Prescott Village Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Prescott, Arizona.
- Location
- 1030 Scott Drive, Prescott, Arizona 86301
- CMS Provider Number
- 035158
- Inspections on file
- 19
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Prescott Village Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to obtain and document informed consent for psychotropic and opioid medications for three residents. Two cognitively intact residents received opioids and psychotropics, including tramadol, oxycodone, trazodone, and Dilaudid, without signed, medication-specific consents, and the opioid consent forms used did not list the drug names. Another resident with severe cognitive impairment was given multiple psychotropic medications, including alprazolam, paroxetine, mirtazapine, and risperidone, but consent was only documented for some of these drugs. Staff reported that they assume an order in the EHR means consent has been obtained and do not routinely verify consents before administering these medications, despite a policy requiring informed consent prior to administration.
The facility failed to ensure PRN pain medications were administered within physician-ordered pain scale parameters for three cognitively intact residents with multiple comorbidities, including diabetes, dementia, joint replacement aftercare, encephalopathy, respiratory failure, and acute kidney failure. MAR reviews showed acetaminophen, tramadol, and oxycodone were repeatedly given for pain ratings outside the ordered ranges over several months. During interviews, an LPN, the ADON, and the interim DON each confirmed that medications had been administered outside the prescribed parameters and described associated risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. The facility’s Medication Administration policy lacked specific language on following physician-ordered pain parameters, despite requiring review of the MAR and three checks against the physician’s order, pharmacy label, and MAR.
The facility failed to ensure that a licensed pharmacist completed and documented required monthly medication regimen reviews for several residents with complex conditions and multiple medications, including psychotropics, opioids, anticonvulsants, antibiotics, diuretics, and hypoglycemics. Record review showed multiple consecutive months without documented pharmacist reviews for four residents, with only occasional single-month reviews noted and no recommendations recorded. The ADON reported that medication reviews are done on admission and that monthly pharmacist packets are reviewed by him and the provider, but he confirmed that pharmacy review records for numerous months could not be located and acknowledged this was not acceptable. The interim DON stated the pharmacist visits monthly but believed reviews were only required quarterly, despite the facility’s policy specifying that each resident’s medication regimen must be reviewed at least monthly and documented in the medical record.
Surveyors found that dietary staff did not consistently follow sanitation and food storage standards. A cook was observed preparing vegetables without a required beard net, despite facility policy and staff statements that hairnets and beard guards must be worn upon entering the kitchen to prevent hair from contaminating food. Inspectors also found expired food items, including pickled beets and processed Swiss cheese, stored in the refrigerator past their labeled use-by dates. Dietary staff, including the Director of Nutritional Services, confirmed they are responsible for labeling and checking food twice weekly and that food must be discarded by the use-by date to prevent foodborne illness, acknowledging that the observed practices did not meet facility expectations.
The facility failed to ensure that direct care staffing information submitted to CMS via PBJ was complete and accurate, as PBJ reports showed repeated excessively low weekend staffing and a one-star staffing rating while the facility’s own assessment documented higher daily nurse and CNA coverage. When surveyors requested detailed staffing submission data, the administrator could not promptly provide it, and a PBJ validation report showed that Total Employee Link Records were not submitted. Multiple residents reported long delays in call light response and assistance, including waits of 30–90 minutes, and one resident noted a nurse working six consecutive days due to open shifts. A CNA described working with only one other CNA in the building when others called off, and an LVN reported frequent staffing issues and difficulty finding replacements amid high turnover. The administrator stated that staffing was planned to meet state minimums, relied on a vendor to transmit timeclock data to CMS, did not personally review PBJ submissions, and was unaware of staffing triggers or low staffing star ratings, despite a policy requiring accurate daily submission of all direct care staffing, including agency and contract staff.
A resident with significant neurological, renal, and mental health diagnoses, and severely impaired decision-making at discharge, was sent home with a family member without a documented physician order authorizing discharge and without discharge goals or objectives in the care plan. An undated discharge planning form cited insurance as the reason for discharge and noted there would be no caregiver or home services in place. Review of the EHR showed no discharge order in the physician order tab, and a verbal discharge order with home health services was only entered months later at the direction of leadership. The ADON, Interim DON, and an LPN all acknowledged that a physician order is required for discharge and that such orders should appear in the EHR, while facility policy specifies that transfers and discharges occur only upon a physician’s order with supporting clinical documentation.
A resident with multiple chronic conditions and intact cognition signed a Prehospital Medical Care Directive refusing all resuscitation measures, and a practitioner note documented the resident as DNR. However, the EHR landing page listed the resident as full code, there was no DNR physician order, and the care plan identified the resident as full code with CPR to be initiated. On the unit, the Advanced Directives Book contained the resident’s DNR form, but the cover sheet still labeled the resident as full code. An RN, the interim DON, and a CNA all confirmed reliance on these records for code status and acknowledged that the documentation was inconsistent, contrary to facility policies requiring accurate, complete physician orders and honoring advance directives.
