Rehab At Scottsdale Village Square
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsdale, Arizona.
- Location
- 2620 North 68th Street, Scottsdale, Arizona 85257
- CMS Provider Number
- 035217
- Inspections on file
- 40
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Rehab At Scottsdale Village Square during CMS and state inspections, most recent first.
Multiple residents with dementia, psychotic disorders, and severe cognitive impairment engaged in repeated resident‑to‑resident physical abuse, including punching, kicking, grabbing, and hitting, often triggered by intrusive wandering, perceived theft, unwanted touching, or attempts to take belongings such as blankets or food. Several aggressors had documented histories of delusions, sexually inappropriate behavior, prior altercations, or intolerance of others in their personal space, but these risks were not consistently reflected as physical aggression in care plans, and staff often intervened only after altercations had begun. Staff interviews described frequent resident‑to‑resident incidents, acknowledged that hitting constitutes abuse, and indicated reliance on post‑incident monitoring rather than clearly defined, proactive measures to prevent contact and escalation, despite a facility policy guaranteeing residents freedom from physical abuse.
The facility failed to individualize comprehensive care plans for multiple residents involved in resident-to-resident altercations, instead applying the same generic psychosocial focus and interventions to all parties regardless of whether they were victims or aggressors. Residents with dementia, psychotic disorders, PTSD, parkinsonism, and other psychiatric conditions had documented histories of wandering into others’ rooms, delusional accusations about stolen money, taking others’ food or belongings, prior physical aggression, and rapid behavioral escalation, yet these specific triggers and behaviors were not reflected in their active care plans. Staff, including LPNs and CNAs, described knowing resident-specific behaviors and effective de-escalation strategies, but reported limited or no access to update care plans, while the MDS nurse acknowledged using vague, standardized interventions and relying on separate Risk Management records for incident details. This disconnect between staff knowledge and the written care plans resulted in care plans that did not meet the policy requirement for comprehensive, person-centered planning based on individualized data and known behavioral patterns.
The facility failed to adequately track, trend, and analyze resident-to-resident abuse incidents within its QAA/QAPI process. QAA meeting minutes showed missing and inconsistent data on reportable incidents and unit trends, and the DON’s clinical review did not specifically address resident-to-resident abuse. The only documented action plan was a general, non-measurable strategy focused on staff education and keeping residents at arm’s length, with no evidence of resolved plans or measurable progress. Interviews with the DON and Administrator confirmed that altercations were tracked mainly as reportable events by location, without deeper analysis of triggers or patterns, despite policies requiring QAPI review and performance improvement initiatives for abuse-related events.
The facility failed to update behavioral health care plans to reflect individualized triggers and documented behaviors for two residents with severe cognitive impairment and psychiatric conditions. One resident, known by staff to have delusions about others stealing his money and to escalate quickly, accused another resident of theft and punched him in the eye, yet his care plan and IDT behavior review did not specifically address this recurrent trigger. Another resident had multiple documented episodes of taking other residents’ food and becoming difficult to redirect, but his behavioral treatment plan and care plan focused on sexual inappropriateness, elopement, and isolation without including his history of taking food or belongings. These omissions occurred despite a facility dementia protocol requiring the IDT to identify and document residents’ conditions, behaviors, and needed supports and to review changes as they arise.
A resident with schizophrenia, quadriplegia, and moderately impaired cognition became very upset in a common area, used an electric wheelchair aggressively, and kicked a CNA who intervened. The CNA responded by grabbing the resident’s leg, transferring the resident from the wheelchair to a recliner, and yelling loudly at the resident. Facility records showed no head-to-toe or skin assessment of the resident after this staff–resident altercation, and progress notes did not document risk related to the incident. Despite facility policies requiring protection from abuse, assessment, documentation, and prompt reporting of suspected staff-to-resident abuse to the State Agency, the DON and administrator determined the event was not abuse and did not report it.
A resident with quadriplegia, schizophrenia, depression, and moderately impaired cognition became physically and verbally aggressive, attempting to run into staff and others with an electric wheelchair. A CNA intervened, was kicked by the resident, then placed the resident in a recliner while yelling loudly, behavior later deemed inappropriate in a behavioral setting. No head-to-toe or skin assessment was documented after the altercation, and there was no evidence that this staff-to-resident abuse allegation was reported to the State Agency within required timeframes, despite facility policy and leadership statements that such allegations must be reported promptly.
The facility failed to submit a required 5‑day abuse investigation report to the State Survey Agency after an incident in which a resident with depression, schizophrenia, quadriplegia, and moderately impaired cognition became physically and verbally aggressive, attempted to run into staff and others with an electric wheelchair, kicked a CNA, and was then transferred to a recliner while the CNA yelled loudly. Although the event was documented on an internal suspected abuse investigation form and facility leadership described a process that includes immediate investigation and submission of a detailed report within 5 working days, surveyors found no evidence in the clinical record or facility files that the mandated 5‑day investigation report was completed or sent, and the administrator confirmed that no such report existed.
The facility failed to protect three severely cognitively impaired residents from physical abuse by another resident and by a family member. In one incident, two residents with dementia and psychiatric diagnoses were in the dining room when one, who was standing, repeatedly hit another who was in a wheelchair, resulting in a forehead injury and knuckle hematomas. Staff and documentation confirmed the altercation, and prior care plans had already identified behavior issues and the need to protect others’ rights and safety. In a separate incident, a resident with dementia, Parkinsonism, and a history of falls was verbally and physically abused by her husband, who became frustrated when assisting with medications and was reported by staff to have kicked her when she refused medication. Staff interviews and the DON’s statements confirmed that the husband’s actions, including kicking the resident, were physical abuse, despite a facility policy stating residents have the right to be free from abuse.
Multiple incidents occurred where residents with cognitive impairments engaged in physical altercations, including hitting, slapping, pushing, and punching, resulting in injuries such as abrasions, hematomas, and fractures. These events were witnessed by staff and documented in clinical records, with care plans in place for behavioral risks but insufficient to prevent abuse. Facility policies defined these actions as abuse, and staff interviews confirmed the incidents did not meet expectations for resident safety.
Multiple residents with cognitive impairment were involved in physical altercations with other residents, resulting in injuries and hospitalizations. Staff often became aware of the incidents only after they had begun, despite care plans indicating behavioral risks. The DON and staff confirmed that these events met the definition of abuse and did not meet expectations for resident safety.
Two residents with severe cognitive impairment engaged in a physical altercation in the dayroom, resulting in both sustaining skin tears and contusions, while a CNA present was unable to separate them alone and was injured in the process. The incident occurred with only one CNA supervising twelve residents, and staff interviews and video footage confirmed the escalation and injuries.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
Multiple residents with cognitive and behavioral issues engaged in physical altercations, including hitting, biting, and kicking, resulting in injuries and distress. Staff were often unable to prevent or promptly intervene in these incidents, despite care plans identifying behavioral risks. Documentation and interviews confirmed these events were considered abuse, and the facility failed to ensure residents' rights to be free from physical abuse.
Two residents with psychiatric and behavioral diagnoses were involved in a physical altercation, resulting in one resident sustaining minor injury and property damage. Staff intervened, and the incident was recognized as abuse by facility leadership. However, the facility failed to provide required investigation documentation and did not fully adhere to its abuse prevention and reporting policies.
Two residents were involved in a physical altercation during a medication pass, resulting in one resident sustaining minor injury. Staff had difficulty separating the residents, and the incident was not reported or investigated within the facility's required timeframe for suspected abuse.
The facility did not ensure accurate documentation in the medical records for multiple residents regarding abuse incidents, resident assessments, and missing property. For example, a resident receiving dialysis did not have required pre- and post-treatment assessments documented, and several residents involved in altercations or reporting missing items had no related entries in their clinical records, despite facility policies requiring such documentation.
Surveyors found that the facility failed to maintain consistent advance directive documentation for two residents. In both cases, signed pre-hospital and/or VA advance directive forms indicated DNR status and refusal of CPR, while the face sheets, care plans, progress notes, and physician orders documented full code status. Staff, including an MDS coordinator, an LPN, and the DON, reported that advance directives are initiated on admission, reviewed quarterly, and should be updated in both physical and electronic records using a specific form, but acknowledged that discrepancies remained in these residents’ charts, creating a risk that their end-of-life wishes would not be honored.
Surveyors identified that the facility failed to remove multiple expired medications from two medication rooms, including nasal spray, stimulant laxatives, vitamin E, and influenza vaccine, which remained stored despite a policy requiring prompt removal of expired drugs. In a separate incident, a resident with multiple chronic conditions and moderate cognitive impairment was found sleeping with a cup of medications left on the bedside table after an LPN believed the doses had been taken; the resident had not been assessed or approved for self-administration as required by facility policy.
A resident with severe cognitive impairment physically and verbally abused another resident after a dispute over food. Staff intervened to separate the residents, and no injuries were reported. The incident was classified as both verbal and physical abuse according to facility policy, which states residents have the right to be free from abuse.
Multiple residents with cognitive and behavioral impairments engaged in physical and sexual abuse of peers, including incidents of unwanted touching, hitting, and altercations resulting in injuries. Despite care plans and staff awareness of behavioral risks, interventions were not effectively implemented, leading to repeated episodes of abuse and neglect among residents.
