Sandstone Of Tucson Rehab Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 2900 East Milber Street, Tucson, Arizona 85714
- CMS Provider Number
- 035099
- Inspections on file
- 33
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Sandstone Of Tucson Rehab Centre during CMS and state inspections, most recent first.
Two cognitively intact residents sharing a room, one with spinal and depressive conditions and the other with cerebral palsy, scoliosis, and documented behavioral disturbances including physical aggression and poor impulse control, became involved in a physical altercation after a disagreement about television volume. One resident reported being strangled and grabbed around the neck and shoulder, resulting in a skin tear on the forearm and neck redness, while the other resident reported being punched and had a minor raised area on the cheek. The aggressive resident’s care plan already identified behavioral risks and listed interventions such as 15-minute checks and noise reduction, yet the incident still occurred in the shared room. Staff interviews reflected that a CNA heard the report of choking and saw arm scratches, the DON initially characterized the event as a behavioral outburst rather than abuse before later acknowledging it could be abuse, and the Administrator described the event as a very aggressive attack on the resident’s neck and categorized it as abuse, consistent with the facility’s abuse policy and subsequent verification of resident-to-resident abuse.
A cognitively impaired resident with dementia and behavioral symptoms was started on PRN Hydroxyzine for anxiety following a psych evaluation, and the MAR showed four doses were administered. Multiple LPNs and the DON confirmed that facility protocol and policy require a signed consent from the resident or responsible party before administering psychotropic medications and that staff must verify this consent in the system. Record review and staff interviews established that no signed consent for Hydroxyzine existed in the chart or medical records at the time the doses were given, resulting in administration of a psychotropic medication without the required informed consent.
A cognitively impaired resident with dementia and behavioral symptoms was allegedly abused during a night shift, but the LPN who witnessed the incident did not report it to the administrator before going home, later citing shock and misunderstanding of the reporting timeframe. The allegation was reported to the administrator the following afternoon, rather than immediately, despite regular abuse training and a facility policy requiring immediate reporting of suspected abuse to the administrator or designee and prompt notification of the State Agency.
A cognitively intact resident with multiple behavioral health and neurological diagnoses, including Huntington’s disease and anxiety disorder, repeatedly requested a replacement cellphone after her previous phone broke, but the facility did not facilitate obtaining one despite the resident having sufficient personal funds and being her own responsible party. The business office manager acknowledged the resident’s request and available trust fund balance but delayed action while waiting for the resident’s sister, who was minimally involved, to decide, citing prior excessive food spending via cellphone. The social service director reported that the resident’s cellphone had been removed for several months due to concerns about a hot charger and weight gain from food orders, limiting her to using facility phones at the nurses’ station or unit. This inaction conflicted with the resident’s care plans, which emphasized phone-based communication to support mood and psychosocial well-being, and with facility policy guaranteeing residents the right to keep personal possessions and have reasonable access to a telephone for private conversation.
A cognitively impaired resident with dementia, aphasia, and hemiplegia, living on a secured unit and care planned as at risk for psychosocial and cognitive problems, was punched twice in the nose in a hallway by another resident with dementia, schizophrenia, psychosis, and a documented history of physical aggression toward staff and other residents. The victim sustained a nasal abrasion, pain, and subsequent bruising around one eye, while the aggressor later stated he acted because he believed the other resident had touched his girlfriend’s hand, although she was not present. Prior episodes in which the aggressive resident hit another resident and struck a CNA’s hand and threw a bedside commode were documented in nursing notes but were not incorporated into care plans with specific preventive interventions at the time. Facility policies required assessment, care planning, monitoring, and implementation of interventions for residents with aggressive behaviors and for resident-to-resident altercation risk, but these measures were not effectively implemented for the aggressive resident, leading to the verified abuse incident.
A cognitively intact resident with depression and COPD befriended a younger, cognitively intact resident with a history of poor impulse control. The older resident gave the younger resident a debit card and cash to hold, after which the younger resident used the funds without permission for online purchases, clothing, and virtual slot game coins. The victim later reported that money was being stolen and became upset, anxious, and withdrawn after realizing the financial exploitation. Staff interviews confirmed that the victim’s funds were used without consent and that boxes of purchases were observed in the alleged perpetrator’s room. Although staff described the situation as financial abuse and exploitation, the facility’s incident follow-up report omitted the residents’ names, no self-report for the relevant period was found, and the administrator could not locate a complete reportable event or investigation record, demonstrating a failure to protect the resident’s property and to properly document the substantiated misappropriation.
The facility failed to maintain documentation showing that an allegation of financial misappropriation between two cognitively intact residents was thoroughly investigated. One resident with depression, COPD, anemia, and weakness reported that a younger resident, whom she had befriended, used her debit card and cash without permission, leading to distress, increased anxiety, and a desire to leave the facility. Staff interviews confirmed that the situation was viewed as financial abuse or exploitation and that outside agencies and police were contacted, but the incident follow-up report omitted the residents’ identities and lacked staff or resident interview statements. When surveyors requested the self-report and investigation records for the period in question, the administrator could not locate any reportable event or complete investigative documentation, resulting in a deficiency for failure to maintain records of a thorough investigation.
A resident was readmitted with multiple conditions including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit, and was assessed on admission as a high fall risk using the Morse Fall Scale. Despite this, the facility did not develop a required baseline care plan within 48 hours to address the resident’s immediate needs, and the comprehensive care plan was not initiated until later. Nursing notes documented unsteady gait, poor balance, and the resident’s attempts to ambulate independently, followed by multiple falls and subsequent neuro checks. An RN later confirmed that no baseline care plan existed in the EMR, and the DON acknowledged that the fall care plan did not reflect the high fall risk identified in the assessment and was not updated after the falls, contrary to facility policy and CMS requirements for baseline care planning.
A resident with multiple comorbidities, impaired mobility, and severely impaired cognition was assessed as high risk for falls on admission and had an initial care plan addressing fall risk and ADL deficits. Nursing notes later documented unsteady gait, poor balance, refusal to follow instructions, and three separate fall incidents, including unwitnessed falls with injuries, with neuro checks and immediate post-fall assessments completed each time. Despite these events and the documented high fall risk, the comprehensive care plan was not reviewed or revised after the falls, and the DON acknowledged that the fall care plan did not reflect the high fall risk identified in the assessment, in contrast to the facility’s fall prevention policy and interdisciplinary care planning expectations.
A cognitively intact resident with Huntington’s disease and significant behavioral issues participated in a group activity using toy guns and foam darts, where residents were not positioned as the activity director required to prevent darts from striking others, and the sole activity aide left the room briefly, leaving all participants unsupervised. Another cognitively intact resident with a history of suicidal ideation, substance use, homelessness, and extensive incarceration was assessed as low risk for wandering/elopement using a tool that did not address psychosocial or substance‑use factors, and later left the premises by car during an unsupervised smoking break after requesting a dressing change be delayed until after smoking. Subsequent observation showed multiple residents smoking outside without staff present while the receptionist remained inside, despite facility policies requiring adequate supervision, elopement risk assessment, and activity programming coordinated with comprehensive assessments.
A resident with intact cognition and a documented history of altercations, including a care plan intervention to be removed from the environment when verbally escalating, approached a cognitively impaired, wandering resident in a hallway, verbally challenged her, and scratched her arm, causing multiple superficial skin tears and pain. Documentation and interviews showed that staff recognized the event as physical abuse and that it occurred despite an existing abuse policy requiring an environment free from abuse.
A resident with severe cognitive impairment and psychiatric diagnoses was subjected to verbal and physical abuse by a roommate with a known history of aggression and behavioral disturbances. Despite staff awareness of both residents' behavioral histories and concerns about room compatibility, the two were assigned as roommates, leading to an incident where one resident verbally threatened and physically struck the other. Staff intervened during the altercation, but the facility failed to prevent the abuse, resulting in a violation of the resident's right to safety.