A resident with documented generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, and use of aripiprazole for behavior management was admitted with a hospital PASRR that showed no serious mental illness or mental illness. Despite multiple layers of review by admissions, social services, MDS, and corporate auditing, staff did not identify or correct the inaccurate Level I PASRR on admission, even though the facility’s policy requires a complete Level I PASRR screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
A resident with generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and a BIMS score indicating cognitive intactness, remained in the facility for more than 30 days while receiving aripiprazole for PTSD and bipolar disorder. The only PASARR in the record was the hospital preadmission PASARR, which was null for serious mental illness and mental illness, and no new Level I PASARR was completed within 40 days as required by facility policy. Staff interviews showed that the social services clerk did not handle PASARRs, the regional LMSW reported the facility had only recently obtained information to submit PASARRs and that incorrect hospital PASARRs should be corrected, the MDS nurse relied on social services for PASARR review and did not check for Level II PASARRs, and the admissions coordinator stated that PASARRs are reviewed before admission by intake and a corporate auditor, yet no updated PASARR was present for this resident.
A resident with multiple serious medical conditions, intact cognition, and documented ADL deficits requiring assistance with personal hygiene was observed with yellow, brittle toenails extending several centimeters beyond the toes and a jagged fingernail, despite being unable to perform self-care. The EHR, shower sheets, and skin checks contained no documentation that nail issues had been identified or that nail care had been provided, and there was no evidence of podiatry involvement. A CNA and an LVN described that CNA staff are responsible for routine nail care and documentation, with podiatry used for certain residents, while the RN confirmed that excessively long nails should have been identified during weekly skin checks. Review of records and staff interviews showed that required nail care and documentation, as outlined in facility policy, were not carried out for this resident.
A resident with moderate cognitive impairment and multiple medical conditions was found with various treatment items and medications left on an overbed table at the bedside, including Medihoney wound treatment, skin protectant, a wound cleanser, and a bottle of mineral oil labeled as a lubricant laxative. Nursing staff acknowledged that medications and treatment supplies should not be left at the bedside and were unclear about which items qualified as medications. The DON confirmed that medications, including mineral oil, are not to be stored at the bedside without a completed self-administration assessment and proper documentation, and facility policies required secure storage of medications and prohibited bedside storage without documented interdisciplinary assessment, which was not present for this resident.
A resident with severe cognitive impairment and multiple comorbidities, including acute kidney failure and a UTI, had an indwelling Foley catheter with orders for enhanced barrier precautions and routine catheter care. During ambulation with assistance from a PTA, the resident’s catheter drainage bag was observed hanging below the wheelchair and dragging on the floor, and this continued as the resident walked with the wheelchair behind. A RN, the interim DON, and a CNA all stated that catheter bags are expected to be secured, covered, and never allowed to touch the floor due to infection control concerns. The facility’s catheter care policy also specifies that the collection bag must not touch the floor at any time, but this requirement was not followed in this incident.
A deficiency was cited when a resident's care plan did not address all assessed needs and failed to include measurable timetables and specific actions, as observed in the care planning documentation.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wanderguard in place, as the front door alarm was not functioning. Staff were unaware of the resident's departure until notified by an outside party, and interviews confirmed that required monitoring procedures were not effectively carried out.
A resident with a history of fractures and mobility deficits was injured during a hoyer lift transfer when two CNAs, including an agency staff member unfamiliar with the resident, used the wrong type and size of sling and failed to remove a leg strap securing the resident to the wheelchair. The improper transfer caused acute pain and resulted in a right distal femur fracture, as confirmed by x-ray and hospital evaluation. Staff did not follow established procedures for safe transfers or ensure the correct equipment was used.
A resident with multiple health issues suffered a leg injury during a hoyer lift transfer when her leg remained strapped to the wheelchair, causing significant pain. Although CNAs notified the nurse and pain medication was given, there was no timely assessment, incident report, or notification to the physician or family as required by policy. The resident's pain worsened, and only the next day was the physician notified and x-rays ordered, which later revealed a femur fracture. Required documentation and notifications were delayed, contrary to facility policy.
A resident experienced an injury during a hoyer lift transfer, but the facility failed to document the incident, assessments, and notifications in a timely and complete manner, resulting in incomplete medical records. Additionally, the facility did not provide requested therapy documentation for another resident within the expected timeframe, and staff qualification records for a contracted CNA were not readily available, causing delays during the survey process.
The facility failed to ensure that dishes and utensils were cleaned under sanitary conditions, with inconsistent dishwasher temperature readings and improper documentation by the senior cook. The Administrator confirmed the issue and the expectation for proper logging of temperatures.
The facility failed to provide timely written transfer/discharge notices to three residents, including one with severe cognitive impairment and another who was cognitively intact. The facility's practice of verbal notification in emergencies contradicted its policy, leading to potential unsafe discharges.
The facility failed to assess and administer pain medications according to accepted standards for two residents. One resident with severe cognitive impairment and another who is cognitively intact had inconsistencies in their pain medication administration, with some medications not being administered and others given without a specified pain scale. Interviews revealed a discrepancy in understanding pain scale requirements for PRN medications.
The facility failed to ensure that a pharmacy medication recommendation for a resident on anticonvulsant therapy was reviewed and implemented. The resident's valproic acid levels were not monitored as recommended, and interviews revealed a lack of clear responsibility for following up on pharmacy recommendations.
The facility failed to ensure that a resident's clinical record included the required information for transfer/discharge. A resident with severe cognitive impairment and multiple diagnoses was discharged to a medical center due to shortness of breath, but no discharge summary was found in the clinical record. The DON acknowledged the absence, and the Administrator was unsure of the discharge policy.
