly struck by another resident with a history of behavioral symptoms, resulting in a deficiency. The incident occurred in the day room, where staff reported an altercation involving yelling and physical contact. Despite the facility's investigation, the deficiency highlights a failure to protect the resident from abuse, as confirmed by staff interviews and documentation of redness on the resident's face.
A resident with Unspecified Dementia, Bipolar disorder, and Anxiety Disorder reported being inappropriately touched by another resident with toxic encephalopathy, major depressive disorder, and adjustment disorder in the dayroom after an activity. The resident who reported the incident pushed the other resident away and informed staff. The resident who admitted to the inappropriate behavior had a history of similar actions towards female staff, leading to interventions such as being placed on cares in pairs.
The facility failed to develop comprehensive care plans for two residents, one with a left-hand contracture and another on psychotropic medications. The first resident lacked a care plan or orders for their contracture, while the second resident's care plan did not include non-pharmacological interventions before medication. Observations and staff interviews confirmed these deficiencies, indicating a failure to adhere to the facility's care planning policy.
The facility failed to provide necessary assistance for transfers and grooming hygiene for two residents. One resident, with severe cognitive impairment, was not assisted in participating in group activities due to miscommunication among staff about their ability to be transferred. Another resident, requiring extensive assistance, was observed with long and jagged nails, indicating a lack of proper grooming care. Staff interviews revealed inconsistencies in care practices and documentation.
The facility failed to provide appropriate activities for three residents, impacting their mental and social well-being. A resident with quadriplegia was not assisted to participate in activities as per their care plan. Another resident, who is legally blind, was inaccurately documented as attending activities they did not participate in. A third resident, dependent on a vent/trach, was also incorrectly documented as attending group activities, with no evidence of one-on-one activities being provided.
The facility failed to implement non-pharmacological interventions for two residents prescribed psychotropic medications. One resident with Alzheimer's and depression was given multiple medications without documented non-pharmacological approaches. Another resident with bipolar disorder received psychotropic medications without prior non-pharmacological interventions, despite no documented physical aggression. Facility policies emphasize non-pharmacological interventions, but these were not followed, leading to potential duplicate therapy.
The facility failed to accurately document activities for two residents, one legally blind and the other bed-bound, leading to concerns about their care. Interviews revealed that staff might have marked activities as completed without them occurring. The activities director and assistant acknowledged discrepancies in the documentation.
The facility failed to ensure proper infection control practices, with staff observed leaving dirty dishes in public areas and not adhering to PPE protocols for residents with C-Diff. CNAs were seen handling contaminated items without proper hygiene, and PPE was not removed before exiting rooms, contrary to facility policy. These actions risked spreading infections, as confirmed by the Infection Preventionist and DON.
The facility failed to provide a homelike dining environment, as observed during lunch services. Meal trays were delivered late with dome lids left on, and residents ate off trays with disposable cups. Some residents were in reclining chairs or motorized wheelchairs, unable to fit under tables, while the TV was on in the dining area.
A facility failed to thoroughly investigate an alleged sexual abuse incident involving two residents with dementia. One resident allegedly touched another inappropriately in the dining room, but the facility's report stated the allegation was not substantiated. The investigation lacked interviews with other residents and did not document corrective actions to prevent further abuse. The DON could not provide details due to a lack of documentation and a change in facility ownership.
A resident with schizophrenia and TBI was not submitted for a Level II PASARR despite exhibiting significant behavioral issues and being on multiple psychotropic medications. The facility's failure to follow its policy for PASARR evaluations resulted in the lack of identification and provision of specialized services for the resident.
The facility failed to ensure a cognitively intact resident participated in their care plan development and did not document a care plan revision for a resident with dementia who requested a door lock. Despite policies requiring resident involvement, there was no evidence of participation or documentation of care plan meetings for these residents.
A facility failed to document non-pharmacological pain management for a resident with chronic pain and other conditions. Despite orders to try alternate measures before administering pain medication, the MAR showed no evidence of such interventions for February 2024. Staff interviews revealed inconsistencies in documentation practices, with CNAs not documenting interventions and LPNs unaware of the lack of documentation. The DON acknowledged the expectation to document these interventions, highlighting a potential risk related to documentation failure.
A resident was discharged without a complete discharge summary, missing essential information about their stay and care needs. The resident, who was cognitively intact, had diagnoses including acute kidney failure and spinal stenosis. The facility's policy requires a comprehensive discharge summary, but it was not completed, and a care conference was not held due to the discharge.
A resident with a left femur fracture and other conditions did not receive physician-ordered side rails for bed mobility, as the facility failed to install them. Despite a bedrail assessment and physician order, no work order was placed for the installation. Interviews revealed confusion between physical therapy, maintenance, and nursing staff regarding responsibility for the installation, resulting in the deficiency.
A resident with a left hand contracture and hemiplegia was not provided with appropriate care and services to prevent further decline in range of motion. Despite being cognitively intact, the resident's care plan lacked specific interventions for the contracture. Observations showed no splint or towel was used on the affected hand, and interviews with staff confirmed the absence of orders or occupational therapy evaluations. The facility's policy on maintaining range of motion was not followed, leading to a deficiency in care.
A resident was found with a medicated ointment at her bedside, which was not authorized for self-administration. The facility's policy requires such items to be stored securely, but staff interviews revealed that the ointment was not the brand used by the facility and should have been stored on the wound cart. The DON confirmed that no assessment for self-administration was completed for the resident.
A resident with end-stage renal disease was not provided care in accordance with physician-ordered fluid restrictions, leading to multiple days of excessive fluid intake. Staff interviews confirmed the importance of adhering to these restrictions to prevent complications, but noted lapses in practice and documentation.
A resident with multiple medical conditions experienced a delay in receiving assistance with ADLs, including dressing and oral hygiene, before a scheduled appointment. The CNA was unable to assist the resident in a timely manner due to being occupied with other residents, resulting in a forty-four-minute delay. The facility's policy requires timely assistance, but the response time exceeded expectations.
