Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgewood Health Care Center during CMS and state inspections, most recent first.
Resident-to-resident abuse occurred during smoking episodes when one resident struck another in the face after a cigarette-related confrontation, causing a facial laceration requiring sutures, and another resident kicked a peer in the head, causing bleeding and a scalp laceration requiring staples. The involved residents had significant psychiatric, cognitive, and behavioral histories, and facility interviews and records substantiated both events as physical abuse.
A resident with multiple psychiatric and behavioral diagnoses was physically assaulted by another resident after a verbal dispute in a common area. Staff statements and the facility investigation described the other resident yelling, striking the resident in the face multiple times, and causing black eyes, scratches, and abrasions that required hospital evaluation. The other resident also had a history of aggressive behavior and medication refusal, and the incident was substantiated as resident-to-resident physical aggression with injury.
Multiple residents with psychiatric and behavioral histories engaged in separate resident‑to‑resident physical altercations, despite an abuse policy prohibiting willful infliction of harm. In one event, a resident on 1:1 observation verbally argued with another resident in a hallway, threatened to kick the peer, then kicked the peer’s leg; the second resident responded by punching the first in the head, causing head swelling and a hand injury. In another event, a behaviorally escalated resident left an assigned unit against direction and, while upset about access restrictions and peer issues, kicked a cognitively impaired peer in the shin. In a third incident, two cognitively intact residents with psychiatric diagnoses bumped into each other, exchanged words, raised fists, and one intentionally struck the other in the face, causing facial scratches and a fall against a wall before CNAs could intervene. These episodes were substantiated as intentional, non‑accidental resident‑to‑resident abuse.
The facility failed to prevent multiple episodes of resident‑to‑resident physical abuse involving cognitively intact and impaired residents with significant psychiatric and behavioral histories. In separate incidents, two residents fought over misdirected clothing, leading one to stab the other with broken scissors; one resident struck another in the eye and banged the resident’s head on the floor, causing a hematoma; a dispute over a small cash debt for shoes escalated when one resident hit another near the ear; a resident who frequently exhibited aggressive behaviors dismantled an air conditioner skirt and another resident slammed this resident to the floor, causing a head injury; and other altercations arose when a resident hit another after a drink was thrown on staff, and when a resident scratched and struck another in a dining area, causing a swollen, lacerated lip and scalp scratches. Staff often heard or observed verbal escalation but did not consistently intervene or separate residents before physical contact occurred, resulting in injuries that in some cases required hospital evaluation.
Two residents with significant psychiatric histories and documented triggers related to theft and personal space became involved in a verbal dispute over a misdirected package containing jeans that one resident had received and attempted to sell. Staff who heard and observed the escalating argument did not immediately activate the facility’s behavioral emergency Code [NAME] as required, and one resident produced a broken pair of scissors kept in his/her room despite policies requiring sharp objects to be secured by staff. The confrontation escalated into a physical fight in which both residents exchanged punches and one resident stabbed the other in the forearm, resulting in a hospital visit for a stab wound repair and concussion. Staff involved had not reviewed the residents’ individualized care plans and ICSPs outlining behavioral triggers and coping strategies, front desk/package-handling procedures were not properly followed, scissors were not retrieved from the resident after use, and the psychiatric NP was not notified of the behavioral incident, all contributing to the failure to provide necessary behavioral health care and services.
The facility failed to follow its abuse and neglect policy requiring written statements from all involved staff and residents during investigations of alleged abuse. In two separate resident-to-resident altercations involving individuals with schizophrenia and schizoaffective disorder, one event resulted in a hematoma and eye redness and the other in a head injury after a resident was taken to the ground. In both cases, the RNI documented the incidents and was signed as complete, but no witness statements were collected, even though a CMT and an LPN who were directly involved reported they were not asked to write statements. The DON and administrators acknowledged that complete investigations should include written statements from all witnesses and capable residents, but the investigations for these incidents consisted only of the RNI forms without the required documentation.
The facility failed to prevent repeated episodes of resident-to-resident physical abuse involving multiple cognitively intact and cognitively impaired residents with significant psychiatric, behavioral, and neurocognitive diagnoses. In separate incidents, residents punched, hit, or pushed one another in halls, rooms, and smoking areas over triggers such as being bumped by a door, being touched on the shoulder, food being taken, urinating on a smoke deck, refusal to share a cigarette, and interpersonal conflicts. These altercations resulted in injuries including a facial laceration requiring sutures, a nasal fracture, a hand laceration from a brick wall, neck discoloration, and reported pain, while witnesses and staff consistently described the conduct as abuse under the facility’s own abuse policy.
A resident with significant psychiatric and behavioral diagnoses engaged in self-injurious behavior with a broken plastic mirror, prompting a behavioral Code response by the DON, an LPN, an RN, and other staff. After the resident dropped the shard and repeatedly requested hospital transfer, the situation escalated when the resident attempted to leave the room and the DON blocked the doorway, told the resident he/she was not going anywhere, and initiated physical contact. Video and multiple witness statements showed the DON pushing the resident into the hallway wall, placing hands and/or forearms on the resident’s shoulder, clavicle, and neck area in a manner inconsistent with CPI techniques and facility policy, which strictly prohibited any neck contact. The facility’s investigation substantiated that the DON used unnecessary physical force and violated the resident’s dignity and rights, while the resident reported being choked, expressed fear and nightmares, and stated not feeling safe. Despite policy requiring immediate removal of staff accused of mistreatment from resident contact, the DON continued working on the unit after the incident.
A resident with complex psychiatric and neurocognitive diagnoses, a history of self‑harm, and a detailed behavioral care plan experienced an escalation after becoming upset while on the smoke deck. Despite care‑plan directives to avoid confrontation, respect personal space, reduce stimulation, and use specific coping skills, the DON engaged in yelling with the resident, blocked the resident’s room doorway, and followed the resident into the hall. Video and witness accounts showed the DON pushed the resident against a wall and placed a hand or forearm near the resident’s neck/clavicle area while attempting a CPI hold that did not follow approved CPI training. Other staff reported CPI verbal de‑escalation and care‑planned coping strategies were not fully used, the DON was a trigger and did not disengage, and the resident later reported being choked and scratched and feeling unsafe. The facility’s investigation found CPI techniques were not correctly implemented, the resident’s behavioral care plan was not followed, and the resident was subjected to unnecessary physical contact and psychosocial distress.
A resident with schizoaffective disorder, PTSD, anxiety, and autism engaged in self‑injurious behavior, prompting a behavioral code response during which the DON physically engaged the resident, including pushing the resident against a wall and placing hands or forearm in the neck/clavicle area while other staff attempted CPI techniques. Staff present, including an LPN, RN, and an assistant administrator, did not immediately report the DON’s actions as suspected abuse to the administrator or state agency, and one nurse later stated fear of retaliation. The administrator initially received only a report of resident self‑harm, learned of the alleged abuse later from an LPN, and completed an internal abuse reporting form days after the event; a subsequent fax of this report to state and federal agencies failed and was not promptly re‑sent. As a result, the suspected employee‑to‑resident abuse with possible injury was not reported to the state survey agency within the required two‑hour timeframe.
Failure to Protect Residents from Physical Abuse: Multiple residents with psychiatric and behavioral diagnoses were involved in resident-to-resident assaults, including punching, kicking, pushing, and striking with a mop stick. Staff accounts and resident statements described escalating behaviors, a CNA asking one resident to help de-escalate another resident, and code green responses occurring after residents were already physical. Several incidents caused injuries such as bruises, scratches, a lip laceration, a rib fracture, and a shoulder contusion, and some events were not initially marked as abuse.
Failure to provide behavioral health care and de-escalation for a resident with severe psychiatric and behavioral diagnoses led to repeated aggressive incidents with other residents. Staff did not document behavior monitoring, did not use the resident's care plan interventions or PRN antipsychotic medication, and did not implement ordered monitoring or PASARR recommendations. The resident assaulted multiple residents, causing injuries including bruising, scratches, a lip laceration, and a rib fracture.
A facility failed to maintain enough washcloths, hand towels, bath towels, sheets, and blankets for multiple residents. Residents reported having to wash their own linens or going without, and surveyors found unit closets and the laundry room with very limited or no supplies, including stained and tattered washcloths. Staff said the facility had recently had a pipe burst, there was no laundry supervisor until the Maintenance Assistant took over, and the facility did not have a policy for maintaining sufficient linen supplies.
Unsafe and Unsanitary Resident Areas: A resident with multiple mental health diagnoses reported a long-standing unattached heater, a clogged sink with odor, and a dirty room with grime on the floors, while surveyors observed standing brown water in the sink and dirty bathroom areas. Two 200-hall bathhouses were found unlocked and accessible with a missing sink and protruding metal poles in one, and a toilet filled with brown water and odor in the other. Surveyors also found an HVAC unit in the dining room with an uncovered opening exposing bent sharp metal edges.
Two residents with significant psychiatric histories and documented behavioral risks engaged in escalating verbal and physical altercations after one repeatedly requested money from the other. Following the first incident, staff briefly separated them, but did not escort or supervise the aggressive resident back to another hall or ensure ongoing separation, despite care plan directives to monitor for agitation, divert attention, remove residents from situations, and protect others’ safety. The residents encountered each other again near the nurse’s station, where one punched the other in the face, causing a fall to the floor, and then kicked the resident in the head, resulting in a bloody nose, loss of consciousness, and facial contusions documented at the hospital. This sequence of events, corroborated by resident statements, staff interviews, and progress notes, shows a failure to protect a resident from physical abuse.
Two residents with significant psychiatric histories, including schizophrenia, schizoaffective disorder, PTSD, and prior violence and aggression, engaged in a verbal dispute that escalated into a physical altercation in a hallway, during which one resident punched the other twice before staff separated them. After separation, one resident was allowed to walk unescorted toward a locked unit while the other returned to their room, and no intensive behavioral monitoring or escort was implemented despite facility policies and known behavioral risks. Shortly thereafter, the residents encountered each other again near the nurse’s station, where one resident punched the other in the face, causing a fall, and then kicked the resident in the head, resulting in a bloody nose and loss of consciousness. Staff interviews confirmed that residents from the locked unit typically walked unescorted through another hall, the door between units did not always lock, and no staff had been directed to provide extra monitoring for either resident after the first incident, demonstrating a failure to ensure sufficient and competent behavioral health staffing and monitoring.
A resident with a history of mental health disorders was assaulted while sleeping by another resident, resulting in multiple facial lacerations caused by fingernails and a broken pen. The incident followed a dispute involving accusations of theft and property disruption. Staff responded to the altercation, observed the injuries, and law enforcement was involved, with the aggressor receiving a citation for assault.
A CNA physically abused a resident with severe cognitive impairment and behavioral health diagnoses during a behavioral incident, resulting in a nasal bone fracture and other injuries. The CNA struck the resident multiple times after being hit by the resident, and staff had to intervene to separate them. The incident was witnessed by multiple staff and another resident, and was reported as abuse and assault, with medical evaluation confirming significant injuries.
The facility did not ensure all staff received required behavioral health and CPI training, resulting in several employees, including a CNA, working without proper preparation. This led to an incident where a CNA without documented training physically struck a resident with psychiatric diagnoses during a behavioral crisis, causing injury. Staff interviews and record reviews confirmed gaps in training and documentation, and the facility lacked an effective system to track staff training compliance.
A resident with a gastrostomy tube and multiple medical conditions was served lumpy oatmeal instead of the physician-ordered pureed diet with nectar-thick liquids. Staff interviews revealed confusion about proper pureed food preparation, and the cook admitted to not pureeing the oatmeal due to time constraints. Facility policy required pureed foods to have a smooth, pudding-like consistency, but this was not followed, and there was no documentation supporting any change in the resident's diet.
A staff member failed to maintain professional boundaries by hugging and kissing two residents, making one feel uncomfortable, and by taking a resident's spending card off the premises. Both residents had significant mental health diagnoses and required protective oversight. Multiple staff and video surveillance confirmed the inappropriate conduct, which violated facility policies on dignity, respect, and resident rights.
A resident with a history of psychiatric and behavioral issues physically assaulted another resident after a refused sexual advance, resulting in the loss of two front teeth. The incident was not reported by either resident at the time, and staff only discovered the injury the following morning during routine observation.
The facility did not maintain a full-time qualified LSW as required, resulting in missed social services documentation, assessments, and care planning for residents with complex mental health and psychosocial needs. Multiple residents went without necessary social work interventions, and required discharge logs were not submitted to the Ombudsman, as confirmed by staff and external interviews.
The facility did not provide access to condoms or private spaces for sexually active residents, despite several cognitively intact residents expressing interest in safe sexual activity and recalling that such resources were previously available. Leadership acknowledged that these measures were not implemented due to a perceived lack of resident interest, resulting in a failure to support residents' rights to privacy and safe sexual expression.
A resident with multiple mental health diagnoses and a low level of personal hygiene was left without access to clean clothing, resulting in wearing the same soiled clothes for two days. Observations and interviews confirmed the absence of clothing in the resident's room, and staff did not consistently follow procedures to provide replacement clothing. The deficiency reflects a failure to support resident choice and dignity as outlined in facility policy.
A resident with mild cognitive impairment was denied visitation by their friend and family member after the DON refused access to the unit and did not facilitate an alternative meeting location. Multiple staff and the resident's guardian reported no negative interactions with the visitors, and the facility lacked a written visitor policy, resulting in a failure to uphold the resident's rights.
Multiple rooms on a gender-specific unit were found with unsanitary conditions, including clogged sinks with standing dirty water, soiled bathrooms, and inadequate hot water temperatures below 105°F. A resident and others reported these issues to staff, but no timely action was taken. Staff interviews revealed inconsistent housekeeping due to staffing shortages and a recent transition in cleaning services, resulting in direct care staff being expected to perform cleaning duties in addition to their primary roles.