Two residents with severe cognitive impairment and histories of aggressive behavior physically assaulted peers in separate incidents. In one case, a resident struck another on the head, causing bleeding, while in another, a resident hit a peer on the nose following a wheelchair collision. Staff interviews and documentation confirmed that both incidents involved residents with known behavioral risks who were able to harm others before being separated by staff.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found that staff were not consistently trained or monitored, and there was a lack of regular review or updating of procedures to protect residents.
Two residents with cognitive and behavioral impairments were involved in an altercation where one threatened to harm the other, requiring CNA intervention. Although the incident was documented by an LPN and later verified, it was not reported to state agencies or investigated immediately as required by facility policy. Staff interviews confirmed the delay in reporting and lack of prompt action.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Multiple residents experienced abuse and neglect due to lapses in supervision and failure to implement care plans. Incidents included a resident with cognitive impairment physically assaulting another resident and a CNA after being removed from 1:1 supervision, a resident with dementia entering another's room and striking her, and a resident with Parkinson's disease sustaining a burn from hot coffee due to inadequate supervision and lack of appropriate adaptive equipment. Staff interviews confirmed that interventions were not consistently followed, leading to these events.
A resident with behavioral symptoms and a history of resistance to care reported verbal abuse and neglect by a CNA, but the allegation was not reported to the State Survey Agency within the required timeframe. Staff interviews revealed confusion about reporting responsibilities, and internal records confirmed that the incident was not reported as required by facility policy.
The facility failed to monitor and document behaviors before administering medications to two residents, risking over-medication. One resident with severe cognitive impairment was prescribed Paroxetine and Risperidone, while another was on Escitalopram and Olanzapine. Staff interviews confirmed that behavior tracking was not conducted as required by facility policy.
A resident with severe cognitive impairment and high fall risk experienced an unwitnessed fall, resulting in a head abrasion. The facility failed to conduct and document the required neurochecks as per policy, with only one check recorded. Staff interviews confirmed the importance of neurochecks for identifying potential issues like brain bleeds, highlighting a lapse in following professional standards of practice.
A facility failed to protect residents from abuse, as two cognitively impaired residents were involved in an inappropriate incident due to inadequate supervision. Despite care plans for frequent safety checks, a resident with dementia was found in another resident's room without pants, with the other resident's hand in her groin. Staff interviews revealed insufficient supervision and confusion about consent and abuse policies.
A resident with severe cognitive impairment assaulted another resident due to inadequate supervision by a CNA, who failed to maintain the required one-on-one supervision. This lapse allowed the resident to leave a shared bathroom and attack another resident, resulting in physical injury. The facility's policy mandates that residents be free from abuse, but the failure to adhere to supervision requirements led to this incident.
A resident with cognitive impairments eloped from a secured unit after being mistakenly identified as a visitor by a staff member. Despite being assessed as a low elopement risk, the resident had shown exit-seeking behavior. Staff failed to secure the exit, and the facility lacked a documented policy for security doors.
The facility failed to hold regular resident council meetings and address grievances and recommendations voiced during these meetings. Reviews of council minutes and grievance logs showed no written documentation of feedback or resolution. Interviews with residents and staff confirmed that issues raised were not followed up on, leading to residents feeling unheard and frustrated.
The facility failed to ensure that meals were provided to residents seated together at the same time, compromising their dignity. Observations revealed sporadic meal service without regard to seating arrangements, confirmed by interviews with the Food Service Director and Administrator.
A resident admitted with a fracture of the left patella was not informed of their rights due to the facility's failure to complete the non-clinical admission packet. The absence of a ward clerk led to this oversight, as confirmed by the DON and ADON.
The facility failed to protect a resident with dementia from physical abuse by another resident with a history of aggression. Despite multiple incidents and internal reports, the aggressive resident's care plan was not updated to include interventions to manage her behavior, contrary to facility policy.
The facility failed to ensure timely PASARR level II referrals for two residents with serious mental disorders, resulting in potential lapses in appropriate service provision. Despite having policies in place, the facility did not adhere to the required procedures, as evidenced by the delayed referrals and lack of documentation.
The facility failed to ensure that a resident or the resident's representative was able to participate in the care planning process. Despite being cognitively intact and wanting to provide input, the resident was not invited to care plan meetings for about a year, and there was no documentation of invitations or attendance in the medical record.
The facility failed to administer medications as ordered for three residents, resulting in incorrect medication administration. Errors included administering the wrong type of insulin, an incorrect dosage of a nicotine patch, and a chewable aspirin tablet instead of an enteric-coated capsule. These errors were identified through observations and staff interviews, indicating a failure to follow the facility's medication administration policy.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director was hired without the necessary qualifications and had not completed the required training course. Despite this, the facility's owners and Administrator allowed her to transfer from another facility. The job description clearly states that satisfactory completion of a training course and a minimum of two years of experience are required, which the current Activity Director did not meet.
A resident with cognitive intactness had several medications left at the bedside without proper self-administration assessment or approval, posing a risk of medication-induced harm. Staff confirmed that the medications should not have been at the bedside without proper approval, and the facility's policy on self-administration was not followed.
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.11%. Errors included incorrect administration of insulin, nicotine patches, and aspirin to three residents. The Director of Nursing acknowledged the issue, which violated the facility's policy.
The facility failed to ensure that expired medications and devices were not readily accessible for use. During observations, expired enteral feeding supplies and a topical medication were found in the medication storage room and a medication cart. The LPNs confirmed the expiration dates and stated that the expired items would be discarded. The DON acknowledged that expired items should be removed and discarded according to the facility's policy.
The facility failed to provide food at a palatable and appetizing temperature, as evidenced by multiple resident complaints and a test tray observation showing food temperatures below the facility's standard. The Administrator acknowledged the issue, but the current food service did not meet expectations.
The facility failed to maintain proper food safety and hygiene practices, including transporting uncovered food past COVID-19 isolation rooms and storing undated and expired food items in a filthy resident refrigerator/freezer. Staff acknowledged the deficiencies, which did not meet the facility's standards.
Failure to Protect Cognitively Intact Resident From Roommate’s Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from abuse by his roommate during a resident-to-resident altercation. One resident with a history of spinal fusion, lower back pain, and major depressive disorder reported to an RN that his roommate physically attacked him after a disagreement about the television volume. Nursing documentation and a skin assessment noted a skin tear on the resident’s left forearm and redness on the right side of his neck, attributed to physical contact/aggression with another resident. The resident later told surveyors that his roommate started strangling him after he asked him to turn down the television volume, and the surveyor observed a quarter-sized scab on his left arm that the resident stated was from the attack. The roommate involved in the altercation was also cognitively intact and had diagnoses including cellulitis of both lower limbs, cerebral palsy, scoliosis, and documented behavioral disturbances such as physical aggression, impulsivity, verbal aggression, and poor impulse control related to a mood disorder. The care plan for this resident identified these behavioral issues and included interventions such as 15-minute checks, reducing noise, dimming lights, and offering choices. Despite these identified risks and planned interventions, the altercation occurred in the shared room, where the roommate allegedly grabbed the first resident around the neck and shoulder area after a verbal disagreement about the television volume. Nursing notes documented that the aggressor resident reported being punched in the face and then reacting by grabbing the other resident’s neck and shoulder, and that he had a minimal raised area on the left cheekbone without discoloration or pain. Interviews with staff and leadership showed uncertainty and inconsistency in recognizing and characterizing the incident as abuse. A CNA reported hearing the resident state that his roommate had choked him and observed scratches on the resident’s left arm, but did not witness the event. The DON initially described the event as a behavioral incident stemming from anger and emotions, expressed uncertainty about who grabbed whom, and stated that she did not initially consider it abuse because she viewed abuse as an intentional act, later acknowledging that the situation could probably be abuse. The Administrator described the event as a very aggressive altercation in which the roommate went under the curtain, was very angry, and went after the resident’s neck with both hands, and categorized the incident as abuse toward the resident. The facility’s abuse and neglect policy defined abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, and the facility’s own 5-day report ultimately verified the allegation of resident-to-resident abuse.