A resident with severe cognitive impairment and a history of behavioral disturbances was not consistently provided with adequate supervision, resulting in multiple altercations with other residents. Despite care plans and behavior assessments indicating the need for interventions such as 1:1 monitoring and frequent observation, these measures were not always implemented, leading to preventable incidents of physical aggression.
A resident with severe cognitive impairment and a history of behavioral disturbances physically struck another cognitively impaired resident in a common area, resulting in visible injury. The incident was witnessed by an LPN, who intervened to stop further harm. Despite existing care plans and behavioral interventions, the facility did not prevent the altercation, leading to a deficiency related to resident protection from abuse.
Two residents with cognitive impairments were involved in a physical altercation, resulting in one sustaining a skin tear to the hand. The incident was reported by the injured resident to an LPN, who observed the injury and questioned both parties. Conflicting and delusional accounts were given, and the facility's investigation was unsubstantiated due to lack of witnesses, despite documentation of prior aggressive behavior by one resident.
The facility failed to prevent resident-to-resident abuse, involving incidents where a resident with dementia hit another, causing injury, and another resident with severe cognitive impairment struck a fellow resident. Despite known behavioral issues, the facility did not effectively implement monitoring and supervision protocols, leading to these altercations.
Two residents with dementia eloped from a facility due to inadequate supervision and door functionality issues. One resident, identified as an elopement risk, left undetected and was found by police. Another resident, initially assessed as not at risk, also eloped and was returned by police. Staff reported concerns about door locks and insufficient staffing levels, contributing to the incidents.
A long-term care facility failed to administer medications within the required timeframe to six residents, leading to potential risks of unmanaged symptoms and adverse effects. Observations showed that medications scheduled for 8:00 a.m. were administered late, with some residents receiving their medications over two hours past the scheduled time. Interviews with staff revealed a lack of adherence to the policy of administering medications within one hour of the prescribed time.
A resident with severe cognitive impairment and a history of aggressive behavior hit another resident in the face during an incident in the dayroom. Despite being on one-to-one supervision, the aggressive resident managed to make contact, leading to an altercation. Staff intervened by separating the residents, and an assessment showed no apparent injury to the affected resident.
A resident with schizophrenia and dementia, identified as an elopement risk, successfully left the facility due to a malfunctioning exit door. Despite interventions like Wanderguard checks and door alarm maintenance, the resident eloped and was found outside before being redirected back. Staff interviews revealed previous maintenance issues with the door, highlighting a lapse in supervision and security measures.
A facility failed to provide adequate supervision, resulting in an altercation between two residents. One resident with PTSD was injured after being hit and kicked by another resident with anxiety disorder. Despite staff intervention, the aggressive resident was not easily redirectable, leading to emergency services being called. The facility's reliance on surveillance cameras and staff monitoring was insufficient, as the lack of cameras in certain units and inadequate staff presence contributed to the incident.
A resident in an LTC facility was administered multiple psychotropic medications without being informed of the risks and benefits, as required by facility policy. The facility relied on outdated consents from a sister facility, failing to obtain new consents upon the resident's admission. Staff interviews confirmed the oversight, highlighting a deficiency in compliance with informed consent policies.
A facility failed to complete a level 2 PASRR for a resident with mental illness, including schizoaffective and bipolar disorders, upon admission. The resident's care plan involved psychotropic and other medications, but the necessary referral for specialized services was not made. Interviews with staff revealed the oversight, and the facility lacked a physical copy of the level 2 PASRR, failing to follow up with ALTCS.
A resident with dementia and depressive disorder wandered away from a facility due to inadequate supervision and care planning. Despite documented wandering behaviors, the resident's care plan did not address these issues, and an elopement risk evaluation inaccurately indicated no risk. The resident exited through an unalarmed window and was later found by police with minor injuries. Staff interviews revealed awareness of the resident's desire to leave and the ease of opening the window.
The facility failed to protect residents from abuse, with incidents involving inappropriate touching and physical aggression. A resident with a history of sexually inappropriate behavior was not adequately monitored, leading to an incident with another resident. Additionally, two residents with severe cognitive impairments were involved in altercations due to insufficient staffing and inadequate interventions. The facility's leadership did not report incidents appropriately, citing cognitive status as a reason for inaction.
The facility failed to report abuse allegations involving three residents to the State Agency, APS, and law enforcement. A resident with Alzheimer's was inappropriately touched by another resident with a history of sexual inappropriateness, and another resident was found naked and touching a sleeping female resident. These incidents were not reported, and staff were unclear on what constituted a reportable event, leading to a deficiency in handling resident safety and abuse prevention.
The facility failed to thoroughly investigate allegations of abuse involving residents. In one case, a CNA found a resident cornered and inappropriately touched by another resident, but no comprehensive investigation was conducted. Another incident involved a resident found naked in another's room, with no evidence of a thorough investigation. The facility's policy outlines specific steps for investigations, but these were not followed, leading to a deficiency in ensuring resident safety and rights.
The facility failed to provide sufficient staffing, resulting in inadequate supervision and incidents of inappropriate behavior between residents. A resident with Alzheimer's was inappropriately touched by another resident with a history of behavioral disturbances. Staffing levels were below the facility's assessed needs, with staff expressing concerns about their ability to monitor and care for residents effectively. The director of nursing and administrator acknowledged staffing challenges but did not document daily assessments of residents' needs.
A resident with severe cognitive impairment attacked another resident after being told to "shut up" in the day room. The altercation was broken up by a nurse, but the aggressive resident then threatened the nurse. The facility's investigation confirmed the incident, highlighting a failure to prevent the altercation despite existing care plans and protocols.
The facility failed to consistently enforce PPE use during a COVID-19 outbreak, with staff and visitors observed not wearing masks despite clear signage and protocols. The concierge admitted to forgetting to wear a mask, and the DON and Administrator removed their masks during a conference. Shared spaces with another company complicated enforcement, and the Infection Preventionist noted challenges in ensuring compliance among non-facility staff.
The facility failed to protect residents from abuse and assess their capacity to consent to relationships. A resident reported sexual abuse by a CNA, which was not reported or addressed by management. Another resident was injured due to rough handling by the same CNA, and the incident was not properly investigated. Additionally, the facility did not assess the ability of two residents with severe cognitive impairments to consent to a sexual relationship, leading to deficiencies in care.
The facility failed to report allegations of abuse and inappropriate incidents involving residents with cognitive impairments. A resident reported sexual abuse by a CNA, but the incident was not reported to authorities. Another resident was found with bruises, allegedly from rough handling by a CNA, yet it was not reported. Two residents with severe cognitive impairments were involved in an incident of physical touching, but it was not reported, and no documentation of consent assessment was found.
The facility failed to investigate abuse allegations involving a resident with cognitive impairments who reported sexual abuse by a CNA. Another resident with severe cognitive impairment was found with bruises and scratches, allegedly due to rough handling by a CNA, but the incident was not reported or investigated. Additionally, two residents with severe cognitive impairments were found engaging in sexual acts without proper consent assessment or investigation.
A resident with severe cognitive impairment sustained a leg injury, but the LTC facility failed to notify the family, contrary to its policy. Staff interviews revealed confusion about notification requirements, and the DON confirmed no documentation of family notification was found.
A facility failed to prevent abuse between two residents with cognitive impairments, resulting in two physical altercations. The first incident involved a slap, with no immediate care plan updates or separation of residents. A second incident led to a superficial injury, prompting a psychological evaluation and relocation of the aggressive resident. Care plans were updated later to address behavioral triggers.
Failure to Prevent Repeated Resident‑to‑Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse, despite known behavioral histories and documented patterns of aggression, delusions, and boundary violations. Multiple residents with dementia, psychotic disorders, mood disorders, and severe cognitive impairment were involved in separate altercations in which one resident physically struck, grabbed, or otherwise assaulted another. In several cases, residents had documented histories of intrusive wandering, delusions, sexually inappropriate behavior, or prior physical altercations, yet these behaviors were not consistently reflected in care plans as physical aggression risks, and preemptive interventions to prevent contact or escalation were not clearly implemented. Staff and leadership interviews repeatedly described the facility as a “behavioral facility” with unpredictable behaviors and acknowledged frequent resident‑to‑resident altercations. In one incident, a resident with dementia, severe cognitive impairment, and a history of entering other residents’ rooms reported being punched in the nose by another resident who had a personality disorder, anxiety, and a documented pattern of making false accusations, going into other residents’ rooms, and breaking their belongings. Another incident involved a resident with severe cognitive impairment and Alzheimer’s disease who was found with a purple/blue bruise under the eye after reporting that his roommate, a resident with parkinsonism, psychotic disorder, and severe cognitive impairment, punched him while accusing him of stealing millions of dollars. The facility’s investigation initially concluded that this event did not happen and later characterized it as an accident, despite an IDT note documenting that the punch occurred. In a separate case, a resident with severe cognitive impairment and bipolar and depressive disorders had his wrist grabbed and squeezed hard by another resident with dementia and severe cognitive impairment, who was described as trying to be helpful by pulling him away from automatic doors. Additional altercations included a resident with severe cognitive impairment and a history of physical aggression toward staff and others being kicked multiple times in the thigh by another resident with schizoaffective disorder, dementia with agitation, and a prior documented assault on another resident and threats toward a nurse. Staff interviews indicated that this resident became verbally and physically aggressive when frustrated, such as when needs for cigarettes, beverages, or television viewing were not met, and that another resident’s wandering likely triggered the kicking incident. Another event involved a resident with vascular dementia, anxiety disorder, violent behavior, and prior involvement in a physical altercation punching a cognitively impaired resident in the stomach after the latter attempted to help push his wheelchair, despite the aggressor’s known intolerance of being touched. In yet another case, a resident with Alzheimer’s disease, dementia with agitation, and a history of taking others’ food and becoming combative during redirection admitted to hitting his moderately cognitively impaired roommate in the head to take his blanket because he was cold. Across these events, the facility’s own abuse policy stated that residents have the right to be free from abuse, including physical abuse, yet residents repeatedly experienced physical contact and assaults from other residents.