The facility failed to reassess and coordinate the return or alternative placement of three residents who were transferred to the hospital and later found to be medically stable and no longer a safety risk. Despite providing immediate discharge notices and required information to guardians and the ombudsman, the facility did not communicate or collaborate with hospital staff or guardians to facilitate the residents' return or alternative placement, and did not reassess the residents' needs after hospitalization.
Multiple resident rooms experienced ongoing issues with clogged sinks and discolored standing water, with some sinks and toilets remaining unusable for several days. Affected residents, including those with mental health conditions, reported the problems to staff, but maintenance response was delayed due to inadequate communication and staffing. Staff interviews confirmed that improper items were being placed in sinks and toilets, and that the facility's system for reporting and addressing maintenance concerns was ineffective.
Two residents were not protected from abuse, resulting in one being sexually abused multiple times by a cognitively impaired roommate with a history of sex offenses, and another suffering a physical injury requiring sutures after being struck by a cup thrown by a roommate with behavioral health issues. Staff failed to act promptly on reports of abuse, did not separate the residents involved, and did not follow facility policy for immediate intervention.
A CMT responded to a resident with dementia and traumatic brain injury by using foul language after the resident made an unintelligible or possibly inappropriate comment. The incident, witnessed by the Administrator and another CMT, violated facility policies and the resident's care plan, which required staff to maintain professionalism and treat residents with dignity and respect.
A resident with a history of depression and stroke, who was cognitively intact, reported being sexually abused by another resident during the night. The CNA informed the LPN, but the LPN did not escalate the report to administrative staff as required by policy. The incident was not addressed until the DON learned of it during morning rounds, resulting in a delay in reporting the allegation of abuse.
Multiple residents experienced physical abuse, including being pushed, held, bitten, and struck, due to staff and peer altercations. Staff failed to intervene or provide required supervision, and care plans for behavioral management and safety were not followed, resulting in injuries and fear among residents.
The facility did not thoroughly investigate multiple abuse allegations, including incidents involving two residents with psychiatric conditions and legal guardians who engaged in sexual activity without complete capacity to consent assessments, and another resident who alleged being struck by a CNA. Required witness interviews, documentation, and assessments were incomplete or missing, and the facility did not follow its own policies for abuse investigations.
A resident with complex behavioral health diagnoses and a history of self-harm and aggression was not provided with the required continuous 1-1 supervision as outlined in their care plan and facility policy. Staff were often not within eyesight or arms reach, failed to document supervision, and sometimes performed other duties while assigned to 1-1. This lack of supervision led to the resident being assaulted by another resident and sustaining a head injury, as well as additional self-harm incidents when left unsupervised.
Facility staff did not notify the legal guardian when a resident with multiple psychiatric and medical conditions was transferred to the hospital after calling 911. Despite facility policy requiring notification of guardians for significant changes in condition or transfers, staff interviews and documentation confirmed that the guardian was not informed.
A resident with a history of psychiatric and neurocognitive disorders became agitated after their room was cleaned and laundry removed, leading to a physical altercation with an LPN. During the incident, the resident was held on the floor by both staff and another resident, contrary to facility policy and CPI training, which prohibit floor holds and resident involvement in restraints. Staff did not redirect other residents away from the situation, and the required de-escalation strategies in the resident's care plan were not followed.
The facility did not notify physicians or resident representatives when three residents, including those with severe cognitive impairment and complex psychiatric diagnoses, missed multiple prescribed medications due to unavailability. Despite facility policy requiring such notifications, documentation and staff interviews confirmed that neither clinicians nor guardians were informed, and the administrator and nurse practitioner were unaware of the missed doses.
Multiple residents with significant psychiatric and behavioral histories engaged in physical altercations, resulting in injuries and hospital evaluations. Staff and administration confirmed these incidents met the definition of abuse according to policy and state statute, indicating a failure to prevent resident-to-resident abuse despite known risks.
Three residents with severe mental health and behavioral diagnoses did not receive prescribed medications for extended periods, resulting in sexually charged behaviors between two residents in a community shower and an altercation involving another resident. Staff and resident interviews confirmed that medication lapses contributed to these incidents, and facility policies requiring medication administration and monitoring were not followed.
Three residents with chronic mental health and medical conditions did not receive their prescribed medications for several days, including antipsychotics, mood stabilizers, and seizure medications. Staff interviews and records showed that medication lapses were due to pharmacy delivery issues, incomplete prior authorizations, and lack of communication, with no documentation that physicians or guardians were notified. These omissions led to increased behavioral incidents and, in one case, seizure activity.
Two medication carts were left unlocked and unattended, allowing four residents with histories of substance abuse and psychiatric disorders to access and obtain medications, including controlled substances such as Oxycodone. Staff failed to maintain direct supervision and did not secure the carts or keys as required, resulting in unauthorized removal and ingestion of medications.
A facility failed to provide appropriate behavioral health care and supervision for a resident with PTSD and self-harming behaviors. The resident was inconsistently supervised, leading to self-harm incidents. The facility did not involve the IDT in decision-making, and the resident's care plan was not consistently followed, contributing to the resident's continued self-harming behaviors.
Two residents with significant behavioral and psychiatric histories were physically abused by staff members, including a CNA and a hall monitor, who engaged in altercations resulting in injuries to one resident. Other staff present failed to intervene appropriately, and video evidence confirmed that staff used physical force instead of de-escalation techniques, despite having received training on abuse prevention.
A resident with a history of psychiatric illness and self-harm was able to obtain and conceal a disposable razor, later using it to inflict a superficial cut on their forearm. Despite a facility protocol requiring razors to be checked out by a charge nurse, supervised use, and immediate return for disposal, staff did not observe the resident shaving or ensure the razor was returned. The incident revealed a lapse in following safety protocols for sharps management and resident supervision.
A resident with dementia frequently wandered into other residents' rooms, causing distress and safety concerns. Despite being identified as at risk for wandering, the care plan lacked specific interventions, and staff were not adequately trained to manage the situation. This led to incidents of physical aggression and highlighted a deficiency in the facility's dementia care practices.
A resident with COPD and other conditions reported feeling belittled by a CNA who was rough and rude during care. Audio recordings revealed the CNA's gruff manner and dismissive attitude towards the resident's discomfort. The facility's Administrator acknowledged the CNA's inappropriate behavior, highlighting a deficiency in maintaining resident dignity and respect.
A resident with schizophrenia was sent to the hospital due to aggressive behavior and a swollen arm. The facility failed to notify the resident's guardian about the hospitalization, the abscess treatment, and the new antibiotic prescription, despite policy requirements. The LPN left a voicemail but did not confirm receipt, and the guardian reported not being informed or receiving requested documentation.
A resident with a history of elopement and significant mental illness left the facility without guardian consent. The receptionist allowed the resident to leave with someone they claimed was their spouse, without verifying permissions or completing the required outside pass form. The facility failed to conduct necessary elopement assessments and did not follow established protocols for resident departures.
A resident in a LTC facility was assaulted by another resident, resulting in a broken nose. The incident was unwitnessed, and both residents involved had complex mental health histories. The facility's investigation concluded that the injury was not preventable, and no prior interaction or triggers were observed between the residents on the day of the incident.
Resident-to-Resident Physical Abuse During Smoking Episodes
Penalty
Summary
The facility failed to ensure that two sampled residents were free from abuse when resident-to-resident physical assaults occurred on the smoke deck. One resident with diagnoses including schizoaffective disorder, major depressive disorder, generalized anxiety, and a history of needing direction, wandering, and disorganized behavior was involved in an altercation with another resident who had diagnoses including persistent traumatic brain injury, bipolar disorder, mild cognitive impairment, and a history of aggressive behavior, impulsivity, and medication non-compliance. The incident began when the first resident asked the other for a cigarette, became verbally aggressive, used racial slurs, and moved into the other resident’s personal space. The other resident then struck the first resident in the right eye with a closed fist, causing a 3-4 cm laceration that required sutures and hospital evaluation. The record review and interviews showed conflicting accounts of the smoke deck incident, but facility documentation identified it as resident-to-resident abuse. The injured resident’s statements described being hit after the exchange over a cigarette, while the other resident stated he/she was offended and terrified by the verbal aggression and hit back because the first resident was in his/her face. A witness resident stated the two residents fought about cigarettes and that staff broke it up. A CNA who intervened reported seeing two residents arguing and separating them, and later observed the injured resident bleeding. The facility’s abuse policy defined physical abuse to include hitting, slapping, punching, and kicking. The facility also failed to protect another resident from abuse when a resident with diagnoses including Asperger’s syndrome, paranoid schizophrenia, major depressive disorder, anxiety disorder, mild intellectual disability, impulse disorder, obsessive compulsive personality disorder, schizoaffective disorder, and dissociative identity disorder kicked another resident in the head. That resident had severe cognitive impairment and behaviors, and the care plan noted physically threatening strikes, a history of aggression, and the need for staff to watch for signs of anxiety and personal space issues. During the incident, staff observed the resident abruptly stand up and kick the other resident in the head with significant force, causing visible bleeding, a bump to the forehead, and a scalp laceration requiring staples and hospital treatment. Interviews showed the resident who kicked the other resident acknowledged the kick and described switching bodies, while staff witnesses confirmed the kick occurred during smoking time and that the victim was not doing anything but smoking. The nurse practitioner and DON both stated that hitting and kicking other residents was abuse. The facility’s own investigation documented both events as substantiated resident-to-resident physical aggression and identified them as abuse.
Resident-to-Resident Physical Abuse With Facial Injury
Penalty
Summary
The facility failed to prevent physical abuse involving one resident who was assaulted by another resident during a verbal confrontation in the dining room/hangout area. The assaulted resident had multiple mental health and behavioral diagnoses, including bipolar disorder, anxiety disorder, mood disorder, adjustment disorder, impulse control issues, intermittent explosive disorder, autism, PTSD, ADHD, and impaired judgment and insight requiring staff supervision and verbal cues to maintain boundaries. The other resident involved also had significant psychiatric and behavioral history, including schizoaffective disorder, anxiety disorder, intermittent explosive disorder, adult antisocial behavior, a history of verbally and physically aggressive behaviors, and poor medication compliance. According to the investigation, the two residents were seated near a third resident when comments about the third resident escalated into an argument. One account stated the assaulted resident told the other resident to leave the third resident alone, after which the other resident became aggressive and struck the assaulted resident. Multiple staff statements described the other resident hitting the assaulted resident in the face, with one staff member reporting the assaulted resident was punched to the floor. The assaulted resident sustained visible facial injuries, including two black eyes, scratches under the eyes, an injury/marking on the nose area, an abrasion on the right forehead, and red marks on both cheeks, and was sent to the hospital for evaluation and treatment. The record also contained conflicting resident statements about who struck first, but the facility investigation substantiated a resident-to-resident physical altercation with injury. The assaulted resident later stated the other resident hit him/her, knocked him/her out of the chair onto the floor, and that staff pulled the other resident off. The third resident stated the other resident came to the table, started yelling, and attacked the assaulted resident. The psychiatric NP was aware the other resident had been refusing medications for weeks and had increased outbursts, and ordered psychiatric treatment after the incident. The facility’s abuse policy defined physical abuse as purposefully beating, striking, wounding, or injuring a resident, including hitting and punching.
Failure to Prevent Multiple Resident-to-Resident Physical Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse in multiple resident‑to‑resident altercations, despite having an Abuse and Neglect Policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The policy specifies that physical abuse includes hitting, slapping, punching, biting, and kicking, and applies to all residents regardless of mental or physical condition. In several incidents, residents with known psychiatric and behavioral histories engaged in physical aggression toward peers, resulting in injuries such as head swelling, knuckle injury, and a facial laceration. In the first series of events, one resident with bipolar disorder, intermittent explosive disorder, ADHD, intellectual disability, major depressive disorder, anxiety disorder, and a history of angry outbursts and poor judgment (assessed as cognitively intact on the MDS) was on 1:1 observation with a CNA when he/she became verbally involved with another resident in the main front hall. This second resident had bipolar disorder, ADHD, bipolar II disorder, chronic PTSD, generalized anxiety disorder, autistic disorder, and a PASRR noting behavioral difficulty, anger control issues, boundary problems, and impaired judgment, and was also assessed as cognitively intact. During a verbal altercation about another resident, the 1:1 CNA attempted to redirect the first resident and instructed him/her to walk away. As the resident began to walk away, he/she stated an intention to kick the other resident in the face and then kicked the peer in the leg. The second resident responded by striking the first resident on the right side of the head multiple times, causing several lumps and swelling, while sustaining injury to his/her own right hand/knuckles. Staff called a behavioral emergency code and separated the residents after the physical fight had already occurred. In a separate incident, the same second resident, who had a documented history of behavioral escalation, fixation, and difficulty with redirection, left his/her assigned unit against direction during a period of ongoing behavioral concerns. While upset about not having access to a hangout area and distressed about another resident’s family not wanting him/her around, this resident directed aggression toward another peer who was walking by and kicked that resident in the shin. The targeted resident, who was cognitively impaired and generally kept to him/herself, reported remembering being kicked, feeling upset, but not retaliating; no physical injury was documented. Facility documentation characterized this as a resident‑to‑resident altercation initiated by the aggressive resident after several days of escalating behaviors. Another altercation involved two cognitively intact residents with psychiatric diagnoses, including traumatic brain injury and paranoid schizophrenia for one resident, and mild cognitive impairment, paranoid schizophrenia, and anxiety disorder for the other. Multiple CNAs reported that the two residents bumped into each other in a hallway, exchanged words, and then “squared up” with raised fists. One resident hit the other above the eye, with some accounts indicating two punches to the face, causing the struck resident to hit his/her head on the wall and fall to the floor. The injured resident was later observed with two scratches above the left eyebrow, which staff cleaned and covered with a bandage. The aggressor resident admitted he/she hit the other resident on purpose and was trying to hurt him/her. Staff were present in nearby halls and ran over when they heard yelling, but the physical blows occurred before they could stop the assault. Across these events, the facility’s own investigation documents describe the altercations as substantiated resident‑to‑resident physical aggression, initiated by residents who kicked or struck peers intentionally and not accidentally. The Psychiatric NP acknowledged that kicking someone for no reason constitutes abuse and noted that residents involved had impulsive behaviors and difficulty reasoning about consequences. The DON and Administrator described the residents as impulsive and overstimulated, with actions they considered not predictable, while also confirming the sequence of verbal escalation, threats, and subsequent physical aggression in the incidents. These documented episodes of willful physical contact—kicking and punching—between residents, resulting in injuries and occurring despite staff presence and prior knowledge of behavioral histories, constitute the failure to prevent physical abuse as required by the facility’s abuse policy.
