Santa Rosa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 1650 North Santa Rosa Avenue, Tucson, Arizona 85712
- CMS Provider Number
- 035004
- Inspections on file
- 28
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Santa Rosa Care Center during CMS and state inspections, most recent first.
A resident with right-sided hemiplegia, contractures, and a documented need for two-person Hoyer lift transfers reported right shoulder pain, which led to imaging that showed a moderately displaced comminuted fracture of the surgical neck of the humerus. Staff interviews indicated the resident was always a two-person Hoyer lift transfer, while the resident later alleged that a CNA had manually lifted her from wheelchair to bed, during which she heard a crack and felt pain, and that she reported this pain and bruising to a CNA, an LPN, and the DON. The DON confirmed the resident reported shoulder pain and an incorrect transfer and that an investigation was initiated, but the DON did not notify the state agency, APS, Ombudsman, or police as required by facility policy for alleged abuse or serious bodily injury, delaying the report to the state agency until 26 days after the fracture was identified and only after APS contacted the facility.
A resident with cognitive impairment and behavioral issues was injured after being pushed by a roommate with dementia and a history of aggression, following a disagreement about a room light. Despite known behavioral risks and prior incidents, staff interventions were limited to medication and redirection, and the altercation resulted in a 4-cm head laceration.
Multiple residents with cognitive and behavioral impairments were not adequately protected from abuse, resulting in incidents where one resident was bitten by another, a resident was struck in the face by a CNA, and several residents suffered injuries during altercations despite being on 1:1 supervision. Staff interviews and facility documentation confirmed that these events were substantiated as abuse or neglect, reflecting failures in supervision and intervention.
Two cognitively impaired residents with behavioral issues were involved in a physical altercation after one resident wandered into another's room and bed. The aggressor, who had a history of verbal and physical aggression, struck the other resident, resulting in visible injuries. Staff and documentation confirmed that monitoring was insufficient at the time, as the assigned hall monitor was assisting elsewhere, and both residents had known behavioral risks that were not adequately managed.
The facility failed to prevent resident-to-resident abuse, resulting in multiple altercations and injuries. A resident with schizophrenia exhibited aggressive behavior, hitting two others with a wheelchair part. Another resident was scratched during a verbal exchange, and a third altercation led to redness in a resident's eye. These incidents involved residents with cognitive impairments and highlight the facility's inability to manage aggressive behaviors effectively.
The facility failed to prevent abuse between residents, resulting in two incidents. One involved a resident with no cognitive impairment being attacked by a newly admitted resident with severe cognitive impairment, leading to injuries. Another incident involved a resident with severe cognitive impairment being kicked by a cognitively intact resident with a history of aggression. The facility did not implement adequate behavioral interventions or recognize warning signs, contributing to these deficiencies.
A resident with mild cognitive impairment was administered a Dulcolax suppository against their will, despite having had a bowel movement the previous day. The LPN involved did not adhere to the facility's protocol, which requires respecting a resident's decision to refuse medication. Interviews with staff, including the DON, confirmed that the practice was unacceptable, leading to the LPN's termination.
A resident with a history of sexual disinhibition kissed another resident without consent, leading to emotional distress. Despite previous incidents of sexual disinhibition, no additional interventions were implemented, and the lack of supervision on the patio contributed to the incident. The facility's policies on abuse and neglect were not adequately followed, resulting in a deficiency.
The facility failed to prevent resident-on-resident abuse, resulting in physical and psychosocial harm. In one incident, a resident with dementia and schizoaffective disorder struck another resident in the back after being touched. In another incident, a resident threw coffee at another resident's face during a disagreement. Both incidents involved residents with known behavioral issues, and the facility did not provide adequate supervision or implement effective strategies to manage these behaviors.
Two residents with severe cognitive impairments were involved in separate altercations with other residents, resulting in physical contact and injury. Staff interventions were insufficient to prevent these incidents, and the facility's abuse prevention policy was not effectively implemented.