The facility failed to revise care plans for two residents following falls, resulting in delayed or missing interventions. Staff interviews confirmed that the expected protocol for falls was not followed, and the Administrator acknowledged the delay in updating care plans.
Failure to Obtain and Document Informed Consent for Psychotropic and Opioid Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic and opioid medications for multiple residents, despite a policy requiring such consent before administration. For one cognitively intact resident with dementia, diabetes, dysphagia, and acute kidney failure, the MDS showed use of antidepressant and opioid medications. Physician orders included PRN tramadol and oxycodone for pain and PRN trazodone for insomnia. Review of the electronic health record did not show signed consents for tramadol, oxycodone, or trazodone. An opioid consent form in the record had an effective date but did not identify the specific opioid medications. Medication administration records showed that tramadol and oxycodone were administered numerous times over several months without documented, medication-specific informed consent. Another resident with severe cognitive impairment, Alzheimer’s disease, dementia, dysphagia, and a cognitive communication deficit was receiving multiple psychotropic medications, including alprazolam, paroxetine, mirtazapine (Remeron), and risperidone. The facility produced signed consent forms for paroxetine, mirtazapine, and risperidone, but there was no documented consent for alprazolam, despite an active order for chronic anxiety. The orders for these medications had been in place and updated over an extended period, indicating ongoing use without complete corresponding consents for all psychotropic agents. A third cognitively intact resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and knee pain had an order for scheduled oral Dilaudid three times daily for pain. The EHR did not contain a signed consent specific to Dilaudid. An opioid consent form in the record had an effective date but did not list the name of the opioid medication. Staff interviews confirmed that nurses rely on the presence of orders in the EHR as an indication that consents have been obtained and do not routinely verify consent before administering psychotropic or opioid medications. The ADON and regional nurse acknowledged that consents are required, that forms in use did not include medication names, and that an opioid consent form had been created in-house without a field for the specific drug name, contributing to the lack of medication-specific informed consent documentation.
Failure to Administer PRN Pain Medications Within Ordered Pain Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PRN pain medications were administered within the physician-ordered pain scale parameters for three residents. For one resident with type 2 diabetes, dysphagia, dementia, acute kidney failure, and a cognitive communication deficit, the MDS showed she was cognitively intact and receiving antidepressant and opioid medications. Pharmacy review in December 2025 specifically requested that nursing staff be reminded that pain medications must be given within parameters. Despite this, review of the MARs showed acetaminophen and tramadol were repeatedly administered outside the ordered pain scale ranges across multiple months, including June, November, December, January, and February. Another cognitively intact resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure had an order for acetaminophen 325 mg, two tablets every six hours PRN for generalized or breakthrough pain rated 1–4. The February MAR showed acetaminophen was administered outside of these parameters on three separate dates. This resident’s care plan, initiated in September 2025, identified a need for pain management related to right hip pain and included an intervention to administer analgesia per physician’s orders, yet the MAR documentation demonstrated that the ordered parameters were not consistently followed. A third cognitively intact resident with encephalopathy, acute and chronic respiratory failure, and acute kidney failure had an order for oxycodone 10 mg every four hours PRN for pain rated 6–10. The February MAR showed oxycodone was administered once when the resident rated pain as 3, which was outside the ordered parameters. During interviews, an LPN, the ADON, and the interim DON each reviewed the MARs and acknowledged that acetaminophen, tramadol, and oxycodone had been administered outside the prescribed pain parameters, and they described risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. Review of the facility’s undated Medication Administration policy showed it did not contain language about administering medications according to physician-established pain parameters, although it did reference reviewing the MAR for special considerations and conducting three checks against the physician’s order, pharmacy label, and MAR.
Failure to Ensure Monthly Pharmacist Medication Regimen Reviews for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly medication regimen reviews (MRRs) for multiple residents, as required by facility policy. The facility’s written Drug Regimen Review policy, revised in January 2025, states that the pharmacist will review each resident’s medication regimen at least monthly to detect irregularities and clinically significant risks, and will document in the resident’s medical record that the review has been completed. Surveyors’ review of pharmacy review documents, closed records, and staff interviews showed that these monthly reviews were missing for several residents over multiple months. For one resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure, who was cognitively intact and receiving antidepressant, opioid, and anticonvulsant medications, there were no documented pharmacy reviews for October and November 2025, and January and February 2026; only a December 2025 review was present with no recommendations. Another resident with Alzheimer’s disease, dysphagia, dementia, and cognitive communication deficit, who had severe cognitive impairment and was receiving antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and hypoglycemic medications, had no documented pharmacy reviews for September, October, and November 2025, and January and February 2026, with only a December 2025 review available showing no recommendations. A third resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and left knee pain, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for August, September, October, and November 2025, and January and February 2026. A fourth resident with type 2 diabetes, dysphagia, unspecified dementia, acute kidney failure, and cognitive communication deficit, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for September, October, November, and December 2025, and January and February 2026. During interviews, the ADON stated that medication reviews are conducted upon admission with the facility provider and that the facility receives a monthly packet from the pharmacist, which he and the provider review, sometimes with pharmacist suggestions that may or may not be accepted, and then sent to medical records. However, he confirmed that he could not locate the pharmacy review records for the missing months for the identified residents and acknowledged that not having monthly pharmacy reviews was not acceptable. The interim DON reported that the pharmacist is in the facility monthly but believed pharmacy reviews only needed to be conducted quarterly, which conflicted with the facility’s written policy requiring at least monthly reviews and documentation in the medical record.
