Payson Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Payson, Arizona.
- Location
- 107 East Lone Pine Drive, Payson, Arizona 85541
- CMS Provider Number
- 035117
- Inspections on file
- 19
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Payson Care Center during CMS and state inspections, most recent first.
A resident with multiple health conditions and high risk for skin breakdown did not receive consistent weekly skin assessments as required by facility policy. CNAs documented several new skin issues, including blisters and bruising, but there was no evidence that nurses performed further assessments, notified providers, or obtained new treatment orders. The DON confirmed that scheduled skin checks were missed and follow-up on new findings was not documented.
A facility failed to obtain informed consent from a resident before administering Duloxetine and Trazodone for depression. The resident's care plan included these medications, but the required consents were not completed, as confirmed by staff interviews. The facility's policy mandates obtaining consent before starting psychotropic medications, which was not adhered to in this case.
The facility failed to maintain an effective training program for five staff members, leading to incomplete training in dementia, infection prevention, resident rights, and abuse. Personnel files and interviews confirmed the lack of documentation for required training, despite multiple requests. The facility's policy mandates regular training, which was not adhered to, resulting in a deficiency.
The facility failed to ensure that five staff members received ongoing education on abuse, neglect, exploitation, and dementia care. Personnel files and interviews revealed that required annual training for 2024 and 2025 was not completed by a CNA, OT, LPN, another CNA, and an RN. Interviews with management highlighted the facility's expectations for training completion, but documentation was lacking. This deficiency could lead to a deficit in staff knowledge and skills, potentially affecting resident care.
Two residents with severe cognitive impairment were involved in an altercation, resulting in a deficiency due to the facility's failure to prevent abuse. The incident involved physical aggression, and the facility's investigation was incomplete, lacking documentation and assessments of harm. Staff interviews revealed both residents exhibited aggressive behaviors, but the facility did not adequately address the situation.
A facility failed to document and retain evidence of an investigation into an altercation between two residents with severe cognitive impairments. The incident involved physical aggression, but the facility did not complete a thorough investigation or retain necessary documentation. Staff interviews revealed that both residents exhibited aggressive behaviors, making altercations plausible. Despite understanding the importance of proper investigation, the facility did not meet its own expectations for documentation and evidence retention.
The facility failed to issue timely Medicare Non-Coverage notices to two residents. One resident with Alzheimer's was informed of the end of Medicare services on the same day, leaving no time for appeal. Another resident, cognitively intact, did not receive the required SNF ABN form. Staff interviews revealed confusion about determining the last covered day of service.
A resident with bilateral lower extremity amputations experienced a delay in receiving a left leg prosthetic due to missing documentation, despite measurements being completed. The resident was not included in the restorative therapy caseload, and the facility's records lacked a care plan for the amputation. This delay hindered the resident's ability to ambulate, contrary to the facility's Prosthesis Care and Management policy.
A resident admitted for orthopedic aftercare following a lower extremity amputation did not receive necessary restorative nursing services, despite recommendations from therapy discharge summaries. The resident was not on the facility's restorative therapy caseload, and there was no documentation of a Restorative Care Referral form. Interviews with staff confirmed the lack of evidence supporting the resident's participation in restorative therapy, which does not meet facility expectations.
A resident with moderate cognitive impairment and mobility issues experienced multiple falls, resulting in injuries, due to inadequate supervision and failure to implement fall prevention measures. Despite having a care plan, there was no evidence of specific interventions, and staff interviews revealed inconsistencies in communication and execution of fall checks. The facility's policy required updates to the care plan after falls, but this was not done, highlighting a deficiency in fall prevention.
A resident with a history of falls and moderate cognitive impairment experienced a fall due to inadequate supervision and failure to address behavioral changes. Despite signs of restlessness and confusion, the facility did not implement effective interventions, resulting in the resident being found on the floor with labored breathing. Incomplete documentation and lack of communication among staff contributed to the deficiency.
A resident with multiple health issues required continuous oxygen therapy, but the facility failed to provide a specific oxygen dose in the physician's order and did not consistently document the dose. Interviews with staff revealed that the facility's process for administering oxygen was not followed, as the order lacked necessary parameters and the care plan did not include oxygen use details.