Psychotropic Medication Administered Without Required Consent
Penalty
Summary
The deficiency involves the facility’s failure to obtain a signed consent from the responsible party before initiating a new psychotropic medication, Hydroxyzine, for Resident #4. The resident was admitted with dementia with associated psychotic, mood, and anxiety disturbances, a history of UTIs, and repeated falls. An admission MDS showed a BIMS score of 02, indicating cognitive impairment, and documented behaviors including physical and verbal symptoms, other behavioral symptoms interfering with care and activities, rejection of care, and wandering. On February 3, 2026, a psych evaluation note ordered Hydroxyzine 50 mg by mouth every 6 hours as needed for anxiety manifested by calling out, and the MAR showed that the resident received four doses between February 3 and February 7, 2026. Review of the clinical record did not reveal a signed consent for the Hydroxyzine 50 mg order. LPN Staff #10 stated that consents for psychotropic medications are to be obtained at admission and must be signed by the resident or responsible party prior to administration, with verbal consent allowed if the family cannot come in to sign. After reviewing the record, Staff #10 confirmed she could not locate a signed consent for Hydroxyzine, acknowledged the medication should not have been administered without consent, and reported that the family member knew the medication was being given. She further stated that the family member had agreed to the medication during a care plan meeting but ultimately decided not to sign the consent form, and she herself had not attended that meeting. The Behavioral Health Unit Manager (LPN Staff #37) and LPN Staff #86 both confirmed that there was no signed consent for Hydroxyzine in the chart, despite the medication having been administered four times. Staff #37 stated that nurses are not to administer Hydroxyzine without a signed consent and that administration without consent was not in accordance with protocol. Staff #86 reported that the resident had been on Mirtazapine, that the family did not want the resident on Seroquel, and that the family wanted non-pharmacological interventions tried first, while acknowledging that a signed consent was required before administering Hydroxyzine. The DON (Staff #22) explained that the nurse who enters or verifies a psychotropic order is responsible for obtaining consent and that nurses are expected to check the system for a signed consent before administering such medications. She confirmed that no signed consent for Hydroxyzine could be found and that the medication had been administered four times without it. The facility’s psychoactive drug use policy stated that residents and/or responsible parties will be asked to make an informed choice concerning psychoactive drug use, with risks and benefits explained.
Delayed Reporting of Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident #4 to the State Agency within the required regulatory timeframe. Resident #4 had dementia with cognitive impairment, as evidenced by a BIMS score of 02, and a history of behavioral symptoms that interfered with care and participation in activities. The resident’s care plan noted a potential for behaviors and directed staff to allow time for the resident to respond to directions due to dementia. An allegation of abuse involving this resident occurred on the evening of February 8, 2026, between approximately 11:30 P.M. and midnight. LPN/Staff #34, who was working the 6:00 P.M. to 6:30 A.M. shift when the alleged abuse occurred, did not report the allegation to the administrator before going home after her shift. She later stated she was in shock and that there was a lot going on at the time, and she believed she had 24 hours to report the suspected abuse. She returned to the facility and reported the allegation to the Administrator/Staff #29 around 2:00 P.M. on February 9, 2026, more than 12 hours after the incident. Interviews with another LPN (Staff #10), the Administrator, and the DON/Staff #22 confirmed that staff receive regular abuse training and that facility policy and expectations require all allegations or suspicions of abuse to be reported to the Administrator or designee immediately, and to the State Agency immediately after ensuring resident safety. The delay in reporting by Staff #34 did not meet the facility’s policy or the DON’s expectations.
Failure to Honor Resident’s Right to Personal Cellphone and Independent Communication
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to communication and personal possessions by not facilitating her access to a personal cellphone. The resident, who had diagnoses including type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington’s disease, was her own responsible party and had a BIMS score of 15, indicating she was cognitively intact. Her care plans identified risks for altered mood and psychosocial well-being related to panic disorder and emphasized encouraging alternative communication with visitors and family via phone or video calls, as well as promoting independence and assessing for lower levels of care as needed. Despite these documented needs and goals, the resident had been without a cellphone for several months after her previous phone broke, and she repeatedly expressed that she needed a cellphone. Facility documentation and staff interviews showed that the resident had financial resources available and the cognitive ability to express her needs, yet her request for a replacement cellphone was not acted upon. A behavioral health note documented that the resident complained about her phone and asked staff to use their online account to buy her a new one, and she was told that the business office and social services would be notified. The business office manager confirmed that the resident had a trust fund balance of $543.00 and stated that the resident could verbalize her needs and had requested a cellphone, but the manager was waiting for the resident’s sister to decide because the resident had previously spent $1000.00 on food using her debit card via her cellphone. The business office manager also stated that she only handled the resident’s trust fund and that the resident’s finances were otherwise managed by a third party, with the sister acting as surrogate decision maker, even though the resident’s public fiduciary petition had been denied due to her intact cognition. Additional interviews revealed that the resident did not know how to obtain another cellphone, did not have her sister’s contact number, and had not spoken with her sister since the previous year, while believing the facility had made her sister her power of attorney. The social service director acknowledged that everyone is allowed a cellphone but stated that this resident’s cellphone was considered a safety concern due to a hot phone charger, significant weight gain from ordering food, and related safety issues, and confirmed that the resident had not had a cellphone for several months. The director stated that the resident’s access to a phone was limited to using the facility phone at the nurses’ station or in the unit. The DON stated that residents with a BIMS score of 15 have the right to have their own phone and that social services and the business office should assist them in purchasing one with their own money. The facility’s Resident Rights policy affirmed residents’ rights to keep and use personal possessions and to have reasonable access to a telephone for private conversation, but the resident’s ongoing lack of a personal cellphone, despite her expressed wishes, available funds, and intact cognition, demonstrated the facility’s failure to honor her rights to communication and personal possessions as outlined in policy and regulation. The facility’s own documentation further showed that the resident’s care plan interventions included encouraging alternative communication with visitors and family members via phone and other electronic means, and encouraging participation in supportive visits and activities important to the resident. However, the resident was observed sitting somewhat apart from other residents during an activity, interacting with staff who were showing her products on a cellphone, while she herself did not have a phone. Staff interviews indicated inconsistent awareness of the resident’s cellphone status, with one CNA stating that the resident’s phone had broken the previous month and an LPN stating she did not know if the resident had a cellphone. The combination of the resident’s documented need for communication to support her psychosocial well-being, her repeated verbal requests for a cellphone, her available personal funds, and the facility’s decision to defer to a sister who was not actively involved, resulted in the resident being without a personal cellphone and without independent access to persons and services outside the facility, contrary to her rights and the facility’s own policies.
Failure to Prevent Resident-to-Resident Physical Abuse by Known Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with a known history of aggression. The alleged victim, resident #911, had diagnoses including aphasia, hemiplegia, hemiparesis, dementia, major depressive disorder, and anxiety disorder, and resided on a secured unit due to vascular dementia. A recent MDS showed short- and long-term memory problems and moderate cognitive impairment in daily decision-making, with documented physical and verbal behavioral symptoms and wandering. Care plans identified risks for psychosocial well-being problems, cognitive problems, and abuse related to dementia, with interventions such as emotional support, calm reassurance, increased 1:1 activities, and monitoring for mood or behavior changes after incidents. On the date of the incident, an incident report and nursing documentation described a resident-to-resident altercation in a hallway in which another resident, identified as the occupant of room [ROOM NUMBER]B (resident #999), suddenly rose from his wheelchair and struck resident #911 twice on the nose with a closed fist. Resident #911 sustained a small, open, bleeding area across the bridge of the nose, reported pain at 5/10, and later developed bruising around the right eye. A wound care note and skin assessment documented an abrasion on the bridge of the nose, and subsequent nursing notes confirmed ongoing bruising and healing of the nasal abrasion. Social Services documented that resident #911, who had limited verbal communication and primarily responded by nodding or brief statements, recalled the incident and stated he was okay, appearing calm and without observable distress. The alleged perpetrator, resident #999, had diagnoses including dementia, anxiety disorder, schizophrenia, psychosis, and major depressive disorder, and had been placed on a secured unit due to psychosis and schizophrenia with verbal and physical aggression toward staff. Prior documentation showed a pattern of physical aggression: a nursing note from October 28, 2025 recorded that he hit another resident on the nose after claiming his wheelchair had been kicked, and a note from November 1, 2025 recorded that he hit a CNA’s hand, was verbally aggressive, and threw a bedside commode. These incidents were not reflected in care plans with specific interventions to prevent further incidents at the time they occurred. A behavioral care plan initiated later documented combative and aggressive behaviors such as yelling, hitting, and grabbing, with general interventions to monitor behaviors and protect others’ rights and safety. On the date of the abuse incident involving resident #911, an incident report and nursing notes documented that resident #999 approached resident #911 and punched him twice on the nose, later stating he did so because the other resident touched his girlfriend’s hand, although the girlfriend was not present in the hallway. The facility’s investigation, including witness and resident interviews, concluded that the allegation of abuse was verified. Facility policies on Abuse and Neglect and on Accident Hazards/Supervision/Devices required assessment, care planning, monitoring, identification of residents likely to be involved in altercations, and implementation of interventions to minimize resident-to-resident altercations, which were not effectively carried out for resident #999 despite his known aggressive history.