Failure to Prevent Repeated Resident‑to‑Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known psychiatric and behavioral histories. One incident occurred when a cognitively intact resident with schizophrenia and a history of aggressive behavior was mistakenly given another resident’s jeans. After the resident attempted to sell the jeans, the rightful owner, who also had multiple serious psychiatric diagnoses and a history of psychosis and combative behavior, confronted the resident. Staff observed the verbal escalation during shift change but did not separate the residents before the argument became physical. The confrontation escalated into both residents punching each other, and one resident produced broken scissors and stabbed the other in the forearm, resulting in a stab wound requiring staples and hospital treatment. Another incident involved a cognitively intact resident with schizophrenia and documented physical behaviors toward others one to three days per week. This resident engaged in a physical altercation with another cognitively intact resident diagnosed with schizoaffective and antisocial personality disorders. Staff and documentation indicated that one resident struck the other in the eye, causing a fall against a wall, followed by the aggressor banging the victim’s head on the floor. The victim developed a visible hematoma above the right eye with redness and irritation. Although EMS was activated, the injured resident repeatedly refused treatment and nursing assessments. The facility’s investigation substantiated this as abuse, citing exposure to an aggressive resident and the resulting head injury. Additional resident‑to‑resident altercations occurred in various contexts, including disputes over money and personal items, and reactions to other residents’ behaviors. In one case, a cognitively intact resident with multiple psychiatric diagnoses struck another cognitively intact resident with schizophrenia and TBI during a banking/activity interaction after a verbal disagreement about a $5 debt for shoes, causing an abrasion behind the ear. In another event, a resident with paranoid schizophrenia who exhibited daily physical and verbal behaviors dismantled an air conditioner skirt and swung it toward staff; another cognitively intact resident with schizophrenia and schizoaffective disorder then grabbed this resident and slammed them to the floor, causing a head injury that required hospital evaluation. Other incidents included a cognitively intact resident hitting another resident after a verbal altercation involving thrown ice and chairs, and a resident with schizoaffective disorder striking and scratching a cognitively intact resident with multiple psychiatric diagnoses in the dining area, resulting in a swollen, lacerated lip, scalp scratches, and reported fear of the aggressor. Across these events, staff either arrived after physical contact had already occurred or did not intervene in time to prevent physical abuse between residents. The facility’s own records and interviews show that staff were aware of residents’ significant psychiatric histories, behavioral patterns, and prior aggression, yet resident‑to‑resident altercations repeatedly escalated to physical abuse causing injuries such as stab wounds, hematomas, abrasions, and lacerations. In several cases, staff heard arguments or saw verbal escalation but did not promptly separate residents or call the facility’s behavioral emergency code before physical violence occurred. The Administrator acknowledged that once staff hear raised voices, they should move toward the source and determine if residents are escalating and, if so, call a Code immediately. The pattern of incidents from multiple dates, involving different residents and locations within the facility, demonstrates a failure to consistently implement the facility’s abuse and neglect policy to prevent physical abuse between residents. The survey identified these failures as an Immediate Jeopardy situation beginning on 3/23/26, based on the repeated resident‑to‑resident physical abuse incidents and the facility’s inability to prevent them. The facility’s own investigations repeatedly substantiated these events as abuse, noting preventable circumstances such as mishandled property, failure to remove escalating residents from shared areas, and delayed staff intervention despite observable verbal conflicts. The deficiency was ultimately cited at a lowered severity level after onsite verification that corrective actions had been implemented, but the documented events themselves reflect the underlying failure to protect residents from physical abuse by other residents during the period reviewed.
Failure to Implement Behavioral Health and Safety Protocols During Resident Altercation Over Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to implement its behavioral health practices and procedures when two residents with significant psychiatric histories escalated from a verbal dispute into a physical altercation resulting in injury. One resident had a PASRR diagnosis of schizophrenia with a history of difficulty getting along with others, frequent altercations, evictions, fear of strangers, and failed placements in less restrictive environments due to aggressive behaviors. The other resident had PASRR diagnoses including schizoaffective disorder bipolar type, Bipolar I Disorder, Major Depressive Disorder, psychosis, schizophrenia, and epilepsy with potential cognitive impairments such as memory loss, slow processing, and poor safety awareness. Both residents’ care plans and ICSPs identified triggers related to theft or loss of belongings, people getting into their personal space, and being bullied, and listed individualized coping strategies such as drawing/painting, going outside, smoking, having coffee or soda, and watching TV. The sequence of events began when an activity aide, who reported never being educated on how to receive and distribute packages, gave a package to one resident after confirming the name on the package, not realizing that the resident’s first name matched another resident’s last name. The package actually contained jeans intended for the other resident. The resident who received the package later realized the jeans were not his/hers and decided to sell them to another resident. The intended recipient discovered the jeans were missing and confronted the resident who had received and attempted to sell them. Staff, including a CNA and a CMT, reported that they heard or observed a verbal argument between the two residents about the pants and that residents in the facility often became upset when others borrowed, stole, or sold their belongings, with such issues frequently leading to fights. Despite facility expectations and staff education that a behavioral emergency Code [NAME] should be called as soon as a verbal altercation or escalation was observed, staff did not initiate the code at the onset of the argument. CMT A acknowledged responding to the verbal altercation but did not call the code until seeing scissors in one resident’s hand, and CNA A stated he/she heard yelling, went to the residents, and tried to break up the fight without calling a code when the situation was still verbal. During the altercation, both residents exchanged punches, and one resident produced a broken pair of scissors and stabbed the other in the left forearm. Staff then intervened using CPI techniques, separated the residents, and removed the scissors. The injured resident was transported to the hospital, where records documented a stab wound to the underside of the left forearm that required repair and staples, and a concussion with a neck brace. The facility’s own investigation substantiated that resident property was mishandled, staff identified the argument but did not intervene soon enough to separate the residents, and the delay in calling Code [NAME] and failure to promptly remove scissors from the resident contributed to the physical altercation and resulting injury. Additional deficiencies in behavioral health coordination and safety procedures were identified. The facility’s behavioral health policy required close monitoring for distress, documentation of behavioral changes and triggers, and multidisciplinary team involvement, including psychiatric input, when behaviors occurred. However, review of the injured resident’s medical record showed no documentation that the psychiatric nurse practitioner was notified of the resident-to-resident altercation, despite the PNP’s expectation to be informed of every incident and behavior to provide appropriate recommendations. The facility’s policy on screens/searches upon entering the facility required all sharp objects to be secured by staff and not kept with residents, yet one resident reported keeping scissors locked in a drawer in his/her room and using them for art, and the DON and administrator both stated that staff should always retrieve scissors from the resident after use and that the resident should never have kept scissors in the room. Staff also reported that they had not reviewed the residents’ ICSPs and were not familiar with their specific triggers and interventions, even though the ICSPs contained detailed behavioral triggers and coping strategies intended to guide staff responses. These combined failures to follow behavioral health policies, emergency response procedures, contraband/sharp object controls, and psychiatric notification requirements led to the escalation of a known trigger situation into a serious resident-to-resident physical altercation with injury. The facility’s own Registered Nurse Investigation documented that the incident was substantiated as physical aggression not involving the head, arising from mishandling of resident property and delayed staff intervention. Staff statements and interviews with the DON, administrator, and PNP confirmed that the Code [NAME] was not called at the first sign of verbal escalation, that staff did not consistently remove scissors from the resident after use, that front desk/package-handling staff were not fully educated on package protocols, and that the PNP was not notified of the behavioral incident. Observations of the injured resident after return from the hospital showed a healing wound on the left forearm with staples removed and surrounding redness. These facts collectively demonstrate that the facility did not ensure residents received necessary behavioral health care and services in accordance with its own policies, did not adequately implement crisis prevention and intervention practices, and did not maintain environmental and procedural controls (including contraband/sharp object management and package handling) necessary to support residents’ mental and psychosocial well-being and safety. The deficiency is further supported by staff acknowledgments that resident-to-resident altercations frequently occur over borrowing, stealing, or selling items, and that many residents are triggered when their belongings are taken or tampered with. Despite this known pattern and the specific triggers documented in both residents’ care plans and ICSPs, staff involved in the incident had not reviewed those plans and were unaware of the residents’ individualized triggers and de-escalation strategies. The facility’s behavioral health policy required staff to monitor for distress, evaluate behavioral changes, and develop person-centered care based on identified concerns, but in this case, staff did not use the available information on triggers and coping skills to intervene early or redirect the residents before the situation escalated. The lack of timely behavioral emergency activation, failure to secure sharp objects, improper handling of resident property, and absence of psychiatric notification after a significant behavioral event collectively demonstrate a failure to provide necessary behavioral health care and services as required by the facility’s own policies and procedures.
Failure to Obtain Required Witness Statements in Abuse Investigations
Penalty
Summary
The deficiency involves the facility’s failure to follow its Abuse and Neglect policy requiring collection of personal statements from staff and residents involved in any situation with an accusation of abuse, including resident-to-resident abuse. The policy, revised 6/12/24, directed the Administrator or designee to complete an administrative investigation that included written statements from all involved parties. For multiple resident-to-resident physical altercations, the facility’s investigations, documented on Registered Nurse Investigation (RNI) forms, did not include any witness statements, despite staff and leadership acknowledging that such statements were expected and normally obtained. In one incident, two residents with serious mental health diagnoses (schizophrenia and schizoaffective disorder) were involved in a physical altercation. Nursing progress notes documented that one resident struck the other multiple times, causing a fall and head impact against a wall, after which the other resident banged the fallen resident’s head on the floor. One resident had no apparent injuries, while the other had a hematoma above the right eye with surrounding redness and a reddened right eye. The RNI described the event, the calling of a behavioral emergency code, and staff intervention to separate and secure the residents, and bore the Administrator’s signature as completed; however, no witness statements were attached. Interviews with a certified medication technician and an LPN confirmed they were present and typically would have been asked to write statements, but were not asked and did not provide any for this incident. In a separate incident, two other residents with diagnoses including paranoid schizophrenia, schizophrenia, and schizoaffective disorder were involved in an altercation after one resident became agitated outside. As staff attempted to lead this resident back inside, the resident dismantled part of an air conditioner unit skirt and swung it toward staff. Another resident intervened by grabbing the agitated resident and taking the resident to the ground, resulting in a head injury from hitting the floor. The RNI documented the sequence of events and identified the incident as physical aggression involving the head, but again contained no witness statements. An LPN who was the primary staff member involved reported not being asked to write a statement, despite usually doing so for such events. The DON and both Administrators acknowledged that a complete investigation should include written statements from all staff and capable residents involved, and that the DON was typically methodical in collecting and organizing these, but in these cases the investigations were limited to the RNI forms without the required statements.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents, despite known behavioral histories and triggers. The facility’s own Abuse and Neglect Policy defines abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and includes hitting, slapping, punching, biting, and kicking. Across several incidents, residents with significant psychiatric and neurocognitive diagnoses engaged in physical altercations that resulted in injuries such as a lacerated lip requiring sutures, nasal fracture, and hand laceration. These events occurred in common areas such as smoke decks, patios, and halls, often in the presence of other residents and sometimes without staff immediately present. One incident involved a cognitively intact resident with paranoid schizophrenia and a history of hitting behaviors, whose care plan identified triggers such as when someone was “mouthing off” and noted unused coping skills. This resident and another cognitively intact resident with schizophrenia and a history of agitation and threatening behavior had a physical altercation after a bump with a door, resulting in a facial laceration and lip injury requiring sutures. In another event, a resident with traumatic brain injury and moderate cognitive impairment placed a hand on the shoulder of a cognitively intact resident with multiple serious psychiatric diagnoses, who responded by punching the first resident in the chest. Witness accounts confirmed that the contact to the shoulder was not forceful, but the response was a hard punch that caused pain and sadness to the victim. Additional altercations occurred between residents with complex psychiatric and behavioral profiles. One cognitively intact resident with schizoaffective and personality disorders entered another cognitively intact resident’s room and ate that resident’s food, leading to a fight in which both hit each other and one sustained a nasal fracture. Another cognitively intact resident pushed a cognitively impaired peer who was urinating on a smoke deck, after verbally telling the peer to stop; the pushed resident slipped in urine and scraped a hand on a brick wall, causing a laceration. On a smoking patio, a cognitively intact resident with bipolar disorder and intermittent explosive disorder refused to share a cigarette with another cognitively intact resident with schizophrenia and psychosis; the latter admitted to hitting the former multiple times in the head and face with a fist, causing the resident to fall to the ground. Further, a cognitively intact resident with bipolar disorder, ADHD, intellectual disability, and a history of angry outbursts was involved in a separate altercation with another cognitively intact resident with bipolar disorder, PTSD, autism, and anger control issues. Conflicting statements indicated that one resident had been “messing with” or bullying the other and that both admitted to hitting each other, with witnesses describing one resident running toward the other and initiating contact, leading both to fall to the ground. Discoloration was noted on one resident’s neck, and another resident reported temple pain. Throughout these events, staff and resident interviews, written statements, and facility documentation consistently characterized the physical acts—punching, hitting, and pushing—as abuse, and leadership acknowledged that residents “could not go around hitting each other,” yet multiple episodes of resident-to-resident physical aggression occurred involving nine sampled residents.