A resident with a history of falls was found on the floor with labored breathing and twitching, but the facility failed to document the incident accurately. Despite staff observations and actions taken, the clinical record lacked evidence of the fall and necessary assessments, contrary to facility policies. Interviews revealed that the facility's process for handling falls was not followed, resulting in incomplete documentation.
Multiple residents with cognitive impairments engaged in physical altercations, resulting in injuries and a lack of timely care plan updates or skin assessments. Staff supervision was inconsistent, with periods where residents were left unsupervised despite known behavioral risks. Additionally, a CNA was reported by several residents and a family member for verbal and physical abuse, with evidence of neglect in care provision. The facility's documentation revealed failures to follow internal and federal reporting and investigation procedures for abuse incidents.
A resident with dementia and behavioral issues struck another resident and used inappropriate language, but the facility did not complete an incident report, conduct an investigation, or update the care plan. The DON was unaware of the event, and required abuse prevention and reporting procedures were not followed.
A resident with dementia struck another resident with a rolled-up newspaper and used inappropriate language, but the incident was not reported, assessed, or investigated by staff. The DON and Administrator were unaware of the event until the survey, and there was no evidence of timely reporting to the State Agency or mandated entities as required by policy and regulation.
A resident with dementia and ongoing behavioral issues struck another resident with a rolled-up newspaper and used inappropriate language, but the facility did not complete an incident report, conduct an investigation, or update the care plan. The DON and Administrator confirmed the event was not reported or managed according to policy, and no interventions were documented to ensure resident safety.
A resident with dementia and behavioral issues struck another resident and used inappropriate language, but staff failed to complete an incident report, conduct an assessment, or update the care plan. The DON was unaware of the event, and required documentation and investigation procedures were not followed.
Failure to Adequately Assess and Treat Resident Skin Conditions
Penalty
Summary
The facility failed to ensure that a resident's skin was adequately assessed and treated according to professional standards and facility policy. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, obesity, and recent orthopedic aftercare, was identified as high risk for skin breakdown. The care plan required weekly skin checks and treatment as ordered, but there was no evidence of a physician's order for weekly skin checks, and documentation of these assessments was inconsistent or missing. Multiple skin issues were documented by CNAs on shower sheets, including a popped blister on the sacral region, blisters on the chest, red spots on the abdomen, and bruising on the arm. Despite these findings, there was no evidence that nurses completed further skin assessments, notified providers, or obtained new treatment orders for the newly identified skin conditions. The clinical record lacked documentation of follow-up assessments or interventions for these issues, and scheduled skin assessments were missed without follow-up. Interviews with staff confirmed that the expected process was for CNAs to report new skin findings to nurses, who would then assess, notify providers, and document actions taken. The Director of Nursing acknowledged that the required weekly skin assessment was not completed and that there was no documentation or follow-up on new skin issues identified by CNAs. The facility's policy required comprehensive skin assessments on admission and weekly thereafter, but these procedures were not consistently followed for this resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from a resident before administering psychotropic medications, specifically Duloxetine and Trazodone. Resident #23, who was admitted with diagnoses including pneumonitis, respiratory failure, and chronic obstructive pulmonary disease, was prescribed Duloxetine for depression. However, the consent form for this medication was not signed by the resident or a representative, and it lacked information on non-drug approaches, the reason for the prescription, and expected benefits. The resident's care plan included the use of antidepressants, and the Medication Administration Records showed that Duloxetine and Trazodone were administered. Despite this, there was no evidence of a signed informed consent for Trazodone prior to March 5, 2025. Interviews with staff, including an LPN and the interim DON, confirmed that the required consents were not completed before administering these medications, which did not meet facility expectations. The facility's policy on psychotropic medication informed consent, reviewed in September 2024, mandates obtaining consent before starting such medications. The policy emphasizes that the resident or their representative must understand the benefits and risks associated with the medication. The lack of completed consents for Duloxetine and Trazodone before administration indicates a failure to adhere to this policy, potentially impacting the resident's ability to make informed decisions about their treatment.