Failure to Protect Resident From Financial Misappropriation and Inadequate Documentation of Exploitation Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from financial misappropriation/exploitation of property by another resident and to ensure appropriate reporting of the incident. One resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including anemia, COPD, weakness, and major depressive disorder, reported that money was being taken after befriending another, younger resident. This resident had a care plan addressing depression and psychosocial risks, including monitoring for changes in mood and behaviors related to situational stressors. Documentation shows that the resident became upset and distressed after an encounter involving being robbed by a fellow resident, later experiencing increased anxiety, sadness, and a desire to move to another facility. The alleged perpetrator was also cognitively intact, with a BIMS score of 15, and had diagnoses including major depressive disorder, obesity, and life management difficulty, as well as a care plan for self-harmful ideation and poor impulse control. According to the facility’s incident follow-up report, the perpetrator stated that the victim initially gave permission to use her funds and then continued to use them without permission. Staff interviews revealed that the victim had given her debit card and cash to the other resident to hold, and that the other resident used the funds to buy clothes for herself and the victim, and to purchase coins for virtual slot games. Another staff member reported noticing boxes of purchases in the alleged perpetrator’s room and learning that the victim’s debit card was being used without permission. The deficiency is further supported by inconsistencies and gaps in the facility’s documentation and reporting of the event. The incident follow-up report did not include the names of the residents involved. During the onsite survey, when a self-report for the relevant month involving the victim was requested, the administrator provided documentation that did not include any self-report for that period. The business office manager stated she had no documentation of the incident other than an investigator’s card, and the administrator reported having no prior knowledge of the incident and being unable to locate the reportable event or investigation in the facility’s records. Although staff described the situation as abuse and financial exploitation and referenced notifications to external agencies, the lack of a self-report in the requested timeframe and incomplete internal documentation demonstrate the facility’s failure to properly document and maintain records of the misappropriation incident, contributing to the cited deficiency. The facility’s own Abuse and Neglect policy states that residents are to receive care in an environment free from misappropriation of property and exploitation, and that suspected abuse will be investigated based on facts, observations, and statements from the alleged victim and witnesses. In this case, the victim’s report of stolen money, the perpetrator’s admission of continued use of funds without permission, and staff observations of unusual purchases and changes in the victim’s demeanor all point to financial misappropriation by one resident against another. The absence of a complete, identifiable self-report and investigation record available for review, along with the omission of resident names in the incident follow-up report, shows that the facility did not fully adhere to its own policy requirements in documenting and tracking this substantiated misappropriation event.
Failure to Maintain Documentation of Thorough Investigation of Alleged Financial Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation that an alleged incident of financial misappropriation between two residents was thoroughly investigated. One resident with major depressive disorder, obesity, and a history of self-harm ideation was cognitively intact per a BIMS score of 15 and did not exhibit behavioral symptoms. Another cognitively intact resident with anemia, COPD, weakness, and major depressive disorder, with a BIMS score of 13, reported being financially exploited by this fellow resident. Clinical notes show that the alleged victim became upset and anxious after reporting being robbed by another resident, spoke with detectives, experienced transient chest pain, and expressed a desire to move to another facility, eventually refusing to return after a hospital stay. The facility’s incident follow-up report for the alleged financial misappropriation did not identify the residents involved by name or number and lacked interview statements from staff or other residents who might have interacted with the two residents. Although the report stated that the interdisciplinary team completed a thorough investigation, including outreach to police, APS, and the ombudsman, it did not contain the underlying interview documentation or detailed investigative findings. During the survey, when a self-report for the month of the incident involving the alleged victim was requested, the administrator produced no self-report related to that resident for that period. Interviews with the BOM, SSD, LPN, and administrator confirmed that an allegation of financial exploitation had occurred between two residents, that it was considered abuse or financial exploitation by staff, and that external agencies and law enforcement were contacted. However, the BOM stated she had no documentation of the incident other than an investigator’s card and indicated that the SSD might have documentation. The SSD reported notifying APS and other parties and described steps she took after learning of the situation, but no corresponding investigative documentation was produced for surveyor review. The administrator, who was not employed at the time of the incident, reported having no knowledge of the event until the day before the interview and was unable to locate the reportable event or the investigation in the facility’s records, acknowledging that such a report and investigation should be retained and available. This lack of accessible, complete investigative documentation for the alleged misappropriation constitutes the cited deficiency.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline care plan within 48 hours of admission for a newly readmitted resident, as required by 42 CFR §483.21(a)(1). The resident was readmitted with diagnoses including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. An admission clinical evaluation documented that the resident arrived by wheelchair and was alert and oriented times three with some forgetfulness, and the physician’s admission history noted a recent two‑day history of weakness, falls at home, inability to ambulate, and dizziness. An admission Morse Fall Scale completed the day of admission showed a score of 65, indicating high fall risk. Despite these findings, review of the medical record revealed that no baseline care plan was developed within 48 hours of admission to provide instructions to meet the resident’s immediate needs. A comprehensive care plan was not initiated until two days after admission. That care plan identified an ADL self‑care performance deficit related to deconditioning and risk for falls related to deconditioning and gait/balance problems, and included interventions such as encouraging participation in care, ensuring the call light and commonly used items were within reach, and anticipating and promptly responding to needs. Prior to this comprehensive care plan, there was no documented baseline care plan outlining initial goals, physician orders, dietary orders, therapy services, social services, or other minimum health information necessary to guide staff in providing person‑centered care immediately after admission. The absence of a baseline care plan occurred despite the facility’s own fall prevention policy, which required timely assessment and initiation of individualized interventions for residents at risk for falls. Following admission, the resident experienced multiple falls. Nursing documentation described unsteady gait, poor balance, and the resident’s refusal to follow instructions and insistence on going to the bathroom independently, even while wearing briefs. Progress notes recorded that the resident was found on the floor on more than one occasion, with neuro checks initiated after each event and vital signs monitored. An admission MDS later showed a BIMS score of 6, indicating severely impaired cognition. In a subsequent interview, the RN stated that the unit manager is responsible for initiating the baseline care plan and confirmed that no baseline care plan was found for this resident in the electronic medical record. The DON also acknowledged that the resident’s fall care plan did not reflect the high fall risk identified in the fall assessment and that the care plan was not updated after the resident’s fall incidents. These findings collectively demonstrate that the facility did not develop and implement a baseline care plan within 48 hours of admission to address the resident’s immediate needs as required by regulation and facility policy. The facility’s fall prevention policy, adopted several months before the events, specified that each resident would be evaluated upon admission and that the IDT would review fall risk assessments and initiate fall prevention protocols as appropriate. It also stated that the DON or designee would ensure that residents identified at risk for falls or who had experienced a recent fall had all recommended interventions in place, with current assessments and documentation reflecting notification of applicable disciplines, the physician, and the resident’s family or responsible party. Despite this written process, the resident’s record lacked a timely baseline care plan and did not initially incorporate the high fall risk status into the care planning process, contributing to the cited deficiency.