Failure to Individualize Care Plans for Resident-to-Resident Abuse and Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and update individualized, comprehensive care plans with measurable objectives and timetables to address resident-to-resident abuse and aggression. Surveyors found that for all sampled residents involved in altercations, the facility used the same generic psychosocial well-being care plan focus and identical interventions, regardless of whether a resident was a victim or perpetrator. These standard interventions typically included 72-hour observation, consultations with pastoral care, social services, and psychiatric services, monitoring and documenting responses, and removing residents to a calm, safe environment when conflict arose. The facility’s own policy required comprehensive, person-centered care plans based on data gathering and careful consideration of problem areas and causes, but this was not reflected in practice. Multiple resident pairs were involved in documented altercations where individualized triggers and behavior patterns were not incorporated into active care plans. One resident with dementia and severe cognitive impairment, who wandered and entered other residents’ rooms, reported being punched in the nose by another resident with a history of going into others’ rooms and breaking personal items; staff knew that one resident preferred to be left alone and that the other frequently entered rooms, but these behaviors and staff interventions were not reflected in the care plans. In another case, a resident with severe cognitive impairment and parkinsonism was bruised under the eye after his roommate, who had psychotic disorder and severe cognitive impairment, accused him of stealing millions of dollars and punched him; staff described frequent delusions about stolen money and rapid escalation, yet the care plans did not document these specific triggers or staff strategies. Similarly, a resident with severe cognitive impairment and PTSD had his wrist grabbed and squeezed by another resident with dementia who was described as trying to be helpful by pulling him away from automatic doors, but the individualized behaviors and triggers for both residents were not integrated into their care plans. Additional incidents showed a pattern of unaddressed history of physical aggression and specific behavioral triggers. One resident with schizoaffective disorder and dementia had a prior documented assault on another resident and threats toward a nurse, but his active care plan did not reflect a history of physical aggression; later, he was observed kicking another resident multiple times, and both residents received identical, non-individualized psychosocial care plan focuses. Another resident with PTSD and cognitive impairment had prior documented physical aggression in resident-to-resident altercations, yet his care plan lacked any concern for physical aggression until after he was punched in the stomach by another resident with vascular dementia and a history of arguing and swinging at others; the aggressor’s behavioral care plan listed only anxiety and screaming/agitation as current behaviors despite a recent altercation. In a separate case, a resident reported being hit in the head by his roommate, who admitted striking him to take his blanket; this roommate had multiple prior behavior notes for taking other residents’ food and becoming combative during redirection, but his behavioral treatment plan did not reflect this history and instead focused on sexually inappropriate and isolative behaviors. Staff interviews confirmed that knowledge of resident behaviors and effective interventions was not consistently translated into the care plans. An LPN stated that all behaviors should be documented in the care plan but reported that nursing staff did not have access or did not know how to access and update care plans, indicating reliance on the MDS nurse for updates. A CNA reported that she documented incidents in the charting system and informed the nurse but did not have access to care plans. The MDS nurse acknowledged that all residents involved in resident-to-resident altercations were given the same vague, general interventions and that more detailed information about incidents was kept in Risk Management, to which not all staff had access. Corporate nursing staff stated that care plans were expected to be customized and that anyone in the building could update them, but this expectation was not reflected in practice, resulting in care plans that did not capture individualized triggers, histories of aggression, or specific staff interventions known to be effective.
Failure to Analyze and Trend Resident-to-Resident Abuse Incidents in QAA/QAPI
Penalty
Summary
The deficiency involves the facility’s failure to track, trend, and analyze resident-to-resident abuse incidents and to implement a measurable, data-driven prevention plan through its Quality Assessment and Assurance (QAA) process. Review of QAA meeting minutes for a December meeting covering November showed that the number of reportable incidents for November was left blank, despite trends indicating multiple incidents across specific units. The Director of Nursing’s clinical systems review did not specifically address resident-to-resident abuse, and the documented action plan remained a general approach focused on education about behaviors, memory care, and keeping residents at arm’s length, without measurable elements. The section for resolved action plans was left blank, and there was no documentation of measurable progress on preventing resident-to-resident abuse. Further review of QAA minutes for a February meeting covering December and January showed inconsistencies between the total number of reportable incidents and the number of incidents listed by unit, and again reflected the same non-specific action plan without measurable outcomes. Interviews with the DON and the Administrator confirmed that resident-to-resident altercations were only tracked as reportable events and primarily by location, with no deeper trend analysis such as triggers, patterns, or other causative factors. The Administrator acknowledged that trend tracking for resident-to-resident abuse did not go far enough, and the DON stated that the facility did not know what triggered residents, relying on psych services after altercations. These practices did not align with facility policies requiring QAPI review and analysis of all abuse-related occurrences and integration of confirmed abuse findings into performance improvement initiatives.
Failure to Update Behavioral Care Plans for Individualized Triggers and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update and individualize behavioral health care plans to reflect known triggers and behaviors for two residents with severe cognitive impairment and significant psychiatric diagnoses. For one resident with parkinsonism, major depressive disorder, psychotic disorder, and anxiety disorder, the care plan initiated in November 2025 identified behaviors such as putting himself on the floor, hiding, refusing care, and making statements that no one was offering him anything. Interventions included medication administration, positive interaction, explaining why behavior was inappropriate, protecting others’ rights and safety, diverting attention, and removing the resident from situations. A Behavior IDT Review in February 2026 added general approaches for agitation, anxiety, or restlessness, such as calm approaches, guiding to a quiet safe space, and offering calming activities. Despite these documented approaches, the resident had a known pattern of delusional accusations about others stealing his “four million dollars,” as described by staff interviews, and this behavior was associated with rapid escalation when he became agitated. An IDT note from February 13, 2026 documented that this resident accused another resident of stealing millions of dollars and punched that resident in the eye. Staff interviews confirmed that the resident frequently accused others of stealing his money and that this was a recurrent behavior, but the care plan and behavioral interventions were not updated to specifically address this individualized trigger or the associated risk of resident-to-resident altercations. For the second resident, admitted with Alzheimer’s disease, dementia with agitation, personality change, major depressive disorder, and anxiety disorder, multiple behavior notes from July and November 2024 documented repeated incidents of taking other residents’ food and becoming combative or difficult to redirect. However, the behavioral treatment plan dated December 19, 2025 focused on sexually inappropriate and isolative behaviors, with known triggers of female staff assisting with care, and listed past behaviors such as elopement and exposing himself, without indicating a history of taking other residents’ food. A care plan focus initiated in December 2025 similarly addressed sexual inappropriateness, delusions, elopement risk, and self-isolation, with interventions such as cares in pairs and following the behavior plan, but did not include the documented pattern of taking other residents’ food or belongings. Staff interviews indicated that this resident would try to take items he wanted and that staff attempted redirection, yet these behaviors and triggers were not incorporated into the current care plan, contrary to the facility’s dementia clinical protocol requiring the IDT to identify and document the resident’s condition and needed supports and to review changes as they arise.
Failure to Protect Resident From Staff Abuse and to Report Alleged Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to follow required abuse identification and reporting processes after a staff–resident altercation. Resident #6 had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, with a care plan indicating risk for unmet emotional, intellectual, physical, and social needs related to schizophrenia and directing staff to converse with the resident while providing care. A quarterly MDS showed moderately impaired cognition with a BIMS score of 10. On the date of the incident, behavior charting documented that the resident became very upset and physically and verbally aggressive with staff, but the clinical record contained no evidence of a skin assessment after the altercation between staff and the resident. According to the facility’s suspected abuse investigation report and staff interviews, Resident #6, in an electric wheelchair, was in the common/day room and became upset with an LPN while the LPN was at the medication cart. The resident ran into or knocked over the medication cart, spilling its contents, and used the electric wheelchair in a manner described as a weapon, moving around the day room and heading toward other residents. A CNA intervened by getting in front of the wheelchair; the resident then kicked the CNA, and the CNA responded by physically grabbing the resident’s leg, transferring the resident from the electric wheelchair to a recliner, and yelling loudly at the resident. The resident then moved himself to the floor and attempted to crawl back toward the wheelchair. The facility’s documentation and interviews confirm that the CNA’s loud, angry verbal response occurred during this altercation. The DON and administrator both described abuse as including physical, verbal, emotional, and financial harm and stated that the facility’s process for staff-to-resident abuse includes separating the parties, performing a head-to-toe assessment of the resident, and reporting suspected abuse to the State Agency within two hours, followed by an investigation. However, the progress notes from August 6, 2025, to February 3, 2026, did not document risk related to this incident, and there was no documentation of a head-to-toe or skin assessment of Resident #6 after the altercation. The DON and administrator each stated they did not consider the incident to be abuse because they believed the CNA’s actions were not intentional and were aimed at protecting other residents, and therefore the incident was not reported to the State Agency, contrary to the facility’s abuse identification and investigation policy and resident rights policy that require protection from abuse and appropriate assessment and documentation when staff are implicated in potential abuse situations.