Deficient Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for five out of nine sampled staff members, which could lead to a deficit in staff knowledge and skills affecting resident care. The personnel files and training records revealed that several staff members did not complete required annual training for dementia, infection prevention and control, resident rights, and abuse for the years 2024 and 2025. Specifically, a CNA hired in 2010, an OT hired in 2024, an LPN hired in 2020, another CNA hired in 2021, and an RN hired in 2023 were all found to have incomplete training records. Interviews with the Business Office Manager and other staff members confirmed the lack of documentation for training completion. The Business Office Manager was unable to provide proof of training completion for several staff members, despite multiple document requests. The interim director of nursing and the regional director of clinical services acknowledged the facility's expectations for training completion and the risks associated with not maintaining proper training records. The facility's policy on education and training requirements mandates that training on topics such as abuse, dementia management, infection control, and resident rights should be completed prior to providing services independently, annually, and as needed based on the facility's assessment. The facility's assessment requires quarterly training for resident rights and abuse, including dementia care, and annual training for infection prevention and control. The failure to adhere to these requirements was identified as a deficiency in the facility's training program.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that five out of nine sampled staff members received ongoing education on abuse, neglect, exploitation, and dementia care. This deficiency was identified through a review of personnel files, staff interviews, and facility policy review. Specifically, the certified nursing assistant (CNA), occupational therapist (OT), licensed practical nurse (LPN), another CNA, and a registered nurse (RN) did not complete the required annual training for dementia and abuse for the years 2024 and 2025. The lack of training could lead to a deficit in staff knowledge and skills, potentially affecting resident care and leading to harm. Interviews with the Business Office Manager, interim director of nursing, regional director of clinical services, and the executive director revealed that the facility had expectations for training completion and maintaining documentation. However, they were unable to provide proof of training completion for several staff members. The facility's policy required that training on topics such as abuse and dementia management be completed prior to independently providing services, annually, and as necessary based on the facility's assessment. Despite these requirements, the facility did not maintain adequate records of training completion, which could result in incompetent care and services being provided.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by each other, resulting in a deficiency. Resident #104, who was readmitted with severe cognitive impairment and multiple diagnoses including PTSD and vascular dementia, was involved in an altercation with Resident #400. The incident occurred when Resident #400 punched Resident #104 and attempted to push them, which was witnessed by a CNA. Both residents had a BIMS score of 00, indicating severe cognitive impairment, and exhibited behaviors such as exit-seeking and aggression. The facility's documentation and investigation into the incident were incomplete. The report submitted to the Department of Health Services lacked supporting documentation of the facility's investigation, and there were no assessments of the residents' cognition or psychosocial and physical harm following the incident. Interviews with staff revealed that both residents were ambulatory and had a history of aggressive behaviors, making altercations plausible. However, the facility did not adequately document or investigate the incident to prevent further occurrences. Interviews with the interim director of nursing and the executive director highlighted an understanding of the importance of identifying, reporting, and investigating incidents. However, the facility's expectations for notifying the chain of command and completing investigations were not met. The facility's policy on abuse identification outlined risk factors and defined abuse, but the failure to execute these expectations led to the deficiency.
Failure to Document and Investigate Resident Altercation
Penalty
Summary
The facility failed to ensure proper documentation and evidence retention of an investigation into an alleged incident between two residents. Resident #104, who was readmitted with severe cognitive impairment and other behavioral disturbances, was involved in an altercation with Resident #400, who also had severe cognitive impairment. The incident involved Resident #400 allegedly punching and attempting to push Resident #104, which was witnessed by a CNA. However, the facility did not retain documentation of a thorough investigation or assessments of the residents' cognition or harm following the incident. The report indicates that the facility submitted an incomplete reportable event record to the Department of Health Services, lacking documentation supporting the investigation. Interviews with staff revealed that both residents exhibited exit-seeking behaviors and aggression, making altercations plausible. Despite this, the facility was unable to provide documentation of the investigation when requested, indicating a failure to complete a thorough investigation and retain necessary evidence. Interviews with the executive director and other staff members highlighted an understanding of the importance of identifying, reporting, and investigating alleged incidents. However, the facility did not meet its own expectations for notifying the chain of command and ensuring a complete investigation. The facility's policies on abuse and investigation require thorough evidence collection and review, which were not adhered to in this case.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required written notices of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two residents within the mandated timeframe. One resident, who had Alzheimer's disease and other mobility-related diagnoses, was not issued the NOMNC and SNF ABN until the day Medicare services were set to end, which was February 3, 2025. The resident's power of attorney was verbally informed on the same day, which did not allow sufficient time for the resident to appeal the decision or prepare for discharge. The facility's policy requires these notices to be given at least two days before the end of Medicare Part A stay or when Part B therapies are ending. Another resident, who was cognitively intact and had undergone orthopedic aftercare, was not provided with the SNF ABN form at all, despite the end of Medicare services on December 20, 2024. Interviews with the Social Services Director and Business Office Manager revealed a lack of understanding of how to determine the last covered day of service and the necessity of issuing the SNF ABN form. The facility's policy states that the SNF ABN should be issued if the beneficiary intends to continue services that may not be covered by Medicare, informing them of potential financial liability.
