Citations in Arizona
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arizona.
Statistics for Arizona (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Arizona
Two residents’ care plans were not updated to reflect known behaviors and treatment needs. One resident with multiple sclerosis, anxiety, bipolar disorder, and moderate cognitive impairment repeatedly called 911 for brief changes due to confusion and anxiety, but this behavior was not included in the care plan despite staff awareness and facility expectations that behaviors be care planned. Another resident with TBI, epilepsy, dementia, and mood disorders had an active order and care plan focus to wear a helmet when out of bed, supported by physician notes and therapy training, yet was repeatedly observed ambulating without the helmet, while staff were unsure of the order, could not find it on the MAR/TAR, and had not documented refusals or any discontinuation. The DON and policies confirmed that refusals and high-risk services must be documented and incorporated into the care plan, but the resident’s electronic care plan lacked the noted refusal, demonstrating a failure to maintain accurate, updated care plans.
A resident with intact cognition and multiple medical conditions, including a fracture and Type 2 DM, was verbally abused by a family member during an unsupervised visit. Staff and a CNA reported hearing a brief but loud verbal argument about bills, and facility documentation later confirmed that the visitor was verbally aggressive and abusive. The DON and ED substantiated the verbal abuse allegation. Although facility policies required protection of residents during abuse investigations and trauma-informed assessment of interpersonal violence history, the resident was nonetheless subjected to verbal abuse by a visitor, resulting in a cited deficiency for failure to protect the resident from abuse.
A resident admitted with multiple medical conditions, including malignant neoplasm of the prostate, substance abuse, long-term anticoagulant use, and acute cystitis, did not have a comprehensive admission MDS completed within the required 14-day timeframe. The ARD was set and the MDS showed intact cognition, but the RN Assessment Coordinator signed completion several days past the regulatory deadline. The MDS Coordinator reported relying on a manual tracking system due to electronic system issues, managing a high volume of assessments without dedicated MDS support, and experiencing delays from interdisciplinary documentation and resident hospitalizations. The DON indicated that MDS oversight is handled corporately and acknowledged that staffing limitations and absences contribute to assessment backlogs.
An unattended computer workstation was observed with a resident’s personal dietary information actively displayed on the monitor while no staff were present. A non-employee walked past the exposed screen without any staff attempt to shield or secure the information. The DON later returned to the workstation, logged off, and acknowledged that leaving PHI visible on an unattended workstation could violate HIPAA and did not meet facility expectations, despite existing policies and staff training on confidentiality and protection of resident records.
Two residents were transferred to the hospital for acute changes in condition, including unresponsiveness and hypotension, with documentation in nursing notes, physician visit notes, transfer forms, and discharge MDS assessments indicating hospital transfers with return anticipated, but no written transfer/discharge notices containing required elements were found in their records. One resident had multiple serious conditions including acute respiratory failure, heart failure, and pneumonia; the other had ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, and severe cognitive impairment. Staff interviews revealed that Social Services was not involved in notifications, the Medical Records Director only began tracking notifications months after the events and was unsure how mailed notices were tracked, and the liaison who visited residents in the hospital did not provide any transfer/discharge forms. The Medical Records Director confirmed no transfer/discharge notices existed for the two residents and that the form in use contained incorrect appeal and ombudsman contact information, while the Administrator stated she was unaware that this version of the form was being used. Review of the facility’s discharge/transfer policy showed it addressed bed-hold review after emergent transfers but did not address providing written transfer/discharge notices or the required content.
A resident admitted on an antipsychotic (olanzapine 2.5 mg daily) with moderate cognitive impairment and no documented behavioral symptoms had the medication discontinued, as reflected on the MAR, but the discontinuation and rationale were not accurately documented in provider progress notes. A PA’s psychiatric note stated no medication changes were made and did not mention stopping olanzapine, while a telephone discontinue order was entered by an LPN and no further doses were given. Behavioral monitoring tied to the antipsychotic remained active with no recorded behaviors, and subsequent NP notes incorrectly documented that the resident would continue olanzapine, even though it was no longer administered and was not included on discharge prescriptions, resulting in inconsistent and inaccurate clinical documentation.