Failure to Update High-Risk Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan after each fall incident, as required. The resident was readmitted with multiple diagnoses including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. On admission, the resident’s mode of mobility was wheelchair, and she was documented as alert and oriented with some forgetfulness. A physician history and physical noted a recent 2‑day history of weakness and falls at home with associated dizziness and inability to ambulate. An admission Morse Fall Scale completed the same day showed a score of 65, indicating high fall risk. A comprehensive care plan dated shortly after admission identified an ADL self‑care performance deficit related to deconditioning and documented that the resident was at risk for falls related to deconditioning and gait/balance problems. Interventions initiated included encouraging participation in care, use of the call bell for assistance, anticipating and meeting needs, ensuring the call light and commonly used items were within reach, and providing prompt responses to requests for assistance. A daily skilled charting note documented that the resident had unsteady gait, poor balance, was bedfast most of the time, and sometimes refused to follow instructions, insisting on going to the bathroom even while wearing briefs. The admission MDS later showed a BIMS score of 6, indicating severely impaired cognition. The resident experienced three separate fall incidents. After the first fall, a nurse’s note documented that the resident was found sitting on the floor after slipping while trying to stand to go to the bathroom; assessments were completed, neuro checks were initiated, and fall‑related reminders and signage were implemented. After the second fall, a nurse’s note documented the resident lying on the floor, denial of head impact, initiation of neuro checks, and advice to use a walker with the walker placed within reach. After the third, unwitnessed fall, the resident was found on the floor in a prone position with a forehead laceration and a left knee skin tear, appeared confused, and was transferred to the hospital after assessment and initiation of neuro checks. Despite these three fall events and the resident’s documented high fall risk and cognitive impairment, review of the comprehensive care plan showed it was not updated after the falls on the identified dates. The DON confirmed that the resident’s fall care plan did not reflect high fall risk as indicated by the fall assessment and that the care plan was not updated after the fall incidents, contrary to facility policy requiring interdisciplinary review and implementation of individualized fall prevention interventions.
Failure to Supervise Behavioral Activities and Identify Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a hazard‑free environment and adequate supervision to prevent accidents during activities and smoking breaks, and to properly identify and plan for elopement risk. One cognitively intact resident with Huntington’s disease and significant behavioral issues was care planned as being at risk for harm to self or others, with interventions including supervision during activities and removal from group activities if behaviors became disruptive. During an observed group activity in the dining room, residents from both long‑term care and behavioral health units participated in a target‑practice game using toy guns and foam darts aimed at balloons, along with karaoke/music. The resident with Huntington’s disease was seated alone at one end of a table, facing other residents across the table, and was allowed to handle a toy gun and foam darts. A foam dart landed on this resident, who then reloaded it into the toy gun. The activity director later stated that residents should have been lined up in front of the balloons, 2–3 feet away, to prevent residents from being hit by darts and to avoid triggering behaviors, and that the aide should have repositioned residents accordingly. During this same activity session, only one activity aide was present to supervise the group. At one point, the aide left the dining/activity room to wheel a resident out, leaving all remaining residents in the activity room without any staff supervision until he returned about a minute later. The activity aide stated that residents from the behavioral unit are supposed to be 100 percent supervised during activities and acknowledged that he left the room because coworkers were busy. The activity director stated that only one staff member is assigned per activity, that staff must remain in the room at all times while residents are present, and that staff are not permitted to leave residents unattended; if assistance is needed, staff are expected to call her or a CNA. She further stated that if there is no staff with residents during an activity session, residents could have behaviors, wander into the kitchen, or go out into the hall, and that this was not safe. The deficiency also involves the facility’s failure to adequately identify and plan for elopement risk for a newly admitted, cognitively intact resident with complex psychosocial and substance‑use history. Hospital records prior to admission documented abscess and cellulitis, drug use, amphetamine use, moderate fentanyl dependence, and suicidal ideation, and the resident reported interest in obtaining medical marijuana. A psychosocial evaluation documented self‑reported bipolar disorder, schizophrenia, approximately 20 years of incarceration, and current parole status. A smoking evaluation identified the resident as a smoker who preferred morning and afternoon smoking, was considered a safe smoker, and could access smoking materials with frequent monitoring. A wandering/elopement risk assessment scored the resident as low risk, focusing on mobility, mental status, speech, and history of wandering, but did not address psychosocial, behavioral health, or substance‑use‑related risk factors. On the evening of the incident, the resident independently showered after staff covered his PICC line and wound dressing. Afterward, staff informed him that the PICC line and dressing needed to be changed, and he requested that this occur after the scheduled smoking break. During the 7:30 p.m. smoking break, the on‑duty receptionist observed the resident get into a black car and leave the facility. The physician and administrator were notified, and 911 was called; an AMA form was later entered into the record documenting that the resident left during the smoking break. The DON stated that narcotic use, homelessness, and suicidal ideation are risk factors for elopement, that the wandering/elopement assessment did not adequately evaluate this resident’s risks or capture his needs and concerns, and that the resident’s departure should have been considered an elopement rather than an AMA discharge. A case manager similarly stated that suicidal ideation, homelessness, and drug use could indicate higher elopement risk and should prompt referral to behavioral health. Further observations and interviews showed additional supervision lapses related to smoking. A receptionist stated that staff rotate responsibility for monitoring residents in the smoking area and that the receptionist is responsible for monitoring residents during the early morning and evening smoking times. However, an observation on a later morning revealed three residents smoking outside without staff supervision while the receptionist on duty remained seated inside at the reception desk. Facility policy on elopement required that all residents receive adequate supervision to ensure the safest environment possible and that residents be assessed for behaviors or conditions placing them at risk for wandering or elopement. The activities/recreation therapy policy required that programs be provided in coordination with the resident’s comprehensive assessment, but the observed practices during the target‑practice activity and smoking breaks did not align with these requirements.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Skin Tears
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when a cognitively intact resident with a known history of resident-to-resident and resident-to-staff altercations engaged in a physical altercation with a cognitively impaired resident. The alleged perpetrator had diagnoses including depression, psychosis, anxiety, and dysphagia, and a recent MDS showed a BIMS score of 15, indicating intact cognition. This resident’s care plan documented a confirmed history of altercations and included an intervention to remove the resident from the environment when verbal escalation began. Despite this, the resident was able to approach another resident in the hallway and initiate an aggressive interaction. On the date of the incident, staff documented that the alleged perpetrator and the alleged victim were in the hallway when the perpetrator verbally challenged the other resident by saying, "Do you want to fight?" and then advanced toward the resident and scratched the resident’s left arm. The cognitively impaired resident, who had diagnoses including dementia, hypertension, chronic kidney disease, and depression and an MDS BIMS score of 7 indicating significant cognitive impairment, backed away and stated that she had done nothing and was just standing there when scratched. Social services documentation described three superficial skin tears approximately 3 mm by 3 mm on the victim’s left arm with a small amount of bleeding and reported that the resident experienced pain at the injury site. Facility interviews and documentation confirmed that the incident was substantiated as physical abuse. The DON and the administrator acknowledged that the aggressive behavior by the perpetrating resident toward the cognitively impaired resident in the hallway constituted physical abuse. The facility’s abuse and neglect policy stated that residents are to receive care in an environment free from any type of abuse, including physical abuse. Staff interviews indicated awareness that such an incident would be considered abuse and that responsibility for preventing it rested with facility employees, yet the event still occurred, resulting in the resident-to-resident physical altercation and injury.
