Winslow Campus Of Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Winslow, Arizona.
- Location
- 826 West Desmond Street, Winslow, Arizona 86047
- CMS Provider Number
- 035254
- Inspections on file
- 29
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Winslow Campus Of Care during CMS and state inspections, most recent first.
A resident with dementia, chronic pain, and other serious conditions had an order for PRN liquid Morphine, with a controlled substance log that initially showed a steady countdown of 0.25 mL doses but later contained an undated entry and a documented remaining volume that did not match the actual amount in the bottle. During narcotic count and administration observations, an RN reported discovering that approximately 7 mL of Morphine was missing compared to the narcotics record, and described that hospice-supplied Morphine bottles lacked measurement markings, leading staff to estimate remaining amounts by sight. The RN and DON both acknowledged that staff sometimes failed to document Morphine removal in either the narcotics book or the eMAR, and that in-house leur-lock syringes were used instead of the hospice-provided syringe, which could trap or leak medication. The DON confirmed that the amount of Morphine in the bottle did not match the 10.25 mL recorded on the log and stated that this discrepancy, combined with imprecise measurement practices, meant the facility did not consistently meet its own policy and procedures for accurate controlled substance storage, documentation, and reconciliation.
Two residents with severe cognitive impairment were involved in a medication error when an LPN crushed quetiapine and trazodone, ordered for one resident, into hot chocolate and left the medicated drink unattended on a dining table. The intended resident, who had a history of refusing medications and preferring them in hot chocolate, sipped the drink and then pushed the cup away and attempted to give it to another resident. Video later showed the first resident handing the cup to the second resident, who appeared to drink from it and subsequently became lethargic, hypotensive, and fell from a chair, leading to ED evaluation where it was documented she had ingested the other resident’s Seroquel and trazodone. The DON and facility policies specified that medications, including those mixed in food or beverages, must not be left unattended and that medications ordered for one resident must not be administered to another.
Two residents with severe cognitive impairment and behavioral disturbances were involved in a physical altercation during meal service, resulting in one resident sustaining scratches to the breast after attempting to take food from another. Staff were present but not directly observing the incident, and the altercation was later confirmed by video review and staff interviews. The event was treated as abuse in accordance with facility policy.
A resident with severe cognitive impairment was struck by another resident during breakfast after their wheelchairs became entangled due to a change in seating arrangement. Staff and video evidence confirmed the physical altercation, which resulted in minor redness but no significant injuries. The incident was documented according to facility policy.
A resident with severe cognitive impairment and behavioral issues repeatedly exhibited verbal and physical aggression toward another resident with dementia, including kicking and pushing the resident in his wheelchair. Despite staff interventions and documentation of prior incidents, the aggressive behaviors escalated to physical abuse, with staff and camera footage confirming the events. Staff interviews indicated a known pattern of behavior and communication between shifts, but timely escalation to management and effective preventive measures were lacking.
A resident with severe cognitive impairment and multiple comorbidities experienced repeated falls due to the facility's failure to consistently and promptly update and implement effective fall prevention interventions in the care plan. Despite available fall prevention tools and policies requiring immediate review and revision of care plans after each fall, new interventions were often delayed or omitted, resulting in multiple falls and injuries.
Two residents with cognitive impairments and histories of aggression were involved in a physical altercation in a LTC facility. One resident attempted to interact verbally, leading to the other resident becoming agitated and striking out. The first resident responded by shoving the other. The incident was observed on camera, and both residents were assessed with no injuries. The facility's policy on abuse prevention was reviewed, highlighting a failure to prevent the altercation.
A facility failed to provide adequate supervision, resulting in multiple resident-to-resident altercations. Despite having care plans in place, staff were unable to prevent physical contact between residents with cognitive impairments and behavioral issues. The incidents highlight deficiencies in monitoring and intervention measures.
The facility failed to protect residents from abuse, resulting in multiple incidents of physical aggression. A resident with cognitive impairment shook another's wheelchair, while two others engaged in a physical altercation despite care plans to prevent such behaviors. Additional incidents involved residents with cognitive impairments engaging in physical contact, highlighting a failure to implement effective supervision and intervention strategies.
The facility failed to maintain sanitary conditions in dishwashing practices, as observed during a kitchen inspection. The low temperature dishwashing machine required multiple runs to reach the necessary temperature, and chlorine sanitizer levels exceeded the manufacturer's recommended 50 ppm, reaching up to 150 ppm. The facility's documentation did not include ppm test results, despite performing the tests, indicating a lack of adherence to professional standards.
A resident with multiple falls and conditions such as dementia and anxiety was improperly monitored for physical restraints. Despite discontinuation, a seat belt alarm was observed tied to the resident, indicating non-compliance with care plans. Staff interviews revealed inconsistencies in restraint policy understanding and alarm functionality, with no fall assessment conducted prior to alarm use. The DON confirmed the seat belt alarm should not have been in use, as it was discontinued.
A facility failed to notify the State Long-Term Care Ombudsman of a resident's discharge, as required by policy. The resident, with diagnoses including dementia and hypertension, was sent to the Emergency Department after being found unresponsive. Staff interviews revealed that the Ombudsman was not notified, contrary to facility policy, potentially depriving the resident of necessary advocacy during the discharge process.