The facility did not update the daily staff posting as required, with the last update observed being several days old. The DON acknowledged the requirement for daily updates but was unsure of the responsible party on weekends. Facility policy mandates daily posting of staffing numbers, hours, census, and date.
An LPN left a medication cart unlocked and unattended while transferring medications, contrary to facility policy requiring carts to be locked when out of sight. The DON confirmed the policy, emphasizing the need to prevent unauthorized access.
The facility was found deficient in food storage and sanitation practices. Observations revealed undated opened food items, expired food available for use, and incomplete refrigerator logs. Additionally, staff failed to follow infection control policies, with improper beard/mustache coverings and unclean vents. These issues could lead to foodborne illnesses.
A facility failed to ensure a safe environment by installing a keypad lock on a resident's room in a secured memory care unit without proper documentation or staff awareness. The lock, requested by the resident, lacked a physician order, care plan, or safety assessment. Staff were unaware of the lock's existence or the access code, and there was no policy or training provided. Concerns were raised about potential risks if the lock failed, and the facility could not provide a policy for resident door locks.
A facility failed to maintain a resident's privacy and confidentiality when an agency nurse accidentally sent a photo of the resident's genital area to the family instead of the physician. The incident occurred after the resident was treated for a UTI and candidiasis. Staff interviews revealed gaps in HIPAA training, with some staff unaware of protocols regarding photographs. The facility's policy and admission agreement emphasized the importance of protecting resident privacy.
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite previous interventions, the facility did not implement new measures to address ongoing issues. Additionally, a resident with schizophrenia was physically abused by two different residents with histories of aggression. The facility's response was inadequate, leading to repeated incidents of abuse.
The facility failed to provide written notification of transfer or discharge to the resident's representative for two residents, leading to a deficiency in communication. A resident with Huntington's Disease was transferred to the hospital twice without written notification to their representative. Another resident with rhabdomyolysis and ESRD was transferred due to influenza and pneumonia, but the facility did not notify the Ombudsman. The facility's policy did not specify whether notifications should be verbal or written, contributing to the deficiency.
Failure to Secure Electronic Health Record Screen and Protect Resident Privacy
Penalty
Summary
The facility failed to maintain confidentiality of a resident’s electronic health record (EHR) when a nurse left the record open and visible on a medication cart computer. During a medication pass observation, RN Staff #169 gathered medications for Resident #159 and then turned and walked into the resident’s room. When the nurse returned to the medication cart, surveyors observed that Resident #159’s EHR remained open and in view on the screen. Staff #169 confirmed that the visible record belonged to Resident #159 and acknowledged that anybody could see it. Multiple staff interviews confirmed awareness that leaving computer screens unsecured poses a risk to resident privacy and could constitute a HIPAA violation. The social services director stated that leaving a computer screen unsecured would be a risk for a HIPAA violation. A CNA reported that charting on certain screens may be visible to residents, noted there is a way to lock the screen, and stated that leaving the screen open is a HIPAA violation. An LPN stated that if staff need to leave their computer, they must secure it because anyone could access resident information. The DON confirmed that documentation is done in the EHR and that leaving a computer screen unsecured could allow someone to see HIPAA information. The facility’s Resident Rights policy prohibits unauthorized release, access, or disclosure of resident information and requires that all access or disclosure comply with current privacy laws.
Failure to Complete Required PASRR for Resident With Schizophrenia and Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASRR) was properly completed for one resident with serious mental illness and cognitive impairment. The resident was admitted with diagnoses including a personal history of traumatic brain injury, opioid use, unspecified schizophrenia, and cognitive communication deficit. An MDS dated July 23, 2025 documented a BIMS score of 7, indicating severe cognitive impairment, and the care plan included an antipsychotic medication focus related to schizophrenia with hallucinations and delusions. A PASRR Level I completed on July 18, 2025 indicated an exemption or categorical determination (such as convalescent care, respite, terminal/severe illness, or primary dementia diagnosis), but the resident remained in the facility beyond the exempt stay. When the resident’s status changed from skilled nursing to long-term care, there was no evidence in the record of a new PASRR Level I or any PASRR Level II being completed or present in the documents section. SSD staff reported that a PASRR Level I should be done if a resident remains longer than 30 days and that diagnoses such as schizophrenia with related medications would typically lead to a Level II, but acknowledged that the resident was not submitted for another Level I when transitioning to long-term care. The facility’s own PASRR policy states that all applicants to a Medicaid-certified nursing facility must be evaluated for serious mental disorder and/or intellectual disability, be placed in the most appropriate setting, and receive needed services, but this process was not followed for this resident when they remained in the facility for long-term care.
Improper Maintenance and Sanitation of Dumpster Area
Penalty
Summary
Surveyors identified a deficiency related to improper disposal of garbage and refuse in the facility’s designated dumpster area. During a kitchen inspection with the Dietary Director, surveyors observed an accumulation of refuse around and behind the trash dumpsters, including a clear bag of trash, miscellaneous trash, yard waste, and a dead bird. The Dietary Director stated that the clear bag of trash contained “medical stuff, swabs, tissue,” and that it looked clinical. Review of the facility’s undated “Refuse and Trash” policy indicated that waste should be disposed of immediately after use, with general waste going into standard trash bins. In subsequent interviews, the Maintenance Director reported that the protocol for maintaining the dumpster area was to inspect it every day, that maintenance staff shared responsibility for the area’s cleanliness, and that someone was designated every morning, but acknowledged that the dumpster area’s condition did not meet his expectations and presented an infection control risk. The Housekeeping Supervisor stated that refuse outside the dumpster area posed a potential risk of contamination and spread of germs if the trash contained something contagious and someone touched it. The Administrator stated that the protocol for the dumpster area was that lids should be closed and the area should be free from rubbish or refuse, that the maintenance team was responsible for its cleanliness, and that the area should look better and be clean. The Administrator also stated that refuse outside the dumpster could bring pests, foul odors, create a less than homelike environment, and present an infection control issue.