Failure to Provide Timely Prosthetic Care
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthetic device, specifically in preparing the left prosthetic device for use. The resident, who was readmitted following an amputation of the left lower extremity, had a history of Type 2 Diabetes Mellitus, bilateral lower extremity amputations, muscle weakness, and limited activity due to disability. Despite the resident's eagerness to receive the left leg prosthetic and the completion of measurements, there was a significant delay in obtaining the prosthetic device, which was attributed to the need for additional documentation from the provider. The clinical records did not reflect a care plan for the left lower extremity amputation or an order for prosthetic follow-up. The resident expressed frustration and concern over the delay, fearing muscle weakness due to the prolonged wait. Interviews with staff revealed that the resident was not on the restorative therapy caseload, despite the existence of a special treatment plan for residents with prosthetic needs. The delay was further compounded by the lack of a signed and dated letter of medical necessity, which was only drafted on March 6, 2025. The facility's Prosthesis Care and Management policy mandates that residents with prosthetic devices receive the necessary care and assistance to use their prostheses. However, the resident's inability to ambulate due to the delay in receiving the prosthetic device highlights a failure to meet this policy. The resident attended prosthetic fitting appointments, but the lack of a timely follow-up and the absence of a comprehensive care plan contributed to the deficiency identified by the surveyors.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary restorative nursing services to attain their highest level of health and well-being. The resident, who was admitted for orthopedic aftercare following a lower extremity amputation, did not receive the recommended restorative nursing services, including training and skill practice in amputation/prostheses care. Despite recommendations from both Occupational and Physical Therapy discharge summaries, the resident did not participate in the restorative nursing program during the assessment period, and there was no documentation to support the initiation or completion of a Restorative Care Referral form. Interviews with the resident and staff revealed that the resident was not on the facility's restorative therapy program caseload, and the resident did not recall being offered participation in the program. The Rehabilitation Director and the RNA confirmed the lack of evidence supporting the resident's participation in restorative therapy, which does not meet facility expectations. The facility's policies on Activities of Daily Living and Restorative Nursing were not adhered to, as the resident's needs for restorative care were not addressed, despite being identified as a fall risk with decreased mobility and functional task participation.