Improper Hair Restraint Use and Storage of Expired Food in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in the facility’s food service operations related to improper use of hair restraints and failure to discard expired food items. During an initial kitchen observation, a cook was seen preparing vegetables at the food preparation counter without a beard net, despite having a beard. Multiple staff interviews, including with another cook and the Director of Nutritional Services, confirmed that facility policy requires hairnets and beard guards to be worn upon entering the kitchen to prevent hair from falling into food or onto plates. The facility’s written Kitchen Sanitation policy, last revised January 1, 2025, also states that all kitchen staff must wear hairnets and beard guards when needed. Surveyors also observed expired food items stored in the kitchen refrigerator. A container of pickled beets with a use-by date of February 27, 2026 was found on the third shelf of the refrigerator during the initial observation. On a subsequent observation, a gallon-sized ziplock bag containing several partial blocks of pasteurized processed white Swiss cheese was found with a received date of February 23, 2026 and a use-by date of March 3, 2026, but it had not been discarded. Staff interviews revealed that cooks and the Director of Nutritional Services are responsible for checking food dates twice weekly and labeling food with received and use-by dates, and that food is not to be served past the use-by date. When shown the expired cheese, a cook acknowledged it should have been discarded and stated that expired food could cause residents to get sick. Another cook and the Director of Nutritional Services similarly stated that food not discarded by the discard date could cause a potential outbreak and foodborne illness, and both acknowledged that the observed situations did not meet expectations or policy requirements.
Inaccurate PBJ Staffing Data Submission and Reported Delays in Resident Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure that direct care staffing information submitted to CMS through the Payroll-Based Journal (PBJ) system was complete and accurate, based on verifiable and auditable data. PBJ reports showed the facility consistently triggered for excessively low weekend staffing for three quarters and received a one-star staffing rating for two fiscal quarters. The facility assessment documented a licensed capacity of 58 residents with a current census of 50 and indicated daily nursing staffing of three nurses on day shift and two on night shift, with an RN present at least 8 consecutive hours per day and three CNAs on night shift and four on day shift. However, when surveyors requested detailed staffing submission data, the administrator stated that timeclock data went to a vendor (Xchieve) which then submitted to CMS, and that the information was located out of state and not immediately available. Review of the PBJ submitter final file validation report obtained from the facility showed that the Total Employee Link Records portion failed to be submitted. Resident and staff interviews and facility documentation further demonstrated discrepancies and concerns related to staffing. Multiple alert and oriented residents reported long waits for assistance, including call lights taking 30–60 minutes or up to 1.5 hours to be answered, and one resident reporting that a nurse worked six days in a row due to open shifts. Another resident reported the facility felt understaffed with CNAs, especially on day shift. A CNA reported having to work with only one other CNA in the building when others called off, and an LVN stated that staffing was an issue when staff called out and that finding replacements was difficult, with significant staff turnover in the prior six months. The administrator stated that staffing expectations were to meet state minimums, that direct care staff included CNAs, LPNs, RNs, and therapy, and that all staff clocked in and out with data sent to the vendor, but the administrator did not review PBJ data after submission, was unaware of staffing triggers or low staffing star ratings, and could not state the nursing turnover rate. The facility’s staffing policy required submission of daily direct care staffing information, including agency and contract staff, to the CMS PBJ system and directed staffing inquiries to the administrator or designee, but the incomplete PBJ submission and lack of administrative oversight led to inaccurate staffing information being reported.
Failure to Obtain and Document Physician Order Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order prior to discharging a resident. The resident was admitted with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side, dysphagia, acute kidney failure, and major depressive disorder. On admission, staff assessed the resident’s cognitive skills for daily decision making as moderately impaired, and at discharge they were assessed as severely impaired. Progress notes documented that the resident was discharged home with a family member, but the physician’s orders did not contain an order authorizing discharge, and the resident’s care plan did not include discharge goals or objectives. A Discharge Planning Review form, which was undated, indicated the resident was discharged home due to insurance, noted that the resident would not have a caregiver after discharge, and that no home services were in place. Surveyor review of the EHR did not show a discharge order in the physician’s order list or order tab. A physician’s order for discharge with home health services, dated as a verbal order on the day of discharge, was not entered into the EHR until months later, with a printed date corresponding to the survey. The ADON stated that residents who discharge require a discharge summary, physician’s orders indicating the resident is able to discharge, and a recapitulation of the stay, and acknowledged being asked by the Interim DON to enter the discharge order on the survey date, while being unsure whether the physician had actually given an order at the time of discharge. The Interim DON reported that a physician’s order was received the day of discharge but confirmed it was only entered into the EHR on the survey date. An LPN stated that everything related to a resident, including discharge, requires a physician’s order and that the order tab is the only place in the system where such orders can be found, and confirmed that the discharge order for this resident was created the day before his interview. The facility’s Transfer and Discharge policy, last revised in June 2020, states that residents are transferred or discharged upon a physician’s order and that the clinical record must contain physician documentation supporting the necessity of the transfer or discharge.