Failure to Timely Report Serious Injury and Alleged Improper Transfer
Penalty
Summary
The deficiency involves the facility’s failure to timely report a serious injury and alleged improper transfer of a cognitively intact resident to the appropriate state agencies within the required timeframe. The resident had right-sided hemiplegia/hemiparesis due to cerebrovascular disease, contracture of the right wrist, muscle weakness, and required assistance with personal care. The care plan documented behaviors including false accusations and indicated the resident required two-person care and Hoyer lift transfers. A quarterly MDS showed a BIMS score of 15, indicating the resident was cognitively intact and had no documented mood or behavioral indicators. On one morning, the resident reported right shoulder pain to nursing staff, leading to physician notification and a STAT x-ray order. The x-ray later revealed a moderately displaced comminuted fracture of the surgical neck of the right humerus, and an orthopedic report documented swelling, bruising, and tenderness over the proximal humerus. The facility’s internal investigation, initiated the same day, included an interview with a CNA who stated that he and another CNA had transferred the resident from wheelchair to bed using a Hoyer lift per protocol and without incident. Other staff interviews indicated the resident reported arm soreness and pain, requested to see the doctor, and was known to be a two-person Hoyer lift transfer. The resident later reported that on the prior day a CNA had transferred her by wrapping his arms around her shoulders and lifting her from wheelchair to bed instead of using the Hoyer lift, that she heard a crack and felt pain, and that she informed the CNA and then an LPN and the DON about the pain and bruising. The DON acknowledged that the resident approached her and reported shoulder pain and an incorrect transfer, and that an investigation was started that same day. Despite the facility’s policy requiring that all alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source, be reported immediately but not later than two hours if the events involve abuse or result in serious bodily injury, the DON did not make required notifications to the state agency, APS, Ombudsman, or police. The DON stated she believed reporting was not required because the complainant was known to make false accusations, even though a major injury had occurred and an investigation into the cause of the injury was underway. The incident was not reported to the state agency until 26 days after the facility became aware of the fracture, and only after APS reported the incident to the facility.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in physical injury. One resident, who had a history of schizoaffective disorder, bipolar type, and moderate cognitive impairment, was involved in a verbal disagreement with his roommate, who had dementia with behavioral disturbances and moderate cognitive impairment. The disagreement centered around the use of a room light, escalating to the point where the roommate pushed the resident, causing him to lose balance and fall. This resulted in a 4-centimeter laceration to the back of the resident's head, which required immediate attention from staff. Prior to the incident, both residents had documented behavioral issues, including agitation, restlessness, and difficulty with communication or redirection. The resident who initiated the physical contact had a recent history of behavioral escalation, including irritability and verbal aggression, and had previously been transferred from another facility after an assault on another resident. Despite these known risks, the facility's interventions were limited to medication management, monitoring, and attempts at redirection, without additional measures to prevent resident-to-resident altercations. Staff interviews confirmed that there had been ongoing disagreements between the two residents about the room environment, and that the resident who pushed had become increasingly agitated in the days leading up to the incident. The facility's policy defined resident-to-resident abuse as a form of abuse, and the Director of Nursing acknowledged that the incident constituted willful harm. The facility's failure to implement effective interventions to prevent the altercation directly led to the injury sustained by the resident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident and staff-to-resident incidents. In one case, a resident with severe cognitive impairment and multiple comorbidities was bitten on the hand by another resident, resulting in injury. The incident was observed by staff, and the injured resident was found to have puncture wounds on the left hand. The biting resident was subsequently relocated, but the initial failure to prevent the altercation constituted a deficiency in protecting residents from abuse. Another incident involved a staff member physically abusing a resident with severe cognitive impairment and behavioral issues. The resident, who was known to wander and sometimes be combative, was struck in the face by a CNA after the resident allegedly grabbed the staff member. The abuse was witnessed by another CNA, who intervened and reported the incident. The staff member involved was terminated, but the event highlighted a lapse in ensuring residents were free from staff abuse. Additional deficiencies were identified in cases where residents with histories of aggression and cognitive impairment engaged in repeated altercations, resulting in physical injuries such as bruises and lacerations. In several instances, residents who were supposed to be under 1:1 supervision still managed to physically harm others, indicating that the supervision was inadequate. Facility documentation and interviews confirmed that these incidents were substantiated as abuse, and in one case, a staff member assigned to 1:1 supervision was terminated for neglect after failing to prevent an assault. The facility's actions and inactions in these cases failed to ensure residents were protected from all forms of abuse and neglect.