Abusive Physical Intervention by DON and Failure to Remove Accused Staff from Resident Contact
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to follow its own abuse and CPI (Crisis Prevention Intervention) policies during a behavioral incident. A cognitively intact resident with multiple psychiatric diagnoses, including Schizoaffective Disorder, Bipolar I Disorder, PTSD, Autism Spectrum Disorder, and a history of self-harm and violent temper, became upset and engaged in self-injurious behavior using a broken plastic mirror. A Code for behavioral crisis was called, and the DON, an LPN, an RN, and other staff responded. In the resident’s room, the resident held a shard of the broken mirror, threatened to harm staff if they came closer, and attempted to cut his/her left forearm. Staff, including the DON and LPN, attempted verbal de-escalation and CPI techniques, and the resident eventually dropped the shard and sat down, repeatedly asking to be sent to the hospital. The situation escalated again when the resident attempted to leave the room. Multiple witness statements and video footage show that the DON blocked the doorway with his/her body and told the resident he/she was not going anywhere, contrary to facility policy that staff should never attempt to confine a resident to a room during a behavioral episode and should use the least restrictive interventions. As the resident tried to get past, the DON initiated physical contact, placing hands and/or forearms on the resident’s shoulder, collarbone, and neck area while the resident backed into the hallway and against the wall. The video showed the DON extending both arms toward the resident’s neck/clavicle/shoulder area, lifting a foot to block the resident’s movement, and pushing the resident’s back against the wall while holding the resident there. Witnesses, including the LPN and AA, reported that the DON’s hands appeared to move from the shoulders up to the neck, and the AA was heard repeatedly yelling for the DON to keep hands on the resident’s shoulders. The facility’s internal investigation, supported by witness accounts, video footage, and the resident’s own statements, determined that the DON initiated inappropriate physical contact, used unnecessary physical force, and placed a hand around the resident’s neck area during the attempted hold. This contact around the neck was not consistent with approved CPI techniques, was strictly prohibited by facility policy, and represented a misuse of authority and a violation of the resident’s dignity and rights. The investigation concluded that CPI techniques were not correctly utilized, that alternative de-escalation methods were not fully employed before physical intervention, and that the DON’s actions further stimulated and escalated the resident’s behavior. The resident reported being choked by the DON, expressed fear, nightmares, and flashbacks of the DON coming back to strangle him/her, and stated he/she did not feel safe living at the facility. Despite the incident occurring at approximately 7:40 p.m., the DON continued to work the shift until 9:45 p.m., and the employee was not immediately removed from the facility or from resident contact as required by the facility’s Abuse and Neglect Policy. The facility’s Abuse and Neglect Policy required that employees accused of mistreatment be immediately removed from contact with residents and leave the facility pending investigation, and specifically prohibited any form of contact involving a resident’s neck. The policy also required that, if the alleged abuser was the Administrator or DON, they could remain only in non-resident areas with no resident contact. In this case, the DON remained on duty and in the facility after the incident and was not removed from resident contact during the time period described. The combination of the DON’s physical actions toward the resident, the improper and non-approved CPI techniques used, the blocking of the resident’s exit, and the failure to remove the accused staff member from resident contact constituted the abuse-related deficiency identified by surveyors.
Failure to Implement Behavioral Care Plan and CPI Techniques During Resident Crisis
Penalty
Summary
Facility staff failed to provide necessary behavioral health services and to implement the person‑centered behavioral care plan and CPI de‑escalation techniques for one resident with complex psychiatric and neurocognitive diagnoses. The resident had schizoaffective disorder bipolar type, Bipolar I disorder, DMDD, ODD, borderline personality disorder, PTSD, autism spectrum disorder, traumatic brain injury, and an unspecified neurocognitive disorder related to self‑harm brain injury. The PASRR and care plan documented high‑risk behaviors, history of violent temper, multiple psychiatric admissions, suicide attempts, self‑injurious head‑banging, and the need for a safe, secure setting. The care plan directed staff to ensure a safe environment, avoid confrontation and power struggles, be mindful of personal space, closely monitor for agitation, decrease stimulation, and use specific coping skills such as music with headphones, computer use, reading, writing, and diamond art, as well as weekly meetings with the Administrator as desired. On the evening of 03/06/26, a behavioral incident began on the smoke deck where the resident and the DON were yelling at each other, with the resident upset about limits on calling a parent/guardian. The resident, who was on one‑to‑one monitoring for safety, became increasingly agitated, broke a plexiglass mirror, and obtained sharp plastic pieces. Staff called a behavioral Code. According to staff interviews, LPN A was able to get several pieces of plastic away from the resident and was talking with the resident when the DON entered the room. The resident picked up another sharp piece, threatened self‑harm, and also threatened to stab the DON if approached. Witnesses reported the DON picked up a jagged piece of plastic and made antagonistic statements, and the DON did not remove themself despite being identified as a trigger for the resident. The DON blocked the resident’s doorway with their body, preventing the resident from leaving, contrary to the care plan direction to avoid confrontation and be mindful of personal space. Video footage and multiple witness statements showed that when the resident exited the room and backed down the hallway, the DON followed closely, continued to engage, and initiated physical contact rather than fully utilizing verbal CPI de‑escalation and the resident’s coping strategies. The DON extended arms toward the resident’s clavicle/neck area, pushed the resident against the wall, and attempted a physical hold. The facility’s internal investigation and witnesses, including RN A and LPN A, described the DON’s hand or forearm placement near the resident’s neck or collarbone, with the resident yelling that the DON was choking them. The investigation concluded CPI techniques were not correctly or fully used, that contact with the resident’s neck area occurred despite this being strictly prohibited, and that the DON blocked the resident in the room, followed the resident into the hall, yelled, entered the resident’s personal space, and failed to use the resident’s identified coping skills or person‑centered interventions. The resident was later observed with a 9‑cm red scratch from below the jawline to above the collarbone and reported being choked and scratched by the DON, feeling unsafe, and having nightmares about being strangled by staff. Psychiatric NPs and the Corporate Director of Behavioral Health Services stated staff did not follow CPI principles, did not consistently use the resident’s coping skills or care plan, and that the DON should have disengaged once other staff were present, but instead escalated the situation, resulting in unnecessary physical contact and psychosocial distress for the resident.
Failure to Timely Report Suspected Employee‑to‑Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an employee‑to‑resident altercation with injuries and possible abuse to the state survey agency within the required time frame. The facility’s Abuse and Neglect Policy requires that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property be reported immediately to the Administrator and to appropriate agencies within prescribed state and federal time frames, including within two hours in cases of serious bodily injury. Despite this policy, an incident involving physical contact between the DON and a resident on the evening of 03/06/26 was not reported to the state agency within two hours of occurrence or discovery. The resident involved had diagnoses including schizoaffective disorder, bipolar type, PTSD, anxiety, and autistic disorder, and was assessed as cognitively intact on a recent MDS. Video footage from the date of the incident showed the DON and other nursing staff responding to a behavioral code near the resident’s room. The footage documented the DON extending both arms toward the resident’s neck/clavicle area, placing a hand or forearm against the resident’s clavicle/neck, raising and extending both arms toward the resident’s upper body while the resident attempted to block, and positioning a foot between the resident’s legs while the resident was pushed against the wall. The DON was also seen pushing the resident’s back against the wall and holding the resident there, while other staff, including an LPN, RN, and the Assistant Administrator, were present and at times attempted to separate the DON from the resident. Staff interviews indicated that at least one nurse believed the incident was not appropriate and that the DON did not follow CPI training. Following the incident, documentation in the medical record and initial internal reporting focused on the resident’s self‑injurious behavior and the use of CPI techniques, and did not immediately characterize the DON’s actions as potential abuse. The Assistant Administrator reported to the Administrator that the resident had engaged in self‑harm but did not report that the DON had put hands on the resident’s neck or failed to follow CPI techniques. The LPN and RN who witnessed the event did not directly report suspected abuse to the Administrator or external agencies at the time, relying instead on the Assistant Administrator to contact the Administrator, and one staff member expressed fear of retaliation due to the DON and Assistant Administrator being superiors. The Administrator later learned of the alleged abuse from the LPN on a subsequent date and then initiated the facility’s Initial Reporting Form, which was dated 03/08/26, indicating physical abuse as the allegation type. This sequence of events resulted in the allegation of employee‑to‑resident abuse with injury and possible serious bodily harm not being reported to the state survey agency immediately, and not within the required two‑hour timeframe after the incident occurred or was discovered. Additional delay occurred when the Initial Reporting Form, once prepared, was not successfully transmitted to the state and federal agencies on the first attempt. The Administrator provided the report to the receptionist to fax on the morning of 03/09/26. The receptionist sent the fax but did not verify successful transmission at that time and only checked the transmission report when the Administrator later requested proof of faxing, at which point the transmission was shown as failed. The receptionist did not refax the report after seeing the failure because the Administrator requested the report back. These actions and inactions by multiple staff members, from the time of the incident through the failed fax transmission, contributed to the facility’s failure to ensure that the suspected abuse incident was reported to the state survey agency within the required regulatory timeframe.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse during multiple resident-to-resident altercations involving residents with significant behavioral and psychiatric diagnoses. The report describes incidents in which one resident punched another resident in the back of the head, struck another resident with a mop stick, pushed another resident to the floor causing a rib fracture, and was involved in additional fights with other residents. Several of the involved residents had diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety, intellectual disability, impulse disorder, intermittent explosive disorder, traumatic brain injury, and violent behavior, and some were documented as cognitively intact while others were severely cognitively impaired and had behaviors. On one occasion, a resident punched another resident in the back of the head after becoming upset during an interaction with staff and another resident. The second resident then placed the first resident in a hold and the first resident fell and hit his/her head. Staff and witnesses described that the residents argued, became physical, and that a code green was not called until after the residents were already fighting. The incident was not marked as abuse in the facility’s investigation, although the administrator later stated it should have been. The report also states that staff should have intervened and de-escalated the situation before it escalated to abuse. In another incident, a resident who was being assisted by a CNA became escalated, picked up a mop stick, and struck another resident in the head after that resident had been involved in trying to calm the situation. The struck resident then punched the first resident multiple times in the face and head, causing a bruise and raised area on the forehead, while the first resident had scratches and red marks on the face, neck, and head. The report states that the CNA asked the second resident to help protect staff from the first resident, and multiple interviews confirmed that the second resident was drawn into the confrontation while trying to help de-escalate. The facility did not mark the incident as abuse, and the administrator stated the second resident should not have been involved in de-escalating a peer. Additional incidents involved a resident punching another resident in the head, causing a laceration to the lip when the second resident struck back; a resident pushing another resident to the floor and causing a rib fracture; a resident punching another resident out of a wheelchair and kicking the resident in the shoulder and head, causing a contusion; and a resident punching another resident in the face and body, causing a bruised and bloody nose and rib contusion. The report states that several of these incidents were considered abuse by the administrator or other staff, while others were not initially marked as abuse in the facility’s investigations. Witness statements and resident interviews described aggressive behavior, injuries, pain, and staff responses after the residents had already become physical.
Failure to Provide Behavioral Health Care and De-escalation for an Aggressive Resident
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for one resident with a significant behavioral health history and multiple mental health diagnoses, including Asperger's syndrome, paranoid schizophrenia, major depressive disorder, anxiety disorder, mild intellectual disability, impulse disorder, obsessive compulsive personality disorder, schizoaffective disorder, and dissociative identity disorder. The resident's PASARR indicated behavioral difficulties and/or mental illness symptoms requiring 24-hour monitoring and management, psychiatric follow-up, medication administration and monitoring, a secure behavioral unit, and assessment of the level of supervision needed to prevent harm to self and others. The resident's care plan identified behavioral challenges, triggers, and interventions such as counseling, 1:1 intervention as needed, pharmaceutical interventions as needed, calm communication, music, reading the Bible, smoking, and showering. After multiple escalated behavior incidents, staff did not implement the resident's plan of care, did not document behavior monitoring, and did not document use of nonpharmacological interventions or the ordered PRN chlorpromazine for agitation/anxiety. Following one incident in which the resident kicked through the front doors, threw a shampoo bottle at a television, charged at staff, and was placed in a hold, the record showed no urinalysis or CBC completed as noted in the investigation, and the care plan was not reviewed or updated. Staff interviews indicated clinical staff were not present to monitor or de-escalate the resident during the incident, and the resident continued to have escalated behaviors afterward. The resident was involved in repeated resident-to-resident altercations in which the resident was the aggressor and sustained or caused injuries. The resident punched another resident in the back of the head, struck another resident with a mop stick, and later pushed another resident to the floor, resulting in a rib fracture. Other incidents resulted in bruising, scratches, red marks, a bleeding laceration to the lip, and a black eye. Staff interviews showed that code green responses were delayed or not initiated until after residents were already physical, staff were unsure how to respond, and the resident was not placed on intensive monitoring or given PRN medication after the incidents. The record also showed no implementation of the resident's individualized behavioral interventions or PASARR recommendations after the behaviors escalated.