Failure to Timely Report Alleged Staff-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse involving one resident to the State Agency (SA) as required by regulation and facility policy. The resident had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, and a recent MDS showed a BIMS score of 10, indicating moderately impaired cognition. On the date of the incident, behavior charting documented that the resident became very upset and physically and verbally aggressive with staff. According to the facility’s suspected abuse investigation report, the resident was attempting to run into staff and other residents with an electric wheelchair in a common area, and a CNA intervened by getting in front of the wheelchair. The resident then kicked the CNA, and the CNA placed the resident into a recliner while yelling loudly. The investigation concluded that the CNA’s loud complaining voice was not appropriate in a behavior setting. However, there was no evidence in the clinical record of a head-to-toe or skin assessment after this altercation. Record review and staff interviews revealed no documentation that this allegation of staff-to-resident abuse was reported to the SA within the required timeframe, and the facility was unable to provide any documentation of reporting when requested by surveyors. The DON and the administrator both described abuse as including physical, verbal, emotional, and financial harm and stated that the facility’s process is to separate the parties, assess the resident for injury, and notify the SA within 2 hours for staff-to-resident incidents. Both the DON and the administrator acknowledged that the incident between the CNA and the resident was not reported to the SA, explaining that they did not consider the CNA’s actions to be intentional abuse. Review of the facility’s policy on identification and investigation of abuse, neglect, misappropriation, and injuries of unknown origin showed that any alleged abuse, including physical or verbal, must be reported to the SA immediately, but not later than 2 hours after the allegation is made, and all other reportable allegations must be reported within 24 hours, which did not occur in this case.
Failure to Submit Required 5‑Day Abuse Investigation Report
Penalty
Summary
The deficiency involves the facility’s failure to submit an abuse investigation report to the State Survey Agency within 5 working days for an allegation involving one resident. The resident had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, and a recent MDS showed a BIMS score of 10, indicating moderately impaired cognition. A behavior charting assessment documented that the resident became very upset and physically and verbally aggressive with staff. On the date of the incident, documentation in a suspected abuse investigation report indicated that the resident attempted to run into staff and other residents with an electric wheelchair in a common area, a CNA positioned themself in front of the wheelchair, the resident kicked the CNA, and the CNA then placed the resident into a recliner while yelling loudly. The investigation concluded that the CNA’s loud complaining and raised voice were not appropriate in a behavioral setting. Surveyors requested the facility’s 5‑day investigation report for this abuse allegation, but the facility was unable to provide it. Review of the clinical record showed no evidence that the incident investigation report was submitted to the State Agency within 5 working days. Interviews with the DON and the administrator confirmed that facility policy and practice require immediate initiation of an abuse investigation, separation of the resident and staff, notification to the State Agency within 2 hours, and submission of a detailed investigation report within 5 working days. The administrator specifically stated that the facility did not have any 5‑day investigation report for the abuse allegation between the CNA and the resident. Review of the facility’s written policy on identification and investigation of abuse, neglect, misappropriation, and injuries of unknown origin confirmed that investigations must be completed within five working days, with limited exceptions, underscoring that the required 5‑day report was not completed or submitted in this case.
Failure to Protect Cognitively Impaired Residents From Physical Abuse by Resident and Visitor
Penalty
Summary
The deficiency involves the facility’s failure to protect three cognitively impaired residents from physical abuse by another resident and by a family member. For the first incident, two male residents with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, depression, anxiety, and mood disorders, were involved in a resident‑to‑resident altercation in the dining room. One resident, seated in a wheelchair, was observed by an LPN and the activities assistant being repeatedly hit with full force by another resident who was standing over him. Staff ran to separate the residents. Initial skin assessment documented no injury to the resident in the wheelchair, but a later change in condition evaluation identified an injury described as a knot on the left side of his forehead. The resident who initiated the hitting was found to have discoloration and hematomas on the knuckles of his right hand. The facility’s own care plans and assessments documented that both residents had severe cognitive impairment, with BIMS scores of 7 and 5, and that one resident had a known behavior problem related to taking things and flushing them down the toilet. The care plan for that resident included interventions such as anticipating and meeting needs, intervening as necessary to protect the rights and safety of others, diverting attention, and removing the resident from situations as needed. Following the altercation, a new care plan focus was added for psychosocial well‑being problems related to resident‑to‑resident altercations, with interventions such as 72‑hour observation and removing residents to a calm, safe environment when conflict arises. Staff interviews confirmed that several staff members witnessed the altercation, that the resident who hit the other stated someone was trying to get into his backside, and that the other resident denied doing anything. Both residents later denied or could not consistently report the altercation when interviewed by surveyors. The second incident involved a visitor‑to‑resident altercation between a severely cognitively impaired resident with dementia, Parkinsonism, hypertension, postconcussional syndrome, and a history of falls, and her husband. A CNA reported to a nurse that he heard the husband and the resident arguing loudly in another language and that the husband physically abused the resident in the day room. Another CNA later reported that her coworker had told her she witnessed the husband kicking the resident very hard when the resident refused to take medication, and that the resident was crying afterward and unable to express herself because she spoke Korean. Additional staff interviews corroborated that the husband became frustrated when assisting the resident with medications, eating, and ADLs, had yelled at and physically touched her in those situations, and that he had kicked her when she spat out medication. The DON acknowledged that the husband’s actions, including kicking the resident, constituted physical abuse. A care plan focus for psychosocial well‑being related to dementia and the husband’s behavior documented that he became frustrated and had yelled and physically touched the resident when trying to help her, and that the resident did better when he was present, with interventions including supervised visits in public places only and removing residents to a calm, safe environment when conflict arises. Across both incidents, staff interviews showed that personnel were generally aware of different types of abuse and the expectation to separate involved parties and report incidents to the nurse, DON, or administrator. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention stated that residents have the right to be free from abuse, including physical abuse. Despite this, the survey findings concluded that the facility failed to protect the rights of three residents to be free from physical abuse by other residents and family members, based on the resident‑to‑resident altercation in the dining room and the visitor‑to‑resident altercation involving the resident’s husband physically abusing her.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of multiple residents to be free from abuse by other residents, as evidenced by several documented incidents of resident-to-resident altercations resulting in physical harm and psychosocial distress. In one case, a resident with moderate cognitive impairment and a history of dementia was struck in the face with a door by another resident, resulting in an abrasion. The incident was witnessed by a staff member, who observed a verbal argument escalating to physical aggression. The perpetrator, who also had dementia and behavioral disturbances, was placed on increased supervision following the event. Another incident involved a resident with severe cognitive impairment who sustained a hematoma around the left eye after being slapped multiple times by another resident during an altercation in the dayroom. The aggressor, also severely cognitively impaired, had a care plan indicating a risk for verbal aggression. The altercation occurred while an LPN was present in the room but had their back turned at the time. Documentation indicated that the victim exhibited non-verbal signs of pain and distress following the incident. Additional altercations included a resident being pushed to the ground by another, resulting in a fracture, and a separate event where a resident was punched in the stomach after taking another resident's food. There was also an incident where two residents began arguing and physically hitting each other at the dinner table, requiring staff intervention. In each case, the facility's own policies defined such actions as abuse, and interviews with staff confirmed that these events met the definition of abuse and did not meet facility expectations. The report details that care plans for the involved residents included interventions for behavioral risks, but these measures were insufficient to prevent the abusive incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of several residents to be free from abuse by other residents, as evidenced by multiple incidents of resident-to-resident altercations. In one case, a resident with severe cognitive impairment and a history of Alzheimer's disease was struck in the abdomen and upper body on two consecutive days by another resident with moderate to severe cognitive impairment. Both incidents occurred in the dayroom, with staff intervention occurring only after the altercations had already taken place. Documentation showed that the residents were separated and assessed, but the altercations were witnessed by staff only after the events had begun, and there was a lack of proactive supervision or intervention to prevent recurrence, despite care plans indicating risk for such behaviors. Another incident involved a resident with severe cognitive impairment and behavioral disturbances who was struck on the arm by another resident with dementia and agitation. The altercation occurred in the dayroom and was only noticed by staff after a commotion was heard. Both residents were separated and assessed, but neither could recall the incident shortly after it occurred. The care plans for both residents included interventions for behavioral risks, but the altercation still occurred without immediate staff prevention. A further incident involved a resident with moderate cognitive impairment and multiple comorbidities who was pushed to the floor by another resident with severe cognitive impairment, resulting in a fractured hip. The altercation followed a verbal exchange in the dayroom and was witnessed by staff, but intervention was not immediate enough to prevent injury. The resident who was pushed required hospitalization for the injury. Interviews with staff and the DON confirmed that these incidents met the definition of abuse and did not meet the facility's expectations for resident safety and supervision.