Improper Foley Catheter Bag Placement on Floor
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper urinary catheter bag placement for one resident. The resident had multiple medical conditions, including sequelae of cerebral infarction, chronic respiratory failure, acute pulmonary edema, type 2 diabetes mellitus, immunodeficiency, and a neurogenic bladder requiring an indwelling catheter. The resident’s care plan included interventions for indwelling catheter care, such as positioning the catheter bag and tubing below the level of the bladder and away from the entrance door, and using a privacy cover on the Foley bag. The admission MDS showed the resident was severely cognitively impaired. Physician orders directed indwelling catheter care. Despite these orders and care plan interventions, observations on the survey date showed the catheter drainage bag placed under the bed on the floor, with the catheter tubing touching the full surface of the floor, covered by a blue privacy bag. During interviews, a CNA stated that catheter care involved using appropriate PPE, changing urine drainage bags, cleaning the genitourinary area, and recording urine output, and acknowledged that the catheter should never be on the floor because it could pose a risk of infection. An RN reported that catheter care was performed every shift by CNAs or nurses and stated that the catheter should not touch the floor, and that the tubing should hang to the side of the bed covered with a dignity bag. The DON explained that CNAs were responsible for cleaning and emptying the Foley catheter, placing a privacy bag on the catheter, and ensuring it was hung up so it did not touch the floor, and stated that catheters should not be left on the floor. Facility policies on catheter care and the infection prevention and control program, as well as CDC guidance, specified that the collection bag should be kept below the level of the bladder and not rest on the floor. The observed placement of the catheter bag and tubing on the floor for this resident was inconsistent with the care plan, staff statements, facility policy, and CDC standards.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosing and Delayed Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by eight medication administration errors out of twenty-six observed opportunities, resulting in a 30.77% error rate. For one resident with diagnoses including hydronephrosis, type two diabetes mellitus, and immunodeficiency, a registered nurse administered only one tablet of Cholecalciferol (Vitamin D3) 1000 IU, despite a provider order specifying five tablets (totaling 5000 IU) to be given once daily. This discrepancy was confirmed upon review of the provider order and by the Director of Nursing, who stated that the expectation was to administer the full ordered dose. Another resident, with diagnoses including type two diabetes mellitus with ketoacidosis, reduced mobility, and a need for personal care assistance, did not receive their scheduled 08:00AM medications on time. The registered nurse responsible for medication administration acknowledged that the medications were overdue, as indicated by the red status in the electronic health record, and attributed the delay to a high patient load. The facility's policy and staff interviews confirmed that medications should be administered within one hour of the scheduled time and in accordance with prescriber orders, which was not followed in these instances.
Expired and Unlabeled Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors observed that several single-dose blister packets of Omeprazole were stored in a medication cart without their original box, and the individual packets did not display an expiration date. The LVN assigned to the cart confirmed that the expiration date could not be located on the packets and that the original box, which may have contained the expiration date, was not retained. The LVN was unable to verify the expiration dates or how long the medications had been stored in this manner. Additionally, in a medication storage room, a pile of blood culture collection kits was found on a shelf, and inspection revealed that at least one kit was expired. Nursing staff were unsure about the meaning of the date on the kit until the Executive Director confirmed it was expired. The expired kits were present in the medication room, contrary to facility policy, which requires medications and biologicals to be stored in their original packaging and for expired items to be removed.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and multiple psychiatric and medical diagnoses was physically abused by another resident who was moderately cognitively impaired and had a history of behavioral problems, including verbal and physical aggression. The incident occurred in a hallway where the aggressor began punching the victim, resulting in skin discoloration to the victim's arms and upper body. Staff intervened to separate the residents, and the incident was reported to facility leadership and law enforcement. Review of the care plan for the resident with behavioral issues showed interventions were in place to protect others, such as removing the resident from situations and monitoring behaviors, but the altercation still occurred. Staff interviews confirmed that immediate action was taken to separate the residents and report the incident, but the event demonstrated a failure to fully protect residents from abuse as required by facility policy and resident rights.
Failure to Report Misappropriation Allegation to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of a resident's property was appropriately reported to the state agency as required. A resident reported a missing wallet to a certified nursing assistant, and later to the social services director. The social services director attempted to submit the complaint through the state agency's reporting portal and received an email requiring verification to complete the submission. However, the staff member did not verify the email address and did not follow up with the state agency to confirm receipt of the report. As a result, the incident was not documented as received by the state agency. Facility documentation indicated that the incident was reported, but review of the state agency's intake system showed no record of the submission. Interviews with staff confirmed that the required verification step was not completed and no further action was taken to ensure the report was received. The facility's policy requires immediate reporting of abuse, neglect, exploitation, or misappropriation, but this process was not followed in this case.
Failure to Prevent Falls and Injury in Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including Parkinson's disease, dementia, and a prior TIA, was identified as high risk for falls and had multiple documented falls after admission. The care plan included several interventions such as floor mats, use of a front wheeled walker, and staff intervention when ambulating without assistive devices. Despite these interventions and ongoing care plan revisions, the resident continued to experience falls, including one that resulted in a significant injury requiring surgical intervention. On one occasion, the resident sustained a skin tear and was found rolling on the floor while a CNA was attempting to assist him back onto his floor mat. Subsequently, the resident was sent to the emergency department for evaluation of a right hip deformity and returned to the facility with multiple bruises and surgical staples following an open reduction internal fixation of a right hip fracture. Staff interviews confirmed the process for responding to falls, but the documentation and interviews indicated that the implemented interventions were not sufficient to prevent further falls and injury for this resident.