Insufficient linens and towels available for residents
Penalty
Summary
The facility failed to maintain sufficient supplies of washcloths, hand towels, bath towels, sheets, and blankets for five sampled residents. During interviews, Resident #7, who was cognitively intact, said he/she started washing his/her own clothes, towels, and sheets so he/she would have some, because if he/she did not wash them, he/she did not get any. Resident #22, who was severely cognitively impaired, said the room frequently did not have washcloths and hand towels. Resident #10, who was cognitively intact, said the room often did not have towels, washcloths, or sheets, and the bed had no sheets when observed. Resident #23, who was moderately cognitively impaired, said they did not get any kind of towels in the room. Resident #14, who was moderately cognitively impaired, said he/she kept one fitted sheet and two towels and washed them himself/herself or otherwise would not have any, and used wipes for washing the face. On tour, surveyors found very limited linens and towels in unit storage areas and the laundry room. The men's unit had 11 sheets, five blankets, five towels, and no washcloths; the women's unit had no sheets, blankets, towels, or washcloths; and the medical unit laundry room had only three towels, five sheets, no blankets, and no washcloths. The laundry cart contained stained and tattered washcloths, and there were no additional linens, towels, or washcloths elsewhere in the laundry room. Staff stated the facility had recently had a pipe burst and that supplies were low, that there was no laundry supervisor until the Maintenance Assistant took over supervision, and that the facility had just made two big orders. The Administrator said he/she and the Maintenance Assistant were responsible for ensuring enough supplies, and the facility did not have a policy regarding maintaining sufficient supplies of these items.
Unsafe and Unsanitary Resident Areas
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functioning environment in multiple resident-accessible areas. In room 215, the sink had standing discolored water with a bad odor, the bedroom and bathroom floors had brown grime built up, and the heating unit was pulled away from the wall. Resident #4, who had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, agoraphobia with panic disorder, PTSD, and obsessive-compulsive personality disorder, stated the heater had been unattached for over a month, the sink had been plugged up for 2 weeks, the room was always dirty, and the unsanitary environment was making him/her sick. The 200 hall bathhouse #1 was observed unlocked and accessible with no out-of-order sign, a missing sink, poles protruding from the wall, ripped tile behind the bathtub, exposed plumbing, black substance on broken tile, and a bathtub faucet running. The 200 hall bathhouse #2 was also unlocked and accessible with no out-of-order sign and had a toilet filled with brown water and a bad odor. Staff interviews reflected that several staff members were unaware of the missing sink, running water, or overflowing toilet conditions in the bathhouses, while others stated housekeeping was responsible for keeping resident rooms and bathrooms clean and that the rooms were not kept as clean as they should be. During a Life Safety Code walk-through, the HVAC unit in the Main Dining Room was found with a rectangular panel opening approximately 7 inches by 10 inches with no cover, exposing bent metal edges around the opening. The facility policies reviewed stated the environment should be safe, clean, comfortable, and homelike, that housekeeping and maintenance services should maintain a sanitary and comfortable environment, and that all areas should be monitored daily and kept clean and odor free.
Failure to Maintain Separation After Initial Altercation Leads to Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during two altercations between two residents on the same evening. One resident with schizophrenia, delusional disorder, and a history of physical aggression per PASRR approached another resident with schizoaffective disorder bipolar type, PTSD, anxiety, OCD, and schizophrenia, repeatedly asking for money. Both residents had care plans that identified behavioral and crisis-intervention needs, including poor impulse control and a history of violence, impulsivity, and lack of judgment, as well as instructions for staff to monitor for agitation, avoid arguing, divert attention, remove residents from situations, and intervene to protect the rights and safety of others. Despite these identified risks and interventions, the residents engaged in a verbal confrontation in the front hall outside one resident’s room, which escalated into physical violence when one resident punched the other in the head twice. Staff intervened and separated the residents after the first incident. One resident went into his/her room with the door shut, and the other resident walked toward his/her room on a different hall. However, no staff were assigned to escort or supervise the resident returning to the back hall, and staff did not ensure that the two residents remained separated. Shortly thereafter, the resident who had returned to his/her room came back out, went looking for the other resident, and encountered him/her again near the nurse’s station. At this point, the second altercation occurred. Witness accounts and progress notes state that the aggressive resident punched the other resident in the face twice, causing him/her to fall face down to the floor, and then kicked the resident in the head twice. As a result of the second altercation, the injured resident experienced a bloody nose, loss of consciousness, confusion upon regaining consciousness, and a bruise under the left eye. Staff and the ADON observed the resident on the floor, face down, making a gurgling sound and not responding right away. The resident was later evaluated at the hospital, where documentation noted assault, lip abrasion, contusion to the lip, and nasal contusion. Interviews with the ADON, DON, NP, and Assistant Administrator confirmed that staff did not maintain separation of the two residents after the first incident and did not escort the aggressive resident back to his/her hall, despite expectations and care plan directives to intervene and protect the safety of others. This failure to adequately supervise and separate the residents after the initial altercation led to the second, more serious physical assault and constituted a failure to protect the resident from abuse. The facility’s own abuse and neglect policy defined abuse as the willful infliction of injury and specifically included physical abuse such as hitting, punching, and kicking. The events described, including multiple punches to the face and kicks to the head, fit the facility’s definition of physical abuse. The residents’ statements, staff interviews, and medical records consistently describe the sequence of events: repeated requests for money, escalating verbal conflict, an initial physical assault, incomplete separation and supervision, and a subsequent, more severe assault near the nurse’s station. The combination of known behavioral histories, documented care plan interventions, and the lack of continuous supervision or enforced separation after the first incident directly contributed to the occurrence of the second assault and the resulting injuries, demonstrating the facility’s failure to protect the resident from physical abuse.
Failure to Provide Adequate Behavioral Health Monitoring After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and competent staff to meet the behavioral health needs of residents, resulting in two physical altercations between two residents with significant psychiatric histories. One resident had diagnoses including schizophrenia, delusional disorder, and a history of social exclusion and rejection, with a PASRR indicating behaviors including physical aggression, poor impulse control, and triggers related to stealing. The other resident had schizoaffective disorder bipolar type, PTSD, anxiety, OCD, and schizophrenia, with a care plan noting a history of violence, impulsivity, lack of judgment, and triggers when feeling threatened. Both residents’ MDS assessments documented no behaviors, despite care plan information indicating behavioral risks. On the day of the incident, the two residents argued in the front hall outside one resident’s room, reportedly over money and the sale of items. During this first altercation, one resident punched the other in the head twice. Staff, including the ADON, intervened and separated them, with one resident returning to their room and the other walking toward their room on a separate, locked unit in the back hall. No staff were assigned to escort or monitor the resident returning to the back hall, and there was no documentation of behavioral intensive monitoring between the first and second incidents, despite the facility’s policy that residents requiring increased monitoring for behavioral or psychiatric issues should receive intensive or one-to-one monitoring with documentation in the medical record. A short time later, the residents encountered each other again near the nurse’s station. One resident confronted the other, reportedly grabbing the other’s shirt, and the same resident who initiated the earlier physical aggression punched the other resident in the face twice, causing the resident to fall to the floor, then kicked the resident in the head twice. Staff reported hearing a loud noise and then finding the resident on the floor by the nurse’s station. The injured resident experienced a bloody nose and loss of consciousness and was transported to the hospital for evaluation and treatment. Interviews with staff, including the CMT, ADON, DON, NP, and Assistant Administrator, confirmed that no staff escorted the resident back to the locked unit after the first altercation, that the door between the units did not always lock reliably, that residents from the back hall typically walked unescorted through the front hall to smoke, and that no one had been instructed to provide extra or intensive monitoring for either resident after the initial incident. These actions and inactions demonstrate the facility’s failure to implement its behavioral health and intensive monitoring policies to protect residents and address known behavioral health needs.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, who had diagnoses including bipolar disorder, major depressive disorder, schizoaffective-bipolar disorder, and anxiety disorder, was assaulted while sleeping by another resident with a history of schizoaffective disorder, bipolar disorder, unspecified psychosis, and anxiety disorder. The assault involved the use of fingernails and a broken pen, resulting in multiple facial lacerations of varying depths and redness on the left side of the victim's face. The incident was witnessed by staff, and law enforcement was called to the scene. Prior to the assault, the resident who was attacked had entered the assailant's room, accused them of theft, and disrupted their belongings, including tearing up a picture and putting shampoo on the bed. The assailant, angered by these actions, entered the other resident's room while they were sleeping and initiated the physical altercation. Staff responded to the incident after hearing screams and found the assailant on top of the victim, clawing at their face with fingernails and holding a broken pen. The victim sustained multiple scratches and lacerations, some deep enough to draw blood, and was sent to the hospital for evaluation and treatment. Interviews with staff and residents confirmed the sequence of events, with multiple staff members observing the physical altercation and the injuries sustained. The facility's investigation documented the altercation, the residents' behavioral histories, and the physical evidence of abuse. The incident was classified as abuse in the facility's investigation, and law enforcement issued a citation for assault to the resident who initiated the attack.
Physical Abuse of Resident by CNA During Behavioral Incident
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) physically abused a resident during an altercation. The incident began when the resident, who had a history of impulse disorder, paranoid schizophrenia, and obsessive-compulsive personality disorder, became upset about not having a cigarette. The resident, described as severely cognitively impaired and with a history of physical aggression, was running toward a door when the CNA attempted to intervene by grabbing the resident from behind. The resident responded by striking the CNA in the face and pulling the CNA's hair. In response, the CNA struck the resident in the face with a closed fist, causing both to fall to the floor, with the CNA on top of the resident and continuing to swing at the resident with a closed fist. Multiple staff members, including another CNA and an LPN, witnessed the CNA on top of the resident, with the resident sustaining visible injuries such as a laceration and bleeding from the nose, a scratch under the left eye, and later confirmed acute avulsion fracture of the distal nasal bone. The altercation required intervention from several staff members to separate the CNA from the resident. Witnesses reported that the CNA continued to strike the resident even after both were on the floor, and staff described the incident as abuse, noting that the CNA's actions were excessive and not in line with de-escalation or non-physical intervention techniques outlined in facility policy. The facility's own policies emphasized the use of non-physical interventions and de-escalation as first-line responses to behavioral crises, and specifically prohibited the use of force or physical punishment. Despite these policies, the CNA engaged in physical violence against the resident, resulting in significant injury. The incident was reported to law enforcement as an assault, and medical evaluation confirmed the extent of the resident's injuries. Multiple interviews with staff and another resident corroborated that the CNA's actions constituted physical abuse.
Failure to Ensure Behavioral Health Training for Staff
Penalty
Summary
The facility failed to implement and maintain an effective behavioral health training program for all staff, as required by its own policies and facility assessment. Despite identifying 140 residents with behavioral health needs and 140 residents requiring long-term psychiatric management, documentation showed that several active employees, including a Certified Medication Technician, multiple CNAs, and an LPN, did not have completed behavioral health training. Additionally, one previous CNA involved in a resident incident had no documented behavioral health or CPI (Crisis Prevention Institute) training. Interviews with staff confirmed that some employees had not received specialized training since hire, were unsure how to respond to behavioral incidents, and did not understand facility codes related to behavioral emergencies. A specific incident involved a resident with a history of impulse disorder, paranoid schizophrenia, and obsessive-compulsive personality disorder, who was severely cognitively impaired. The resident had a care plan indicating a history of physical aggression and required staff to use de-escalation techniques and maintain personal space. During a behavioral crisis, a CNA without documented CPI training physically struck the resident multiple times after the resident pulled the CNA's hair. The altercation resulted in the resident sustaining a bloody nose and a bruise under the eye, and required intervention from other staff to separate the CNA from the resident. Record reviews and interviews revealed that the facility did not have an effective system to track behavioral health training prior to a certain date, and that some staff were allowed to work with residents or respond to behavioral emergencies without the required training. The facility's own policies required all staff, including non-nursing staff, to complete behavioral health and CPI training before working with residents, but this was not consistently enforced. The lack of training and documentation directly contributed to staff being unprepared to manage behavioral health crises, as evidenced by the incident involving the CNA and the resident.
Failure to Provide Physician-Ordered Pureed Diet in Correct Consistency
Penalty
Summary
The facility failed to provide a physician-ordered pureed diet in the correct consistency for one resident who required a pureed texture with nectar-thick liquids. The resident, who had a history of kidney disease, depression, anemia, heart disease, and a gastrostomy tube, was observed receiving a bowl of oatmeal that was lumpy and not of the required smooth, pureed consistency. Staff interviews revealed uncertainty about what pureed consistency should look like, with one CNA noting the oatmeal resembled regular oatmeal rather than the expected pudding-like texture. The cook responsible for preparing the meal admitted to not pureeing the oatmeal due to time constraints and demonstrated a lack of clear understanding regarding the proper preparation of pureed foods. Review of the facility's policy indicated that pureed foods should be prepared using standardized recipes, with appropriate liquids such as broth or milk, and should not be thinned with water. The policy also required that pureed foods have a smooth, applesauce-like consistency and retain the flavor of the original menu item. However, the cook reported using water and thickener when pureeing foods and was not certain about the correct texture. The dietary manager, new to the facility, had not yet assessed the staff's knowledge or observed the preparation process prior to the incident. There was also no evidence in the resident's medical record of a dietician or speech therapy assessment supporting any change from the prescribed pureed diet. Observations confirmed that the resident did not receive the prescribed pureed diet at breakfast, and staff interviews highlighted gaps in training and understanding of pureed food preparation. The resident reported difficulty eating the oatmeal and indicated a preference for softer foods that were easier to swallow. The deficiency was further underscored by the lack of documentation supporting any dietary waiver or change in the resident's prescribed diet, as well as the absence of proper monitoring and adherence to facility policy regarding pureed food preparation.
