Sun Health La Loma Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Litchfield Park, Arizona.
- Location
- 14260 South Denny Boulevard, Litchfield Park, Arizona 85340
- CMS Provider Number
- 035264
- Inspections on file
- 13
- Latest survey
- October 28, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Sun Health La Loma Care Center during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions had conflicting documentation regarding code status, with some records indicating DNR/DNI and others indicating full code. When the resident was found unresponsive, staff relied on a shift report and chart information that listed the resident as DNR, and CPR was not initiated. Interviews confirmed that staff were unsure of the correct code status due to inconsistent documentation and communication breakdowns.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised and remained outside for about an hour before being found by staff from a neighboring building. Although 15-minute checks were part of the care plan, the resident was not detected missing until discovered outside, demonstrating a failure to provide adequate supervision and prevent elopement.
Staff failed to ensure that prepared food was served to a resident at a safe and appetizing temperature, with a cheese steak sandwich measured at 123°F upon delivery, below the FDA-recommended hot holding temperature of 135°F. Facility policy and staff interviews confirmed this did not meet meal service expectations.
Two residents with orders for urostomy, ileostomy, and Foley catheter care did not have these treatments included in their baseline care plans or EHR care plans within 48 hours of admission, despite documentation confirming the presence of these devices and staff acknowledging the omission. Facility policy required such care to be included in baseline care plans, but this was not done.
Two residents received anti-hypertensive and pain medications outside of physician-ordered parameters, with staff administering drugs despite vital signs falling outside specified limits. MAR reviews showed multiple instances of non-compliance, and interviews with an LPN and the DON confirmed that these actions did not meet facility expectations. Facility policies requiring documentation of vital signs and adherence to medication orders were not consistently followed.
A resident with a documented history of frequent falls and multiple risk factors was inaccurately coded on the MDS assessment as having no prior falls, despite clinical records and care plans indicating otherwise. The error was identified during a surveyor review, and both the MDS Coordinator and DON confirmed the assessment did not accurately reflect the resident's status.
A resident with a Foley catheter for urinary retention did not receive required catheter care, timely bladder scans, or prompt re-insertion of the catheter as ordered. Documentation and staff interviews confirmed missed care and assessments, with facility policy and provider orders not followed.
A resident with an ileostomy experienced repeated leakage of the ostomy bag, which was not promptly addressed by nursing staff despite early notification by a CNA. The bag was not changed for several hours, and there was no documentation of required care or provider notification regarding the ongoing leakage. Facility policies for ostomy care and documentation were not followed.
Surveyors observed that staff did not consistently label and date opened food and leftovers in nourishment refrigerators, as required by facility policy. Multiple items, including a container with a pink substance and wrapped items in the freezer, were found without proper labeling or dating. Staff interviews confirmed that this practice did not meet facility expectations and that daily checks were not always performed.
Two residents experienced lapses in infection control: a nurse performed urostomy care without proper PPE use or hand hygiene, allowing her gown to fall and contaminating clean supplies with soiled gloves, while another resident's foley catheter bag outlet was left open and on the floor, cleaned only with a personal wipe and not reported to nursing, resulting in the bag not being changed as required by policy.
The facility failed to notify the State Long-Term Care Ombudsman of a resident's discharge on two occasions, despite the resident's severe cognitive impairment. Staff interviews revealed confusion over who was responsible for the notification, and the facility's policy was not followed, as the notifications were only sent on the day of the surveyor's visit.