Failure to Protect Resident from Verbal and Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses was not protected from verbal and physical abuse by a roommate, who also had severe cognitive impairment and a history of behavioral disturbances. The two residents were assigned to share a room after the first resident was moved due to inappropriate sexual behaviors by a previous roommate. Staff were aware of both residents' behavioral histories, including the second resident's aggressive tendencies and the first resident's vulnerability due to dementia and confusion. The incident leading to the deficiency involved the second resident becoming verbally and physically aggressive toward the first resident, including yelling inappropriate language and punching the resident while in bed. Staff intervened immediately upon hearing the altercation, separated the residents, and assessed the first resident for injuries. Documentation and interviews confirmed that the first resident did not exhibit aggressive behaviors and was calm and nonreactive during the event, while the second resident had previously expressed frustration about the roommate's behaviors and admitted to staff that he had taken matters into his own hands due to perceived lack of staff intervention. Despite knowledge of both residents' behavioral histories and the potential for conflict, the facility assigned them as roommates. Staff interviews revealed concerns about the compatibility of the room assignment, and there was a lack of awareness among some staff regarding the behavior care plans in place. The facility's failure to adequately assess and prevent the risk of resident-to-resident abuse resulted in the first resident being subjected to verbal and physical abuse, violating the resident's right to safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse by other residents. In the first incident, a resident with severe cognitive impairment, schizophrenia, and a history of physical behaviors physically assaulted another resident and a CNA. The resident was observed wandering the halls, attempting to enter other residents' rooms, and ultimately struck another resident on the head, resulting in bleeding from the lower gums. Staff interviews confirmed that the resident was redirected multiple times but was able to physically assault both a peer and a staff member before being separated. In a separate incident, another resident with severe cognitive impairment and a history of physical and verbal aggression struck a peer on the nose following a collision involving a wheelchair. The aggressor admitted to hitting the other resident in response to the perceived provocation. Staff present at the time separated the residents and assessed them for injuries, with no acute injuries noted. Both residents involved in this altercation had documented behavioral concerns and histories of aggression related to their cognitive decline. In both cases, the facility's documentation, staff interviews, and clinical records indicate that residents with known behavioral risks were able to physically harm other residents. The incidents were verified by facility-reported incident forms and involved residents with significant cognitive and behavioral challenges, including dementia, schizophrenia, and a history of aggression.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were either not in place or not consistently followed. The lack of comprehensive and enforced policies contributed to an environment where incidents of abuse, neglect, or theft could occur without adequate prevention or timely detection. Surveyors noted that staff were not consistently trained or monitored regarding the prevention of these incidents, and there was insufficient evidence of regular review or updating of the facility's procedures related to resident protection.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents. On August 21, 2025, two residents with significant cognitive and behavioral diagnoses were involved in a resident-to-resident altercation in their shared room. One resident threatened to physically harm the other, and a CNA intervened to prevent escalation. Documentation by an LPN confirmed the incident, and the facility's own investigation later verified the allegation. Despite the altercation and the facility's policy requiring immediate reporting and investigation of suspected abuse, there was no evidence that the incident was reported to the appropriate state agencies or that an investigation was initiated immediately after the event. Interviews with staff revealed that the incident was only brought to the attention of facility leadership the following day through a 24-hour report, and staff acknowledged the importance of timely reporting. The clinical records and interviews confirmed the lack of immediate action in accordance with facility policy and federal guidelines.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Abuse and Neglect Among Residents
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by several incidents involving both resident-to-resident aggression and inadequate supervision. In one case, a resident with severe cognitive impairment and a history of physical and verbal aggression was taken off 1:1 supervision, which led to an altercation where this resident entered another resident's room and physically assaulted both the resident and a CNA. Staff interviews confirmed that the aggressive resident was difficult to redirect and that the incident resulted in physical contact, though no injuries were noted. The care plan for this resident had previously identified the need for close supervision due to safety concerns, but this intervention was not maintained at the time of the incident. Another incident involved a cognitively intact resident who was physically assaulted by a resident with severe dementia and a history of wandering and aggression. The aggressive resident entered the other resident's room, took personal belongings, and struck the resident multiple times when confronted. Staff interviews and documentation indicated that the aggressive resident was sometimes redirectable but could become combative, and that interventions such as frequent checks and behavioral documentation were in place. However, these measures did not prevent the physical altercation from occurring. Additionally, the facility failed to ensure the safety of a resident with Parkinson's disease and moderate cognitive impairment during an activity where hot coffee was served. The resident, who required a non-spill cup and typically used a straw due to tremors, was given an open cup without a straw and was not adequately supervised. As a result, the resident spilled hot coffee on herself, sustaining a partial thickness burn. Staff interviews revealed inconsistent knowledge and implementation of the resident's care needs, and the care plan lacked specific interventions to prevent burns, despite identifying the risk.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse and neglect involving a resident was reported to the State Survey Agency within the required timeframe. The resident, who was cognitively intact and had a history of behavioral symptoms and resistance to care, reported that a CNA had been mean to him and was subsequently removed from his care. The resident expressed feelings of being treated poorly and mentioned possible retaliation but was unable to provide specific details or dates regarding the incident. Interviews with multiple staff members, including CNAs, an LPN, and the DON, revealed inconsistent knowledge and actions regarding the reporting of the abuse allegation. While staff acknowledged the requirement to report abuse allegations immediately, there was confusion and lack of clarity about who was responsible for making the report. The LPN admitted to not reporting the allegation, assuming that another shift had already done so, and the DON confirmed that she had not received any report regarding the incident. A review of internal records showed no evidence that the alleged abuse had been reported to the state agency as required by facility policy. Staff interviews indicated that while there was awareness of the need for immediate reporting and regular training on abuse prevention, the process was not followed in this instance, resulting in a failure to notify the appropriate authorities about the allegation.
Failure to Monitor and Document Resident Behaviors Before Medication Administration
Penalty
Summary
The facility failed to ensure that behaviors were monitored and documented prior to medication administration for two residents, which could result in over-medication. Resident #1, who was admitted with diagnoses including atrial fibrillation, chronic kidney disease, and major depressive disorder, had a BIMS score indicating severe cognitive impairment. Despite being prescribed Paroxetine and Risperidone for depression and psychotic disorders, there was no evidence in the care plan or medication records that behaviors or side effects were being monitored. Similarly, Resident #2, who had severe cognitive impairment and was prescribed Escitalopram and Olanzapine for depression and mood stabilization, also lacked documentation of behavior monitoring in the medication records. Interviews with facility staff, including a CNA, RN, ADON, and DON, confirmed that behaviors should have been tracked in the electronic health record and TAR, but were not. The staff acknowledged the risk of administering medication unnecessarily if behaviors are not monitored. The facility's policy on medication administration and documentation requires that medications meet the needs of the resident and that any changes in the resident's condition be documented, which was not adhered to in these cases.
Failure to Conduct and Document Neurochecks After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who had a severe cognitive impairment and was at high risk for falls, experienced an unwitnessed fall resulting in an abrasion to the back of the head. Despite the facility's policy requiring comprehensive neurological assessments following such incidents, only one neurocheck was documented, indicating a failure to adhere to the established protocol. Interviews with staff, including a CNA, RN, ADON, and DON, confirmed that neurochecks are critical for identifying potential issues such as brain bleeds following a fall. The facility's policy outlined specific intervals for conducting neurochecks, which were not followed in this case. The lack of documentation and adherence to the neurocheck schedule posed a risk of missing a change in the resident's condition, as acknowledged by the staff.