Failure to Maintain Professional Boundaries and Resident Dignity
Penalty
Summary
Facility staff failed to maintain professional boundaries and provide dignity and respect to two residents. On the specified date, a staff member, Cook A, hugged and kissed one resident on the cheek in the dining room and took possession of that resident's spending card, removing it from the premises. The resident had a history of multiple mental health diagnoses, including PTSD, schizoaffective disorder, and borderline personality disorder, and required a structured environment, supervision for safety, and financial management services. The resident was cognitively intact and had a guardian. The resident reported that Cook A frequently hugged female residents and that this was the first time Cook A had kissed them. The resident did not desire a relationship with Cook A and described the kiss as 'weird.' The resident's guardian was not notified about the incident or the removal of the spending card. Another resident, also with a history of mental health diagnoses including schizoaffective disorder, PTSD, and anxiety disorder, reported feeling uncomfortable after being hugged by Cook A in the dining room. This resident witnessed Cook A kissing the first resident and described additional inappropriate interactions, such as Cook A asking the first resident to go around the corner with them. The second resident was also cognitively intact and required protective oversight and assistance from staff for emotional and social needs. Multiple staff interviews and video surveillance confirmed that Cook A hugged and kissed the first resident and hugged the second resident in the dining room. Staff members, including the Dietary Manager, Human Resources Manager, and Staffing Coordinator, observed or were aware of the inappropriate conduct and reported it to administration. The incident was captured on camera, and staff confirmed that Cook A had previously been restricted from certain duties due to similar allegations. The facility's policies required staff to treat residents with dignity and respect, maintain professional boundaries, and not accept or remove residents' personal possessions without proper authorization.
Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. On the night in question, one resident asked another for a sexual act. When the request was refused, the first resident initially began to walk away but then returned and struck the other resident in the mouth, resulting in the loss of the victim's two top front teeth. The incident was not immediately reported to staff, and the injured resident did not inform anyone about the assault. The injury was only discovered the following morning when staff noticed the missing teeth. The resident who committed the abuse had a documented history of schizophrenia, psychotic disorder, anti-social personality disorder, delusional disorder, and severe substance use disorders. This resident also had a history of aggressive behaviors, including physical and verbal aggression, and required ongoing behavioral monitoring and support. The victim had diagnoses including sickle-cell disease without crisis, schizophrenia, and sexual dysfunction, and was described as minimally cognitively intact with moderate mood issues and no negative behaviors during the relevant assessment period. Staff interviews revealed that neither resident reported the incident at the time it occurred, and the charge nurse on duty was unaware of any altercation during the night. The staff only became aware of the abuse after observing the physical injury the next morning. The facility's own investigation concluded that the incident constituted abuse, as it resulted in injury and was unprovoked.
Failure to Maintain Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time Licensed Social Worker (LSW) as required for facilities with more than 120 beds, affecting all residents in need of social services. The last full-time LSW left the facility on 5/23/25, and since then, there was no qualified individual consistently fulfilling the role. The facility census was 151 residents, and the absence of a full-time LSW resulted in lapses in required social services documentation, assessments, and participation in care planning for multiple residents with significant mental health and psychosocial needs. Record reviews for several residents revealed that there were no social worker progress notes or social services interventions documented for extended periods following the departure of the LSW. For example, one resident with diagnoses including schizophrenia and sickle-cell disease had no social worker notes from January through the present, and no evidence of social services involvement in critical processes such as sexual consent forms. Similar gaps were found for other residents with complex psychiatric and behavioral diagnoses, including a lack of social services assessments, absence from care plan meetings, and no input on important documentation such as sexual consent forms. Interviews with facility staff and external partners confirmed the deficiency. The administrator acknowledged the absence of a full-time LSW and stated that a consultant was only available for questions and not present daily or performing the full scope of LSW duties. The consultant LSW confirmed they were not acting as the facility's LSW and only provided limited assistance. The regional director of operations noted that a non-licensed staff member had temporarily filled the role, but this did not meet regulatory requirements. The Ombudsman reported not receiving required discharge logs for two months, which had previously been provided by the LSW, further evidencing the breakdown in social services processes.
Failure to Provide Safe Means for Sexual Expression and Privacy
Penalty
Summary
The facility failed to uphold residents' rights to a dignified existence, self-determination, and safe sexual expression for three sampled residents who were sexually active. The facility's policy required that residents be informed of their rights, including the right to privacy, reasonable accommodation of preferences, and participation in social activities, provided these did not infringe on others' rights. Despite this, interviews and record reviews revealed that the facility did not provide access to condoms or a designated private area for residents to engage in consensual sexual activity. One resident, with a history of psychiatric disorders and a guardian, was found to have the capacity to consent to sexual activity but reported no interest in sexual activity and noted the absence of condoms and uncertainty about private spaces. Another resident, with multiple mental health diagnoses but no history of sexual inappropriateness, was also cognitively intact and expressed interest in sexual activity, stating that condoms were not available in the facility. A third resident, with a history of schizoaffective disorder and substance dependence in remission, also had the capacity to consent and expressed a desire for both condoms and a private space, recalling that such resources were previously available but no longer provided. Facility leadership acknowledged that while they had discussed providing condoms and private spaces, they did not implement these measures due to a perceived lack of expressed interest from residents. Interviews confirmed that residents had not been offered sexual health resources or education recently, and the facility had not pursued further action to support safe sexual activity, despite residents' rights and expressed needs.
Failure to Ensure Resident Access to Clean Clothing and Support Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination and choice by not ensuring that a resident had access to clean clothing, resulting in the resident wearing the same soiled clothes for two consecutive days. Observations revealed that the resident wore a purple pullover shirt with smudges and food stains, and oversized jeans that repeatedly fell down, on two consecutive days. Upon inspection of the resident's room, no clothing was found in the closet, drawers, or hamper. Interviews with the resident, family, and staff confirmed that the resident had no clean clothes available and had reported missing clothing to the facility. The resident had a history of epilepsy, paranoid schizophrenia, hallucinations, personality disorder, anxiety disorder, delusional disorder, and a very low level of personal hygiene. The care plan indicated the resident required supervision and assistance with personal hygiene and activities of daily living. Despite this, the resident was left without clean clothing, and family members reported multiple instances of the resident having no clothes in the room and wearing soiled garments. The resident's friend, who sometimes assisted with laundry and personal care, also confirmed the lack of available clothing and noted that the only clothes present at one point were not the resident's. Staff interviews revealed that when a resident lacked clothing, the expectation was for staff to obtain clothes from the basement, but this was not consistently done. Some staff were unaware of the resident's lack of clothing, while others acknowledged that clothing was not always transferred to residents' rooms as required. The administrator and DON both stated that residents should have access to clean clothes and that missing clothing should be replaced, but in this case, the resident was left without appropriate clothing for an extended period.
Failure to Allow Resident Visitation and Lack of Written Visitor Policy
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing at the time of their choosing. Specifically, a resident's friend and family member attempted to visit the resident in the evening, but were denied access by the Director of Nursing (DON). The DON stated that the visitors were not allowed on the unit because of a previous verbal altercation and concerns about the unit becoming 'worked up.' The DON also did not facilitate a visit in the lobby, citing that the resident was in bed, despite the resident later stating they would have liked to receive visitors that evening. The resident in question had mild cognitive impairment and was independent in meeting emotional, intellectual, physical, and social needs, according to their care plan and assessment records. The resident's friend was noted to be very involved in their care and visited several times per week, with no negative interactions reported by multiple staff members, including a Certified Medication Technician, a Certified Nurse Assistant, and an LPN. The resident's guardian also expressed the expectation that the resident's right to visitors be upheld and that staff should facilitate visits if access to the unit is restricted. Additionally, the facility did not have a written visitor policy in place, as confirmed by the Administrator. The lack of a visitor policy and the denial of visitation rights to the resident's chosen visitors constituted a failure to protect and promote the resident's rights as outlined in the facility's own policy and federal requirements.
Failure to Maintain Cleanliness and Adequate Hot Water Temperatures
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary conditions and inadequate hot water temperatures in several resident rooms on a gender-specific unit. Hot water temperatures in multiple rooms were measured at approximately 76 degrees Fahrenheit, well below the minimum required 105 degrees Fahrenheit, and these issues persisted over several days. Residents reported that they had informed staff about the lack of hot water and clogged sinks, but no effective action was taken to resolve these concerns. Interviews with staff confirmed that maintenance was unaware of the hot water issue and that a new system for communicating maintenance needs had not yet been implemented. Observations in resident rooms revealed significant cleanliness and maintenance issues, including sinks clogged with standing brown or gray water, dirty countertops with brown substances, soiled personal care items, and bathrooms with brown splatter, missing fixtures, and dirty floors. In some cases, disposable briefs were found submerged in toilet water, and there was evidence of water damage such as sagging ceiling tiles and water dripping from the roof. The hallways and common areas on the unit were also found to be soiled, with dried substances and build-up along the floors and door frames. Interviews with residents and staff indicated that housekeeping services had been inconsistent, with some areas not being cleaned for weeks due to staffing shortages and a recent transition from a third-party cleaning company back to in-house staff. Direct care staff, including CNAs and CMTs, reported being expected to perform cleaning duties in addition to their primary responsibilities, but stated they did not have sufficient time to do so. The lack of regular housekeeping and maintenance contributed to the ongoing unsanitary conditions and failure to provide a safe, clean, and homelike environment as required by facility policy and resident rights.
Failure to Reassess and Coordinate Discharge for Hospitalized Residents
Penalty
Summary
The facility failed to adhere to all required components of the discharge process for three residents who were found to be medically stable and no longer a safety risk after being transferred to the hospital. Documentation and interviews revealed that, although immediate discharge notices were provided to guardians and the ombudsman, the facility did not reassess the residents' conditions after hospitalization to determine if their needs could be met upon return. The facility also did not collaborate with guardians or hospital staff to facilitate the residents' return or alternative placement, despite requests and appeals from guardians and hospital case managers. For each of the three residents, the facility issued immediate discharge notices citing health and safety concerns, and transferred the residents to the hospital. The discharge letters included required information such as the reason for discharge, appeal rights, and ombudsman contact details. However, after the residents were stabilized in the hospital and deemed ready for return, the facility refused to reassess or accept them back, and did not engage in further communication or planning with the hospital or guardians regarding their return or alternative placement. Guardians and hospital staff reported a lack of follow-up and communication from the facility, and appeals were filed in response to the discharges. The residents involved had significant psychiatric and medical histories, including diagnoses such as vascular dementia, paranoid schizophrenia, bipolar disorder, and Wernicke's encephalopathy. Despite being medically cleared for return by hospital staff, the facility maintained its decision not to readmit the residents, and did not provide evidence of reassessment or efforts to ensure safe and appropriate discharge planning. The ombudsman confirmed receipt of discharge notices and ongoing appeals, with all three residents remaining in the hospital awaiting further placement.
Failure to Maintain Sanitary and Functional Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functioning environment for residents, as evidenced by multiple rooms with sinks that were either clogged or filled with discolored standing water. Observations revealed that in several resident rooms, sinks did not drain after running water for two minutes, and in some cases, the water in the sinks was brown or gray with visible sediment. Toilets in these rooms also contained discolored water and, in one instance, an adult incontinent brief was found in the toilet. These issues persisted for several days, impacting nine residents, some of whom reported the problems to staff without resolution. Residents affected by these deficiencies included individuals with significant mental health diagnoses such as schizoaffective disorder, bipolar type, agoraphobia with panic disorder, and post-traumatic stress disorder. At least one resident was cognitively intact and reported the issue to staff, while another, who was moderately cognitively impaired, stated that the sink had been clogged for two or three days and that staff had attempted to use a plunger to resolve the issue. Staff interviews confirmed that clogged sinks and toilets were a recurring problem, with residents reportedly placing items such as ramen noodles, tea bags, toilet paper, and sanitary pads in the plumbing, contributing to the blockages. The facility's maintenance and communication systems were found to be inadequate in addressing these ongoing environmental concerns. The Maintenance Director reported being the only maintenance staff member and stated that a new system for reporting maintenance needs had not yet been implemented. Staff were unclear about the process for reporting maintenance issues, with some relying on communication books at nurse stations and others reporting verbally to nurses or administration. The Department Manager and DON acknowledged that the clogged sinks and toilets had been a persistent issue, and that maintenance was not always promptly notified or able to resolve the problems in a timely manner.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in multiple incidents of sexual and physical abuse. One resident, who was cognitively intact but physically dependent due to a stroke, reported being sexually abused by a roommate with a history of severe dementia and prior sex offender status. Despite the resident immediately reporting the first incident to a CNA, and the CNA informing the LPN, no immediate action was taken to separate the residents or investigate the allegation. As a result, the abuse continued two more times during the same night, with the victim remaining in the same room as the alleged perpetrator until the following morning when the DON became aware and intervened. In a separate incident, another resident with quadriplegia and cognitive intactness was physically abused by a roommate who had a history of bipolar disorder, TBI, and depression. The abusive event occurred when the roommate threw a hard plastic cup at the resident, causing a deep cut to the lip that required sutures. The incident was reported to staff, and the police were notified. The resident was sent to the hospital for treatment. Both residents involved in the altercation had no prior history of negative behaviors or altercations, and staff care plans included monitoring for escalation and providing support for coping skills. The facility's policies required immediate removal of alleged perpetrators and interventions to protect residents from abuse, but these were not followed in the cases described. Staff failed to escalate reports of abuse and did not implement protective interventions in a timely manner, resulting in repeated abuse and injury to the residents involved. The deficiencies were identified through observation, interviews, and record reviews, and were determined to be at the immediate jeopardy level at the time of the survey.