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident, who had diagnoses including alcohol-induced dementia and major depressive disorder and was noted to be cognitively impaired, was found in another resident's room with visible injuries, including blood on his face and neck. Documentation and staff interviews confirmed that this resident had a history of wandering, restlessness, and irritability, and his care plan included monitoring and removing him from situations when he began to escalate. On the day of the incident, he was found in another resident's bed, and the other resident admitted to striking him after becoming upset by the intrusion. The second resident involved had diagnoses of dementia, schizoaffective disorder, and bipolar disorder, and was also cognitively impaired. His care plan noted behaviors such as physical and verbal aggression, delusions, and hallucinations, with interventions including medication administration and redirection. Staff interviews and progress notes indicated that this resident became agitated when the first resident entered his room and bed, leading to the physical altercation. Staff observed blood on the aggressor's knuckles and confirmed that he admitted to hitting the other resident. At the time of the incident, a hall monitor assigned to observe residents was not present in the hallway, as they were assisting another resident. Staff interviews revealed that the first resident had a pattern of wandering into other residents' rooms, and the second resident had a history of verbal threats but no prior physical aggression. The facility's policy required monitoring for aggressive behaviors and recognized that wandering into others' rooms could provoke reactions, but the monitoring in place was insufficient to prevent the altercation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from physical abuse, resulting in incidents of resident-to-resident altercations. Resident #1, who was admitted with schizophrenia and other behavioral issues, exhibited aggressive behavior towards other residents. On December 4, 2024, Resident #1 threatened and attempted to hit another resident, and later in the day, hit two residents with a part of his wheelchair hidden in a sock. This incident was witnessed by staff, and the Tucson Police Department was called. Resident #1 was taken to the hospital for psychiatric treatment. The facility's investigation confirmed the occurrence of the altercation. Resident #11, with severe cognitive impairment, and Resident #111, also with severe cognitive impairment, were involved in the altercation with Resident #1. Resident #111 sustained a small bruise on the left forearm as a result of the incident. Staff interviews revealed that Resident #1 had been agitated throughout the day, possibly triggered by personal belongings being dropped off by his sister. Despite being regularly followed for behavioral health needs, Resident #1's aggression was not effectively managed, leading to the physical altercation. Another incident involved Resident #2, who was scratched by Resident #22 after a verbal exchange. Resident #22, with moderate cognitive impairment, had a history of behavioral issues that were reportedly managed with medication. The facility's investigation noted that Resident #2 had a small scratch on the face. Additionally, Resident #3 and Resident #33 were involved in a verbal altercation that escalated to physical contact, resulting in redness to Resident #3's eye. These incidents highlight the facility's failure to prevent resident-to-resident abuse, as evidenced by multiple altercations and injuries among residents with cognitive impairments.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving four residents. Resident #4, who had no cognitive impairment, was attacked by Resident #5, who had severe cognitive impairment and was newly admitted to the facility. The altercation occurred in Resident #4's room and continued in the hallway, resulting in Resident #4 sustaining a laceration on the right eyebrow and a scratch on the back. Staff witnessed the second altercation and intervened, but the facility had not implemented any behavioral interventions for Resident #5, who was known to be easily triggered. In another incident, Resident #1, who had severe cognitive impairment, was kicked by Resident #2, who was cognitively intact but had a history of fluctuating aggressive behaviors. The incident occurred after Resident #2 returned from a smoke break and became agitated. Staff witnessed the altercation, but there were no injuries reported. The facility had identified Resident #2's potential for aggression but failed to prevent the incident by not recognizing the warning signs of increased agitation. The facility's policy defines abuse as including physical actions such as hitting and kicking, and acknowledges that abuse can occur between residents. Despite this, the facility did not adequately address the behavioral issues of Residents #5 and #2, leading to the incidents of resident-to-resident abuse. The lack of appropriate interventions and failure to recognize warning signs contributed to the deficiencies observed by the surveyors.
