The Lingenfelter Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingman, Arizona.
- Location
- 1099 Sunrise Avenue, Kingman, Arizona 86401
- CMS Provider Number
- 035262
- Inspections on file
- 15
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Lingenfelter Center during CMS and state inspections, most recent first.
Two residents with dementia and documented behavioral issues became involved in a physical altercation over a bedside table, resulting in one resident being struck in the face. Staff intervened after the incident, but the altercation led to a visible injury, indicating a failure to protect residents from physical abuse as required by facility policy.
A resident with cognitive impairment and aggressive behavior attacked his roommate in an LTC facility, resulting in injuries. Despite having care plans and monitoring protocols, the facility failed to provide adequate supervision, leading to the altercation. Staff interviews revealed that limited staffing and insufficient intervention contributed to the incident.
A facility failed to provide adequate supervision, resulting in an altercation between two residents with cognitive impairments. One resident, known for aggressive behavior, attacked another, causing injuries. Despite care plans and monitoring protocols, staff did not prevent the incident, highlighting a deficiency in supervision and resident safety.
The facility failed to include actual hours worked for licensed and non-licensed staff on the daily staff posting, as required by their policy. The Resident Care Coordinator was unaware of this requirement, believing payroll was responsible for tracking actual hours. The Administrator confirmed the oversight and stated the regulation would be reviewed with the coordinator.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital twice, but the facility failed to document a physician order for one of the transfers. Staff interviews confirmed that an order is required for hospital transfers, but the facility could not locate the order for the November transfer. The facility's policy mandates physician documentation for necessary transfers.
A resident with severe cognitive impairment and behavioral issues, including wandering and aggression, had a care plan that was not updated to address ongoing sleep disturbances and behaviors. Despite documented symptoms and a medication adjustment, the facility failed to notify the provider of continued issues or revise the care plan accordingly. Interviews with staff indicated that the care plan should have been updated to meet the resident's needs.
A resident on dialysis with severe cognitive impairment was not maintained on the prescribed fluid restriction of 950 cc, as documented fluid intake exceeded this limit on several occasions. Staff interviews revealed a misunderstanding about the flexibility of fluid restrictions, and there was no evidence of physician notification regarding the excess fluid intake, contrary to facility policy.
A facility failed to appoint a qualified individual to direct recreational activities. The Director of Life Enrichment, employed without the necessary certification or experience, did not meet the job requirements. Interviews confirmed the lack of certification, although the Director was close to completing the necessary training.
A resident with severe cognitive impairment and multiple diagnoses was observed receiving less oxygen than prescribed, with the concentrator set at 1.5 liters instead of the ordered 2 liters. This was confirmed by an LPN and corrected after checking the order. The DON highlighted the risk of under-oxygenation if orders are not followed, as per facility policy.
A resident with severe cognitive impairment and multiple diagnoses exhibited behavioral symptoms such as aggression and wandering. Despite documented sleep disturbances, the facility failed to notify the provider or update the care plan after an initial medication adjustment. Interviews with staff and review of facility policy revealed expectations for provider notification and non-pharmacological interventions, which were not met, leading to a deficiency in care.
The facility failed to properly dispose of medications, as observed during medication administration by an LPN. Medications were improperly discarded in the trash instead of using the designated MedSafe bin, contrary to facility policy. Interviews revealed inconsistent disposal practices among staff, highlighting a lack of adherence to established procedures.
The facility failed to maintain a sanitary kitchen, as observed during a tour with the Director of Nutritional Services. Moldy strawberries, a brown grape, and shriveled peppers were found in the refrigerator. Additionally, cockroaches were seen near the dishwasher. The Administrator confirmed the Director's responsibility for daily quality checks to ensure food freshness, as per facility policy.
The facility failed to properly dispose of garbage and refuse, leading to potential pest attraction. Cockroaches were observed in the kitchen, and a grease trap near the garbage dumpster was leaking grease and food particles, which could attract bugs. The facility's policy requires garbage to be stored in a manner inaccessible to pests and storage areas to be kept clean.
The facility's high-temperature dishwasher failed to consistently reach the required temperatures for proper sanitization, with the rinse cycle often falling short of the necessary 180 degrees. The Director of Nutritional Services acknowledged the issue, and a new dishwasher was ordered. However, the dishwasher/Nutrition Service Worker continued using the malfunctioning dishwasher instead of the alternative three-sink method. The Administrator confirmed the potential risk of infection due to improper sanitization.