Failure to Protect Residents from Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents with cognitive impairments. Resident #114, who was moderately cognitively impaired with dementia and bipolar disorder, was found in a male resident's room without pants, with the male resident's hand in her groin area. This incident occurred despite the resident being on a care plan that included frequent safety checks and interventions to prevent wandering and inappropriate behavior. The care plan was not effectively implemented, as the resident continued to wander into other residents' rooms and engage in inappropriate behavior. Staff interviews revealed that there was insufficient supervision on the day of the incident, with only two CNAs and a float covering multiple halls. The CNAs reported that the residents on this particular hall required more supervision due to their cognitive impairments and behaviors. The staff also indicated that both residents involved in the incident were not capable of consent due to their cognitive impairments, yet the facility's Director of Nursing stated that a person is capable of consent unless deemed otherwise by a court. The facility's policy on abuse and neglect defines sexual abuse as non-consensual sexual contact with a resident, which includes situations where a resident lacks the cognitive ability to consent. Despite this policy, the incident was not immediately recognized as abuse by some staff members, and there was confusion about the appropriate response and documentation. The facility's failure to adequately supervise and protect residents from abuse, as well as the lack of clarity in staff roles and responsibilities, contributed to this deficiency.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in an incident where one resident was physically assaulted by another. Resident #1, who has a history of cognitive and psychological disorders, was attacked by Resident #2 with a television remote control, causing an abrasion to the back of his right ear. The incident occurred despite Resident #2's care plan requiring one-to-one supervision at all times due to severe cognitive impairment and a history of wandering. The deficiency was primarily due to the inaction of staff #46, a CNA assigned to provide one-on-one supervision for Resident #2. On the night of the incident, the CNA allowed Resident #2 to be unsupervised while in the bathroom, which had a door leading to another resident's room. This lapse in supervision enabled Resident #2 to leave the bathroom unnoticed and enter Resident #1's room, where the assault took place. Staff #46 admitted to not maintaining the required arm's length supervision and acknowledged the potential risk of harm due to this oversight. Interviews with other staff members, including a registered nurse and the Director of Nursing, confirmed that the facility's policy mandates residents be free from abuse and that proper supervision is crucial to prevent such incidents. The failure to adhere to the care plan's supervision requirements directly contributed to the occurrence of resident-to-resident abuse, highlighting a significant deficiency in the facility's ability to ensure resident safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent an avoidable elopement of a resident, who was admitted with mild cognitive impairment, schizoaffective disorder, and aphasia. The resident was initially assessed as a low risk for wandering or elopement, and no further Wander Risk Scale assessments were conducted during their stay. Despite the resident's inability to complete a Brief Interview for Mental Status (BIMS) assessment, their cognitive skills were assessed as modified independence. The care plan was revised to address the resident's elopement risk, including interventions such as socialization encouragement and reminders of their placement in the unit. The resident's progress notes indicated multiple instances of exit-seeking behavior and discussions about leaving the facility. On September 19, 2024, the resident was identified as a high elopement risk after successfully exiting the secured unit by following staff. Staff were subsequently educated on the importance of securing exit doors. However, on September 20, 2024, the resident left the secured unit with their belongings. Staff attempted to redirect the resident back to the facility but were unsuccessful, leading to police and family involvement. The resident ultimately agreed to go to a crisis facility instead of returning. Interviews with staff revealed that a kitchen staff member mistakenly allowed the resident to exit the secured unit, believing them to be a visitor due to their backpack. The staff member did not verify if the resident had a badge or visitor's sticker. The Director of Nursing explained that residents were expected to be escorted and that staff should ensure doors are closed. The facility lacked a documented policy for security doors, which was requested but not provided.
Failure to Address Resident Council Concerns and Grievances
Penalty
Summary
The facility failed to demonstrate that resident council meetings were held regularly and that grievances and recommendations voiced during these meetings were addressed. A review of the resident council minutes for the past six months revealed no written documentation of feedback provided to residents regarding issues brought forth during the meetings. Additionally, the grievance log showed no evidence of written documentation that grievances had been addressed, with logs denoting an open date but not a closed date. Interviews with residents and staff confirmed that issues raised during resident council meetings were not followed up on, and residents were not informed of the outcomes of their grievances or recommendations. Interviews with the Ombudsman and several residents revealed that the most recent resident council meeting had been canceled by the facility and not rescheduled. Residents expressed frustration that their concerns, such as quality of food, installation of grab bars, and night-time staffing issues, were not being addressed. The activities director and the director of social services confirmed that there was no documentation of feedback provided to residents and that responses to grievances were only given verbally. The director of social services also acknowledged that the grievance log was incomplete and that responses to formal grievances were not documented. The administrator stated that her expectation was for residents to feel heard and for necessary changes to be made based on their feedback. However, the facility's policies on resident rights and grievance procedures were not being followed, as there was no evidence of a facility response to resident council concerns or written documentation of grievance decisions. This lack of communication and follow-up could lead to residents feeling unheard and upset, as confirmed by staff interviews.
Failure to Serve Meals Simultaneously to Seated Residents
Penalty
Summary
The facility failed to ensure that meals were provided to residents seated together at the same time, compromising their dignity and potentially affecting their mental health. On 11/01/23 at 12:30 PM, an observation in the downstairs B hall dining room revealed that residents were served meals sporadically without regard to their seating arrangements. Specifically, a corner table with two residents was served first and second to last, while other tables were served in a similar disorganized manner. Interviews with the Food Service Director and the Administrator confirmed that staff were expected to serve all persons at a table simultaneously, which was not done in this instance.
Failure to Inform Resident of Their Rights
Penalty
Summary
The facility failed to ensure that a resident was informed of their rights during their stay. The resident, who was admitted with a fracture of the left patella, stated during an interview that she was curious about her rights and had not been provided a copy of them. An interview with an LPN revealed that the admission packet reviewed by the nurse did not include a copy of the resident rights. Further investigation showed that the facility had two admission packets, one clinical and one non-clinical, with the latter containing the resident rights information. However, due to the absence of a ward clerk, the non-clinical packet had not been completed for some time, and no one had been providing residents with a copy of their rights during this period. The Director of Nursing and Assistant Director of Nursing confirmed that the responsibility of providing the resident rights form did not fall on the nurses and acknowledged the lapse in the process due to the lack of a ward clerk. The facility's policy included in the admission packet mandates a copy of the patient's rights along with an acknowledgment of receipt. Despite this policy, the absence of a ward clerk led to a failure in providing residents with their rights information. The new ward clerk was still in training, and the process of completing the second admission packet had not resumed. This deficiency highlights a significant gap in the facility's admission process, potentially leaving residents uninformed about their rights and unable to advocate for themselves effectively.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that Resident #51 was protected from physical abuse by another resident, Resident #154. Resident #51, who has dementia and moderate cognitive impairment, was the victim of three altercations with Resident #154. Despite these incidents, Resident #154's care plan did not include any goals or interventions related to her physical aggression towards staff and other residents. The facility's policy requires that care plans be updated to address behaviors that might lead to conflict, but this was not done for Resident #154, who had a history of aggressive behavior documented in nursing notes and internal incident reports. Resident #154, who also has dementia, exhibited multiple instances of physical aggression towards staff and other residents. Her behavior was documented in nursing notes and internal incident reports, but her care plan did not reflect any interventions to manage her aggression. The facility's policy on preventing abuse states that staff should identify, assess, develop care plan interventions, and monitor residents with behaviors that might lead to conflict. However, this policy was not followed, as evidenced by the lack of behavior monitoring orders and incomplete Certified Nursing Assistant daily task documentation for Resident #154. Interviews with staff, including an LPN and the DON, revealed that care plans should be updated after every incident and should include specific interventions for residents who exhibit aggressive behavior. Despite this, Resident #154's care plan remained unchanged, and no new interventions were added to address her aggression. This failure to update the care plan and implement appropriate interventions contributed to the continued physical abuse of Resident #51 by Resident #154.
Failure to Ensure Timely PASARR Level II Referrals
Penalty
Summary
The facility failed to ensure timely referrals for PASARR level II determinations for two residents, which could result in the residents not receiving the appropriate level of services. Resident #56, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy, required a level II PASARR review. Although the Director of Social Services claimed to have sent the PASARR to the state in October 2023, there was no documentation to support this, and a follow-up email was only sent on November 2, 2023. The facility's policy requires timely referrals to ensure residents receive appropriate services, but this was not adhered to in this case. Resident #38, who was admitted with diagnoses of major depression, bipolar disorder, and anxiety disorder, also did not receive a timely PASARR level II referral. The resident had a history of suicidal ideation and attempts, including a recent hospitalization for a suicide attempt. Despite this, the PASARR level I screening from the hospital did not indicate the need for a level II referral. The Director of Social Services admitted that a mistake was made in completing the PASARR, as the resident's recent suicide attempt warranted a level II referral. The facility's policy mandates referrals for residents with serious mental disorders, but this was not followed. Interviews with the Director of Social Services and the Administrator revealed that the facility's expectation is for PASARRs to be conducted on admission and reviewed for accuracy. However, the failure to send timely referrals for level II PASARR reviews for both residents #56 and #38 indicates a lapse in following these procedures. This deficiency could result in residents not receiving the appropriate services based on their diagnoses, as required by the facility's policy and state regulations.