Inconsistent Documentation of DNR Status and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent documentation of a resident’s code status and advance directives across the medical record and unit reference materials. A cognitively intact resident, as evidenced by a BIMS score of 14 on the admission MDS, had multiple serious diagnoses including hypertension, osteomyelitis, anemia, MRSA infection, rheumatoid arthritis, chronic kidney disease, type 2 diabetes with neuropathy, muscle wasting, muscle weakness, and gait abnormalities. The resident signed a Prehospital Medical Care Directive indicating refusal of all resuscitation measures in the event of cardiac or respiratory arrest, including chest compressions, intubation, artificial ventilation, defibrillation, ACLS drugs, and related emergency procedures. Despite this signed directive, the electronic health record (EHR) landing page listed the resident as a full code, and there was no corresponding DNR physician order in the orders section. A practitioner progress note documented the resident’s code status as DNR on the same date as the directive, but this was not translated into an active order. The care plan further reflected a full-code CPR focus, with a goal that CPR be initiated and followed, and interventions referencing ensuring proper documents were signed and counseling the resident and family, thereby conflicting with the signed DNR directive and practitioner note. On the unit, the Advanced Directives Book contained the resident’s orange DNR form, but the cover sheet listing resident names identified the resident as a full code, creating additional inconsistency. During interviews, an RN stated she would rely on the Advanced Directives Book to determine code status during an emergency and confirmed the discrepancy between the book’s cover sheet and the DNR form, as well as the EHR landing page showing full code. The interim DON confirmed that the EHR landing page pulls from physician orders, acknowledged there was no DNR order and no care plan reflecting DNR status, and stated that documentation needs to match so everyone is on the same page. A CNA also stated that advanced directives are documented in the EHR and in a binder for DNR residents and emphasized that all documentation must be accurate so staff know how to act. Facility policies on Advanced Directives and Physician Orders required honoring residents’ directives and ensuring orders are complete and accurate, but these expectations were not met for this resident.
Failure to Ensure Accurate Level I PASRR for Resident With Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure a complete and accurate Level I PASRR assessment on admission for one resident. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15 indicating intact cognition. The resident’s care plan documented use of the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. However, the PASRR received from the hospital indicated “null” for serious mental illness and mental illness, meaning no psychiatric diagnoses were identified at the hospital level, despite the resident’s documented psychiatric conditions. During interviews, the social services clerk reported working on discharge planning from the beginning of admission but stated she did not handle PASRRs. A regional LMSW explained that the facility had recently obtained the ability to submit PASRRs electronically and stated that incorrect hospital PASRR data should be corrected immediately, acknowledging that the resident’s psychiatric diagnoses should have been identified and reviewed to determine if a Level II PASRR was needed. The MDS nurse stated he was told social services reviewed PASRRs and therefore did not check whether residents had a Level II, and that he had never seen a Level II from the hospital. The admissions coordinator reported that PASRRs are reviewed prior to accepting a resident by herself, central intake, and a corporate auditor, and that the Level I PASRR is usually the last document sent before admission. Despite this, the inaccurate Level I PASRR for this resident was not corrected on admission, contrary to the facility’s PASRR policy requiring Level I screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
Failure to Complete Required Level I PASARR for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a new Level I PASARR was completed within the required timeframe for a resident who remained in the facility for more than 30 days. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15, indicating cognitive intactness. The care plan documented that the resident was receiving the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. The only PASRR available in the record was the preadmission PASRR from the hospital, which was null for serious mental illness and mental illness, and there was no evidence of a second Level I PASARR being completed after the resident had been in the facility for more than 30 days. Interviews with staff revealed gaps in responsibility and process for PASARR completion and review. The social services clerk reported working on discharge planning from admission and stated she did not handle PASARRs, while the regional LMSW explained that the facility had only recently received information to be able to submit PASARRs and that incorrect hospital PASRR data should be corrected immediately; however, no corrected PASRR was found for this resident. The MDS nurse stated he was told that social services reviewed PASARRs, that he did not check for Level II PASARRs, and that he had never seen a Level II from the hospital, acknowledging that an inaccurate Level I on admission could affect needed services. The admissions coordinator reported that PASARRs are reviewed prior to accepting a resident by herself and the central intake team, and that a corporate auditor reviews the PASARR and admission information. The facility’s PASRR policy stated that if a facility stay is longer than 30 days, a Level I screening must be performed within 40 days of admission, which was not done for this resident.