Two residents with severe cognitive impairments were involved in an altercation due to inadequate monitoring and intervention. One resident, known for wandering, approached another resident with a history of aggression, leading to a physical confrontation. Despite staff intervention, the incident resulted in a minor injury, highlighting a deficiency in preventing resident-to-resident abuse.
The facility did not adequately protect the rights of two residents with severe cognitive impairments, leading to a physical altercation. One resident with vascular dementia and behavioral disturbances reported discomfort with another resident with Alzheimer's and major depressive disorder. Both residents exhibited daily physical and verbal aggression. An incident occurred where a CNA witnessed a scuffle resulting in physical injuries. The aggressor could not recall the event, indicating memory issues. The incident was not immediately intervened, highlighting a lack of supervision to prevent such altercations.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of negative physical behaviors, including hitting, kicking, and pushing, was not protected from physical abuse by another resident. The resident's care plan identified issues with being protective of personal space and exhibiting negative behaviors toward others. On the day of the incident, the resident entered a common area and became involved in a physical altercation with another resident who also had a history of negative physical behaviors and severe cognitive impairment. The second resident, who was known to be territorial and required supervision and redirection due to wandering and pacing, engaged in a dispute over a bedside table with the first resident. During the altercation, the second resident balled up his fist and struck the first resident on the cheek, resulting in a visible red mark. Staff intervened to separate the residents and prevent further escalation, but the initial physical contact had already occurred. Staff interviews confirmed that both residents had documented behavioral issues and that the altercation was witnessed by a CNA, who reported the incident according to facility protocol. The facility's policy states a commitment to protecting residents from abuse by anyone, including other residents. Despite this, the incident demonstrated a failure to prevent physical abuse between residents with known behavioral risks.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, resulting in a resident-to-resident altercation involving two residents. Resident #3, who has a history of cognitive impairment, delusional thoughts, and physical aggression, was admitted to the facility with diagnoses including PTSD and dementia. Despite having a care plan that included interventions for monitoring and redirecting behaviors, Resident #3 was involved in an altercation where he physically attacked his roommate, Resident #4, believing he was an intruder in his home. Resident #4, who also has severe cognitive impairment and exhibits physical and verbal behavioral symptoms, was found on the floor with a skin tear and bruising after the altercation. The facility's staff, including CNAs and nurses, were aware of the residents' behavioral issues and had protocols in place for monitoring and addressing such behaviors. However, the incident occurred during a time when staffing was limited, with only one CNA present while another was on break, and the LPN was occupied with other tasks. Interviews with staff revealed that the facility had procedures for handling new admissions and monitoring residents, including 30-minute safety checks for newly admitted residents. Despite these measures, the altercation occurred, indicating a lapse in supervision and intervention. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, yet the incident highlights a failure to protect residents from harm due to inadequate supervision and response to behavioral cues.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, as evidenced by an incident involving two residents. Resident #3, who has a history of cognitive impairment and aggressive behavior, was involved in a physical altercation with Resident #4. The care plan for Resident #3 included interventions for managing confusion, unsafe wandering, and negative physical behaviors, but these measures were not effectively implemented, leading to the altercation. Resident #3 was found to have been the aggressor in the incident, which occurred during the night when staff presence was limited. Resident #4, who also has severe cognitive impairment and requires supervision for activities of daily living, was the victim in the altercation. The incident resulted in Resident #4 sustaining a skin tear and bruising. Despite the care plan indicating the need for close monitoring and interventions to manage behaviors, the facility did not prevent the altercation. The staff on duty at the time of the incident were engaged in other tasks, and the altercation was only discovered after loud noises were heard. Interviews with staff revealed that the facility has procedures for managing new admissions and monitoring residents, but these were not adequately followed in this case. The facility's abuse prevention policy emphasizes the right of residents to be free from abuse, yet the incident highlights a failure to uphold this standard. The lack of effective supervision and timely intervention contributed to the deficiency, putting residents at risk of harm.