Deficient Dialysis Care: Incomplete Assessments, Poor Communication, and Inadequate Policy
Penalty
Summary
The facility failed to ensure proper notification of physicians and resident representatives regarding missed and rescheduled dialysis treatments for three residents. In several instances, residents who were scheduled for dialysis either missed their treatments or had them rescheduled, but there was no documentation that the physician or the resident's representative was informed of these changes. For example, one resident missed dialysis on two separate occasions due to a holiday and staff shortage, but there was no evidence in the clinical record that the provider or representative was notified or that a physician order was obtained to reschedule the treatment. Similar lapses were observed for two other residents, where missed or rescheduled dialysis sessions were not properly communicated or documented as required by facility policy. Additionally, the facility did not consistently complete pre- and post-dialysis assessments for a resident who received outpatient dialysis. The clinical record review revealed that on multiple occasions, the required assessments were either missing or incomplete, despite the resident having received dialysis on those dates. Interviews with nursing staff confirmed that these assessments were expected to be completed and documented in the electronic medical record each time a resident underwent dialysis. However, discrepancies were found between the medication administration record, progress notes, and the actual assessments, with some information missing or not entered in the correct section of the clinical record. The facility's policy on dialysis care was also found to be lacking in several key areas. The policy did not include detailed procedures for the initiation, administration, and discontinuation of dialysis treatments, nor did it specify documentation requirements, communication protocols between the nursing home and dialysis provider, or comprehensive care planning responsibilities. Other omissions included the management of dialysis emergencies, monitoring and documentation of nutrition and hydration needs, and the care and assessment of dialysis access sites. Interviews with facility leadership confirmed that the existing policy was the only one in place and that infection control input had not been incorporated into the policy revision process.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, depression, and a history of falls was not protected from physical abuse by another resident with dementia and behavioral issues. The first resident was known to be resistive to care, exhibited wandering and intrusive behaviors, and was unable to complete a BIMS interview. The second resident also had significant cognitive impairment, agitation, and a history of physical aggression. On the date of the incident, the second resident physically pushed the first resident, causing a fall and resulting in physical injury, as observed by an LPN and documented in the clinical record. Staff interviews revealed that the second resident had a pattern of aggressive behavior, and the first resident was known to wander and interact with others' belongings. The facility's policy required the administrator to determine protective actions upon any abuse allegation, but the incident still occurred, resulting in substantiated physical abuse. The event was witnessed by staff, and the facility's investigation confirmed the occurrence of physical aggression leading to injury.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged resident-to-resident abuse incident involving two residents. Resident #77, who has a diagnosis of dementia and other health conditions, was reported to have struck Resident #88, who also suffers from dementia and other cognitive impairments, in the face during an altercation in the dayroom. The initial investigation report noted that there was insufficient evidence to confirm physical contact, despite a staff member witnessing the incident and a skin assessment revealing redness on Resident #88's face. The investigation was incomplete as it did not include interviews with other residents who were present during the incident, as required by the facility's policy on abuse investigations. Staff interviews revealed that the incident occurred in a crowded dayroom, and a staff member observed Resident #77 making a fist and striking Resident #88. However, the investigation report failed to document these observations adequately and did not include interviews with other potential witnesses. The Director of Nursing and the facility administrator acknowledged the oversight in the investigation process, noting that previous investigations had been accepted without additional resident interviews. The facility's policy mandates that all witnesses to an incident be interviewed, but this was not adhered to in this case, leading to an incomplete investigation and an inaccurate conclusion regarding the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #2, who has severe cognitive impairment due to unspecified dementia, was involved in an incident with Resident #12, who has mild cognitive impairment and a history of verbal and physical aggression. On the day of the incident, staff were distributing dinner trays in the dayroom when Resident #12, upset by Resident #2's screaming, left his table and hit Resident #2 in the eye before staff could intervene. The altercation resulted in a small open area on Resident #2's lower brow. Staff interviews revealed that the incident was quickly addressed by separating the residents and notifying the necessary personnel, including the Administrator, DON, police, and family members. The facility's policy and procedures, as well as the State Operations Manual, emphasize the importance of monitoring and intervening in situations that could lead to abuse. Despite regular abuse training, the staff's inability to prevent the altercation indicates a failure to ensure a safe environment for all residents.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #1, who was admitted with encephalopathy, Alzheimer's disease, and dementia, was involved in an incident where they were allegedly struck by Resident #2. Resident #1's care plan indicated a risk for psychosocial behaviors and behavioral symptoms due to dementia, but no physical aggression was noted prior to the incident. On July 12, 2024, a skin wound note documented redness on Resident #1's face, and subsequent charting noted no signs of pain or bruising, although the resident continued to scream at times. Resident #2, who was admitted with end-stage renal disease, Alzheimer's disease, and dementia, had a history of verbal and behavioral symptoms that posed a risk to themselves and others. Their care plan included interventions for managing these behaviors, such as medication administration and monitoring for side effects. On the day of the incident, staff reported an altercation between Resident #2 and Resident #1, with Resident #2 allegedly striking Resident #1 in the face. Interviews with staff confirmed the altercation, and it was noted that Resident #1's face was slightly red after the incident. The facility's policy on resident rights, which guarantees freedom from abuse, was not upheld in this case. Despite the facility's investigation and documentation of the incident, the deficiency occurred due to the failure to prevent the altercation and protect Resident #1 from abuse by Resident #2. The facility's documentation and staff interviews highlighted the lack of direct observation of the incident, but physical contact was confirmed by staff, indicating a breach in resident safety and care protocols.
Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The facility failed to protect resident #4002 from sexual abuse by another resident, #4805. Resident #4002, diagnosed with Unspecified Dementia, Bipolar disorder, and Anxiety Disorder, reported being inappropriately touched by resident #4805 in the dayroom after an activity. Resident #4002 pushed resident #4805 away and reported the incident to staff. Resident #4805, diagnosed with toxic encephalopathy, major depressive disorder, and adjustment disorder, admitted to touching resident #4002's buttock but denied pulling her pants down. Staff interviews revealed that resident #4805 had a history of inappropriate behavior towards female staff, leading to interventions such as being placed on cares in pairs.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a left-hand contracture. The resident, who was admitted with multiple diagnoses including a contracture of the left hand, did not have a care plan or physician orders addressing this condition. Despite being cognitively intact, as indicated by a BIMS score of 13, the resident did not receive an Occupational Therapy Evaluation to address the contracture. Observations over several days confirmed the absence of any splint or towel on the resident's left hand, and interviews with staff revealed a lack of orders to address the contracture. Another deficiency was identified in the care plan for a resident with a history of atherosclerotic heart disease, dementia, and bipolar disorder, who was prescribed multiple psychotropic medications. The care plan included goals to prevent drug-related complications but did not mention any non-pharmacological interventions before administering these medications. The MAR lacked documentation of any non-pharmacological interventions attempted before medication administration over a four-month period. Interviews with the unit nurse manager and the DON confirmed that non-pharmacological interventions were expected but not performed, as indicated in the resident's medical record. The facility's policy on comprehensive person-centered care plans, revised in December 2016, requires the development and implementation of care plans that include measurable objectives and timetables to meet residents' needs. However, the deficiencies observed in the care plans for the two residents indicate a failure to adhere to this policy, potentially resulting in suboptimal care and services for the residents involved.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to provide necessary assistance for transfers and grooming hygiene for two residents, leading to deficiencies in care. Resident #80, who has severe cognitive impairment and is dependent on staff for all transfers, was not assisted in participating in group activities as outlined in their care plan. Despite having a geriatric chair available, the resident was observed lying in bed with the TV on for several consecutive days, and staff interviews revealed a lack of coordination and communication regarding the resident's ability to be transferred out of bed. The Director of Activities noted that the resident should be participating in group activities, but the CNAs were not getting the resident up due to misinformation about the resident's stability and availability of a wheelchair. Interviews with CNAs and LPNs revealed conflicting information about the resident's ability to be transferred, with some staff believing it was unsafe due to the resident's condition. The Director of Nursing acknowledged the need for the resident to participate in activities but noted that the geriatric chair was shared among multiple residents, which may have contributed to the lack of participation. Regarding resident #406, the facility failed to maintain proper grooming hygiene, specifically nail care. The resident, who has cognitive impairment and requires extensive assistance with activities of daily living, was observed with long and jagged nails over several days. Despite the facility's policy for weekly nail care, there was no documentation of nail care being performed or refused. Staff interviews indicated that nail care was typically done on Sundays, but there was no evidence of this being completed for the resident, posing a risk of injury due to the resident's hand contracture.
Failure to Provide Appropriate Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs of three residents, impacting their mental and social well-being. Resident #80, who is non-verbal and quadriplegic, was observed lying in bed with the TV on for several days, despite care plan interventions that included being out of bed for activities. The Director of Activities acknowledged that the resident had not attended group activities as documented, and there was a lack of coordination between the activities staff and CNAs to ensure the resident was up and participating in activities. Resident #58, who is legally blind and has intact cognition, was documented as attending various activities, but interviews revealed that the resident had not engaged in these activities. The Activities Director and an assistant admitted that activities staff might be documenting attendance inaccurately, and the resident expressed that she did not participate due to her blindness and inability to walk. This discrepancy highlights a failure in accurately assessing and documenting the resident's participation in activities. Resident #108, who is bed-bound and dependent on a vent/trach, was also documented as attending group activities, but interviews with staff revealed that the resident had not participated in these activities. The Activities Assistant confirmed that the resident did not attend group activities due to their medical condition, and there was no evidence of one-on-one activities being provided. This indicates a lack of appropriate activity planning and documentation for residents with significant physical limitations.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions for two residents, leading to a deficiency in care. Resident #61, diagnosed with Alzheimer's Disease, unspecified dementia, depression, and unspecified psychosis, was prescribed multiple psychotropic medications, including Fluoxetine, Lorazepam, and Seroquel, without any documented non-pharmacological interventions. The resident's medication administration record and active orders lacked any indication of attempts to use non-pharmacological approaches, which is a requirement before administering psychotropic medications. Resident #115, with diagnoses including atherosclerotic heart disease, dementia, and bipolar disorder, was also found to have been administered psychotropic medications such as Quetiapine Fumarate, Haloperidol, and Depakote without prior non-pharmacological interventions. Despite the care plan's requirement to monitor for physical aggression, there was no documentation of such behavior from November 2023 to February 2024. Interviews with staff revealed that non-pharmacological interventions were not attempted before administering these medications, and there was no differentiation in targeted behaviors for the medications, which could lead to duplicate therapy. The facility's policies on tapering medications and administering psychotropic medications emphasize the importance of non-pharmacological interventions and gradual dose reduction. However, these policies were not adhered to, as evidenced by the lack of documented non-pharmacological interventions for the residents involved. The Director of Nursing and Unit Nurse Manager acknowledged the absence of these interventions and the potential issue of duplicate therapy due to the same targeted behavior for multiple medications.