Failure to Include Resident in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was able to participate in the care planning process. Resident #114, who was admitted with diagnoses including peripheral vascular disease, morbid obesity, gout, difficulty walking, weakness, hypothyroidism, and hypertension, had a BIMS score indicating cognitive intactness. However, there was no evidence in the resident's electronic health record or the interdisciplinary care conference summary that the resident had participated in the care plan conference. The resident confirmed in an interview that he had not been invited to his care plan meetings for about a year, despite being fairly independent and wanting to provide input for his return to the community. The director of social services explained the scheduling process for care plans and acknowledged that resident participation is inconsistent. He admitted that there was no documentation indicating that Resident #114 had been invited, attended, or refused the care plan meetings. The administrator confirmed that care plans should be reflective of the patient's care and updated as changes occur, with the expectation that the resident or their representative is invited to attend. A review of the facility's care plan policy revealed that residents or family members should be notified in advance of care plan meetings, but this was not done for Resident #114, and no documentation of advance notification, attendance, or declination was evident in the medical record.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for three residents, resulting in incorrect medication administration. Resident #448, diagnosed with Type 2 Diabetes Mellitus, Hypothyroidism, and Hypertension, was given Insulin Glargine instead of the prescribed Insulin Detemir. This error was observed during a medication administration by an LPN, who later acknowledged the mistake. Resident #38, with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder, received a 7 mg Nicotine Patch instead of the ordered 21 mg patch. This error was observed during a medication administration by an RN, who also recognized the mistake upon review. Resident #99, diagnosed with Cognitive Communication Deficit and Cachexia, was given a chewable Aspirin tablet instead of the prescribed enteric-coated Aspirin capsule. This error was observed during a medication administration by an LPN, who justified the substitution due to the unavailability of the correct form in the medication cart. The facility's Clinical Services Policy and Guidelines for Implementation #759, which outlines the six rights of medication administration, were not followed in these instances. The Director of Nursing confirmed that these errors did not meet the facility's standards and acknowledged the need for proper medication administration practices. The errors were identified through observations, staff interviews, and a review of clinical records and policies, highlighting a failure to adhere to professional standards of quality in medication administration.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. The personnel file review for the Activity Director revealed that she was hired without the necessary qualifications for the position. Despite being aware of this, the facility's owners and Administrator allowed her to transfer from another facility without completing the required training course for Activity Directors. An interview with the Director of Human Resources confirmed that there had been no further discussion about completing the training course. The job description for the Activity Director position clearly states that satisfactory completion of a training course and a minimum of two years of experience in a social or recreational program are required qualifications, which the current Activity Director did not meet.
Failure to Ensure Environment Free of Accident Hazards Due to Medications at Bedside
Penalty
Summary
The facility failed to ensure the environment for Resident #58 remained free of accident hazards due to medications being left at the bedside, posing a potential risk of medication self-administration. Resident #58, who is cognitively intact with a Brief Interview for Mental Status score of 15, had several medications within reach, including Zinc Oxide 20% Ointment, Antifungal Powder Miconazole Nitrate 2%, Medicated Body Powder Menthol 0.15%, and Maximum Strength Pain and Itch Relief Cream Lidocaine HCI 4%. There was no evidence of any medication self-administration assessment, request, or approval order by the interdisciplinary team for Resident #58. The antifungal medication was found to have been discontinued on October 16, 2023, yet it was still present at the bedside. Interviews with staff confirmed that the medications should not have been at the bedside without proper approval and assessment. LPN Staff #56 and #131, as well as the Assistant Director of Nursing and the Director of Nursing, acknowledged the risks associated with medications being left at the bedside, including the potential for incorrect usage and double dosing. The facility's policy requires that a resident may self-administer medications only after the interdisciplinary team has determined it is safe and appropriate, with proper documentation in the resident's medical record and care plan. This policy was not followed in the case of Resident #58, leading to the identified deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was below 5%, resulting in an observed error rate of 11.11%. This was identified during a medication administration observation involving 27 randomly selected opportunities by four licensed nurses. Three medication errors were observed involving three residents. One resident with Type 2 Diabetes Mellitus was administered Insulin Glargine instead of the prescribed Insulin Determine. Another resident with Chronic Obstructive Pulmonary Disease and Anxiety Disorder was given a Nicotine Patch 7 Mg/24 hr instead of the prescribed 21 Mg/24 hr. A third resident with Cognitive Communication Deficit and Adult Failure to Thrive received a chewable Aspirin Oral Tablet instead of the prescribed enteric-coated Aspirin Oral Capsule. The Director of Nursing acknowledged that the medication error rate was the highest it had ever been and did not meet the facility's expectations. The facility's Clinical Services Policy and Guidelines for Implementation state that the medication error rate should be less than 5%. The observed errors were in direct violation of this policy, as medications were not prepared and administered in accordance with the prescriber's orders.
Expired Medications and Devices Found in Storage
Penalty
Summary
The facility failed to ensure that expired medications and devices were not readily accessible for use in the medication supply room and medication cart. During a medication storage observation, 13 expired enteral feeding supplies were found in the 2nd floor medication storage supply room. The expiration date on these devices was July 28, 2023. The Licensed Practical Nurse (LPN) confirmed the expiration dates and acknowledged that all products in the medication storage supply room are expected to be checked weekly. Additionally, during another medication storage observation, an expired topical medication with an expiration date of May 2023 was found in a medication cart on the 2nd floor B wing. The LPN confirmed that the expired medication would be discarded and not given to residents. An interview with the Director of Nursing (DON) revealed that the facility had recently performed an audit of the medication carts and expected that all expired medications would be removed. The DON stated that medications and supplies which are out-of-date should be discarded. The facility's Clinical Services Policy and Guidelines for Implementation also specify that medications should be prepared and administered in accordance with manufacturer's specifications and accepted standards of practice.
Failure to Provide Palatable and Appetizing Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was provided at a palatable and appetizing temperature, as evidenced by multiple resident complaints and direct observations. Resident council meeting minutes from three out of four months included food complaints. Interviews with the ombudsman and several residents revealed consistent dissatisfaction with the temperature and quality of the food. Specific complaints included food being cold when it should be hot and overall poor quality of meals. For instance, one resident mentioned that the food had not been at an acceptable temperature for a week, while another stated that almost every meal was a 'lost cause.' Additionally, a test tray observation showed that the temperatures of the food items were below the facility's standard, with beans at 123°F, rice at 106°F, and taco meat at 103°F. The facility's policy, dated July 2018, mandates that food should be served at an appetizing temperature and meet the residents' needs. However, the Administrator acknowledged that the food should be served at 120°F and admitted that the current food service did not meet her expectations. Despite this, she noted that food temperature and quality should be individualized to meet resident preferences. The failure to adhere to these standards has led to widespread dissatisfaction among residents, as documented through interviews and direct observations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the handling and storage of food items. Observations revealed that an uncovered cart loaded with uncovered cakes was transported through a hallway past COVID-19 isolation rooms before being served to residents. Additionally, a resident refrigerator/freezer was found to contain undated and expired food items, including a coagulated carton of milk and browning apples. The refrigerator was also noted to be stained and filthy, with spilled food and undated personal food items. Interviews with staff confirmed that the food items were not dated and that the refrigerator did not meet the facility's expectations for cleanliness and food safety. A resident reported that the refrigerator had been in a poor condition for 2.5 months, and the Assistant Director of Nursing and Food Service Director acknowledged the deficiencies. The facility's policy on food safety requires that food items be labeled and dated, and that food be covered when transported. However, these standards were not met, as evidenced by the uncovered cakes and drinks, and the undated and expired food items in the resident refrigerator/freezer. The Administrator confirmed that the refrigerator should be cleaned weekly and that food items should be maintained according to regulatory standards, which was not the case in this instance.
Latest citations in Arizona
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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