Failure to Include Actual Hours on Daily Staff Posting
Penalty
Summary
The facility failed to ensure that all required information was included on the daily staff posting, as mandated by their policy and procedures. Specifically, the daily staff posting dated April 14, 2024, lacked the actual hours worked for each category of licensed and non-licensed staff. This omission was confirmed during a review of the posting by the Resident Care Coordinator, who acknowledged that the postings did not include the actual hours worked. Furthermore, the facility was unable to provide the daily staff posting for January 1, 2024. Interviews conducted with the Resident Care Coordinator and the Administrator revealed a lack of awareness regarding the requirement to include actual hours worked on the daily staff postings. The Resident Care Coordinator stated that she was responsible for updating and posting the daily staff information but was unaware that actual hours needed to be included, as she believed payroll was responsible for tracking this information. The Administrator confirmed that the purpose of the daily staff posting is to inform residents and visitors of staff ratios in the building, and acknowledged that the regulation regarding daily staff postings would be reviewed with the Resident Care Coordinator.
Missing Physician Order for Hospital Transfer
Penalty
Summary
The facility failed to ensure that a resident's clinical record included the required information for discharge, specifically lacking a physician order for a hospital transfer. The resident, who was admitted with multiple diagnoses including recurrent major depressive disorder, pneumonia, dementia with mood disturbance, agitation, and psychotic disturbance, experienced two short-term unplanned hospital discharges. While the facility had a physician order for the February 12, 2024 hospitalization, there was no evidence of a physician order for the hospitalization on November 7, 2023. Interviews with staff revealed that there is a process in place for handling discharges, including notifying the doctor and obtaining necessary orders. However, the facility was unable to locate the physician order for the November 7, 2023 transfer. The Director of Nursing acknowledged the missing order and stated that an order is expected for each hospital transfer. The facility's policy requires physician documentation in the clinical record when a transfer is necessary for the resident's welfare or other specified reasons.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to reassess and revise the care plan for a resident with severe cognitive impairment and multiple behavioral issues, including wandering and aggression. The resident was admitted with several diagnoses, including chronic obstructive pulmonary disease, malignant neoplasm, metabolic encephalopathy, dementia, major depressive disorder, and insomnia. Despite the resident's care plan indicating the use of psychotropic medications and the need for regular evaluation and adjustment, the facility did not adequately address the resident's intermittent sleep patterns and associated behaviors. The resident exhibited significant behavioral symptoms, such as physical and verbal aggression, rejection of care, and wandering, which were documented in various notes and assessments. Despite these documented behaviors and a physician's order to increase the resident's medication, the facility did not update the care plan to reflect these ongoing issues. The resident's sleep disturbances and behavioral symptoms persisted, yet there was no evidence that the provider was notified of these continued behaviors after the initial medication adjustment. Interviews with facility staff, including an LPN and the DON, revealed that the care plan should have been updated to address the resident's needs. The facility's policies on comprehensive care planning and behavior monitoring emphasize the importance of revising care plans as residents' conditions change. However, the facility did not adhere to these policies, resulting in a care plan that did not meet the resident's needs.
Failure to Adhere to Fluid Restrictions for Dialysis Resident
Penalty
Summary
The facility failed to adhere to ordered fluid restrictions for a resident on dialysis, which could potentially lead to complications such as fluid overload. The resident, who was admitted with diagnoses including congestive heart failure and dependence on renal dialysis, had a physician order for a daily fluid restriction of 950 cc. However, the facility's records showed that the resident's fluid intake exceeded this limit on multiple occasions, with no documentation indicating that CNAs notified nursing staff of the excess intake. Interviews with staff revealed a misunderstanding regarding the flexibility of fluid restrictions, particularly in cases of comfort care. A CNA admitted to providing additional fluids beyond the prescribed limit if requested by the resident, while an LPN confirmed that fluid restrictions should be strictly followed regardless of comfort care status. The DON acknowledged the failure to adhere to fluid restrictions and the lack of physician notification about the resident's excessive fluid intake, which was contrary to the facility's policy requiring physician orders to be followed and any deviations to be reported.