Inaccurate Documentation of Resident Activities
Penalty
Summary
The facility failed to accurately document activities in the clinical records for two residents, which could result in them not receiving appropriate care and services. Resident #58, who is legally blind and has multiple health conditions, was documented as attending various group activities despite her statements that she did not participate due to her blindness and inability to walk. Interviews with the activities director and assistant revealed that staff might have been marking activities as completed without them actually occurring. Resident #108, who has chronic respiratory failure, quadriplegia, and mild cognitive impairment, was also inaccurately documented as attending group activities. Observations showed the resident was bed-bound and non-verbal, making it difficult for him to leave his room. The activities assistant confirmed that the resident did not attend group activities and that staff were documenting attendance inaccurately. The activities director and assistant both acknowledged discrepancies in the documentation of activities for these residents. The activities director admitted uncertainty about how the documentation was completed, and the assistant confirmed that resident #108 had never attended group activities, despite records indicating otherwise. This inaccurate documentation raises concerns about the facility's adherence to professional standards in maintaining accurate medical records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices, as evidenced by multiple observations of staff not adhering to established protocols. On several occasions, dirty dishes were left in public areas, such as the dining room and handrails, which staff acknowledged could lead to the spread of infection. Certified nursing assistants (CNAs) were observed handling potentially contaminated items without following proper hygiene practices, such as washing hands or disposing of personal protective equipment (PPE) correctly. These actions were contrary to the facility's policy, which mandates that dirty dishes be taken directly to the kitchen to prevent contamination. Additionally, there were lapses in following contact precautions for residents diagnosed with Clostridium Difficile (C-Diff). Staff were observed not wearing or improperly using PPE when entering and exiting rooms of residents on contact precautions. For instance, a CNA was seen exiting a room with a surgical mask below her nose and goggles on her head, failing to remove them before leaving the room, which is against the facility's policy. The facility's policy requires that all PPE be removed and hands washed with soap and water before exiting a room to prevent the spread of infection. The facility's infection control policies, including those for handling C-Diff, were not consistently followed, as evidenced by staff not washing hands with soap and water after contact with residents or contaminated items. The Infection Preventionist and Director of Nursing confirmed that these practices were not in line with the facility's expectations and posed a risk of spreading infections. The facility's policies emphasize the importance of maintaining a safe, sanitary environment and adhering to transmission-based precautions, which were not upheld in these instances.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for its residents, as observed during multiple lunch services. On February 25, 2024, meal trays were delivered late to residents, with dome lids left covering the plates, both in residents' rooms and in the dining area of the 200 wing. The television was on in the corner of the dining area while staff distributed coffee. On February 28, 2024, lunch trays were delivered to the dining area first, with domes still on the food, and then to residents in their rooms. Some residents were in reclining chairs or motorized wheelchairs, unable to fit under the tables. On February 29, 2024, trays were delivered to different wings at staggered times, with the 200 wing receiving trays last. Trays with domes were scattered on tables, and lemonade was served in disposable cups, with residents eating off trays.
Failure to Investigate Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents. Resident #79, who has unspecified dementia, a history of traumatic brain injury, and epilepsy, was allegedly touched inappropriately by Resident #252, who has dementia with behavioral disturbance and major depressive disorder. The incident occurred in the dining room, where Resident #252 placed his hand on Resident #79's leg. A CNA intervened and separated the residents, but the facility's report stated that the allegation was not substantiated. The investigation did not include interviews with other residents, and no corrective actions were documented to prevent further abuse. The Director of Nursing (DON) was unable to provide specific details about the incident due to a lack of documentation and not being employed at the facility at the time. The facility's policy on abuse requires thorough investigation and documentation of all incidents, including interviews with witnesses, staff, and residents. However, the report lacked comprehensive interviews and documentation, failing to meet the facility's policy requirements. The DON mentioned that the facility had no incident reports for the residents involved due to a change in ownership.
Failure to Conduct Level II PASARR for Resident with Schizophrenia and TBI
Penalty
Summary
The facility failed to submit a Level II Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with schizophrenia and traumatic brain injury (TBI). The resident was admitted and readmitted to the facility with these diagnoses, and the quarterly Minimum Data Set (MDS) assessment indicated significant behavioral issues, including physical and verbal aggression, wandering, and rejection of care. Despite these indicators, the facility did not complete the necessary Level II PASARR, which is required when a Level I PASARR identifies potential mental disorders or intellectual disabilities. The resident exhibited numerous behavioral issues, such as urinating on the floor, flipping the mattress, verbal outbursts, and physical aggression towards other residents. These behaviors were documented in various behavioral and nurse's notes. The resident was on multiple psychotropic medications, including antipsychotics, antianxiety, and antidepressants, and had a care plan that included interventions for managing physical aggression and agitation. However, the facility's failure to conduct a Level II PASARR meant that specialized services that could have been identified and provided were not considered. An interview with the Social Services Director revealed that the facility's process for handling PASARR was not followed correctly in this case. The director acknowledged that the resident should have been submitted for a Level II PASARR and was not appropriate for the facility. The facility's policy requires that any resident identified with a possible mental disorder, intellectual disability, or related disorder be referred for a Level II evaluation, but this step was not taken for the resident in question.
Deficiencies in Resident Care Plan Participation and Documentation
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact, participated in the development of their care plan. The resident was admitted with diagnoses including hyperlipidemia, type 2 diabetes mellitus, and essential hypertension. Despite being cognitively intact, as indicated by a BIMS score of 13, the resident reported never being invited to a care plan meeting and was unaware of the services and care they were supposed to receive. The facility's records showed that care conferences were held on multiple occasions, but there was no documentation indicating that the resident was invited or participated in these meetings. Another deficiency was identified regarding a resident with moderate cognitive impairment, as indicated by a BIMS score of 9, who was admitted to a secured memory care unit with a diagnosis of unspecified dementia and Parkinson's. The resident requested a battery-powered keypad lock on their room door, but there was no documentation in the care plan or progress notes regarding this request. The care plan lacked measurable objectives or timeframes related to the resident's ability to use the lock, and there was no assessment of the resident's competency or safety concerning the lock. Interviews with facility staff revealed that care plan meetings were conducted quarterly, and residents or their representatives were notified via mail. However, there was an expectation that any facility-initiated care plan meetings would be documented in progress notes, which was not done in these cases. The facility's policies required that residents be informed and participate in their care plans, but these requirements were not met for the residents involved.
Failure to Document Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that non-pharmacological approaches to pain management were offered and documented for a resident with chronic pain syndrome, anxiety disorder, recurrent depressive disorder, chronic migraine, and mobility issues. The resident was cognitively intact and receiving regularly scheduled and as-needed pain medications, as well as non-pharmacological interventions according to the MDS assessment. However, a review of the MAR for February 2024 showed that non-pharmaceutical interventions were not provided or documented for the entire month, despite an order requiring alternate measures to be tried before administering pain medication. Interviews with staff revealed inconsistencies in the documentation process. A CNA stated that non-pharmaceutical interventions were implemented but not documented by CNAs. An LPN confirmed that such interventions should be documented in the MAR, regardless of who provided them, but found no evidence of documentation for the resident in question. The LPN also noted that the resident often refused non-pharmaceutical interventions, which was not documented. The DON acknowledged the expectation to conduct and document these interventions as ordered by the physician, but noted that the risk might be related to the failure to document rather than the administration of medication outside the ordered frequency.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary for a resident contained a recapitulation of the resident's stay, which could result in an unsafe discharge. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was admitted with diagnoses including acute kidney failure, spinal stenosis, and acidosis. Upon discharge, the clinical record lacked a comprehensive discharge summary detailing the resident's physical and mental status, impairments, activities of daily living, special treatments, psychosocial status, discharge potential, dental status, activities, and rehabilitation potential. The Social Services Director indicated that the facility's process involves sending clinical information and medication orders with the resident upon discharge. However, the discharge summary, which should include essential information such as transportation details, durable medical equipment needs, and other critical data, was missing from the electronic health record. The facility's policy requires a discharge summary to be developed when a discharge is anticipated, but in this case, the summary was not completed, and a care conference meeting was not held due to the resident's discharge.