Resident's Right to Refuse Medication Not Honored
Penalty
Summary
The facility failed to honor a resident's right to refuse medication, specifically a Dulcolax suppository, which was administered despite the resident's explicit refusal. The resident, who had mild cognitive impairment, was admitted with diagnoses including Parkinson's disease, type 2 diabetes, and major depressive disorder. The incident occurred after the resident had a bowel movement, and the suppository was administered the following day by an LPN, contrary to the resident's wishes. The resident's Power of Attorney was notified after the medication was given. Interviews with various staff members, including LPNs and the Director of Nursing, revealed a consensus that administering a suppository against a resident's will is not acceptable practice. Staff members indicated that they would typically educate the resident on the medication's purpose and respect their decision if they refused. The Director of Nursing confirmed that the staff member involved did not meet the facility's expectations, leading to the staff member's termination. The facility's bowel movement protocol was reviewed, which outlines steps to be taken if a resident does not have a bowel movement in more than three days, including obtaining an order for a bowel regimen protocol and discussing additional interventions with the resident's physician.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, specifically a non-consensual kiss by another resident. Resident #28, who has diagnoses of Major Depressive Disorder and Schizoaffective Disorder, reported that Resident #6 kissed her on the patio in front of the building after dark. Resident #28 expressed that she still experiences nightmares from the incident and feels uncomfortable seeing Resident #6 during activities. The incident was corroborated by Resident #6, who admitted to kissing Resident #28 and mentioned that he was moved to another unit following the incident. Resident #6, who has diagnoses of sexual disinhibition, Major Depressive Disorder, and cerebral ischemia, was noted to have exhibited sexual disinhibition on previous occasions, as documented in the Medication Administration Record. Despite this, no additional interventions were implemented to address these behaviors. Interviews with staff revealed that Resident #6 was moved to a lockdown unit after the incident, but there was a lack of supervision on the patio during the evening, which contributed to the occurrence of the incident. The facility's policy on identifying sexual abuse defines non-consensual sexual contact as abuse, and the policy on neglect indicates that failure to provide necessary supervision can result in emotional distress. The report highlights that the facility did not adequately monitor or intervene in Resident #6's behavior, leading to the incident with Resident #28. The lack of supervision and failure to implement additional interventions for Resident #6's known behaviors contributed to the deficiency.
Resident-on-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to prevent resident-on-resident abuse, resulting in physical and psychosocial harm. An altercation occurred between two residents in the dining room, where one resident, diagnosed with dementia and schizoaffective disorder, struck another resident in the back after being touched. The aggressive resident had a history of psychiatric behaviors and aggression, which were documented in multiple nursing notes. Despite being aware of these behaviors, the facility did not implement adequate measures to prevent the incident. Another incident involved a resident throwing a cup of coffee at another resident's face during a disagreement in the dining room. The aggressive resident, diagnosed with major depressive disorder and schizoaffective disorder, had a history of verbal aggression and impulsive behavior. The facility's records did not include notes regarding this incident, indicating a lack of proper documentation and monitoring of the resident's behavior. Interviews with staff and residents revealed that the facility's interventions were insufficient to prevent these incidents. Staff members reported that the residents involved in the altercations had known behavioral issues, yet the facility did not provide adequate supervision or implement effective strategies to manage these behaviors. The facility's failure to protect residents from abuse and neglect is a significant deficiency in their care practices.
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. Resident #4, who has severe cognitive impairment and a history of aggressive behavior, was involved in an altercation with Resident #6, who also has severe cognitive impairment and a history of aggression. During an argument on the patio, Resident #6 was being redirected by a CNA when they encountered Resident #4 in the hallway. Resident #4 verbally taunted Resident #6, leading to a physical altercation where Resident #6 made contact with Resident #4, resulting in redness to Resident #4's left eye. In another incident, Resident #1, who has severe cognitive impairment, was involved in an altercation with Resident #5, who also has severe cognitive impairment and a history of being resistive to care. Resident #1 was seated on Resident #5's walker in the dining room, and when Resident #5 attempted to use the walker, Resident #1 did not move. This led to Resident #5 pushing and striking Resident #1 on the cheek. The incident resulted in initial redness on Resident #1's cheek, which subsided by the following day. Interviews with staff revealed that there were no immediate interventions to prevent these incidents, and staff training on abuse prevention was mentioned but not effectively implemented. The facility's policy on abuse prevention was not adhered to, as both verbal and physical abuse occurred. The facility's failure to ensure the safety and protection of residents from abuse by other residents was evident in these incidents.
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A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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