Failure to Prevent Resident-to-Resident Physical Abuse in Dayroom
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse, as evidenced by an altercation between two residents with severe cognitive impairment. One resident with dementia, bipolar disorder, and other comorbidities became agitated over a seating arrangement with another resident diagnosed with Alzheimer's disease, Parkinson's disease, and bipolar disorder. The situation escalated into a verbal and physical altercation in the dayroom, where only one CNA was present with twelve residents at the time. The altercation involved pushing, kicking, and grabbing, resulting in both residents sustaining skin tears and contusions on their right hands. Staff interviews and video footage confirmed that the altercation lasted approximately one minute before additional staff arrived to intervene. The CNA present attempted to separate the residents but was not strong enough to do so alone and sustained scratches in the process. The incident was witnessed by other staff who arrived after the altercation had escalated, and both residents were noted to be upset and verbally aggressive following the event. The care plans for both residents were updated to reflect the psychosocial risk related to resident-to-resident altercations after the incident. A review of facility policies revealed that residents have the right to be free from abuse, including abuse by other residents, and that the facility is committed to preventing such incidents. Despite these policies, the staffing level in the dayroom at the time of the incident was insufficient to prevent or promptly intervene in the altercation, resulting in physical harm to both residents and injury to a staff member.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents of resident-to-resident altercations resulting in physical harm or distress. Several residents with cognitive impairments, behavioral disturbances, or psychiatric diagnoses were involved in physical altercations, including punching, hitting, biting, kicking, and other aggressive behaviors. In many cases, care plans identified behavioral risks and interventions, such as redirection or increased supervision, but these measures were not effective in preventing the altercations. Staff were often present or nearby during these incidents but were unable to intervene in time to prevent physical contact or injury. Specific incidents included residents with severe cognitive impairment or behavioral issues engaging in physical fights, such as punching each other in the face, smacking, or dragging another resident by the arm. In some cases, residents sustained visible injuries, such as bruises, bites, or skin discoloration, and required assessment and treatment. Documentation revealed that staff sometimes struggled to separate residents during altercations, and in several instances, altercations lasted for several minutes before staff could intervene. Some residents had a documented history of prior altercations with the same peers, and staff were aware of these patterns. The facility's documentation and interviews with staff and the administrator confirmed that these incidents were considered abuse and required reporting. However, the recurrence of such events, the inability to prevent or promptly stop physical altercations, and the lack of effective interventions to protect residents' rights to be free from abuse constituted a failure to ensure resident safety. The facility was also unable to provide investigation documents for some incidents beyond a 12-month period, indicating gaps in record-keeping related to abuse investigations.
Failure to Adhere to Abuse Prevention Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention policy following an incident of resident-to-resident abuse involving two residents. One resident, with a history of schizoaffective disorder, bipolar disorder, Asperger's syndrome, and behavioral problems including physical aggression, physically grabbed another resident's arm and attempted to drag him to the floor. Staff intervened with difficulty, and the aggressor attempted to throw a chair but was stopped. The resident expressed indifference when told not to abuse others. The victim, who also had multiple psychiatric and medical diagnoses, was found with slight discoloration on his arm and a ripped shirt sleeve after the altercation. Documentation indicated that the incident was recognized as abuse by the administrator and abuse coordinator. Despite the facility's policies requiring immediate reporting and investigation of abuse allegations, the investigation documentation could not be provided for review beyond 12 months. The facility's policies, revised in 2021 and 2022, clearly state the requirement for immediate reporting and investigation of abuse, as well as the right of residents to be free from abuse, neglect, and exploitation. However, the lack of available investigation records and the events described indicate that the facility did not fully implement or adhere to these policies in response to the incident.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving abuse between two residents. One resident, with a history of schizoaffective disorder, bipolar disorder, and behavioral problems including physical aggression and peer altercations, became physically aggressive during a medication pass. The resident yelled at a nurse, pointed a finger close to the nurse's face, and then charged at another resident, grabbing his arm and attempting to drag him to the floor. Staff had difficulty separating the two residents, and the aggressive resident attempted to throw a chair before being stopped by staff. The incident resulted in the second resident sustaining slight discoloration to his left arm and a ripped shirt sleeve. Despite the severity of the altercation, the facility did not initiate an investigation or notify all required parties until the following day, outside of the facility's policy requirement to report suspected abuse immediately, defined as within two hours. Clinical records and interviews confirmed the delay in reporting. The facility was unable to provide investigation documents beyond 12 months, and policy review confirmed the expectation for immediate reporting and investigation of abuse allegations.
Failure to Accurately Document Abuse Incidents and Resident Assessments
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for six residents in relation to abuse incidents, resident assessments, and the safeguarding of resident-identifiable information. For one resident with end-stage renal disease and multiple comorbidities, there was no evidence that staff completed required assessments before or after dialysis treatments, despite care plan interventions and policy requirements. Interviews with nursing staff and the DON revealed that while some monitoring was claimed to occur, there was no documentation in the medical record to support that assessments, including fistula site checks, were performed as required. Several residents involved in physical altercations did not have any documentation in their medical records regarding these incidents, even though the facility had reported the events to the state agency. The DON confirmed the absence of documentation for these altercations in the clinical records of the affected residents. Additionally, for a resident who reported a missing ring and alleged misappropriation of property, there was no documentation of the incident or the allegation in the clinical record, nor was the missing item recorded on the resident's inventory sheet. Policy reviews indicated that the facility's procedures required documentation of all services, incidents, and changes in resident condition in the medical record, as well as specific protocols for documenting abuse, neglect, and misappropriation allegations. Despite these policies, the facility did not maintain complete and accurate records for the identified residents, as confirmed by staff interviews and record reviews.
Inconsistent Advance Directive Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that advance directives were accurately completed and consistently maintained in the clinical records of two residents. For one resident with multiple diagnoses including hypertension, hyperlipidemia, epilepsy, schizoaffective disorder, intracranial injury with loss of consciousness, and major depressive disorder, a physician’s order documented full code status. However, a pre-hospital medical care directive signed by the resident indicated that the resident did not want CPR and was DNR. Despite this, the face sheet and care plan both listed the resident as full code, while the care plan goal stated that the resident’s end-of-life wishes would be honored. For a second resident with extensive medical conditions including kyphosis, hypertension, Type 2 DM with neuropathy, spinal stenosis, atherosclerotic heart disease, vascular dementia, mood disturbance, GERD, hyperlipidemia, anxiety disorder, COPD, dysphagia, and major depressive disorder, both a VA Advance Directive and a pre-hospital medical care directive signed by the resident documented DNR status and refusal of CPR. In contrast, the face sheet, care plan, progress notes, and a physician’s order all identified this resident as full code. Staff interviews confirmed that advance directives are initiated on admission and reviewed quarterly, that staff are expected to check both physical and electronic charts for code status, and that a specific form is required to document changes with updates to the EHR by medical records. The DON confirmed that discrepancies existed in both residents’ records and acknowledged that this could result in residents’ end-of-life wishes not being honored, contrary to facility policy on advance directives.