Failure to Install Physician-Ordered Bed Rails for Resident
Penalty
Summary
The facility failed to ensure that a resident had side rails installed for mobility independence as ordered by the physician. The resident, who was admitted with a fracture of the left femur, osteoarthritis, and major depressive disorder, was cognitively intact and required extensive assistance for activities of daily living, bed mobility, and transferring. A physician order was placed for two non-restraining quarter side rails to assist with bed mobility, and a bedrail assessment confirmed the need for these rails. Despite the order and assessment, the side rails were not installed, as confirmed by the maintenance director who found no work orders for the resident's room during the relevant period. Interviews with facility staff revealed a breakdown in communication and process. The physical therapist stated that maintenance was responsible for installing the rails, while the maintenance director indicated that nursing was responsible for placing the work order. The Director of Nursing acknowledged that the work order system did not show the rails were installed, and there was no documentation to confirm their installation. Facility policies required maintenance to inspect beds and related equipment and for licensed nursing personnel to ensure physician orders were recorded and implemented, but these procedures were not followed, leading to the deficiency.
Failure to Address Resident's Left Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a left hand contracture, which could result in a decline in the resident's range of motion and mobility. The resident, who was admitted with a diagnosis of contracture of the muscle in the left hand and hemiplegia following a cerebral infarction, was cognitively intact with a BIMS score of 13. Despite the resident's care plan addressing various needs related to hemiplegia and contractures, it did not include specific interventions for the left hand contracture. Observations revealed that no splint or towel was used on the resident's left hand during multiple assessments. Interviews with facility staff, including an LPN and the Director of Rehabilitative Services, confirmed that there were no orders or occupational therapy evaluations to address the resident's left hand contracture. The facility's policy on Resident Mobility and Range of Motion, which aims to prevent avoidable reductions in ROM, was not adhered to, as there was no evidence of assessment or interventions for the contracture. The lack of appropriate care planning and intervention for the resident's condition constitutes a deficiency in the facility's care practices.
Failure to Secure Medicated Ointment at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications were not left unattended at the bedside for a resident, which could result in accidental medication-related injuries. Resident #96, who was cognitively intact according to a recent assessment, was observed with a tube of Chamosyn with Manuka Honey, a medicated moisture barrier, on her bedside table. There was no physician order or assessment of competency for the self-administration of medications for this resident. Staff interviews revealed that the product was not the brand used by the facility, and it was supposed to be stored in a drawer to prevent accidental ingestion by confused residents. Further observations confirmed that the medicated ointment remained in the resident's room, contrary to facility policy. Interviews with staff, including a CNA and an LPN, indicated that such products should be stored on the wound cart and not left in resident rooms. The Director of Nursing confirmed that medications should not be at the bedside and that there was no assessment for self-administration for the resident. Facility policies require that self-administration of medications be documented and approved by the care team, and unauthorized medications found at the bedside should be removed and returned to the nurse in charge.
Failure to Adhere to Fluid Restrictions for Dialysis Patient
Penalty
Summary
The facility failed to adhere to physician orders regarding fluid restrictions for a resident diagnosed with end-stage renal disease, among other conditions. The resident was on a fluid restriction of 1200 ml per day, as per the physician's orders. However, the electronic health record revealed that the resident's fluid intake exceeded this limit on multiple occasions, with recorded intakes ranging from 1380 ml to 1640 ml over several days. Observations also noted the presence of a water pitcher at the resident's bedside, which could contribute to the excess fluid intake. Interviews with staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed the importance of adhering to fluid restrictions for dialysis patients to prevent complications such as fluid overload. The staff acknowledged the failure to follow the physician's orders and noted that previous practices, such as posting fluid restrictions on the wall, were discontinued after facility renovations. The Director of Nursing also confirmed the discrepancies in fluid intake documentation and emphasized the expectation that physician orders should be followed.