The facility failed to revise care plans for three residents, leading to deficiencies in care. A resident with dementia did not have a care plan addressing physical decline. Another resident with cognitive impairments exhibited aggressive behaviors, but their care plan lacked timely updates. A third resident with hemiplegia also showed aggression, yet their care plan was not revised promptly. Staff interviews revealed unclear responsibilities for updating care plans.
A resident with dementia and other health issues was found with a bag of medications in their room, posing a risk of self-administration. The facility's staff, including a CNA and LPN, identified the issue, and the DON confirmed that no residents were assessed for self-administration, contrary to facility policy.
A facility failed to provide specialized rehabilitative services for a resident with dementia, muscle weakness, and adult failure to thrive. Despite the resident's increased dependency and MDS assessments indicating a decline, there was no care plan addressing physical decline or therapy needs. Staff interviews revealed a lack of communication and coordination regarding therapy assessments, with no baseline assessment or evaluation conducted. The facility's policy on ADLs was not followed, leading to a deficiency in care.
A facility failed to administer a pneumococcal vaccine to a resident who had consented to receive it upon admission. Despite having a signed consent form, there was no evidence that the vaccine was given. The resident had a history of acute respiratory failure and pneumonia, and the oversight was confirmed by the ADON/IP during an interview.
A resident with moderate cognitive impairment physically abused two other residents with dementia in separate incidents. Despite staff intervention, the resident pushed and hit the others, leading to substantiated abuse findings. The facility's abuse prevention policy was not effectively implemented, resulting in a deficiency in resident safety.
A cognitively impaired resident initiated a physical altercation with another resident in a common area near the nurses' station. The incident, captured on video, showed the residents kicking each other before being separated by staff. The facility's lack of monitoring in the area contributed to the delay in intervention, highlighting a deficiency in ensuring resident safety.
A resident with a full code status was found without breath sounds and a pulse, but the nurse on duty did not initiate CPR or call EMS, resulting in the resident's death. The resident had multiple health issues and was hypotensive on the day of the incident. Despite the facility's policy requiring CPR in the absence of a DNR order, the protocol was not followed.
A resident with limited mobility and existing pressure ulcers did not receive the planned repositioning every two hours as outlined in their care plan. Despite the care plan's directive, there was no evidence of tracking or implementation of this intervention. Interviews with staff revealed that the task was not included in the plan of care tasks, and the facility's documentation policies were not followed.
The facility failed to implement a COVID-19 screening and testing program during an outbreak, leading to multiple positive cases among residents and staff. A resident with COVID-19 and end-stage renal disease was hospitalized and later died. Staff were not required to screen for symptoms or check temperatures before entering the building. The facility's policy required testing during outbreaks, but this was not followed.
A resident with chronic conditions experienced a decline in oxygen saturation and reported chest pain and difficulty breathing. Despite these symptoms, the facility failed to notify the physician or document the resident's transfer to a community clinic by family. Interviews revealed that standard procedures for notifying the DON and physician were not followed, and the documentation did not meet facility standards.
A resident with severe cognitive impairment was verbally abused by family members during a visit, with staff failing to intervene promptly. Despite hearing the altercation, staff did not stop the abuse or ask the family to leave, resulting in a deficiency in protecting the resident.
A resident with Alzheimer's and dementia experienced a verbal altercation with family members during a visit, where they demanded money and threatened to sell the resident's cows. Despite staff hearing the altercation, no intervention occurred, and the facility failed to implement its abuse prevention policy, allowing the visit to continue without protective measures.