Failure to Provide and Document Necessary Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic nail care and assistance with activities of daily living for a resident who was unable to perform this care independently. The resident was admitted with multiple significant diagnoses, including sequelae of cerebral infarction, systolic heart failure, anemia, acute kidney failure, acute respiratory failure with hypoxia, osteoporosis, major muscle wasting and atrophy, muscle weakness, dysphagia, gait and mobility abnormalities, cognitive communication deficit, need for assistance with personal care, and neuromuscular bladder dysfunction. A 5-day MDS showed the resident was cognitively intact with a BIMS score of 14, had no psychosis or behaviors, but had upper extremity impairment on both sides and lower extremity impairment on one side. The care plan documented significant ADL deficits and indicated the resident required caregiver assistance with personal hygiene/oral care and extensive assistance for repositioning and turning in bed. Despite these documented needs, the EHR contained no evidence that the resident’s finger or toenail issues had been identified, nor that the nails had been trimmed or cleaned. During an observation, the resident was seen in bed with left toenails that were yellowish, brittle, and extending a few centimeters above the tip of the toes, while the right foot had an orthopedic boot and a wound dressing was present on the left foot. In a subsequent observation, the resident’s left thumb nail was jagged, and the right hand had contractures, with no indication that the toenails had been trimmed since the prior day. The resident reported that her toenails had not been cut for several months. Interviews with staff revealed inconsistencies between facility expectations and actual practice and documentation. A CNA stated that nail care is performed during showers and documented on shower sheets, and that CNA staff trim nails that are jagged or extend more than 1/4 inch, with podiatry involved for some diabetic residents’ toenails. An LVN stated that CNA staff provide fingernail care for non-diabetic residents and that nail care documentation should be in the EHR, with podiatry responsible for toenail care. Upon direct observation of the resident, both the LVN and the assigned RN acknowledged that the resident’s fingernails and toenails were excessively long and should have been clipped, and the RN stated that such issues should be identified during weekly skin checks and had not been identified by either CNA staff or nursing. Review of shower sheets and skin checks showed no documentation of excessively long nails, podiatry involvement, or nail care, despite a facility policy requiring CNA staff to trim and document nail care unless specific conditions such as diabetes, circulatory impairment, or problematic nails were present.
Medications and Treatments Improperly Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and treatments at the bedside for Resident #46. The resident was admitted with diagnoses including left hand contracture, dysphagia, major depressive disorder, and muscle weakness, and had a BIMS score of 10 indicating moderate cognitive impairment. The care plan contained no documentation authorizing medications at the bedside. During an observation in the resident’s room, surveyors noted an overbed table covered with a disposable bed pad holding multiple items, including a clear resealable bag with gauze, an abdominal pad package, bandages, an opened 200-count package of 4x4 gauze sponges, three individually wrapped oral swabs, a silver wound dressing package, a small black tube with a white cap, an opened skin protectant packet, a spray bottle of Skintegrity wound cleanser, and a nearly full 16-ounce bottle of mineral oil labeled as a lubricant laxative. In interviews, an RN identified the black tube as Medihoney used for wound treatment and acknowledged that it, along with the skin protectant, should not be kept at the bedside, and was unsure whether the wound cleanser could remain in the room or if mineral oil was considered a medication. A CNA stated that no medications or treatment supplies are allowed to be left at the bedside. The regional interim DON confirmed that medications are not to be left at the bedside unless a self-administration assessment is completed, the physician is contacted, and the appropriate form is completed and signed, and further clarified that medications are anything administered to residents, including mineral oil. The DON was only aware of the wound cleanser being at the bedside and not the mineral oil, Medihoney, or skin protectant. Facility policies on Medication Storage, Medication Administration, and Self-Administration of Medications all required secure storage of medications, prohibited leaving medications at the bedside, and required documentation of interdisciplinary assessment and determination regarding bedside storage in the medical record and care plan, which had not been done for this resident.
Failure to Maintain Catheter Bag Off the Floor During Resident Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control standards for the management of an indwelling urinary catheter for Resident #27. The resident was re-admitted with multiple diagnoses including chronic kidney disease, acute kidney failure, urinary tract infection, infection and inflammatory reaction due to other urinary catheter, obstructive and reflux uropathy, and pneumonia, and had a BIMS score of 7 indicating severe cognitive impairment. Physician orders documented enhanced barrier precautions due to a Foley catheter, catheter care every shift and as needed, and weekly changes of the catheter securement device. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, away from the entrance room door, to check tubing for kinks, and to keep the drainage bag off the floor. On the survey date, the resident was observed in the hallway seated in a wheelchair and being assisted with ambulation by a PTA, with the catheter bag hanging below the wheelchair and dragging on the floor. The PTA then assisted the resident to stand and walk with the wheelchair behind, while the catheter bag continued to trail on the floor. A RN, when the issue was pointed out, stated that the bag should never touch the floor under any circumstances due to infection control concerns and adjusted the bag once the resident was seated in the dining area. The PTA acknowledged that the bag had been touching the floor and stated it should not have been. The interim DON and a CNA both stated that catheter bags are expected to be secured, hanging from the bed or wheelchair, covered with a privacy cover, properly anchored, and never allowed to touch the floor, citing infection control concerns and risk of rupture or the bag popping open. The facility’s catheter care policy, last reviewed in January 2025, specified that the collection bag must not touch the floor at any time, which was not followed in this instance.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was found that the care plan did not comprehensively cover the resident's assessed needs or include clear, measurable objectives and interventions.
Failure to Prevent Resident Elopement Due to Inoperative Door Alarm
Penalty
Summary
A resident with a history of dementia, disorientation, and a recent fracture was admitted to the facility and assessed as a moderate elopement risk upon admission. The resident's cognitive status declined over time, as indicated by a drop in the BIMS score from 10 to 3, reflecting severe cognitive impairment. Physician orders were in place for a wanderguard device due to the risk of elopement, and staff were instructed to monitor the device's function. Despite these measures, the resident was last seen at the nurses station and was later found at a nearby emergency room, having left the facility without staff knowledge. Staff interviews confirmed that the wanderguard was in place at the time of the incident, but the front door alarm was not functioning, allowing the resident to exit undetected. Staff reported that residents at risk for elopement are typically monitored with wanderguards and that door alarms are expected to alert staff if such residents approach exits. However, on the day of the incident, the malfunctioning front door alarm failed to activate, and the resident was able to leave the premises. The deficiency was further evidenced by staff statements acknowledging the resident's increased elopement risk following improved mobility and the lack of immediate staff awareness of the resident's departure. Facility policy required reinforcement of procedures for residents at risk of elopement, but these procedures were not effectively implemented in this case.