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to designate a qualified individual to provide recreational activities, as required by their policy and procedures. Staff #95, who was employed as the Director of Activities and later as the Director of Life Enrichment, did not possess the necessary certification or prior experience in recreational activities. The employee record showed that staff #95 had only a high school diploma and lacked both certification as an activities professional and two years of prior experience in a social or recreational program. Interviews with the Human Resource Director and the Administrator confirmed that staff #95 had not completed the certification for activities specialist, although the Administrator mentioned that staff #95 was close to finishing the training. The job description for the Director of Life Enrichment required satisfactory completion of a training course approved by the Department of Health and Human Services or certification by a recognized accrediting body, along with two years of experience in a relevant program. The absence of these qualifications in staff #95's record led to the deficiency.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident in accordance with the physician's order. The resident, who was admitted with diagnoses including epilepsy, severe dementia with psychotic and mood disturbances, and anxiety, had a physician's order for 2 liters of oxygen to be administered continuously via cannula or mask. However, during an observation on June 3, 2024, the resident was found with the oxygen concentrator set at 1.5 liters instead of the prescribed 2 liters. This discrepancy was again noted on June 6, when the resident was observed in the dining room with the concentrator still set at 1.5 liters. A licensed practical nurse confirmed the incorrect setting and adjusted it to the correct 2 liters after checking the order. The Director of Nursing acknowledged that a physician's order is necessary for oxygen administration and emphasized the risk of under-oxygenation if the order is not followed. The facility's policy on oxygen administration, dated June 1, 2020, mandates that oxygen therapy be administered as ordered by the physician and that the oxygen flowmeter be reassessed for the correct liter flow. The failure to adhere to the physician's order for oxygen administration could result in hypoxia for the resident.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with severe cognitive impairment and multiple diagnoses, including dementia and major depressive disorder. The resident exhibited various behavioral symptoms, such as physical and verbal aggression, rejection of care, and wandering, which were documented in the Minimum Data Set (MDS) assessment. Despite these documented behaviors, the facility did not adequately address the resident's intermittent sleep pattern, which was noted in several evaluation notes over a period of time. The resident's care plan included interventions for psychotropic medication management and monitoring for changes in behavior or cognitive function. However, after an initial adjustment to the resident's medication, there was no further evidence that the provider was notified of the continued sleep disturbances and wandering behavior. This lack of communication and follow-up with the provider contributed to the deficiency in care. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that there were expectations for staff to notify providers and offer non-pharmacological interventions for residents with sleep issues. The facility's policy on behavior monitoring also required documentation of behaviors and interventions, as well as updates to the care plan. However, these procedures were not followed, leading to the deficiency in providing necessary behavioral health care and services to the resident.
Improper Medication Disposal Practices
Penalty
Summary
The facility failed to ensure proper disposal of medications in accordance with professional standards of practice, as observed during medication administration. During a medication pass, an LPN attempted to administer five medications to a resident, who spat out Aspirin and Docusate Sodium into the medicine cup. The LPN then improperly disposed of the medicine cup containing the medications by throwing it into the trash can at the nurse's station. In another instance, the same LPN dropped a Depakote capsule onto the medication cart and disposed of it in the trash can along with another capsule. Interviews with staff revealed inconsistent practices regarding medication disposal. One LPN stated that non-narcotic drugs are typically wasted by throwing them in the trash or sharps container, while another mentioned using a gray box in the conference room for disposal, usually involving two nurses. The Director of Nursing emphasized the use of the MedSafe bin for disposing of expired or unused medications to prevent diversion and ensure safety. The facility's policy indicated the use of Tridecon Healthcare Solutions for pharmaceutical waste management, but the observed practices did not align with this policy.
Deficient Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, as observed during a tour of the kitchen with the Director of Nutritional Services. During the inspection of the large walk-in refrigerator, a box of strawberries was found to contain a strawberry with a fuzzy white mold patch. Additionally, a bag of green grapes had a brown grape, and a box of green peppers appeared shriveled and wilted. The Director acknowledged the presence of mold and the poor condition of the produce, stating that it is everyone's responsibility to monitor and remove old food. Furthermore, during a demonstration of the high-temperature dishwasher, two cockroaches were observed running on the floor, which were then picked up by a staff member using a paper towel. The Administrator confirmed that it is the responsibility of the Director of Nutritional Services to ensure daily quality checks are conducted to maintain the freshness and nutritive value of the food. The facility's policy on Food Storage and Date Marking requires perishable foods to be stored immediately upon receipt to assure quality. The Administrator acknowledged the potential risk of foodborne illness if spoiled or non-fresh food is served to residents, highlighting the importance of proper food storage and handling procedures.