Expired Medications in Storage and Unsecured Bedside Medications
Penalty
Summary
Surveyors found that the facility failed to store and manage medications according to professional standards and facility policy. During an observation of the central medication room, multiple expired medications were identified, including unopened boxes of Alfrin Allergy Sinus nasal spray with an expiration date of January 2025, Bisacodyl stimulant laxative with an expiration date of June 2025, and Vitamin E 180 mg (400 IU) with an expiration date of April 2025. In a separate medication room (Vistas South), twenty boxes of Flucelvax Trival 2024–2025 syringes were found in the medication refrigerator, all expired as of June 17, 2025. These medications remained in storage despite the facility’s written policy requiring that all expired, discontinued, or deteriorated medications be promptly removed from storage and handled per pharmacy instructions. Surveyors also identified a failure to ensure medications were not left at a resident’s bedside without an assessment and authorization for self-administration. One resident with alcohol dependence, major depressive disorder, anxiety disorder, GERD, COPD, type 2 diabetes, and hyperlipidemia had a BIMS score of 12, indicating moderate cognitive impairment, and was documented as alert and oriented times two. During observation, this resident was found sleeping with a small cup of medications (aripiprazole, hydroxyzine, and cholecalciferol) left on the bedside table. The LPN who administered the medications stated she believed the resident had taken them but concluded the resident must have pocketed them and later spit them out after she left. The clinical record contained no evidence that the resident had been assessed and determined able to self-administer medications, despite the facility’s policy that residents may self-administer only if the physician and interdisciplinary team determine they have the decision-making capacity to do so safely.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, ate another resident's cookie during lunch. The second resident, who had severe cognitive impairment and a history of neurocognitive disorder with Lewy bodies, Parkinson's disease, and traumatic brain injury, responded by swinging at and hitting the first resident on the left ear. Staff intervened to separate the residents, and no physical injuries or pain were reported by the resident who was struck. Staff interviews confirmed that the incident involved both verbal and physical abuse, as the aggressor yelled, swore, and made unwanted physical contact. Facility policy defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish, and states that residents have the right to be free from abuse by anyone, including other residents. The incident was observed by staff, and the facility's policies regarding abuse prevention and resident rights were reviewed as part of the investigation.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical and sexual abuse, as well as neglect, as evidenced by several documented resident-to-resident altercations. In one incident, a resident with moderate cognitive impairment and a history of sexually inappropriate behavior was observed pushing a female resident with severe cognitive impairment against a wall and fondling her breasts in a common area. Staff and other residents reported that the female resident appeared frightened and expressed fear of the male resident, who had previously exhibited similar behaviors. Despite care plan interventions to prevent unsupervised contact, the incident occurred, and both residents were interviewed regarding the event. In other cases, residents with behavioral and cognitive impairments engaged in physical altercations resulting in injuries. For example, one resident struck another in the face multiple times in a dayroom altercation, with both residents having documented histories of aggression and care plans indicating the need for close monitoring and separation. Another incident involved a resident hitting a peer in the head over a dispute about a television remote, with witnesses and staff confirming the aggressive behavior. Additional altercations included a resident attacking a roommate, resulting in bleeding and emergency medical intervention, and another resident causing facial injuries to a peer who wandered into his room. The report details that in each of these cases, the facility's interventions, such as care plans for behavioral management and monitoring, were either insufficient or not effectively implemented to prevent abuse. Staff interviews confirmed awareness of the residents' behavioral risks and the definitions of abuse, but the incidents still occurred, indicating lapses in supervision and protection. Facility policies reviewed defined abuse broadly, including physical, sexual, and verbal abuse, and emphasized the right of residents to be free from such harm, yet the documented events demonstrate that these standards were not upheld in practice.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident with severe cognitive impairment and a history of behavioral disturbances, including physical aggression. The resident, diagnosed with dementia, anxiety disorder, and major depressive disorder, had multiple care plans indicating a risk for psychosocial distress and physical aggression, with interventions such as one-on-one care and frequent observation. Despite these interventions, the resident was involved in several resident-to-resident altercations, as documented in the facility's incident log and progress notes. One incident involved the resident physically striking another resident in the dayroom after a dispute over seating. Clinical documentation and behavior charting assessments revealed ongoing agitation, aggression, and poor boundaries, with interventions such as redirection and, at times, 1:1 monitoring. However, the implementation of 1:1 monitoring was inconsistent, as not all assessments indicated this level of supervision. Staff interviews confirmed that one-on-one care was only consistently provided after repeated incidents of aggression. The facility's policy required measures to minimize the possibility of abuse and address problematic resident behavior, but the failure to provide consistent supervision led to preventable altercations.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from being physically abused by another resident, also with severe cognitive impairment. The incident took place in a dayroom where one resident, who had a history of agitation, aggression, and behavioral disturbances, told the other to move and then struck him in the right eye. The altercation was witnessed by an LPN, who intervened to separate the residents. The assaulted resident was found to have discoloration around the right eye, and during an interview, stated he was punched by someone he did not know for no reason. Prior to the incident, the resident who initiated the altercation had documented episodes of agitation, aggression, and other behavioral issues, with interventions such as emotional support and redirection being used. The care plan for this resident identified a risk for psychological and emotional distress following altercations, but the interventions in place did not prevent the physical abuse from occurring. Facility policies reviewed emphasized the right of residents to be free from abuse and the responsibility of staff to minimize the possibility of abuse, but these measures were not sufficient to prevent the incident.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a skin tear injury. One resident, with a history of dementia, major depressive disorder, and traumatic brain injury, was identified as having potential for physical and verbal aggression. This resident was involved in an altercation with his roommate, who had moderate cognitive impairment and multiple psychiatric and medical diagnoses. The incident occurred when the aggressive resident struck his roommate on the left hand, causing a skin tear, as the latter was attempting to leave their shared room. Clinical documentation and staff interviews confirmed that the altercation resulted in a physical injury. The injured resident reported the incident to an LPN, who observed the wound and questioned both residents. Both provided conflicting accounts, with the aggressive resident referencing delusional beliefs and claiming the other resident had provoked him. The LPN and administrator both noted that the explanations given by the residents were inconsistent and, at times, nonsensical, but it was clear that a physical altercation had taken place, resulting in injury. The facility's investigation into the incident was ultimately unsubstantiated due to the lack of witnesses and conflicting statements from those involved. However, documentation revealed that the aggressive resident had a prior history of altercations and of taking belongings from others. Facility policies reviewed during the investigation emphasized the right of residents to be free from abuse and the facility's commitment to preventing such incidents, but the event demonstrated a failure to ensure this protection.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident #44, who has a history of psychological emotional distress, was involved in an altercation with Resident #33. Resident #33, diagnosed with dementia and known for wandering and aggressive behavior, allegedly hit Resident #44, causing him to fall and sustain injuries. Despite interventions in place, such as monitoring and one-to-one supervision, these measures were not effectively implemented, leading to the incident. Another incident involved Resident #70, who has severe cognitive impairment and a history of aggressive behavior, hitting Resident #180 in the back of the head. This incident was witnessed by a CNA, who intervened to separate the residents. Both residents have a history of behavioral issues, and the facility's failure to provide adequate supervision and documentation of checks contributed to the occurrence of this altercation. The facility's policies on abuse prevention were not adequately followed, as evidenced by the lack of consistent monitoring and documentation of residents with known behavioral issues. Staff interviews revealed inconsistencies in the understanding and implementation of abuse prevention protocols, contributing to the facility's failure to ensure a safe environment for all residents.
Inadequate Supervision Leads to Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of two residents, leading to a deficiency in ensuring a safe environment. Resident #13, who was admitted with diagnoses including dementia with agitation and epilepsy, was identified as an elopement risk due to a history of elopements and wandering behavior. Despite this, the resident managed to leave the facility undetected on January 5, 2025. The resident was last seen walking in the hallway, and shortly after, staff realized he was missing. The facility was searched, and the police were called. The resident was found and returned to the facility later that morning. Observations revealed that the door to the Kiva unit could be reopened without re-entering a keycode, which was identified as a potential concern for elopement. Resident #22, admitted with dementia and severe cognitive impairment, was also able to elope from the facility. Although initially assessed as not at risk for elopement, the resident's care plan indicated disorientation and impaired safety awareness. On January 8, 2025, the resident was last seen in the courtyard and was later found missing. A search was conducted, and the police were notified. The resident was eventually found by a passerby and returned to the facility by the police. Interviews with staff revealed that the resident may have followed someone out of the facility, as the unit required a physical key for entry and exit. Interviews with staff and maintenance personnel highlighted issues with door functionality and staffing levels. Staff reported that doors did not always lock properly, and maintenance records showed frequent work orders for door repairs. Additionally, staff expressed concerns about inadequate staffing levels, which may have contributed to the inability to monitor residents effectively. The facility's policy on wandering and elopements was reviewed, indicating a commitment to identifying at-risk residents and preventing harm, but the incidents demonstrated a failure to implement effective measures to prevent elopement.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications within the required timeframe to six residents, which could result in symptoms not being managed effectively and/or adverse effects. Observations revealed that medications scheduled for 8:00 a.m. were administered late to several residents. For instance, Resident #66, who has severe cognitive impairment and multiple diagnoses including Parkinson's disease, received their 8:00 a.m. medications at 9:36 a.m. Similarly, Resident #55, with severe cognitive impairment and conditions such as hypertension and Parkinson's disease, received their medications at approximately 10:07 a.m. Resident #12, with mild cognitive impairment and a history of major depression and transient ischemic attack, was observed receiving their 8:00 a.m. medications at 10:36 a.m. This included a medication that needed to be administered before meals, which was given after breakfast. Resident #2, who is cognitively intact and has a history of venous thrombosis and type II diabetes, received their medications at 10:45 a.m. Additionally, staff was observed administering medications to Resident #15 at 10:55 a.m. Resident #25, with severe cognitive impairment and multiple diagnoses including congestive heart failure and COPD, received their 8:00 a.m. medications at 11:21 a.m. The RN initially withheld blood pressure medication due to a low reading taken at 7:15 a.m., but upon rechecking, the blood pressure was within normal limits. Interviews with staff revealed that medications are supposed to be administered within one hour of the scheduled time, but this was not adhered to, leading to delays in medication administration.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident abuse involving two residents with severe cognitive impairments. Resident #26, who has a history of aggressive behaviors and severe cognitive impairment, was involved in an altercation with Resident #32. On the day of the incident, Resident #26 was agitated and aggressive, and despite being on a one-to-one supervision, managed to hit Resident #32 in the face. The incident occurred in the dayroom during medication administration, and staff intervened by separating the residents and redirecting them. Resident #32, who also has severe cognitive impairment and a history of physical aggression, was unable to recount the incident but indicated discomfort by placing a nurse's hand over his eye/head area. An assessment showed no apparent injury. Interviews with staff revealed that Resident #26 was known for being fast and aggressive, and the CNA responsible for her supervision did not see Resident #32 approaching. The facility's policy emphasizes the residents' right to be free from abuse, yet the incident highlights a failure in ensuring this protection.