Failure to Ensure Safe Hoyer Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide safe assistance to a resident during a mechanical hoyer lift transfer, resulting in an injury. The resident, who had a history of multiple fractures, an open wound on the right foot, epilepsy, and a disorder of bone density and structure, required a mechanical lift for all transfers due to an activity of daily living self-care deficit. On the day of the incident, two CNAs attempted to transfer the resident from her wheelchair to her bed using a hoyer lift. The resident's leg was still strapped to the wheelchair during the lift, and the wrong type and size of sling was used. The resident immediately complained of pain, and the transfer was halted, but the resident sustained a fracture to the right distal femur as confirmed by subsequent x-rays and hospital evaluation. Multiple staff interviews and witness statements revealed that the CNAs involved were not familiar with the resident's specific needs and did not ensure the correct sling was used or that all straps were removed prior to the transfer. One CNA was an agency staff member unfamiliar with the resident, and the other was not experienced with the resident's care. The resident's usual sling was missing, and the staff used a different type of sling, which was not appropriate for the resident's condition. The improper placement of the sling and failure to unstrap the resident's leg from the wheelchair leg rest led to the resident experiencing acute pain and ultimately a femur fracture. Facility documentation and policy review indicated that staff did not follow established procedures for assessing the resident's needs, choosing the correct sling, and ensuring all safety measures were in place before performing the transfer. The incident was not immediately recognized as a significant injury, and there was a delay in notifying the physician and obtaining diagnostic imaging. The lack of adherence to safe transfer protocols and insufficient staff familiarity with the resident's care requirements directly contributed to the accident and resulting injury.
Failure to Timely Assess, Document, and Notify After Resident Injury
Penalty
Summary
A resident with multiple medical conditions, including an open wound, pelvic fractures, and a history of bone disorders, experienced an incident during a hoyer lift transfer. During the transfer, the resident's leg remained strapped to the wheelchair, resulting in immediate pain and distress. Although the CNAs involved notified the nurse within five minutes and Tylenol was administered, there was no documented assessment, incident report, or notification to the physician or the resident's family on the day of the incident. The resident's pain escalated throughout the day, requiring stronger pain medication, but still no communication with the provider was documented at that time. The following day, the resident continued to experience significant pain, prompting further assessment and eventual notification of the physician, who ordered x-rays. The x-rays, completed the next day, revealed a distal femur fracture, and the resident was subsequently sent to the emergency room for further evaluation and treatment. Documentation showed that the required change of condition evaluation was not completed until several days after the incident, and the incident report was also delayed. Interviews with staff confirmed that the incident was not reported or documented according to facility policy on the day it occurred. Facility policies required immediate assessment, documentation, and notification to the physician and family following incidents resulting in injury or significant change in condition. However, the clinical record review, staff interviews, and policy review revealed that these steps were not followed. The lack of timely assessment, documentation, and notification could have resulted in delayed care and lack of awareness by the physician and family regarding the resident's condition.
Incomplete Medical Records and Delayed Documentation Provision
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced an incident during a hoyer lift transfer. The resident, who had multiple medical conditions including an open wound, pelvic fractures, hypothyroidism, epilepsy, and bone disorders, was involved in a transfer incident where the hoyer lift sling was not properly used, resulting in acute pain and a subsequent diagnosis of a distal femur fracture. Despite the incident occurring, there was no documentation in the clinical record on the day of the event, including progress notes, incident reports, or assessments. Notification to the physician and the resident's family was also not documented on the day of the incident. Documentation of the change in condition and related assessments were completed days later, and staff interviews confirmed that required documentation and reporting protocols were not followed at the time of the incident. Additionally, the facility did not provide requested documentation for another resident in a timely manner during the survey process. When therapy documentation was requested, there was a significant delay in providing the records, exceeding the expected two-hour turnaround time. The delay persisted despite multiple reminders to facility leadership, and the required documents were only provided the following day. There were also delays and missing documentation related to staff qualifications and training for a contracted CNA, with competency checklists and orientation records not readily available and only submitted after further requests. Facility policy requires prompt and thorough documentation of incidents, changes in condition, and communication with physicians and families. The failure to document the incident, assessments, and notifications as required, as well as the delay in providing requested records, resulted in incomplete and inaccurate medical records and hindered the survey process. These deficiencies were confirmed through record reviews, staff interviews, and policy review.