Inadequate Supervision and Fall Prevention for Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with moderate cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including osteoporosis and mobility issues, experienced multiple falls within a short period. Despite having a care plan, there was no evidence of specific interventions related to falls before or after each incident. The resident's clinical record documented falls on several occasions, resulting in injuries such as rib fractures and a T1 compression fracture. Interviews with staff revealed inconsistencies in the communication and implementation of fall interventions. A CNA mentioned being informed of fall interventions through nurses or fall packets, while an LPN noted the resident was on a restorative program and had an active order for 15-minute checks. However, another CNA was unaware of any 15-minute checks being conducted, and there was no documentation to support that these checks were performed. The health information management director confirmed the absence of 15-minute check forms for the resident, indicating a lapse in the facility's monitoring process. The facility's policy on fall management required assessment and intervention updates following a fall event, but the care plan was not revised accordingly. The Director of Nursing acknowledged the importance of 15-minute checks to prevent further falls and injuries, yet the lack of documentation and execution of these checks highlighted a deficiency in the facility's fall prevention measures. The failure to implement and document appropriate interventions placed the resident at risk of additional harm.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with a history of falls and moderate cognitive impairment. The resident, who was admitted with diagnoses including spinal stenosis and chronic kidney disease, experienced a significant change in behavior, including hallucinations and agitation, which was not promptly addressed by the staff. Despite the resident's increased restlessness and confusion, the facility did not implement effective interventions to prevent a fall. On the morning of the incident, the resident was found on the floor by a CNA, exhibiting labored breathing and twitching. The resident had been restless and pulling off his oxygen cannula earlier, but the staff did not adequately monitor or intervene to prevent the fall. The facility's documentation was incomplete, with missing progress notes, fall assessments, and neurochecks, indicating a lack of proper follow-up and communication regarding the resident's condition. Interviews with staff revealed inconsistencies in the reporting and handling of the resident's condition. The DON was unaware of the resident's hallucinations and confusion prior to the fall, and the facility's policies on incident management and change in condition were not followed. The failure to recognize and address the resident's behavioral changes and the lack of documentation and communication contributed to the deficiency in providing a safe environment for the resident.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory services according to professional standards for a resident who required continuous oxygen therapy. The resident, who had a history of spinal stenosis, chronic kidney disease, polyneuropathy, and falls, was admitted with a physician's order for continuous oxygen via nasal cannula. However, the order lacked specific instructions or information regarding the oxygen dose. The care plan for the resident did not include any details about oxygen use, and the O2 Sats Summary log showed inconsistencies in documenting the oxygen dose, with only one entry specifying a dose of 3 liters. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's process for administering oxygen was not followed. The RN stated that every resident on oxygen should have a physician's order specifying the dose, which was not the case for this resident. The DON confirmed that the oxygen order lacked parameters for the dose and that the dose was not consistently charted, which did not meet the facility's expectations for providing respiratory care. The facility's policy on oxygen administration required a specific liter flow to be indicated in the order, which was not adhered to in this instance.
Incomplete Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate, which could lead to interdisciplinary team members not being aware of the resident's status and potentially result in a gap in care. The resident, who was admitted with diagnoses including spinal stenosis, chronic kidney disease, polyneuropathy, and a history of falling, experienced an incident on January 19, 2025. The resident was found on the floor by a CNA, exhibiting labored breathing and twitching, and was subsequently sent to the hospital. However, the clinical record lacked documentation of any falls or incidents where the resident was found on the ground, and the fall assessments and neurocheck documents were incomplete and unsigned. The report details that on the morning of the incident, the resident was restless and anxious, removing his nasal cannula and attempting to climb out of bed. Despite these observations, there was no evidence in the clinical record of a fall event or the necessary documentation following such an incident. A witness statement from a CNA indicated that the resident was found face down on the floor with labored breathing, and the nurse on duty assessed the resident and called for emergency services. However, the facility's documentation did not reflect these events accurately, as required by their policies. Interviews with staff, including the DON, revealed that the facility's process for handling falls was not followed. The DON acknowledged the absence of documentation regarding the falls, post-fall assessments, neurochecks, and skin or pain assessments. The facility's policies require that any change in a resident's condition, such as a fall, be documented thoroughly, including assessments and notifications to relevant parties. The lack of complete and accurate documentation in this case did not meet the facility's expectations and standards.