A resident with severe cognitive impairment, a history of falls, and anemia was receiving Enoxaparin for DVT prevention, as ordered by a physician and documented on the MAR. Despite this high-risk medication use being identified on the MDS, the facility did not establish a care plan focus area or specific interventions for anticoagulant therapy. Staff, including a CNA, RN, rehab staff, and the DON, reported that they rely on care plans to identify resident-specific risks, that anticoagulant therapy requires individualized care planning and monitoring for bleeding, and that care plans should be updated after incidents and reflect anticoagulant use per facility policy. Review of the clinical record confirmed the absence of anticoagulant-related care plan interventions for this resident, in conflict with the facility’s care planning and anticoagulation management policies.
A cognitively intact resident with multiple behavioral health and neurological diagnoses, including Huntington’s disease and anxiety disorder, repeatedly requested a replacement cellphone after her previous phone broke, but the facility did not facilitate obtaining one despite the resident having sufficient personal funds and being her own responsible party. The business office manager acknowledged the resident’s request and available trust fund balance but delayed action while waiting for the resident’s sister, who was minimally involved, to decide, citing prior excessive food spending via cellphone. The social service director reported that the resident’s cellphone had been removed for several months due to concerns about a hot charger and weight gain from food orders, limiting her to using facility phones at the nurses’ station or unit. This inaction conflicted with the resident’s care plans, which emphasized phone-based communication to support mood and psychosocial well-being, and with facility policy guaranteeing residents the right to keep personal possessions and have reasonable access to a telephone for private conversation.
A cognitively impaired resident with dementia, aphasia, and hemiplegia, living on a secured unit and care planned as at risk for psychosocial and cognitive problems, was punched twice in the nose in a hallway by another resident with dementia, schizophrenia, psychosis, and a documented history of physical aggression toward staff and other residents. The victim sustained a nasal abrasion, pain, and subsequent bruising around one eye, while the aggressor later stated he acted because he believed the other resident had touched his girlfriend’s hand, although she was not present. Prior episodes in which the aggressive resident hit another resident and struck a CNA’s hand and threw a bedside commode were documented in nursing notes but were not incorporated into care plans with specific preventive interventions at the time. Facility policies required assessment, care planning, monitoring, and implementation of interventions for residents with aggressive behaviors and for resident-to-resident altercation risk, but these measures were not effectively implemented for the aggressive resident, leading to the verified abuse incident.
A cognitively intact resident with depression and COPD befriended a younger, cognitively intact resident with a history of poor impulse control. The older resident gave the younger resident a debit card and cash to hold, after which the younger resident used the funds without permission for online purchases, clothing, and virtual slot game coins. The victim later reported that money was being stolen and became upset, anxious, and withdrawn after realizing the financial exploitation. Staff interviews confirmed that the victim’s funds were used without consent and that boxes of purchases were observed in the alleged perpetrator’s room. Although staff described the situation as financial abuse and exploitation, the facility’s incident follow-up report omitted the residents’ names, no self-report for the relevant period was found, and the administrator could not locate a complete reportable event or investigation record, demonstrating a failure to protect the resident’s property and to properly document the substantiated misappropriation.