Failure to Accurately Document and Reconcile Liquid Morphine for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to accurately record, store, and reconcile a controlled medication, Morphine Sulfate, for one resident with multiple serious diagnoses including senile degeneration of the brain, dementia, cellulitis, nutritional deficiency, psychotic disturbance, anxiety, pneumonia, and chronic pain. The resident had a physician’s order for Morphine solution 20 mg/5 mL (4 mg/mL), 0.25 mL by mouth every 4 hours as needed for pain, initiated in early March. The resident’s care plan identified end-of-life related pain and required prompt response to pain complaints, administration of pain medication as ordered, assessment of pain characteristics and effectiveness of pain medication, monitoring for side effects, and ensuring pain medication was available when needed. The individual controlled substance record for this resident’s Morphine showed a steady countdown in 0.25 mL increments until an entry on July 31, where 25.25 mL remained, followed by an undated entry showing 20 mL remaining before the next dated entry on August 5. The record then continued with a steady countdown until mid-January, when a 0.25 mL dose was documented with 10.25 mL remaining. During an observation of the narcotic count process, surveyors noted that two nurses verified narcotic counts by one reading the name and written amount from the narcotics book while the other visually checked the medication. Staff interviews revealed that the facility’s process for administering liquid narcotics included checking the eMAR, preparing the medication, signing it out in the narcotics book, rechecking the eMAR, and then administering the dose. However, an RN reported that during a narcotics check prior to a shift, the narcotic count for this resident’s Morphine was not correct, with about 7 mL missing compared to what was documented. The RN stated that the Morphine bottles supplied by hospice did not have measurement markings on the side, making it impossible to visually determine the exact amount remaining and requiring staff to estimate by “eyeballing” the bottle. She also reported that there had been incidents where nursing staff failed to document removal of Morphine in the narcotics book or failed to check it out in the eMAR, and vice versa. The DON confirmed that the facility’s medication administration process required verification of the five rights, review of orders, appropriate timing, and documentation on both the eMAR and narcotics sheet, and that this process applied to liquid Morphine as well. She explained that Morphine from the primary pharmacy arrived in bottles with clear panels and increment markings, along with a paper narcotics log, while hospice-supplied Morphine bottles had clear panels but no increment markings. The DON stated that before the incident, nurses would look at the hospice bottles without fully measuring or quantifying the remaining amount. She reported that on a date in late January, staff noticed that the amount in the Morphine bottle did not match the 10.25 mL recorded on the narcotics log for a mid-January administration. When the remaining medication was drawn into a syringe, it was confirmed that it was not 10.25 mL. The DON also noted that staff were using in-house leur-lock syringes instead of the syringe provided with the hospice medication, which could trap or leak liquid in the lower space of the syringe. The facility’s Medication Management policy required narcotics to be kept in a separate locked drawer and accounted for at each shift change, and medications to be stored in their original labeled containers, but the documented discrepancies and missing Morphine demonstrated that these requirements were not consistently met for this resident’s controlled medication. The DON further stated that the lack of measurement markings on hospice Morphine bottles made it hard to know how much medication was left and that prior to the incident, staff relied on visual estimation rather than precise measurement. She indicated that when she examined the bottle at eye level, it did not appear to contain the amount documented on the narcotics log, and that pulling the remaining medication into a syringe confirmed the discrepancy. She also acknowledged that using in-house syringes with a different tip design than the hospice-provided syringe created a risk of medication remaining in or leaking from the syringe. The DON stated that this situation could pose a risk that residents might miss medication doses, remain in pain, or not receive medication at all. Overall, the findings showed that the facility did not ensure accurate documentation, measurement, and reconciliation of a controlled substance for this resident, in contrast to its own policy and stated procedures for narcotic management.
Unattended Medicated Beverage Leads to One Resident Receiving Another’s Psychotropic Medications
Penalty
Summary
The deficiency involves a resident receiving prescription medications that were ordered for another resident, after those medications were left unattended in a beverage. One resident with severe cognitive impairment, who spoke and understood Navajo and had no prescription medications ordered, was care planned for confusion, forgetfulness, and inattention. This resident’s medication regimen consisted only of OTC products such as calcium carbonate, claritin, famotidine, lidocaine patch, Systane eye drops, and Tylenol. On one day, the resident was found lying on the dining room floor next to her chair, responsive but very tired, with slow speech, rapid respirations, hypotension, low oxygen saturation, and an inability to stand without assistance. Nursing documentation recorded these abnormal vital signs, and the on‑call provider ordered transfer to the ED for evaluation. In the ED, documentation reflected that EMS had been called for concern that this resident had accidentally received another patient’s trazodone and Seroquel. The ED physician note recorded a report from the nursing home that the resident had ingested 150 mg of Seroquel and 75 mg of trazodone that had been mixed into another resident’s drink at breakfast. The ED assessment described the resident as mildly somnolent but arousable to voice, oriented x0, moving all extremities at baseline, with no bony extremity injury. Poison control was contacted and advised that the resident could return once at baseline, noting it could take several hours for her to be less sleepy. The resident was observed in the ED for several hours and then discharged back to the facility in stable condition. The other resident involved also had severe cognitive impairment, with a care plan noting forgetfulness and confusion, and spoke and understood English. This resident had active orders for quetiapine totaling 150 mg in the morning and trazodone 25 mg three times daily. A progress note documented that this resident had a history of refusing medications when offered whole or crushed in pudding, and nursing staff had begun giving medications crushed in hot chocolate, which the resident accepted. On the day of the incident, the resident initially began drinking the hot chocolate with medications but then pushed the cup away and attempted to give it to another resident at the dining table. Video reviewed with the DON later showed this resident with a blue cup identified as containing medication, taking a sip, then handing the cup to the cognitively impaired resident, who appeared to drink from it; approximately 40 minutes later, the second resident slumped over and fell. An LPN reported that the morning medication pass could be difficult because some residents would only take medications while eating, and that crushed medications were usually placed in pudding, though some residents preferred them in drinks such as Boost or hot chocolate. The LPN stated that, with this particular resident, they had learned that she did not like to be watched while taking medications and usually finished the entire drink once she picked it up. On the incident day, the LPN mixed the medications in hot chocolate, saw the resident sip from the cup, and then walked away before the drink was finished, acknowledging this was a poor judgment and that the resident should not have been left until the medication was gone. Later, when called to assess the resident who fell, the LPN found her lethargic but able to talk and move, unable to walk as usual, and observed that the medicated cup from the first resident was in front of the second resident’s place, leading the LPN to assume the second resident had ingested some of the medication. The DON stated that expectations for nurses during medication administration included following the five rights (right drug, dose, resident, time, and route), attempting re‑administration if a medication was refused, and documenting and disposing of medications if still refused. The DON further stated that medications could be mixed in applesauce, pudding, or a drink with an order, but that nurses were expected to ensure residents took all of the medication delivered and that leaving medications unattended—including crushed medications in pudding or hot chocolate—was not acceptable. Facility policy on Medication Management specified that only medications ordered by a medical practitioner should be administered to a resident and that staff shall not leave medication unattended. The RN/LPN Charge Nurse job description included responsibility to ensure that prescribed medication for one resident is not administered to another.