Failure to Prevent and Address Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving both resident-to-resident and staff-to-resident abuse. In several cases, residents with significant cognitive impairments and behavioral disturbances engaged in physical altercations with each other. For example, one resident with dementia and a history of behavioral issues struck another resident with a rolled-up newspaper and later with a book, causing a skin tear. There was no evidence that the care plan was updated after these incidents, nor that a skin assessment was completed following the injury. Additionally, there was no documentation of room changes or increased staff monitoring to ensure resident safety after these altercations. Another incident involved two residents, both with severe cognitive impairments, where one resident sat on another who was sleeping, resulting in the latter striking the former in the face. Although the residents were separated and placed on 15-minute checks, the documentation and interviews revealed that staff supervision was inconsistent, and staff were not always present or able to effectively monitor and redirect residents exhibiting aggressive behaviors. Staff interviews confirmed that staffing levels were sometimes insufficient to provide adequate supervision, and that staff had to leave residents unsupervised while attending to other duties. The facility also failed to prevent and address staff-to-resident abuse. One resident, who was cognitively intact but physically dependent, reported that a CNA was rude, rough, and failed to provide necessary care, such as changing and responding to call lights. Additional complaints from other residents and a family member corroborated these allegations, indicating a pattern of neglect and verbal abuse by the same staff member. The facility's policies required prompt investigation and separation of alleged abusers, but the report identified discrepancies between facility policy and federal guidelines regarding the timeliness of reporting abuse. The documentation showed that the facility did not always follow its own procedures for reporting, investigating, and updating care plans in response to abuse allegations.
Failure to Implement Abuse Prevention and Investigation Procedures
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, as evidenced by the handling of an incident involving a resident with dementia and other medical conditions. The resident, who was rarely or never understood according to the MDS assessment, exhibited ongoing behavioral issues, including removing items from nurse carts, interfering with care, and entering peers' rooms. On one occasion, the resident struck another resident with a rolled-up newspaper and used inappropriate language, but there was no evidence that an incident report or assessment was completed following this event. Additionally, the facility did not conduct a thorough investigation of the incident, nor were interventions put in place to ensure resident safety during the investigation. The care plan for the resident was not updated after the incident, and the DON was unaware of the event until it was brought to her attention during the survey. Facility policy required prompt investigation, reporting, and implementation of safety interventions in cases of alleged abuse, but these procedures were not followed in this instance.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately, but not later than two hours, to the State Agency and mandated entities. Specifically, a resident with dementia and other medical conditions struck another resident with a rolled-up newspaper and used inappropriate language during an interaction. Documentation showed that no incident report or assessment was completed following this event, and there was no evidence that the incident was reported to the appropriate authorities as required. Interviews with the DON and Administrator revealed that neither was aware of the incident until it was brought to their attention during the survey. The DON confirmed that the event was not reported, investigated, or communicated to the state agency, which did not meet her expectations for handling resident-to-resident incidents. Review of facility policies and federal regulations highlighted a discrepancy in reporting timeframes, but the facility's failure was in not reporting the incident at all within the required period.
Failure to Investigate and Prevent Further Abuse Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and did not implement measures to prevent further potential abuse during the investigation of an incident involving a resident. Specifically, after a resident with dementia and a history of behavioral issues struck another resident with a rolled-up newspaper and used inappropriate language, there was no evidence that an incident report or assessment was completed. The clinical record did not show that the incident was reported to the Director of Nursing (DON) or the state agency, nor was there documentation of an internal investigation or any interventions to ensure resident safety during the period following the incident. Additionally, the resident's care plan, which already noted behavioral issues, was not updated after the incident. Interviews with the DON and Administrator confirmed that the incident was not reported or investigated according to facility policy, which requires prompt reporting, investigation, and implementation of safety interventions. Facility policies reviewed also mandate separation of residents and assessment for injury in such cases, but there was no evidence these steps were taken.
Failure to Document and Investigate Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including dementia, anemia, type 2 diabetes mellitus, and dysphagia. The resident had a history of behavioral issues, as documented in both the quarterly MDS assessment and behavior notes, which included actions such as removing items from walls and nurse carts, urinating in the hallway, interfering with peers' care, and tampering with safety equipment. On a specific date, a health status note documented that the resident struck another resident with a rolled-up newspaper and used inappropriate language, but there was no evidence that an incident report or assessment was completed following this event. Further review revealed that the facility did not conduct a thorough investigation of the incident, nor were interventions implemented to ensure resident safety during the period following the event. The resident's care plan, which previously addressed behavioral issues, was not updated to reflect the new incident. The Director of Nursing confirmed during an interview that she was unaware of the incident and acknowledged that the expected procedures for managing and documenting resident-to-resident incidents were not followed. Facility policies require comprehensive documentation and investigation of such events, but these standards were not met in this case.
Latest citations in Arizona
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
Trusted data from CMS and state health departments
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