Failure to Follow Advance Directives Due to Code Status Documentation Errors
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately followed, resulting in a discrepancy regarding the resident's code status at the time of a critical event. The resident was admitted with multiple diagnoses, including muscle weakness, MRSA, acute abscess, delirium, atrial fibrillation, dementia, and mood disturbances. Documentation in the clinical record was inconsistent: while the hospital history and some admission documents indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, other records, including a signed advance directive and physician orders, indicated a full code status. The care plan did not specify a code status, and there was no evidence that the code status was clarified with the resident, their power of attorney, or the physician. Shift reports and staff recollections further conflicted, with some indicating DNR and others full code. On the day of the incident, the resident was found unresponsive in bed. Staff interviews revealed that upon discovery, the CNA called for a nurse, and two nurses responded. One nurse checked the resident's vital signs, while another checked the chart for code status and reported the resident as DNR. As a result, CPR was not initiated. There was no documentation in the clinical record that CPR was started, and the facility's self-report confirmed that CPR was not performed when the resident was found unresponsive and without signs of life. The staff relied on conflicting information from shift reports and the physical chart, leading to the decision not to initiate resuscitation. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to verify code status in the physical chart and follow the documented orders. However, the DON acknowledged a breakdown in communication and misreading of the resident's code status. Facility policy required clear documentation and communication of advance directives, but this was not consistently implemented, resulting in the failure to honor the resident's documented wishes regarding resuscitation.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 03 and diagnoses including dementia and cerebral amyloid angiopathy, was admitted to the facility and initially assessed as low risk for elopement. Despite this, a care plan was developed that included interventions such as engaging the resident in purposeful activity, providing reorientation, and conducting 15-minute checks. However, the resident was able to leave the care center building and was found sitting on a bench approximately 700 feet away, outside the facility and not visible from the care center. The resident had been unsupervised for about an hour before being discovered by staff from the independent living building next door. Staff interviews confirmed that 15-minute checks were supposed to be in place for residents at risk of wandering or elopement, but the resident was able to leave the premises without detection. The facility's policy defines elopement as a resident leaving the premises or a safe area without authorization or necessary supervision. Documentation and staff statements revealed that the resident was found hot and sweaty, and required assistance from emergency services upon return. The incident demonstrated a failure to provide adequate supervision and to ensure the area was free from accident hazards, resulting in the resident's elopement.
Failure to Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that prepared food was distributed to residents at a safe and appetizing temperature. On March 26, 2025, observations of the tray line revealed that initial food temperatures were within safe ranges, with meat at 180°F, vegetables at 169°F, starch at 175°F, and a cheese steak sandwich at 172°F. However, by the time a test tray was provided to a resident, the final temperatures had dropped, with the meat at 152°F, vegetables at 140°F, starch at 157°F, and the cheese steak sandwich at 123°F. No cold components were present on the tray line that day due to the menu selection. Interviews with the Interim Director of Dining Services and the Part-Time Registered Dietician confirmed that the facility's policy is to follow FDA recommendations, which require hot foods to be held at 135°F or higher and cold foods at 41°F or lower. The staff acknowledged that serving hot food below 135°F, such as the cheese steak sandwich at 123°F, did not meet the facility's meal service expectations. Review of the facility's kitchen policy and FDA guidelines further emphasized the importance of maintaining proper food temperatures to prevent bacterial growth.
Failure to Include Ostomy and Catheter Care in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans addressing urostomy, ileostomy, and Foley catheter care for two residents within 48 hours of admission, as required by policy. For one resident with a history of cerebral infarction, malignant neoplasm of the bladder, and an artificial urinary tract opening, physician orders specified urostomy care twice daily. Documentation confirmed the presence of a urostomy and that care was being provided per orders, but neither the baseline care plan nor the electronic health record (EHR) care plan included any focus or interventions for urostomy care. Multiple staff interviews confirmed that urostomy care should have been included in the baseline care plan and EHR, but was omitted. Another resident was admitted with diagnoses including peritoneal abscess, type 2 diabetes, depression, colostomy, and recent digestive system surgery. Physician orders required ostomy care every seven days and as needed, as well as Foley catheter care every shift. Observations and progress notes confirmed the presence of an ileostomy and Foley catheter. However, the baseline care plan and EHR care plan did not include any nursing care instructions for either the ileostomy or Foley catheter. Staff interviews confirmed that these care needs should have been included in the baseline care plan within 48 hours of admission, but were not. Policy review indicated that baseline care plans must include instructions for all services and treatments to be provided, and that ostomy care plans should reflect the resident's goals and preferences, including frequency of care and required products. Despite these requirements, the facility did not ensure that baseline care plans for the two residents included the necessary information for urostomy, ileostomy, or Foley catheter care, as confirmed by staff and documentation review.