Failure to Prevent Resident-to-Resident Abuse During Meal Service
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, as evidenced by an incident involving two residents with severe cognitive impairment and behavioral disturbances. One resident, who had a history of aggressive and combative behavior, approached another resident in the dining room and attempted to take food from their plate. In response, the second resident physically grabbed and scratched the first resident's right breast, resulting in three scratches of varying lengths. Both residents were known to have significant cognitive deficits and behavioral symptoms, including wandering and aggression. Staff interviews and documentation revealed that staff were present in the dining room but were not directly observing the altercation when it occurred. One LPN was assisting another resident and had her back to the incident, only becoming aware of the situation after hearing the commotion. A CNA intervened to separate the residents. Video footage confirmed the sequence of events, showing the first resident approaching and the second resident reacting physically. Staff acknowledged that the second resident had a history of aggressive behavior toward others, particularly when her personal space was invaded, and that interventions such as redirection had been previously implemented. The facility's abuse prevention policy defined abuse as the willful infliction of injury or harm, regardless of the mental or physical condition of the residents involved. Staff interviews indicated some uncertainty about whether the incident constituted abuse due to the cognitive status of both residents, but ultimately, the incident was treated as an abuse allegation and reported according to policy. The deficiency was identified due to the facility's failure to prevent the resident-to-resident altercation that resulted in physical harm.
Failure to Prevent Resident-to-Resident Physical Abuse During Meal Service
Penalty
Summary
The facility failed to protect a resident from abuse by another resident during a breakfast meal. One resident, who had severe cognitive impairment and multiple medical diagnoses including senile degeneration of the brain and diabetes, was attempting to back his wheelchair away from the dining table. In the process, his wheelchair unintentionally bumped into another resident's wheelchair. The second resident, who also had significant medical conditions such as expressive language disorder, Parkinsonism, and hemiplegia, responded by striking the first resident in the right arm with a closed fist. Multiple staff members witnessed the incident, with one CNA observing the resident being hit in the chest and another noting contact to the arm and chest area. Video footage confirmed that the two residents' wheelchairs became entangled, leading to a physical altercation where the second resident hit the first resident in the right forearm. The incident occurred because the first resident was not seated in his usual spot, which contributed to the close proximity and subsequent altercation between the two residents. The facility's policy defines resident-to-resident physical altercations as reportable events and includes actions such as hitting and punching as forms of abuse. The incident was documented in progress notes, witness statements, and a facility reportable event record. Both residents were assessed after the incident, with only slight redness noted on the first resident's wrist and no other injuries reported.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in multiple incidents of verbal and physical aggression. One resident, with a history of dementia, restlessness, agitation, and severe cognitive impairment, repeatedly exhibited aggressive behaviors toward another resident who also had dementia and impaired decision-making abilities. The aggressive resident believed the other resident was her abusive ex-husband, leading to repeated verbal altercations and escalating to physical contact, including kicking and pushing the resident in his wheelchair. Staff documented several incidents where the aggressive resident confronted, yelled at, and attempted to physically harm the other resident. On multiple occasions, staff intervened to separate the residents and redirect the aggressive resident. However, despite these interventions, the aggressive behaviors continued, culminating in an incident where the aggressive resident kicked the other resident's wheelchair, pushed him into a room, and later kicked his leg. These incidents were observed by staff and confirmed through camera footage. Staff interviews revealed that there was a known pattern of behavior, and night shift staff had reported similar incidents to day shift staff over a period of one to two months. The facility's documentation and staff interviews indicated that while some incidents were reported and discussed among staff, there was a lack of timely escalation to management or comprehensive intervention to prevent further occurrences. The care plan for the aggressive resident included interventions such as offering a baby doll and documenting behaviors, but these measures did not prevent the escalation to physical abuse. The facility's abuse prevention policy required identification of residents at risk for abusive behavior and the development of intervention strategies, but the repeated incidents suggest these steps were insufficient or not effectively implemented prior to the physical abuse event.