Resident Elopement Due to Door Malfunction
Penalty
Summary
The facility failed to prevent the elopement of a resident identified as an elopement risk due to their medical conditions, including schizophrenia and vascular dementia. The resident, who had a history of attempting to leave the unit by trying different codes on the keypad and setting off alarms, successfully eloped from the facility. The care plan for the resident included interventions such as conducting Wanderguard safety checks and ensuring door alarms were functioning properly. However, on the day of the incident, the exit door malfunctioned, allowing the resident to leave the facility undetected until they were found outside and redirected back. Interviews with staff revealed that the door where the resident exited had previously required electrical wiring replacement, but there was no documentation to confirm when this maintenance occurred. The facility's policy required staff to ensure doors were secured and to account for residents at the beginning of each shift. Despite these measures, the resident was able to elope, indicating a failure in the facility's supervision and maintenance of safety measures. The incident highlights the need for consistent monitoring and maintenance of security systems to prevent such occurrences.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent abuse between two residents, leading to an altercation. Resident #3, who has a history of PTSD and anxiety, was involved in a physical altercation with Resident #4, who has anxiety disorder and other medical conditions. The incident occurred in the dayroom where Resident #3 was found with a bloody thumb after being yelled at by Resident #4. Later, Resident #3 reported being hit and kicked by Resident #4 in his room, resulting in an abrasion on his thumb. Resident #4, who was observed yelling and attempting to approach Resident #3, was described as aggressive and not easily redirectable. Despite staff intervention, Resident #4 continued to exhibit aggressive behavior, leading to the involvement of emergency services. Staff interviews revealed that the altercation was not an isolated incident, as similar conflicts had occurred previously. The staff's response included separating the residents and conducting frequent checks, but the supervision was insufficient to prevent the altercation. The facility's policy on abuse prevention emphasizes protecting residents from abuse by others, including fellow residents. However, the supervision and monitoring practices, as described by the Director of Nursing, were inadequate in this case. The facility relied on surveillance cameras and staff monitoring, but the lack of cameras in certain units and insufficient staff presence contributed to the failure to prevent the altercation between the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of psychotropic medications prior to administration. This deficiency was identified through a review of clinical records, staff interviews, and facility policy. The resident in question was admitted with several diagnoses, including cerebrovascular accident, aphasia, non-Alzheimer's dementia, and hemiplegia. The care plan indicated the use of psychotropic medications for conditions such as schizoaffective disorder and bipolar disorder with hallucinations. However, the facility did not provide evidence that the resident or their representative was informed about the psychotropic medications' risks and benefits. The resident's clinical records showed multiple psychotropic medications being administered over several months, including Rexulti, hydroxyzine, sertraline, and trazodone. Despite the administration of these medications, the facility did not have updated consents for the medications after the resident's admission. The Director of Nursing (DON) revealed that the consents on file were dated before the resident's admission and were transferred from a sister facility. The facility's policy requires that residents and/or their representatives be informed and participate in care planning and treatment, which was not adhered to in this case. Interviews with staff, including an LPN and the DON, confirmed that the facility relied on consents from a sister facility without obtaining new consents upon the resident's admission. The facility's policy on psychotropic medication use emphasizes the right of residents and/or their representatives to decline treatment, highlighting the importance of informed consent. The lack of updated consents and failure to inform the resident or their representative of the medication risks and benefits constitutes a deficiency in the facility's compliance with resident rights and informed consent policies.
Failure to Complete Level 2 PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The resident had a Pre-Admission Screening and Resident Review (PASRR) level one completed at an outside hospital, but the referral determination section was left blank. Upon admission to the facility, the resident had diagnoses including schizoaffective disorder, anxiety disorder, type 2 diabetes mellitus, and bipolar disorder. Despite these diagnoses, a level 2 PASRR referral was not completed, which is necessary for residents with such mental health conditions. The resident's care plan included the use of psychotropic, anti-anxiety, and antidepressant medications, with interventions to monitor for side effects and effectiveness. The resident's medication administration record showed various medications administered for conditions like depression, bipolar disorder, and schizophrenia. Despite these interventions, the facility did not complete the required level 2 PASRR referral, which could have ensured the resident received necessary specialized services. Interviews with facility staff, including the social service director and the administrator, revealed that the level 2 PASRR referral was overlooked. The social service director acknowledged the need for a level 2 PASRR due to the resident's mental health diagnoses. The administrator and DON confirmed that the hospital completed the initial PASRR, but the facility did not have a physical copy of the level 2 PASRR and had not followed up adequately with the Arizona Long Term Care System (ALTCS) to ensure its completion.
Resident Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with amyotrophic lateral sclerosis, dementia with psychosis, and depressive disorder, leading to the resident wandering away and becoming lost in the community. Despite exhibiting wandering and elopement behaviors on multiple occasions, the resident's elopement risk evaluation indicated no risk for elopement, and the care plan did not address these behaviors. The resident's behavior monitoring and intervention notes consistently documented wandering and elopement behaviors, yet no interventions were implemented to address these issues. On September 9, 2024, the resident was found missing from their room, having exited through a window that lacked an alarm. The resident was later located by police officers a block from the facility, having sustained minor injuries from a fall while attempting to enter a moving vehicle. Interviews with staff revealed that the resident had expressed a desire to leave the facility and had been restless and pacing prior to the incident. Staff also noted that the window in the resident's room was easy to open, contributing to the resident's ability to leave the facility undetected. The facility's policy on wandering and elopements, revised in March 2019, stated that residents at risk for unsafe wandering should have care plans with strategies and interventions to maintain safety. However, the director of nursing acknowledged that the resident was not care planned for wandering behaviors, and the facility relied on an initial assessment that inaccurately indicated no risk for elopement. This oversight in care planning and risk assessment contributed to the resident's ability to wander away from the facility, resulting in the incident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, specifically sexual abuse, by other residents. Resident #40, who had severe cognitive impairment and a history of wandering, was inappropriately touched by another resident, #49, who had a history of sexually inappropriate behavior. Despite previous incidents, there was no evidence of new interventions to address resident #49's behavior, and the incident was not reported to the state agency or police. The facility's Director of Nursing (DON) and Administrator were aware of the incident but did not take appropriate action, citing the cognitive status of resident #40 as a reason for not considering it abuse. Additionally, the facility failed to protect residents #25 and #5 from abuse by resident #6. Resident #25, with severe cognitive impairment and a history of aggressive behavior, was involved in an altercation with resident #6, who also had severe cognitive impairment and a history of physical aggression. The facility's staff, including CNAs and LPNs, reported difficulties in managing these behaviors due to insufficient staffing, which hindered their ability to monitor and redirect residents effectively. The facility's policies on abuse and neglect were not adequately implemented, as evidenced by the lack of timely reporting and intervention in these incidents. Interviews with staff revealed a lack of awareness and training on handling such situations, and the facility's leadership did not prioritize the safety and protection of residents. The facility's assessment claimed it could provide the necessary supervision and care, but the incidents demonstrated a failure to meet these standards.