Failure to Administer Medications Within Ordered Parameters
Penalty
Summary
The facility failed to ensure that medications, specifically anti-hypertensives and pain management drugs, were administered within the parameters set by physician orders for two residents. For one resident with diagnoses including parkinsonism, dementia, atrial fibrillation, and hypertension, there were physician orders for Amlodipine and Metoprolol Succinate to be held if the pulse was less than 60 or systolic blood pressure was less than 110. However, the Medication Administration Record (MAR) showed that these medications were administered outside of the ordered parameters on multiple occasions. Additionally, the care plan did not include interventions related to the use of anti-hypertensives, though it did address pain management. Another resident with metabolic encephalopathy had orders for Oxycodone for pain and Metoprolol Succinate for hypertension, both with specific administration parameters. The MAR indicated that Oxycodone and Metoprolol were administered outside of the prescribed parameters on several dates. Interviews with an LPN and the Director of Nursing confirmed that the facility's expectation is for staff to follow medication orders, document vital signs as required, and provide reasons when medications are held. Both staff members acknowledged that the administration of medications outside of ordered parameters did not meet facility expectations. Facility policies reviewed stated that staff are required to document the execution of physician orders, obtain and record vital signs prior to administering certain medications, and hold medications per orders when indicated. The policies also require that vital signs be recorded on the MAR when necessary. The findings showed that these policies were not consistently followed, resulting in the administration of medications outside of the prescribed parameters for the residents involved.
Inaccurate MDS Assessment of Fall History
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment for one resident accurately reflected their history of falls. The resident was admitted with multiple diagnoses, including Parkinson's disease, dementia, repeated falls, muscle weakness, and gait abnormalities. Clinical documentation, including progress notes and care plans, consistently indicated a history of frequent falls and a moderate fall risk. However, the admission 5-Day Medicare MDS assessment incorrectly documented that the resident had no falls prior to admission, despite clear evidence to the contrary in the clinical record. The MDS Coordinator, upon review, acknowledged that the fall section of the MDS was inaccurately coded and should have indicated a history of previous falls. The Director of Nursing confirmed that the MDS should be accurate and that the error was only identified after being brought to the staff's attention by the surveyor. Facility policy and the RAI manual both require that MDS assessments accurately reflect the resident's status, and the inaccurate coding in this case resulted in the submission of incorrect data regarding the resident's fall history.
Failure to Provide Timely Catheter Care and Monitoring
Penalty
Summary
A deficiency occurred when a resident with a history of peritoneal abscess, type 2 diabetes mellitus, depression, and a colostomy did not receive Foley catheter care and monitoring in accordance with provider orders and facility policy. The resident had a Foley catheter for urinary retention, with orders for catheter care every shift and specific instructions for removal, bladder scans, and re-insertion as needed. Documentation revealed that catheter care was not performed on a scheduled shift, and after the catheter was removed, there was no evidence that the required bladder scan was performed at the scheduled time. Following the removal of the Foley catheter, the resident reported not having urinated, and staff interviews confirmed that no bladder scan or assessment was conducted as ordered. When a bladder scan was eventually performed, it showed a small amount of urine in the bladder, and the resident remained unable to urinate. Despite a provider order to re-insert the Foley catheter on a specific night, documentation indicated that the catheter was not re-inserted until the following morning, with staff unable to confirm the exact timing of the procedure. Policy reviews showed that the facility was required to provide ongoing assessments, timely interventions, and thorough documentation for residents with indwelling catheters. However, the medical record lacked evidence of required catheter care, timely bladder scans, and prompt re-insertion of the catheter per provider orders. Staff interviews corroborated these documentation gaps and lapses in following established protocols.