Failure to Timely Update and Implement Effective Fall Prevention Care Plan
Penalty
Summary
The facility failed to evaluate and implement effective care plan interventions related to falls for a resident with severe cognitive impairment and multiple comorbidities, including dementia with behavioral disturbance, cardiomyopathy, and pulmonary fibrosis. The resident was identified as being at risk for falls due to advanced age, dementia, and a history of falls. Despite the initial care plan including interventions such as providing a clutter-free environment, night light, call light within reach, and verbal reminders, the resident experienced multiple falls after the care plan was initiated. New interventions were only added after several additional falls occurred, rather than immediately following each incident. Documentation revealed that after each fall, there was often a delay before new interventions were implemented, and in some cases, no new interventions were added at all. For example, after a series of falls, interventions such as a 'Call, Don't Fall' sign, regular changing of pull-ups, bed and wheelchair alarms, and reminders to ask for toileting assistance were added, but only after repeated incidents. Even after these interventions, the resident continued to experience both witnessed and unwitnessed falls, with some falls not resulting in any updates to the care plan. Staff interviews confirmed that while various fall prevention tools and strategies were available, their application was inconsistent, and staff sometimes struggled to respond to alarms promptly due to staffing issues. The facility's policy required that falls be reviewed daily and that care plans be updated immediately after each fall, but this was not consistently followed. The Director of Nursing acknowledged that care plans were not always updated after every fall, and decisions about adding new interventions were made on a case-by-case basis. The lack of timely and consistent updates to the care plan following each fall, as well as inconsistent implementation of available interventions, led to the resident experiencing multiple falls and injuries, including bruising and pain that required hospital evaluation.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that two residents were free from physical abuse, as evidenced by an altercation between them. Resident #25, who has severe cognitive impairment and a history of physical aggression, was involved in a physical altercation with Resident #20. Resident #25 approached Resident #20 in the hallway and attempted to interact verbally, which led to Resident #20 becoming agitated and swatting at Resident #25's leg. In response, Resident #25 shoved Resident #20 on the shoulder twice. The altercation was observed on camera footage, and both residents were assessed with no injuries noted. Resident #20, who has vascular dementia and is rarely understood, also has a history of physical and verbal aggression. During the incident, Resident #20 was sitting in a wheelchair when Resident #25 approached and attempted to communicate. Resident #20, who did not want to be bothered, struck Resident #25's leg multiple times. The altercation was reported by a dementia unit aide who heard yelling and observed the physical contact. The incident was promptly reported to the nurse, and the residents were separated. The facility's policy on abuse prevention was reviewed, which defines abuse as the willful infliction of injury, including physical contact such as hitting and slapping. The policy requires that any violations or alleged violations be reported to state agencies and thoroughly investigated. The deficiency in this case was the failure to prevent the resident-to-resident altercation, which could result in further incidents and potential injury.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, resulting in multiple resident-to-resident altercations. Eight residents were involved in incidents where physical contact was made, indicating a lack of effective monitoring and intervention by the staff. These incidents occurred despite the presence of care plans that outlined specific interventions to manage the residents' behaviors and cognitive impairments. In one incident, a resident with a history of mood disorder and cognitive impairment provoked another resident, leading to a physical altercation. The staff was present but failed to prevent the initial contact. Similarly, another incident involved a resident with dementia who was on one-on-one supervision but still managed to engage in a physical altercation with another resident. The staff's inability to effectively intervene and redirect the residents contributed to these altercations. The facility's documentation and staff interviews revealed that the staff was aware of the residents' behavioral tendencies and had care plans in place to address them. However, the execution of these plans was inadequate, as evidenced by the repeated incidents of resident-to-resident altercations. The staff's failure to consistently monitor and intervene in these situations highlights a deficiency in the facility's supervision and abuse prevention measures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect seven residents from abuse, resulting in multiple incidents of physical aggression and altercations. Resident #72, who has a history of traumatic brain injury and cognitive impairment, was involved in an incident where he aggressively shook another resident's wheelchair and attempted to push it into a wall. This behavior was documented in his care plan, which included interventions such as documenting behaviors and psychiatric consultations. However, the incident still occurred, indicating a failure to effectively manage and prevent such behaviors. Another incident involved residents #76 and #92, both of whom have cognitive impairments and behavioral issues. Resident #76, who has a history of aggression, was seen on camera preventing resident #92 from entering a common area and engaging in a physical altercation. Despite interventions in their care plans to de-escalate situations and remove residents from potentially harmful environments, the altercation occurred, suggesting inadequate supervision and intervention. Additional incidents involved residents #19 and #42, and residents #54 and #32, where physical aggression was observed. These residents also have cognitive impairments and behavioral issues documented in their care plans. Despite having interventions in place, such as supervision and behavioral management strategies, the facility failed to prevent these altercations, resulting in physical contact between residents. The facility's policy on abuse prevention requires immediate reporting and investigation of such incidents, but the repeated occurrences indicate a systemic issue in effectively implementing these policies.