Staff Used Inappropriate Language Toward Resident
Penalty
Summary
A Certified Medication Technician (CMT) addressed a resident in an inappropriate and disrespectful manner by using foul language in the main dining room. The incident occurred when the resident, who has a history of dementia with behavioral disturbance and traumatic brain injury but was assessed as cognitively intact, made an unintelligible or potentially inappropriate comment toward the CMT. In response, the CMT told the resident, "Shut your ass up!" This exchange was overheard by the facility Administrator and another CMT, both of whom confirmed the inappropriate language used by the staff member. The resident involved was admitted with diagnoses including dementia with behavioral disturbance and traumatic brain injury, but had no negative behaviors documented during the recent assessment period. The resident's care plan instructed staff to remain calm, avoid confrontation, and respond to inappropriate comments by setting clear limits and maintaining professionalism. Despite these guidelines, the CMT's response did not align with the care plan or facility policies on dignity, respect, and professional conduct.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse in a timely manner for one resident. The incident began when a resident, who had a history of major depressive disorder, anxiety, psychotic disorder, and was cognitively intact, reported to a CNA that another resident had fondled their genital area over their underwear around midnight. The CNA informed the LPN, but the allegation was not escalated to administrative staff as required by facility policy. The resident experienced repeated incidents throughout the night, including further unwanted contact and inappropriate behavior from the alleged perpetrator, and remained in the same room as the accused resident until morning. The resident's written and verbal statements confirmed that they reported the abuse to the CNA multiple times during the night, and the CNA stated they relayed the information to the LPN. However, the LPN did not take immediate action, citing being busy with other tasks and forgetting to notify the next shift or administrative staff. The LPN admitted to not reporting the abuse and acknowledged that they should have prioritized the report. The DON only became aware of the incident during morning rounds, several hours after the initial report was made. The facility's policy required immediate reporting of all alleged violations to a superior staff member, with the licensed nurse responsible for escalating the report to the DON. Interviews with the DON, Administrator, and Nurse Practitioner all indicated that the expectation was for immediate notification to administrative staff, which did not occur in this case. The failure to follow established reporting procedures resulted in a delay in addressing the resident's allegation of sexual abuse.
Failure to Protect Residents from Physical Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in several incidents involving both staff-to-resident and resident-to-resident altercations. In one incident, a cognitively intact resident with schizophrenia and psychosis was physically pushed by an activity aide into a washer and then against a wall, where the aide held the resident in place with a forearm against the chest, causing a large bruise and abrasion. Multiple witnesses, including other residents and staff, confirmed the physical altercation, and the resident expressed a desire to press charges. The staff present did not intervene to stop the abuse, and the incident was not initially recognized as abuse by the facility administration until after the injury was discovered. In another event, two residents with significant psychiatric histories and behavioral challenges engaged in a violent altercation after one resident became agitated following an incident with a staff member. The residents ended up on the floor, hitting, pulling hair, and biting, resulting in visible injuries including bruising, a facial bite, and head trauma. Staff failed to provide necessary supervision and did not intervene to prevent the altercation, despite one resident having just exhibited aggressive behavior toward a staff member. The care plans for both residents indicated a need for close monitoring and behavioral interventions, which were not implemented at the time of the incident. Additional incidents included a resident being attacked and having their head banged on the ground by another resident while not under required 1-1 staff oversight, and another resident being struck with a chair thrown by a peer, resulting in physical injuries. The facility's policies and care plans outlined the need for de-escalation, supervision, and protection from abuse, but these were not followed, leading to multiple residents sustaining injuries and expressing fear for their safety.
Failure to Investigate Allegations of Abuse and Assess Capacity to Consent
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse involving three residents. In two cases, two residents with legal guardians and complex psychiatric histories were observed engaging in sexual activity in a public area. The facility did not complete the required capacity to consent assessments, as the forms were missing critical information such as scoring, documentation, and signatures from guardians and evaluators. There was no evidence of a comprehensive investigation to determine whether the incident constituted sexual abuse, and the facility did not interview all potential witnesses or consult with psychiatric professionals as required by policy. Additionally, the facility did not investigate an allegation that one resident provided another with a medication for anxiety, which was not prescribed to the recipient. The incident was reported by the involved residents, but there was no documentation of an investigation to determine the circumstances or whether abuse or neglect occurred. The facility's policies required prompt and thorough investigation of all abuse allegations, including witness interviews, medical record reviews, and administrative review, but these steps were not completed. In a separate incident, a resident with dementia and psychiatric diagnoses alleged that a CNA hit them in the face. The facility's investigation was limited to interviews with the resident, one other resident, and the accused CNA, but did not include interviews with all staff present or other potential witnesses. There was no documentation identifying the alleged perpetrator, and the investigation did not include written statements or a comprehensive review of the incident. Physical observations later confirmed discoloration on the resident's cheek, but the facility did not document a thorough assessment or investigation into the cause.
Failure to Maintain Required 1-1 Supervision for Resident with Behavioral Health Needs
Penalty
Summary
The facility failed to ensure the safety of a resident with significant behavioral health needs by not maintaining required 1-1 supervision as outlined in the resident's care plan and facility policy. The resident had a complex psychiatric history, including borderline personality disorder, depression, schizoaffective disorder, anxiety, and a history of self-harm and suicidal ideation. The care plan and individualized service plan specified continuous 1-1 monitoring, with staff required to remain within eyesight and arms reach of the resident at all times, and to intervene as needed to prevent harm. Despite these requirements, multiple instances were documented where staff assigned to 1-1 supervision were not present or not attentive to the resident. On several occasions, there was no documentation of 1-1 supervision, and staff were observed sitting away from the resident, engaging in unrelated activities, or not being within the required proximity. During one incident, the resident was assaulted by another resident while on the phone at the nursing station, and the assigned 1-1 staff was not close enough to intervene. The resident sustained a head injury and required hospital treatment. Staff interviews confirmed that the 1-1 was not consistently maintained, and some staff lacked necessary crisis intervention training. Further review revealed additional lapses, such as the resident being left alone in their room with the door closed, and staff assigned to 1-1 supervision being responsible for other duties or residents. The Director of Nursing and other facility leaders acknowledged challenges with staffing and confirmed that 1-1 supervision protocols were not followed, particularly during overnight shifts. These failures resulted in the resident experiencing harm and feeling unsafe, as well as additional incidents of self-harm when left unsupervised.
Failure to Notify Guardian of Resident Transfer
Penalty
Summary
Facility staff failed to notify the legal guardian of a resident with multiple psychiatric and medical diagnoses, including schizophrenia, narcissistic personality disorder, unspecified dementia, anxiety disorder, diabetes type II, and a colostomy, when the resident experienced a change in condition and was transferred to the hospital. The resident, who had a guardian assigned to assist with decision-making, called 911 and was transported to the hospital, but there was no documentation that the guardian was informed of this transfer as required by facility policy. Interviews with facility staff, including an LPN, the DON, and the Administrator, confirmed that the guardian was not notified of the resident's transfer, despite the expectation and policy that such notification should occur whenever a resident with a guardian experiences a significant change in condition or is transferred out of the facility. The guardian's office also confirmed they were not contacted and would have expected to be notified in this situation.
Resident Restrained on Floor by Staff and Another Resident During Behavioral Incident
Penalty
Summary
A deficiency occurred when a resident with multiple psychiatric and neurocognitive diagnoses, including psychotic disorder, schizoaffective disorder, and a history of aggressive behaviors, was physically restrained by staff and another resident. The incident began after the resident became agitated upon discovering their room had been cleaned and their laundry removed, leading to a confrontation with an LPN. The resident struck the LPN, who then attempted to block further aggression, resulting in both the LPN and the resident falling to the floor. During this altercation, the LPN and a Certified Medication Technician (CMT) held the resident's arms, while another resident held the agitated resident's legs down. Facility video footage and staff interviews confirmed that the resident was held on the floor by both staff and another resident. The staff involved did not redirect other residents away from the escalating situation, and one resident actively participated in restraining the agitated resident. The facility's own policies and staff training, including CPI (Crisis Prevention Institute) guidelines, prohibit the use of floor holds and the involvement of other residents in restraint situations. Multiple staff, including the DON and Administrator, acknowledged that residents should never be involved in restraining another resident and that holding a resident down is not appropriate. The resident's care plan indicated a need for de-escalation strategies and avoidance of physical confrontation, but these were not followed during the incident. The staff failed to implement non-restrictive interventions and did not prevent another resident from participating in the restraint. The event was not considered abuse or neglect by the facility after internal review, but it was determined that the use of physical restraint and the involvement of another resident constituted a violation of resident rights and facility policy.
Failure to Notify Physician and Responsible Parties of Missed Medications
Penalty
Summary
The facility failed to notify physicians and resident representatives or legal guardians when three residents did not receive their prescribed medications. Facility policy required notification of clinicians and responsible parties in the event of medication unavailability or errors, but documentation and interviews revealed that this did not occur for the affected residents. The issue was identified through record reviews and staff and resident interviews, which consistently showed a lack of communication to the appropriate parties when medications were not administered as ordered. One resident with severe cognitive impairment and diagnoses including schizophrenia and sexual disorder did not receive multiple prescribed medications, such as Olanzapine, Medroxyprogesterone, and Quetiapine, on several occasions. There was no documentation that the resident's physician or guardian was notified of these missed doses. The resident expressed awareness of not receiving medications and a willingness to take them if available. Another resident, also severely cognitively impaired with schizophrenia and sexual dysfunction, experienced repeated missed doses of Paxil, with progress notes indicating the medication was not given and nurses were notified, but again, there was no evidence that the physician or guardian was informed. A third resident, who was cognitively intact and had multiple psychiatric and medical diagnoses, missed several medications over multiple days, including Restoril, Atenolol, Lacosamide, and Prazosin. Progress notes indicated the medications were not available and nurses were notified, but there was no documentation of physician or guardian notification. Staff interviews confirmed that while nurses and pharmacy were sometimes notified about missing medications, the required notifications to physicians and guardians did not occur. The nurse practitioner and administrator both stated they were not informed about the missed medications, and the administrator expected such notifications to be made.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
The facility failed to protect four residents from abuse when two separate incidents of resident-to-resident physical altercations occurred. In the first incident, one resident entered another resident's room and began hitting the resident, who then retaliated, resulting in both residents ending up on the floor before staff intervened. Both residents involved had a history of significant psychiatric diagnoses, including schizophrenia, antisocial personality disorder, and intermittent explosive disorder, with documented behavioral issues such as aggression, hallucinations, and poor impulse control. The incident was witnessed by staff, and interviews with the LPN, Unit Manager, Nurse Practitioner, DON, and Administrator all confirmed that the event met the definition of abuse according to facility policy and state statute. In the second incident, another resident entered a peer's room and struck the resident, who then responded physically. Staff intervened to separate the residents. One resident sustained facial bruising and was sent to the hospital for medical evaluation, while the other was sent for psychiatric evaluation and admitted for inpatient psychiatric treatment. Both residents involved in this altercation also had documented psychiatric conditions, including paranoid schizophrenia, antisocial personality disorder, and schizoaffective disorder, and were cognitively intact at the time of the incident. Interviews with staff and the residents confirmed that the altercation was intentional and met the criteria for abuse. The facility's own policies on abuse and resident rights require immediate reporting and protection from all forms of abuse, including physical abuse, regardless of the residents' mental or physical conditions. Despite these policies and the known behavioral histories of the residents involved, the facility did not prevent the physical altercations from occurring. The events were confirmed through interviews, record reviews, and facility investigations, with staff and administration acknowledging that the incidents constituted abuse as defined by both facility policy and state regulations.
Failure to Administer Behavioral Health Medications Leads to Adverse Resident Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to three residents with significant mental health diagnoses and behavioral challenges. Specifically, the facility did not ensure the administration of prescribed medications for mental health and behavioral management, as evidenced by multiple documented instances where residents did not receive their ordered medications for extended periods. This included medications critical for managing schizophrenia, hypersexuality, and other behavioral symptoms. Staff interviews and progress notes confirmed that medications such as Paxil, Seroquel, and others were not administered due to issues with pharmacy delivery, lack of follow-up on prior authorizations, and breakdowns in communication between medication technicians, nurses, and management. As a result of these medication lapses, two residents with histories of hypersexuality and poor impulse control engaged in sexually charged behaviors in a community shower room, refusing staff redirection. Both residents had documented histories of sexually inappropriate behavior and required close monitoring and medication management as part of their care plans. Staff and residents reported that the absence of these medications contributed to the escalation of sexual behaviors, and staff were aware of the ongoing medication shortages but were unable to resolve them in a timely manner. The facility's own policies required the administration and monitoring of behavioral health medications as part of person-centered care, but these were not followed. A third resident, with a complex psychiatric history including schizophrenia, PTSD, and intermittent explosive disorder, also experienced multiple days without critical medications for both mental health and seizure management. During this period, the resident exhibited escalating aggressive behaviors, including physical altercations with peers and property destruction, ultimately resulting in a psychiatric evaluation at a hospital. Staff interviews confirmed that the lack of medication could have contributed to these behaviors, and there was confusion and lack of accountability regarding who was responsible for ensuring medication availability and administration. The facility's failure to provide necessary behavioral health services and to administer medications as ordered directly led to adverse behavioral events among these residents.