Failure to Provide Timely and Documented Ileostomy Care
Penalty
Summary
The facility failed to provide appropriate ileostomy care in accordance with professional standards for a resident who required such services. The resident, admitted with multiple diagnoses including an ileostomy, had a provider order for ileostomy care every seven days and as needed, which included cleansing the skin and stoma, drying, and applying a wafer and pouch. Documentation on the Treatment Administration Record (TAR) showed no evidence that ileostomy care was performed as ordered on a specific day shift. Additionally, there was no documentation that the provider was notified about the resident's ongoing ileostomy leakage, despite repeated incidents of the bag leaking and requiring multiple changes within a single shift. Observations and interviews revealed that the resident's ileostomy bag was leaking for several hours before it was changed, with both the resident and her daughter noting the delay. Staff interviews confirmed that the leaking was observed early in the morning and reported to a nurse, but the bag was not changed until several hours later. The LPN was not informed about the leakage during shift report, and the Director of Nursing confirmed the lack of provider notification and documentation of care. Facility policies required prompt response to ostomy issues and meticulous documentation, which were not followed in this case.
Failure to Label and Date Opened Food Items in Refrigerators
Penalty
Summary
Staff failed to follow facility policies regarding the labeling and dating of opened food and leftovers in nourishment refrigerators. During multiple observations, surveyors found food items, including canned beverages, a wrapped item in the freezer, and a container with a thick pink substance, that were not labeled or dated. Staff interviews confirmed that facility policy requires all opened or leftover items to be labeled and dated, and that the observed items did not meet this expectation. Staff also stated that refrigerators are to be checked at the end of each shift to dispose of improperly labeled items, but this was not consistently done. Policy reviews revealed that the facility requires all refrigerated food to be labeled and dated, with daily inspections of refrigerators, coolers, and freezers. Despite these policies, the lack of labeling and dating on certain food items was observed on more than one occasion, indicating a failure to adhere to established food safety protocols. No information about specific residents or their medical conditions was provided in the report.
Deficient Infection Control Practices in Urostomy and Foley Catheter Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents, resulting in deficiencies related to urostomy and foley catheter care. For one resident with a urostomy, a registered nurse was observed performing care without properly securing her gown, which repeatedly fell off her shoulders and chest during the procedure. The nurse also failed to perform hand hygiene before donning gloves and entered the resident's room after gathering supplies from other areas without sanitizing her hands. During the care, the nurse touched clean supplies in the resident's closet with gloves that had been used for the urostomy treatment, potentially contaminating those supplies. The nurse admitted to not following facility policy regarding PPE donning and hand hygiene, stating she was in a hurry and did not secure the gown or sanitize her hands as required. For another resident with a foley catheter, the catheter bag outlet spout was observed unclipped, open, and lying on the floor without a privacy bag in place. The CNA responsible for the resident stated she had emptied the catheter bag and noticed the spout on the floor, cleaning it with a personal care wipe instead of an alcohol wipe, and did not notify the nurse of the incident. Facility policy required that if a catheter bag or tubing touches the floor, it is considered contaminated and should be replaced as soon as possible, or at minimum disinfected with an approved wipe. The nurse was not informed of the contamination and the catheter bag was not changed, as confirmed by a review of the treatment administration record and progress notes. Interviews with facility leadership, including the Infection Preventionist and Director of Nursing, confirmed that the observed practices did not meet facility expectations or policy. Both leaders stated that gowns should be secured to prevent exposure, hand hygiene should be performed before donning gloves, and contaminated catheter equipment should be properly disinfected or replaced. The failure to follow these protocols was acknowledged by the staff involved and confirmed by facility policy documentation.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that a copy of the notice of discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman for a resident who was discharged on two separate occasions. The resident, who had severe cognitive impairment as indicated by a BIMS score of 1, was discharged home with hospice care. The clinical records did not show evidence of the required notice being sent for the discharges that occurred on December 16 and December 29, 2023. Interviews with facility staff revealed a lack of clarity regarding the responsibility for notifying the Ombudsman. Staff members, including the admissions coordinator and social worker, each believed the other was responsible for the notification. The facility's policy, reviewed in October 2023, required that the transfer/discharge notice be provided to the resident and the Ombudsman, with evidence maintained of the notice being sent. However, the Administrator admitted that the notifications were only sent on the day of the surveyor's visit, indicating a lapse in following the established procedure.
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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