Deficient Sanitation Practices in Dishwashing Procedures
Penalty
Summary
The facility failed to ensure that dishes and utensils were cleaned using professional standards of practice for sanitary conditions, which could result in residents becoming ill. During a kitchen inspection, it was observed that the low temperature dishwashing machine required multiple runs to reach the necessary temperature of 120 degrees Fahrenheit. The kitchen manager, Staff #201, confirmed that they use a chlorine sanitizer and conducted a test strip to determine sanitation levels, which showed a reading between 100 and 200 parts per million (ppm), approximately 150 ppm. Further review of the facility's Dish Machine Temperature Log for the months of November 2024 through January 2025 revealed that the wash temperatures were consistently logged over 120 degrees Fahrenheit, and the rinse column showed sanitizer levels over 100 ppm. However, the manufacturer's instructions for the dishwashing machine specified not to exceed 50 ppm of chlorine, indicating a discrepancy in the facility's practices. Staff #201 admitted that the ppm test results were not documented in the log sheet, as the current form did not provide an option to record them, despite performing the test strip. Interviews with the kitchen manager and the administrator revealed a lack of awareness and documentation regarding the ppm levels, with the administrator only being familiar with the use of a low temperature dish machine. The facility's policy on cleaning dishes stated that all flatware, serving dishes, and cookware should be cleaned, rinsed, and sanitized after each use, and the dish machine should be checked prior to meals to ensure proper functioning and appropriate temperatures. The absence of a ppm test results log and the use of higher than recommended chlorine levels indicate a failure to adhere to these standards.
Failure to Monitor and Evaluate Physical Restraints
Penalty
Summary
The facility failed to ensure proper monitoring and evaluation of physical restraints for a resident, leading to a deficiency in care. The resident, who was admitted with conditions including atrial fibrillation, dementia, and anxiety, experienced multiple falls, prompting the use of bed and wheelchair alarms. Despite the discontinuation of a self-releasing seat belt alarm, the resident was observed with the seat belt tied to his waist, indicating a lack of adherence to the updated care plan. Interviews with staff revealed inconsistencies in the understanding and implementation of restraint policies. A certified medication assistant and a CNA both noted the resident's instability and fall risk, justifying the use of alarms. However, the CNA mentioned that the new alarm system did not function properly, as it required a switch to be turned off by staff, which the resident was unaware of. This oversight in alarm functionality and staff's lack of awareness of non-pharmacological interventions contributed to the deficiency. The Director of Nursing acknowledged that no fall assessment was conducted before implementing the alarms, and the resident's consent for the seat belt alarm was not obtained, as it was not considered a restraint. The DON also confirmed that the seat belt alarm should not have been in use, as it was discontinued. The facility's restraint policy emphasizes a restraint-free environment unless medically necessary, highlighting the failure to comply with this standard.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that a copy of the discharge notice for a resident was sent to the Office of the State Long-Term Care Ombudsman. This deficiency was identified through clinical record reviews, staff interviews, and a review of facility policy. The resident in question was admitted with diagnoses including dementia, hypertension, and dysphagia. The Minimum Data Set assessment was incomplete, as indicated by a Brief Interview of Mental Status score of 99. The resident was sent to the Emergency Department after being found unresponsive, with a do-not-resuscitate order in place. The facility's policy requires that a copy of the discharge notice be sent to the Ombudsman, but this was not done. Interviews with facility staff revealed a lack of communication and adherence to policy regarding the notification of the Ombudsman. The Social Service staff stated that the Ombudsman is notified at the start of each month, but this did not occur for the resident's discharge. The Director of Nursing confirmed that the transfer was facility-initiated and acknowledged that social services should have notified the Ombudsman. The failure to notify the Ombudsman as required by policy may result in residents not receiving necessary advocacy and support during the discharge process.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were revised as needed for three residents, leading to deficiencies in their care. Resident #45, who was admitted with dementia, muscle weakness, and adult failure to thrive, had a care plan that did not address their physical decline or include therapy interventions, despite changes in their condition noted in the Minimum Data Set (MDS) assessments. Resident #72, admitted with traumatic brain injury and cognitive impairments, exhibited aggressive behaviors towards other residents. Despite multiple incidents documented in progress notes, including attempts to physically engage with other residents, the care plan was not updated to include new interventions to address these behaviors until February 2024, leaving a gap in the management of the resident's behavior. Resident #76, with diagnoses including hemiplegia and aphasia, also displayed aggressive behaviors towards other residents. Although incidents were documented in progress notes, the care plan was not revised to reflect these events until January 2025. Interviews with staff revealed a lack of timely updates to care plans, with responsibilities for updates not clearly defined among the MDS nurse, behavioral health unit manager, and social services staff.
Failure to Ensure Safe Medication Management
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, which could result in a medication overdose. The resident, who was admitted with diagnoses of dementia, type 2 diabetes, and dysphagia, was found to have a bag of medication in their room. A CNA discovered the medication while searching for the resident's clothing and reported it to a nurse. The medications included Bisacodyl, Polyethylene glycol, Melatonin, Docusate sodium, Quetiapine, Acetaminophen, and Diclofenac sodium. The resident had a BIMS score indicating intact cognition, but there was no assessment completed for self-administration of medication. Interviews with staff revealed that the resident did not have permission to self-administer medication, and the presence of medication in the room posed a risk of self-administration or sharing with others. The LPN and CNA involved in the incident confirmed that the medication should have been locked up. The Director of Nursing stated that any medication found in a resident's room should be reported to the assigned nurse and that no residents in the facility were assessed for self-administration of medication. The facility's policy requires a self-administration assessment before residents can manage their own medications.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident, identified as resident #45, who was admitted with diagnoses of dementia, muscle weakness, and adult failure to thrive. The resident's care plan, initiated on September 14, 2020, did not address the resident's physical decline or include a plan related to therapy, despite the resident's increasing dependency on staff for care. The annual Minimum Data Set (MDS) assessments indicated a decline in the resident's ability to perform activities of daily living, yet there was no documented assessment or therapeutic intervention to address this loss. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's need for therapy. A CNA noted the resident's increased dependency and the onset of contractures, while an LPN mentioned that therapy assessments might depend on insurance coverage. The Director of Therapy admitted that no baseline assessment or evaluation had been conducted for the resident, and there was no order for therapy evaluation. The Director of Nursing acknowledged the expectation for staff to notify providers of changes in condition but was unaware of any action taken beyond the MDS findings. The facility's policy on Activities of Daily Living emphasized the need for individualized assistance based on MDS assessments, which was not followed in this case.