Delay in Assistance with ADLs for Resident
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of a resident, resulting in a delay in assistance with activities of daily living (ADLs). The resident, who has a moderate cognitive impairment and multiple medical conditions including a left knee prosthetic joint infection and chronic pressure wounds, required assistance with dressing and oral hygiene before a scheduled appointment with a notary. Despite the resident's request for help from a Certified Nursing Assistant (CNA), assistance was delayed for forty-four minutes, causing the resident to be unprepared when the notary arrived. The delay occurred because the CNA was occupied with assisting other residents and did not seek additional help to meet the resident's needs in a timely manner. The facility's policy requires that appropriate care and services be provided for residents unable to carry out ADLs independently, but the response time for the call-light exceeded the Director of Nursing's expectation of a 15-minute response time. This deficiency highlights a failure in staffing and coordination to ensure timely assistance for residents with scheduled appointments.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting was updated and displayed as required. On February 25, 2024, the staff posting observed was dated February 22, 2024, indicating that it had not been updated for several days. During an interview on February 29, 2024, the Director of Nursing (DON) admitted that the daily staff posting should be updated daily but was unsure who was responsible for this task on weekends. The facility's policy, revised in August 2022, mandates that direct care daily staffing numbers, including the number of nursing staff, hours worked, census, and date, be posted for every shift.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that a medication cart was secured when left unattended, which could result in residents having access to medications and potentially causing harm. On February 25, 2024, at 10:36 a.m., an LPN was observed removing multiple medications from a medication cart located near the nursing station on hall #200. The LPN took these medications to a second cart next to a room and then into the medication room, leaving the first cart unlocked and unattended. Upon exiting the medication room, the LPN acknowledged that the cart should have been locked to prevent unauthorized access. An interview with the Director of Nursing on February 29, 2024, confirmed that medication carts are required to be locked when not within the eyesight of nursing staff to prevent access by residents and staff. The facility's policy, revised in April 2019, states that medication carts must be kept closed and locked when out of sight of the medication nurse or aide. This incident highlights a breach in protocol, as the LPN did not secure the medication cart as required by the facility's policy.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a kitchen inspection. Several food items, including cheese slices, milk, cucumbers, and dessert cups, were found opened and not dated, which is against the facility's policy on food receiving and storage. Additionally, expired food items such as flour and cornstarch were readily available for resident use. The logs for the walk-in refrigerator and freezer were incomplete, with missing dates noted. These lapses in food safety practices could potentially lead to foodborne illnesses among residents. Furthermore, the kitchen staff did not adhere to the facility's infection control policies. During observations, a kitchen staff member was seen without proper beard/mustache covering, and another staff member wore a face mask incorrectly, exposing facial hair. The vents over the food tray line were also found to have a brown string-like substance hanging from them, indicating a lack of cleanliness. The facility's policies require that food and nutrition services staff wear appropriate hair restraints to prevent hair from contacting food, and that environmental surfaces be cleaned regularly to maintain a sanitary environment.
Deficient Safety Measures in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe and functional environment for residents and staff, as evidenced by the presence of a battery-powered keypad lock on the door of a resident's room in a secured memory care unit. The resident, who was admitted with unspecified dementia and other conditions, reportedly requested the lock. However, there was no physician order, progress note, safety or competency assessment, or care plan for the lock, and the staff were unaware of its existence or the code to access the room. Interviews with various staff members, including an LPN, CNA, and the Director of Nursing, revealed a lack of awareness and documentation regarding the lock. The LPN was surprised to find the lock engaged and was initially unable to open the door. The CNA knew the code to access the room, but there was no key available for the lock, and the maintenance staff did not have a schedule for lock maintenance. The Director of Nursing confirmed the absence of a care plan or evaluation for the lock. The plant and operations manager stated that the lock was installed following a work order approved by the administrator, but there was no training or in-service provided to staff regarding the lock. The activities assistant and another LPN expressed concerns about potential negative outcomes if the lock failed, such as the resident being unable to exit the room in an emergency. The facility was unable to provide a policy for resident door locks, highlighting a significant oversight in ensuring a safe environment for residents.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the personal privacy and confidentiality of medical records for a resident, leading to a deficiency. The incident involved an agency nurse who mistakenly sent a photo of the resident's genital area to the resident's family instead of the intended recipient, the physician. This occurred after the resident had been treated for a urinary tract infection and urogenital candidiasis, following a hospital visit. The error was acknowledged in the facility's initial self-report and confirmed in a subsequent 5-day report. Interviews with staff revealed gaps in training and understanding of HIPAA regulations. A Licensed Practical Nurse recalled receiving education on HIPAA but noted it did not cover the use of photographs. A Registered Nurse confirmed that staff were instructed not to discuss resident information outside the treatment team. The Director of Nursing stated that HIPAA education was provided during orientation and annually, emphasizing that resident information should only be shared with authorized individuals. The facility's policy and admission agreement both highlighted the importance of protecting resident privacy and confidentiality.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents from abuse, resulting in incidents of sexual and physical abuse. Resident #79, who had severe cognitive impairment, was subjected to sexual abuse by Resident #252, who had a history of sexually inappropriate behavior. Despite previous incidents and interventions such as a 1:1 sitter and psychiatric evaluations, Resident #252 continued to exhibit inappropriate behavior, including touching Resident #79 inappropriately. The facility did not implement new interventions to address these behaviors, and there was a lack of documentation and incident reports due to a change in facility ownership. In another incident, Resident #33, who had schizophrenia and cognitive impairments, was physically abused by Resident #354. Resident #354, who had moderate cognitive impairment and a history of aggression, hit Resident #33 with a towel after being provoked by a verbal interaction. The facility's response included separating the residents and initiating abuse reporting protocols, but the documentation suggests that the interventions were not sufficient to prevent further incidents. Additionally, Resident #33 was involved in another altercation with Resident #356, who had a history of aggressive behavior and cognitive impairments. Resident #356 physically assaulted Resident #33, punching him in the face multiple times. The facility's investigation confirmed the incident, but the report indicates that the facility's measures to manage aggressive behaviors and protect residents were inadequate, leading to repeated incidents of abuse.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to the resident's representative for two residents, leading to a deficiency in communication. Resident #81, diagnosed with Huntington's Disease and epilepsy, was transferred to the hospital on two occasions due to changes in condition, including fever, seizures, and tremors. Although verbal notifications were made to the resident's family or representative, there was no evidence of written notification as required by facility policy. Interviews with the Director of Nursing (DON) revealed that notifications were typically made verbally in emergency situations, and the facility policy did not specify whether notifications should be verbal or written. Resident #65, with diagnoses including rhabdomyolysis and end-stage renal disease, was transferred to the hospital due to influenza and pneumonia. The clinical record lacked evidence of written notification to the resident's representative regarding the transfer. Additionally, the facility failed to notify the Ombudsman of the resident's transfer, as required. Interviews with the social worker and DON confirmed that notifications for hospital transfers in November and December were not sent to the Ombudsman, and the facility's practice was to prioritize verbal notifications in emergencies. The facility's policy on changes in a resident's condition or status, revised in May 2017, required prompt notification to the resident, attending physician, and representative. However, the policy did not clarify whether notifications should be verbal or written, contributing to the deficiency. The DON emphasized that patient care was prioritized over written notifications in emergency situations, and written notifications were typically reserved for notices of Medicare non-coverage.
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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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