Improper Garbage Disposal and Pest Attraction
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, which could attract rodents and pests. During an initial tour of the kitchen, two cockroaches were observed running on the floor from the dishwasher to under the sink. A staff member used a paper towel to pick up the cockroaches. Additionally, a tour of the garbage/refuse area revealed a large grease trap next to the garbage dumpster, with grease dripping onto the ground and covering a large area. Small particles of food and grease were visible on the grease trap, which staff acknowledged could attract bugs. The facility's policy on garbage disposal requires that garbage containing food wastes be stored in a manner inaccessible to pests and that storage areas be kept clean at all times.
Dishwasher Temperature Deficiency in Kitchen
Penalty
Summary
The facility failed to ensure that essential kitchen equipment, specifically the high-temperature dishwasher, was maintained and in safe operating condition. During an initial tour of the kitchen, it was observed that the dishwasher did not consistently reach the required temperatures for proper sanitization. The wash cycle consistently reached 150 degrees, but the rinse cycle repeatedly failed to reach the necessary 180 degrees, with temperatures recorded at 145 degrees multiple times. The Director of Nutritional Services acknowledged the issue and mentioned that a new dishwasher had been ordered. However, the dishwasher/Nutrition Service Worker stated that he had never used the alternative three-sink method for washing dishes and continued to run the dishwasher until it reached the correct temperatures. The Maintenance Manager attempted to adjust the dishwasher, achieving a rinse cycle temperature of 150 degrees, but this was still below the required range. The Administrator confirmed the potential risk of infection due to improper sanitization if the dishwasher did not reach the appropriate temperatures. The CMA Dishmachines Owner's Manual specifies that the wash cycle should be between 155 to 160 degrees and the rinse cycle between 180 to 195 degrees, indicating that the facility's dishwasher was not operating within these guidelines, potentially compromising the safety of the dishware used for residents.
Resident-to-Resident Altercation Due to Inadequate Monitoring
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, leading to a deficiency. Resident #69, who has severe cognitive impairment due to dementia, exhibited wandering behavior and entered other residents' personal spaces. On multiple occasions, Resident #69 was noted to wander aimlessly, move furniture, and interact with other residents inappropriately. Despite having a care plan that included monitoring and redirecting the resident, these interventions were not effectively implemented, resulting in an altercation with another resident. Resident #25, also with severe cognitive impairment and a history of aggressive behavior, was involved in the altercation with Resident #69. This resident's care plan included interventions to manage physical aggression and anxiety, particularly during interactions with others. However, on the day of the incident, Resident #25 was observed to be anxious and became physically aggressive when approached by Resident #69. The altercation resulted in Resident #25 sustaining a superficial scratch on her arm. The incident was captured on the facility's camera system, showing Resident #69 approaching Resident #25, leading to a physical confrontation. Staff intervened quickly to separate the residents, but the facility's failure to prevent the altercation indicates a deficiency in protecting residents from abuse. The facility's policy on abuse prohibition emphasizes the need for prevention and protection, which was not adequately upheld in this case.
Resident Rights and Safety Concerns Due to Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect the rights of two residents, identified as #520 and #525, to be free from abuse from each other. Resident #520 had diagnoses of vascular dementia with agitation/behavioral disturbances, while Resident #525 had Alzheimer's disease, major depressive disorder, and dementia with agitation/behavioral disturbances. Both residents exhibited severe cognitive impairments and displayed physical and verbal behavioral symptoms directed towards others on a daily basis. An incident on February 24, 2024, involved a scuffle between the two residents, resulting in physical injuries such as abrasions on their bodies. Resident #520 reported feeling uncomfortable with Resident #525's presence in the room, leading to a confrontation where both residents engaged in physical aggression towards each other. The facility's incident report detailed that a certified nursing assistant (CNA) witnessed the altercation between the two residents, with Resident #525 being identified as the aggressor. The report highlighted that Resident #525 was unable to recall the event, indicating potential memory issues. The facility's documentation also revealed that Resident #520 exhibited loud verbal outbursts and physical aggression towards others, while Resident #525 was described as getting easily triggered by loud voices. The report emphasized that the incident was not witnessed by anybody else, indicating a lack of immediate intervention or supervision to prevent resident-to-resident altercations. During interviews with staff members, it was noted that Resident #520 had a history of being verbally and physically aggressive, while Resident #525 was described as easy-going but prone to moments of anger and difficulty in redirection.
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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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