Failure to Administer Pneumococcal Vaccine to Consenting Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine, despite having a signed consent form on file. The resident, who was initially admitted with acute respiratory failure, hypoxia, seizure, major depressive disorder, and pneumonia, had consented to receive the Pneumococcal Prevnar13 vaccine upon admission. However, there was no evidence in the records that the vaccine was administered to the resident. During an interview, the Assistant Director of Nursing/Infection Preventionist confirmed that the resident had consented to the vaccination but had not received it since admission. The facility's policy requires that each resident be presented with a Flu and Pneumonia Vaccine Authorization consent upon admission, which remains in effect until revoked. The failure to administer the vaccine as consented could increase the resident's susceptibility to respiratory infections and pneumonia.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to a deficiency in ensuring resident safety. Resident #2, who has dementia and other medical conditions, was physically assaulted by Resident #1 on two occasions. Despite staff intervention, Resident #1, who also has dementia and moderate cognitive impairment, pushed Resident #2 on the shoulder and upper back. The incidents were witnessed by staff, and although no injuries were observed, the events were substantiated as abuse by the facility's internal investigation. Resident #3, with severe cognitive impairment, was also a victim of physical abuse by Resident #1. While sitting at a CNA station, Resident #3 was struck on the arm by Resident #1, who accused Resident #3 of speaking ill of her. This incident was also witnessed by staff, and the facility's investigation confirmed it as abuse. Both residents were assessed for injuries immediately following the incidents, and appropriate notifications were made. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident #1. The policy outlines the need for identifying residents at risk of abusing others and developing intervention strategies, which were not adequately executed in this case. The facility's failure to prevent these occurrences resulted in a deficiency related to resident safety and protection from abuse.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #3, who was cognitively impaired with a BIMS score of 0, approached and hit Resident #4, who was cognitively intact with a BIMS score of 14. The incident occurred in a common area near the nurses' station, where both residents were in wheelchairs and engaged in kicking each other before being separated by staff. The altercation was captured on video surveillance, which showed Resident #3 initiating the physical contact. Staff #19, a Certified Medical Assistant, witnessed the altercation and intervened by separating the residents and notifying a Registered Nurse. The Director of Nursing, who was not present during the incident, later reviewed the video footage and confirmed the sequence of events. The Director noted that the common area where the incident occurred did not have a room monitor assigned during weekends, which contributed to the delay in staff intervention. The facility's policy on abuse prevention defines physical abuse as hitting, slapping, pinching, and kicking, which occurred in this incident. The Director of Nursing acknowledged that the staff's response did not meet expectations, as more attention should have been paid to the residents in the common area. The incident highlights a deficiency in ensuring a safe environment for residents, as the lack of monitoring allowed the altercation to escalate before staff intervention.
Failure to Initiate CPR for Full-Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, in accordance with the advance directives for a resident who was identified as a full code. The incident involved a nurse who did not initiate CPR or call emergency medical services (EMS) when the resident was found without breath sounds and a pulse. The resident, who had a full code status, expired without receiving the necessary life-saving measures. The resident was admitted with multiple diagnoses, including adult failure to thrive, repeated falls, dysphagia, orthostatic hypotension, hyperglycemia, dementia, protein-calorie malnutrition, and chronic pain. The baseline care plan did not include the resident's advance directives of code status, although the specific treatment form indicated a full code status, meaning CPR should have been employed. On the day of the incident, the resident's oxygen saturation dropped significantly, and despite being hypotensive and requiring medication, there was no change in the code status documented. The nurse on duty, along with another LPN, assessed the resident and determined the absence of vital signs, yet failed to initiate CPR or contact EMS. Interviews with staff revealed a lack of clarity and adherence to protocol regarding the resident's code status. The facility's policy required that in the absence of a DNR order, CPR should be initiated prior to EMS arrival, which was not followed in this case.