Failure to Administer Prescribed Medications Resulting in Behavioral Exacerbations
Penalty
Summary
The facility failed to ensure that three residents with chronic medical and mental health diagnoses received their prescribed medications, resulting in exacerbation of behaviors for all three. For each resident, there were multiple documented instances where medications for conditions such as schizophrenia, hypersexuality, and seizure disorders were not administered as ordered. The medication administration records and progress notes indicated that medications including antipsychotics, mood stabilizers, and other essential drugs were not available or not given over several days, with no documentation that the residents' physicians or guardians were notified of these omissions. For one resident with schizoaffective disorder and a history of hypersexual behavior, medications such as Olanzapine, Quetiapine, and Medroxyprogesterone were not administered as ordered, and there was no evidence of physician or guardian notification. Staff interviews revealed that the resident was aware of not receiving medications and that pharmacy delivery issues and incomplete prior authorizations contributed to the lapses. The nurse practitioner and DON confirmed that they were not informed of the missed doses, and both acknowledged that missing these medications could negatively impact the resident's mental health and behavior management. Another resident with schizophrenia and sexual dysfunction also missed multiple doses of Paxil, with progress notes and staff interviews confirming that the medication was out of stock for an extended period. Staff reported reordering the medication and notifying nurses, but there was no documentation of physician or guardian notification. The resident and staff observed increased behavioral issues during the period without medication. A third resident with multiple psychiatric and neurological diagnoses, including seizure disorder, was also without several prescribed medications for up to a week, leading to behavioral incidents and seizure activity. Staff interviews indicated confusion over responsibility for medication audits and notification procedures, and again, there was no documentation that the physician or responsible party was informed of the missed medications.
Unsecured Medication Carts Lead to Resident Access and Ingestion of Medications
Penalty
Summary
The facility failed to ensure that medications were securely stored, resulting in two medication carts being left unlocked and unattended on two separate occasions. As a result, four residents were able to access and obtain medications from the carts. Specifically, three residents accessed the unlocked cart and obtained medications including Metformin, Seroquel, and Buspirone, while a fourth resident accessed the narcotic box and took sixteen 5 mg tablets of Oxycodone, later admitting to ingesting eleven of them. Video evidence and written statements confirmed that the medication carts were left unattended and unlocked, allowing residents to remove medication cards and conceal them under their clothing. The residents involved had significant histories of substance abuse, psychiatric disorders, and behavioral issues, as documented in their PASRR assessments and care plans. These care plans specifically required that medications be administered only by staff in designated areas and that medication carts never be left unattended or unlocked. Despite these precautions, staff failed to maintain direct supervision of the medication carts and did not secure the carts or keys as required by facility policy. Staff interviews revealed confusion and lack of clarity regarding who was responsible for the cart at the time, with some staff members denying responsibility and others admitting to leaving the cart or keys unattended while performing other tasks. The incidents were further corroborated by resident and staff interviews, written statements, and review of facility video footage. Residents described how they took advantage of the unlocked carts to obtain medications, and staff acknowledged lapses in following medication storage protocols. The events led to unauthorized access and ingestion of medications, including controlled substances, by residents with known vulnerabilities and histories of substance abuse.
Inadequate Behavioral Health Care and Supervision
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with behavioral health needs and a history of PTSD, who displayed self-harming behaviors. The resident was hospitalized due to psychiatric needs after using a disposable razor blade to cut their forearm. Upon returning to the facility, the resident required one-on-one supervision, which was inconsistently applied. The facility did not have a system in place to ensure the interdisciplinary team (IDT) was involved in assessing the resident's needs related to supervision and participating in decision-making prior to implementing changes in the resident's care. The resident was removed from one-on-one supervision without input from the IDT team and subsequently self-harmed again, requiring emergency room treatment. The facility's assessment indicated the ability to treat various psychiatric and mood disorders, and the use of the IDT to discuss changes in residents' care. However, the facility failed to consistently implement the resident's plan of care related to behavioral services. The resident had a history of mental illness, including schizoaffective disorder, bipolar disorder, PTSD, and other conditions, and had been admitted to psychiatric hospitals multiple times. Despite this, the facility did not hold IDT meetings regarding the resident's increase in behaviors, such as screaming at staff and peers, threatening staff, and being physically aggressive. The resident's care plan directed staff to be aware of triggers and provide structure, but the facility staff did not consistently follow these directives. The resident's supervision level was changed from one-on-one staff observations to hourly face checks without proper IDT documentation or meetings. The facility staff failed to ensure no items were available to the resident that could be used for self-harm, leading to another self-harming incident. The facility's lack of consistent supervision and failure to involve the IDT in decision-making contributed to the resident's continued self-harming behaviors.
Failure to Protect Residents from Physical Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from physical abuse by staff members. In one incident, a resident with a history of schizophrenia and schizoaffective disorder was involved in a physical altercation with a CNA. The CNA and the resident exchanged punches, fell to the floor, and continued fighting while two other CNAs observed but did not intervene. After staff initially separated them, the CNA broke free from staff and struck the resident in the face multiple times, resulting in visible injuries including a cut above the eye, bruising, and a broken nose. The resident was sent to the hospital for evaluation and treatment of these injuries. Interviews and video footage confirmed that staff failed to use appropriate de-escalation techniques and that agency CNAs did not intervene due to lack of facility-specific training. In a separate incident, another resident with multiple psychiatric and developmental diagnoses, including schizophrenia, PTSD, and moderate intellectual disability, was physically abused by a hall monitor. The resident, after becoming agitated by a comment made by the hall monitor, ran toward the staff member and initiated a physical altercation. The hall monitor responded by striking the resident, and both exchanged punches and fell to the floor. Other staff and residents intervened to separate them. Video footage and witness statements confirmed that the staff member retaliated physically against the resident, which was classified as abuse, even though the resident did not sustain visible injuries. Both incidents involved staff members who had received training on abuse and neglect, yet failed to follow protocols and used physical force against residents. The facility's own policies defined such actions as abuse. In both cases, staff failed to use appropriate behavioral management and de-escalation strategies, and in the first incident, additional staff failed to intervene to stop the abuse. The events were substantiated through video evidence, witness statements, and interviews with staff and residents.
Failure to Prevent Resident Access to Hazardous Sharps Resulting in Self-Harm
Penalty
Summary
A deficiency occurred when facility staff failed to follow established protocols for the management and supervision of disposable razors, resulting in a resident obtaining a razor and using it to inflict a superficial cut on their left forearm. The facility had implemented a new protocol several weeks prior, requiring disposable razors to be stored in Central Supply, accessible only by the charge nurse, with CNAs required to request razors, supervise residents during shaving, and return razors to the charge nurse for proper disposal. Despite this protocol, a resident with a history of self-harm and multiple psychiatric diagnoses was able to access a razor without supervision and use it to harm themselves. The resident involved had a complex psychiatric history, including schizoaffective disorder, bipolar disorder, psychotic disorder, PTSD, anti-social personality disorder, polysubstance dependence, ADHD, adjustment disorder, major depressive disorder, and mild intellectual disability. The care plan for this resident included specific interventions to prevent self-harm, such as ensuring no items were available that could be used for self-injury, observing the resident during shaving, and collecting and disposing of razors immediately after use. Despite these measures, the resident reported having hidden a disposable razor for several days or weeks and was able to break the plastic covering to access the blade, which was then used to cut their forearm. Interviews with staff revealed that the new razor protocol was in place and that staff had been educated on it, but it was unclear how the resident obtained the razor. Staff did not observe the resident shaving, and the resident was able to conceal the razor after use. The incident was discovered when the resident's roommate alerted staff, and the resident subsequently presented with a bleeding wound. The facility was unable to determine whether the razor had been hidden prior to the new protocol or was obtained in violation of the protocol. The event demonstrated a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents, as required by facility policy.
Deficiency in Dementia Care for Wandering Resident
Penalty
Summary
The facility failed to implement effective interventions for a resident diagnosed with dementia, leading to multiple incidents of wandering and inappropriate interactions with other residents. The resident, who was admitted with Alzheimer's disease and cognitive communication deficits, frequently wandered into other residents' rooms, causing distress and potential safety concerns. Despite being identified as at risk for wandering, the care plan lacked specific interventions to address the resident's behavior, and staff were not adequately trained or informed on how to manage the situation effectively. The resident's wandering behavior resulted in several incidents, including physical aggression towards other residents. On one occasion, the resident entered another resident's room and attempted to take personal belongings, leading to a confrontation. The facility's investigation noted that the incident was not preventable due to the resident's history, yet there was a lack of proactive measures to prevent such occurrences. Staff interviews revealed inconsistencies in the approach to managing the resident's wandering, with some staff members unsure of the specific interventions to employ. The facility's policy on elopements and wandering residents emphasized the need for a systematic approach to monitoring and managing at-risk residents, but this was not effectively implemented. The interdisciplinary team failed to develop a person-centered care plan with clear interventions, and there was inadequate communication and training among staff. As a result, the resident's behavior continued to affect the safety and well-being of other residents, highlighting a deficiency in the facility's dementia care practices.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #4, who was cognitively intact and required substantial assistance with personal hygiene due to conditions such as Chronic Obstructive Pulmonary Disease (COPD), anxiety disorder, depression, and severe obesity. The resident reported that a Certified Nursing Assistant (CNA), referred to as CNA E, was rough and rude during care, making the resident feel belittled. The resident had recorded interactions with CNA E, which revealed that CNA E spoke in a gruff and disrespectful manner, questioning the resident's lack of supplies and being dismissive of the resident's discomfort during incontinence care. The resident's care plan indicated a risk for skin integrity impairment due to refusal to get out of bed and frequent bowel incontinence. Despite this, CNA E did not communicate effectively or gently during care, as evidenced by audio recordings where the resident expressed pain and discomfort. CNA E was heard questioning the resident's lack of supplies and dismissing the resident's expressions of pain, suggesting that the resident could perform tasks independently despite the resident's inability to do so. During an interview, the facility's Administrator acknowledged the inappropriate behavior of CNA E, describing it as brusk and indicating a need for education on proper communication and care techniques. The resident expressed a lack of trust in the facility's staff, which was compounded by having incorrect contact information for the Administrator. The facility's failure to ensure respectful and dignified treatment of the resident by CNA E constituted a deficiency in maintaining resident dignity and respect.
Failure to Notify Guardian of Resident's Hospitalization and Treatment
Penalty
Summary
The facility failed to notify the guardian of a resident with schizophrenia about significant changes in the resident's condition. The resident, who had a legal guardian due to mental illness, was involved in an incident where they became verbally aggressive, expressed pain, and were sent to the hospital for medical attention. Although the facility's policy required immediate notification of the resident's legal representative in such situations, there was no documentation that the guardian was informed about the resident's hospitalization, the abscess on the resident's forearm, or the new order for antibiotics. The Licensed Practical Nurse (LPN) attempted to contact the guardian by phone but did not follow up after leaving a voicemail, and there was uncertainty about which phone number was used. The guardian later reported not receiving any voicemail or notification about the resident's hospitalization or medical treatment. Despite providing the facility with multiple contact numbers and requesting documentation from the hospitalization, the guardian was not informed of the resident's return from the hospital or the medical procedures performed.
Resident Elopement Due to Policy Non-Compliance
Penalty
Summary
The facility failed to maintain a secure environment for a resident who left the facility without permission from their legal guardian. The resident, who had a history of elopement and significant mental illness, was able to leave the facility with an individual they claimed was their spouse. The receptionist allowed the resident to leave without verifying the necessary permissions or completing the required outside pass form. This incident occurred despite the facility's policy requiring guardian consent and specific procedures for residents leaving the premises. The resident had a documented history of elopement and was considered a high risk for such behavior. They had previously fled a residential care facility, resulting in incidents of assault and vehicle wreckage. The resident's care plan identified them as a very high risk for elopement, requiring close monitoring and supervision. However, the facility failed to conduct an elopement assessment upon the resident's admission and did not perform quarterly assessments as required. On the day of the incident, the resident expressed a desire to leave with someone they identified as their spouse. Despite the lack of an approved outside pass and the absence of guardian consent, the receptionist allowed the resident to leave. The facility's staff, including the charge nurse and other personnel, were unaware of any approved pass for the resident. The receptionist did not follow the protocol of verifying the pass with the Administrator or Social Worker, leading to the resident's unauthorized departure.
Resident Assault Results in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck them in the face, resulting in a broken nose. The incident occurred when the resident was standing in the hallway and was approached by another resident who punched them, causing significant injury. The facility's investigation concluded that the injury was not caused by abuse or neglect and was not preventable, despite the serious nature of the incident. The resident who was attacked had a complex medical history, including mood disorder due to traumatic brain injury, schizophrenia, and other mental health conditions. They were known to have behavioral challenges and required protective oversight. The resident who committed the assault also had a history of mental illness, including schizophrenia and bipolar disorder, and had exhibited aggressive behaviors in the past. Both residents were considered cognitively intact according to their assessments. The incident was unwitnessed, and there was no video evidence available. The staff present at the time did not observe any prior interaction or triggers between the two residents that day. The resident who committed the assault was reportedly upset due to family issues, which may have contributed to their behavior. The facility's staff were present in the hall, but the incident occurred unexpectedly, and the staff did not foresee the aggressive act.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 842 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hilltop At Blue River, The | 1.7 mi | ★★★★★ | 3 | 0 |
| Ignite Medical Resort Carondelet Llc | 1.7 mi | ★★★★★ | 34 | 0 |
| Kingswood Senior Living | 2.2 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Grandview | 3.4 mi | ★★★★★ | 23 | 0 |
| Advanced Health Care Of Overland Park | 3.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bridgewood Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.