Failure to Report Abuse and Inappropriate Behavior
Penalty
Summary
The facility failed to report allegations of abuse involving three residents to the State Agency, Adult Protective Services, and local law enforcement. Resident #40, who has Alzheimer's disease and dementia, was inappropriately touched by another resident, #49, who has vascular dementia and a history of sexual inappropriateness. Despite documentation of the incident, it was not reported to the appropriate authorities. The Director of Nursing (DON) and the Administrator were unaware of the incident initially, and the DON later stated that the behavior was not considered abuse due to the cognitive status of Resident #40. Resident #25, diagnosed with vascular dementia and severe cognitive impairment, was involved in incidents where he was found naked in another resident's room and touching a sleeping female resident. These incidents were not reported to the State Agency, APS, or law enforcement. The DON acknowledged a disconnect in staff reporting and mentioned ongoing training to address the issue. The facility's policy requires all reports of abuse, neglect, or exploitation to be reported to local, state, and federal agencies, but this was not followed. The facility's staff, including the DON and Administrator, were not consistently notified of reportable events, leading to a failure in reporting. Interviews with staff revealed confusion about what constitutes a reportable event, with some staff believing that behaviors considered baseline did not need to be reported. The facility's assessment indicated they could provide the necessary supervision and care, but the incidents suggest otherwise. The lack of reporting and proper documentation of these incidents highlights a significant deficiency in the facility's handling of resident safety and abuse prevention.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving residents. In one instance, a certified nurse assistant (CNA) found a resident cornered outside with another resident who touched her inappropriately. Although the CNA intervened and initiated 15-minute checks, there was no evidence of a comprehensive investigation, including interviews with other residents, staff, or witnesses, nor was there documentation of reporting the incident to appropriate agencies or conclusions drawn from the investigation. Another incident involved a resident found naked in another resident's room and touching a sleeping female's thighs. Despite the severity of the situation, there was no evidence of a thorough investigation, including observations, interviews, or reporting to appropriate agencies. The Director of Nursing (DON) acknowledged a disconnect with staff regarding the reporting of such incidents and noted that training was being conducted to address this issue. The facility's policy on abuse, neglect, exploitation, and misappropriation outlines specific steps for conducting investigations, including reviewing documentation, interviewing involved parties, and documenting the investigation thoroughly. However, these procedures were not followed in the reported incidents, leading to a deficiency in ensuring the safety and rights of the residents involved.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure sufficient staffing to provide adequate supervision for residents, leading to incidents involving inappropriate behavior between residents. Resident #40, diagnosed with Alzheimer's disease and dementia, was found in a situation where another resident, #49, touched her inappropriately. This incident was documented on August 28, 2024, and resulted in the initiation of 15-minute checks and notification of the power of attorney, director of nursing, and physician. Resident #49, with a history of vascular dementia and behavioral disturbances, had previous incidents of inappropriate behavior, including an event on August 8, 2024, where he was reported to have fondled Resident #40. The facility's staffing schedule revealed a shortage of CNAs, with only 12 CNAs on the day and night shifts, and 16 on the evening shift, despite the facility's assessment indicating a need for 56 CNAs daily. Interviews with staff, including CNAs and LPNs, highlighted concerns about insufficient staffing levels, which hindered their ability to monitor residents effectively and provide timely care. Staff reported difficulties in preventing falls, providing activities of daily living, and monitoring residents' behaviors due to the reduced staff-to-resident ratio. The director of nursing and the administrator acknowledged the staffing challenges but indicated that staffing decisions were based on daily assessments of residents' behaviors and needs, which were not documented. The staffing coordinator admitted to not reviewing clinical records to determine staffing needs and relied on staff reports. The administrator expressed a belief that the facility provided adequate supervision, despite acknowledging the responsibility to protect residents. The lack of sufficient staff was linked to increased risks of neglect, falls, and vulnerability to inappropriate acts among residents.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #650, who was cognitively intact with a BIMS score of 13, was involved in an altercation with Resident #625, who had severe cognitive impairment with a BIMS score of 4. The incident occurred in the day room when Resident #650 told Resident #625 to "shut up," which led to Resident #625 becoming angry and physically attacking Resident #650. The altercation was broken up by a nurse, and Resident #625 then turned his aggression towards the nurse, threatening and spitting. Resident #650 had been transferred to the facility following an altercation and had a care plan indicating a risk for psychosocial emotional distress related to resident-to-resident altercations. Despite this, the facility did not prevent the altercation from occurring. Resident #625 had a history of verbal aggression and psychotic thinking, as noted in his care plan, and had been reported as irritable and short-tempered prior to the incident. However, no physical aggression had been observed before the altercation with Resident #650. The facility's investigation confirmed the altercation and noted that Resident #625 was triggered by Resident #650's comment. Witness statements corroborated the sequence of events, and the facility's policy on abuse prevention was not effectively implemented to prevent the incident. Interviews with staff indicated that the protocol for handling such altercations involved separating the residents and reporting the incident, but the deficiency lay in the failure to prevent the altercation from occurring in the first place.
Inconsistent PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control standards, particularly in the use of Personal Protective Equipment (PPE), during a COVID-19 outbreak. Observations revealed that staff, including the concierge at the front desk, were not consistently wearing masks despite the presence of signs indicating a COVID-19 outbreak and the requirement for all staff to wear CDC-recommended PPE, including N95 masks. The concierge admitted to forgetting to wear a mask and was not accustomed to wearing one anymore. Additionally, individuals in the reception area and hallway were observed not wearing masks, and the Director of Nursing (DON) and Administrator removed their masks during a conference. Interviews with staff, including CNAs and the Infection Preventionist (IP), highlighted inconsistencies in the implementation of infection control protocols. Staff were aware of the outbreak and the requirement to wear masks upon entering the facility, yet there was confusion about the enforcement of these protocols, particularly in shared spaces with another company operating in the same building. The IP noted that the receptionist, who was not their employee, was expected to wear a mask and educate visitors, but enforcement was challenging. The DON acknowledged the importance of following protocols to prevent the spread of infection but noted that it was up to guests to comply with PPE requirements. The facility's infection control policy, dated October 2018, aimed to maintain a safe and sanitary environment to prevent disease transmission. However, the report indicates a lack of consistent adherence to these policies, particularly in the shared entry areas and among staff not directly employed by the facility. The report does not mention any corrective actions or follow-up measures taken to address these deficiencies.
Failure to Protect Residents from Abuse and Assess Consent Capacity
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, resulting in a condition of Immediate Jeopardy and Substandard Quality of Care. Resident #23, who had a history of schizoaffective disorder, bipolar type, dementia, and anxiety disorder, reported allegations of sexual abuse by a certified nurse assistant (CNA). Despite the resident's moderate cognitive impairment and history of behavioral issues, the allegations were not reported to the State Agency or addressed by management. Interviews revealed that the resident had made multiple allegations of inappropriate touching by the CNA, which were not taken seriously by the facility's staff, including the Director of Nursing (DON), who failed to report the incident. Resident #3, diagnosed with generalized anxiety disorder, major depressive disorder, and Parkinson's disease, was found with bruises and scratches allegedly caused by rough handling by the same CNA. The incident was reported by other CNAs, but management did not take appropriate action. The DON did not consider the event reportable, attributing the injuries to the resident's agitation and history of swinging arms. The facility's failure to investigate and report the incident properly contributed to the deficiency. Additionally, the facility did not assess the ability of residents #45 and #9 to consent to a sexual relationship, despite incidents of inappropriate behavior between them. Both residents had severe cognitive impairments, and the facility lacked documentation of any assessment regarding their capacity to consent. The DON acknowledged the incident but failed to document or report it appropriately. The facility's policies on abuse prevention and reporting were not followed, leading to the identified deficiencies.
Failure to Report Allegations of Abuse and Inappropriate Incidents
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency, Adult Protective Services, and local law enforcement for three residents. Resident #23, who had moderate cognitive impairment, reported allegations of sexual abuse by a certified nurse assistant (CNA). Despite the resident's claims and the involvement of multiple staff members who were aware of the allegations, there was no evidence that the incident was reported to the appropriate authorities. Interviews with staff revealed inconsistencies in the handling of the allegations, with some staff dismissing the claims as false due to the resident's history of behavioral issues. Resident #3, who had severe cognitive impairment, was found with bruises and scratches, reportedly caused by rough handling by a CNA. Witnesses reported seeing the CNA push a table against the resident, yet the incident was not reported to the necessary agencies. The Director of Nursing (DON) did not consider the event reportable, attributing the injuries to the resident's agitation and behavior, despite staff reports suggesting otherwise. Residents #45 and #9, both with severe cognitive impairments, were involved in an incident of physical touching that was not reported. The DON stated that an assessment of the residents' ability to consent to a sexual relationship was conducted, but no documentation was found. The facility's policy requires reporting such incidents, but the DON did not report the incident to the State Agency or police, citing the need for an investigation to ensure resident safety.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving multiple residents, leading to a deficiency in ensuring resident safety. Resident #23, who has schizoaffective disorder, bipolar type, dementia, and anxiety disorder, reported allegations of sexual abuse by a CNA. Despite the resident's moderate cognitive impairment and history of false accusations, the facility did not report the allegations to local agencies or conduct a comprehensive investigation. Interviews with staff revealed inconsistencies in the handling of the allegations, and the alleged CNA continued to work in proximity to the resident without any protective measures in place. Resident #3, with severe cognitive impairment due to generalized anxiety disorder, major depressive disorder, and Parkinson's disease, was found with bruises and scratches. The incident was reportedly caused by rough handling by a CNA, but the facility did not report the incident to appropriate authorities or conduct a thorough investigation. The DON did not consider the event reportable, attributing the injuries to the resident's agitation and behavior, despite witness accounts of the CNA's actions. Additionally, an incident involving residents #45 and #9, both with severe cognitive impairments, was not properly investigated. The residents were found engaging in sexual acts, but there was no documentation of their ability to consent. The facility's policy requires thorough investigation and reporting of such incidents, but this was not adhered to, leaving the residents unprotected and the incidents unaddressed.
Failure to Notify Family of Resident Injury
Penalty
Summary
The facility failed to notify a resident's representative of an injury sustained by the resident, which is a violation of their policy. The resident, who had a history of dementia, hypertension, type 2 diabetes mellitus, and other conditions, sustained an injury to his left lower leg on March 19, 2024. Despite the facility's policy requiring notification of the resident's family in such events, there was no documentation in the electronic health record indicating that the family had been informed. Interviews with staff members revealed a lack of clarity and adherence to the notification policy, with one LPN unsure if the injury required family notification and unable to recall if such notification had occurred. The Director of Nursing confirmed that the expectation was for family notification to be documented, but upon review, no evidence of such documentation was found. The facility's policy on accidents and incidents mandates prompt investigation and documentation, including family notification, but this was not followed in the case of the resident's injury. The failure to notify the family could result in them being unaware of the resident's condition, as well as other staff being uninformed about whether the notification had occurred.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in two incidents of physical altercations. The first incident occurred when a resident with dementia, PTSD, and adjustment disorder was slapped by another resident with dementia, PTSD, and major depressive disorder. The staff conducted a skin assessment on the victim and found no injuries. Despite the incident, no changes were made to the care plans of either resident, and they continued to reside in the same unit. A second incident occurred when the same aggressive resident hit the victim again, causing a superficial scratch. This time, a psychological evaluation was ordered, and the aggressive resident was moved to another unit. However, the care plan for the aggressive resident was only updated later to include triggers for their behavior, such as loud noises or shouting. Interviews with staff revealed a lack of clarity and prompt action in updating care plans and separating the residents after the first incident.
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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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