Removal Plan
- Resident rooms had new labels posted indicating code status
- The nurse who did not initiate CPR was terminated; and, the nurse who knew about the incident but did not follow protocol was placed on probation
- Residents code status was reviewed to ensure that code status match with the physician order and paper copy
- Personnel file review/audit to ensure all staff have current CPR certification
- Facility DNR book audit to ensure all residents had current DNR forms and directives
- In-service training on protocol to follow on implementing code status of residents
- In-service training on who was responsible for making changes in the resident's code status and protocols in place should the resident move to another room
Failure to Implement Repositioning Care Plan
Penalty
Summary
The facility failed to implement a care plan for a resident who required repositioning every two hours due to limited mobility and existing pressure ulcers. The resident, who was admitted with chronic pain, constipation, an open wound on the right lower leg, diabetes mellitus, and age-related physical debility, was at risk for developing further pressure ulcers. The comprehensive care plan dated July 31, 2024, included an intervention to turn the resident every two hours when in bed, starting from January 13, 2024. However, there was no evidence in the CNA plan of care tasks documentation or the clinical record that repositioning was being tracked or implemented as planned. Interviews with staff, including a CNA and the DON, revealed that the task of repositioning every two hours was not included in the plan of care tasks for the resident, and it had been missed. The facility's policy on charting and documentation required that all services provided to the resident be documented in the medical record, and the skin/wound care protocol mandated a change in position at least every two hours for bedfast or chairfast residents. The lack of documentation and implementation of the care plan intervention for repositioning could result in the resident not receiving necessary services, as outlined in their care plan.
Failure to Implement COVID-19 Screening and Testing Program
Penalty
Summary
The facility failed to implement a COVID-19 screening and consistent testing program during a COVID-19 outbreak, which could result in residents becoming ill. Resident #3, who was admitted with diagnoses including COVID-19 acute respiratory disease and end-stage renal disease, was transported to the emergency room for shortness of breath and later passed away. The facility's documentation did not reveal any screening for staff, visitors, or allied healthcare professionals during the outbreak, and there were no COVID-19 testing results for all staff. Staff #9, a maintenance employee, tested positive for COVID-19 but was in contact with other staff while working in the building. Staff #14, a housekeeper, also tested positive, but the testing form did not reveal if she had symptoms. The facility's COVID-19 mapping showed thirty-six resident COVID-19 positive cases from July 7 to July 26, 2024. Interviews with staff revealed that there was no requirement for staff to screen for symptoms or check body temperature before entering the building during the outbreak. The COVID-19 Safety Coordinator and the Director of Nursing confirmed that the facility should have screened everyone before they entered the building and that staff and visitors should be screened to protect the residents. The facility's policy stated that testing should be performed for any staff or resident experiencing symptoms, during an outbreak, or as recommended by the County Health Department. However, the facility did not adhere to these procedures during the outbreak.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident, which could result in a lack of continuity and coordination of care. The resident, who was admitted with chronic kidney disease, chronic pain, and hypertension, experienced a decline in oxygen saturation and reported chest pain and difficulty breathing to her family. Despite these symptoms, there was no documentation that the physician was informed of the resident's condition or that the resident was taken to a community clinic by her family. Interviews with facility staff revealed that the standard procedure for notifying the Director of Nursing and the physician was not followed. The facility's policy requires that any change in a resident's condition or transfer to a hospital be documented and communicated to the appropriate parties. However, the clinical record lacked evidence of such notifications, and the documentation did not meet the facility's standards, as confirmed by the Assistant Director of Nursing.
Failure to Protect Resident from Family Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by family members during visits. The resident, who has severe cognitive impairment due to Alzheimer's disease and dementia, was involved in a verbal altercation with family members who were demanding money and threatening to sell the resident's cattle. Despite the incident being overheard by staff, there was no immediate intervention to stop the abuse or ask the family members to leave. The facility's investigation revealed that the incident occurred when the resident was taken to her room by family members, who then closed the door and began yelling and arguing with the resident. Staff members heard the altercation but did not intervene until after the family members had left, at which point the resident was found crying. The facility's policy requires immediate action to stop suspected abuse, but this was not followed during the incident. Interviews with staff indicated that they were aware of the facility's procedures for handling suspected abuse, including reporting to the DON and asking the perpetrator to leave. However, these procedures were not effectively implemented in this case, as the family members were allowed to continue their visit and were not asked to leave until a later date. The facility's failure to act promptly and decisively during the incident resulted in a deficiency in protecting the resident from abuse.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy on abuse and resident protection for a resident diagnosed with Alzheimer's disease, dementia with behavioral disturbance, agitation, psychotic disturbance, and hypertension. The incident involved the resident's family members who visited and engaged in a verbal altercation with the resident, demanding money and threatening to sell the resident's cows. Despite the altercation being audible to staff, there was no intervention or documentation of actions taken to stop the incident or prevent future occurrences. Interviews with staff, including a Registered Nurse, Certified Nursing Assistant, Receptionist, Activities Assistant, Director of Nursing, and the Administrator, revealed a lack of immediate action to protect the resident during the incident. Staff members acknowledged the importance of intervening in suspected abuse situations, yet no staff member intervened during the incident. The Director of Nursing admitted that the family was allowed to finish their visit despite the altercation, and no immediate protective measures were implemented. The facility's policies on abuse prevention and visitation were not followed, as they require immediate action to stop suspected abuse and protective measures to ensure resident safety. The policies also state that family members suspected of abuse should be restricted from visiting or allowed only supervised visits during an investigation. However, these measures were not documented or enforced, leading to a deficiency in resident protection.
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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