Failure to Maintain Sanitary Conditions in Dishwashing
Penalty
Summary
The facility failed to ensure that dishes and utensils were cleaned under sanitary conditions, which could result in residents becoming ill. During an initial walk-through of the kitchen, it was observed that the temperature gauge on the dishwasher had not been working since December 31, 2023. The senior cook, who was responsible for the kitchen, stated that he had been using an external thermometer to manually check the dishwasher temperature. However, the temperature readings during the wash cycle varied significantly, with readings of 118 degrees, 140 degrees, and 203 degrees, none of which consistently met the required temperature for sanitization. Additionally, the senior cook admitted to not properly documenting the temperature readings on the dishwasher temperature log from January 1, 2024, to January 22, 2024, and falsely indicated that he had checked the temperature for all three meals each day, even on days he was not present at work, as confirmed by his time card records. The facility's policy and the dishwasher instruction manual both require specific temperature ranges for the wash and rinse cycles to ensure proper sanitization, which were not consistently met or documented. An interview with the Administrator revealed that the facility was aware of the issue and was expecting a new dishwasher to be installed. The Administrator also confirmed that the expectation was for the dishwasher temperature log to be initialed by the staff who checked the temperature each meal. The failure to maintain and document proper dishwasher temperatures as per the facility's policy and the dishwasher's instruction manual could lead to unsanitary conditions and potential illness among residents. The facility's policy requires the wash cycle to be between 150 to 165 degrees Fahrenheit and the rinse cycle to be between 150 to 180 degrees Fahrenheit, which were not consistently achieved or recorded during the observed period.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to three residents, as required by policy and regulations. Resident #3, who was cognitively intact with a BIMS score of 13, was transferred to the hospital due to a fall resulting in a pelvic fracture. Although the resident's emergency contact was notified via telephone, there was no documentation of a written notice provided to the resident regarding the transfer. The facility's Administrator confirmed that the facility does not provide written statements for hospital transfers, which is against the facility's policy and regulatory requirements. Similarly, Resident #37, who had severe cognitive impairment with a BIMS score of 7, was transferred to the hospital due to shortness of breath. The clinical record lacked evidence of a written notice of transfer/discharge being provided to the resident or their representative. Interviews with the Director of Nursing and the Administrator revealed that the facility's practice was to notify the resident's representative verbally in case of an emergency transfer, but no written notice was provided, which contradicts the facility's policy. This failure to provide written notification could result in residents having an unsafe discharge.
Failure to Properly Assess and Administer Pain Medications
Penalty
Summary
The facility failed to assess and administer pain medications according to accepted standards of clinical practice for two residents. Resident #16, who has severe cognitive impairment, was prescribed Acetaminophen 325 mg to be given 650 mg by mouth every 4 hours as needed for pain, not to exceed 3,000 mg per day. The Medication Administration Record (MAR) showed that the medication was administered on two occasions in January 2024 with a pain scale of 5. However, the orders did not include a pain scale, which is necessary to determine the appropriateness of the medication for the level of pain experienced by the resident. Resident #30, who is cognitively intact, had multiple pain medication orders, including Acetaminophen, Ibuprofen, and Oxycodone-Acetaminophen. The MAR for December 2023 and January 2024 revealed inconsistencies in the administration of these medications, with some medications not being administered at all and others being administered without a specified pain scale. Interviews with the Clinical Care Coordinator and the Director of Nursing highlighted a discrepancy in the facility's understanding and implementation of pain scale requirements for PRN pain medications. The facility's policy on the administration of PRN medications states that they should be administered consistent with the prescriber's parameters and registered nurse's procedures, but this was not followed in these cases.
Failure to Implement Pharmacy Medication Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy medication recommendation was reviewed and implemented for a resident diagnosed with Major Depressive Disorder and epilepsy. The resident was on anticonvulsant medication therapy with Divalproex Sodium, and a pharmacy consultation report recommended monitoring valproic acid trough concentration. However, the clinical record did not show that the valproic acid levels were drawn as recommended. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that there was no clear responsibility for following up on pharmacy recommendations, and the resident's Depakote level was missed during leadership transitions. The DON acknowledged that pharmacy reviews should be completed timely and expected that pharmacy reviews be presented to the Medical Director or the resident's Primary Care Provider the next business day. The facility's policy on physician/practitioner orders emphasized the importance of processing and transcribing orders immediately upon receipt. Despite this policy, the facility failed to ensure that the pharmacy's recommendation for monitoring valproic acid levels was followed, resulting in a deficiency in the resident's care.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure that a resident's clinical record included the required information for transfer/discharge. Resident #37, who had severe cognitive impairment and multiple diagnoses including COPD, endocarditis, and supraventricular tachycardia, was discharged to Yavapai Regional Medical Center due to shortness of breath. However, a review of the clinical record revealed no evidence of a discharge summary. The Director of Nursing acknowledged the absence of the discharge summary and stated it should have been completed in a timely manner. The facility Administrator was unsure of the resident discharge policy and needed to check it to determine when a discharge summary should be provided.
Failure to Revise Care Plans Following Falls
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents following falls. Resident #15, who was admitted with hemiplegia and epilepsy, experienced a fall on 7/4/23. Despite this incident, no new interventions were documented in the clinical record until 8/21/23. Similarly, Resident #21, admitted with vascular dementia and generalized anxiety disorder, fell on 9/27/22 and sustained a head injury resulting in a subdural hematoma. However, no care plan for falls was documented until 11/20/22, and no immediate interventions were put in place following the fall on 9/27/22. Interviews with staff revealed that the expected protocol for falls, including immediate assessment, notification of relevant parties, and updating the care plan with new interventions, was not followed. The Registered Nurse and Licensed Practical Nurse both confirmed that interventions were either delayed or missing entirely. The Administrator also acknowledged that interventions should have been implemented sooner and that the care plans were not updated promptly to reflect the residents' needs following their falls.
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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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