Failure to Update Care Plans for Behavioral 911 Calls and Ordered Helmet Use
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans to reflect known behaviors and treatment needs for two residents. For the first resident, who had multiple sclerosis, bipolar disorder, anxiety disorder, and a cognitive communication deficit, the MDS documented moderate cognitive impairment and dependence on staff for multiple ADLs. A complaint was filed stating that this resident had called 911 to request a brief change and had a history of doing so. Staff interviews confirmed that the resident experienced anxiety and sundowning, frequently believed she had pressed the call light when she had actually pressed the bed remote, and then, in a panic, dialed 911 for assistance with brief changes. Despite this ongoing behavior, the resident’s care plan, initiated in early 2022 and revised over time, did not include the behavior of calling 911 for brief changes. The acting DON stated that residents’ behaviors are always supposed to be documented in the care plan so clinical staff know what behaviors to expect. CNAs interviewed described the resident’s pattern of anxiety, confusion, and repeated 911 calls when she believed she had not received needed incontinence care, even though staff reported that brief changes were completed frequently. However, there was no evidence in the care plan that this behavior had been identified, addressed, or incorporated into the resident’s person-centered interventions, despite the facility’s own expectation that such behaviors be care planned. For the second resident, who had epilepsy, traumatic brain injury with brain compression and herniation, alcoholic cirrhosis, thrombocytopenia, hypertension, unspecified dementia with moderate cognitive impairment, anxiety disorder, and mood disorders including depression, the care plan and orders required the resident to wear a helmet when out of bed. A care plan focus initiated in mid-2023 identified an ADL self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI, and included wearing a helmet out of bed. An active order entry and physician progress notes documented that the resident was to utilize a helmet when out of bed. There was no evidence in the care plan that the resident refused the helmet or that helmet use had been discontinued. Observations over multiple days showed the resident repeatedly out of bed, standing, walking in his room, in activities, and in the dining room without the helmet, even though a sign in the room initially stated “HELMET ON AT ALL TIMES OUT OF BED,” and the helmet was visible on the nightstand. Nursing and CNA staff interviews revealed uncertainty about why the resident needed the helmet, whether the order was still active, and whether therapy had discontinued it. One LPN stated she had not seen the resident wear the helmet and was unaware of the order, and could not locate the helmet treatment on the MAR/TAR, even though she acknowledged that such an appliance should be documented there and that refusals should be recorded and communicated. A CNA reported that the resident used to wear the helmet more frequently but did not know why he stopped or why he should be wearing it, and had never been instructed to assist with or educate about helmet use. The director of rehabilitation confirmed that therapy had assessed and trained the resident and staff on helmet use, that the resident had been discharged from therapy with the expectation to continue helmet use out of bed, and that there was no documentation that the helmet had been discontinued. The interim DON stated that the facility is expected to follow provider orders as written, that care plans must be updated quarterly and as needed, and that refusals of care should be documented and reflected in the care plan so providers can make necessary changes. When reviewing the resident’s care plan, the interim DON believed there was a note indicating the resident refused the helmet, but the care plan retrieved from the electronic health record did not contain such a note, and she was unsure about the documentation discrepancy. Facility policies on comprehensive person-centered care planning and documenting and charting required that refusals of services posing health and safety risks be identified in the care plan, including the declined care, associated risks, and the interdisciplinary team’s educational efforts, and that the medical record provide a complete account of care and treatment. For both residents, the survey findings showed that the care plans were not updated and revised to accurately reflect known behaviors and treatment orders, leading to incomplete and inconsistent documentation of their current care needs and interventions.
Failure to Protect Resident From Verbal Abuse by Family Visitor
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from abuse by not preventing or adequately safeguarding against verbal abuse from a family member during a visit. The resident was admitted with diagnoses including a right fibula fracture, Type 2 DM, opioid dependence, mood disturbance, anxiety, and a need for assistance with personal care, and had an admission MDS BIMS score of 13, indicating intact cognition, with no behavioral symptoms toward others noted. On the evening of January 22, 2026, staff became aware of loud yelling in the hallway that was traced to the resident’s room, where the resident and his son were engaged in a verbal argument about bills. A CNA reported hearing raised voices but no profanity, and the incident reportedly lasted less than five minutes. The resident later stated that the son became verbally abusive during the visit. The facility’s own documentation, including an incident note and a Facility Reported Incident submitted on January 27, 2026, confirmed that the son was verbally aggressive and verbally abusive toward the resident. The DON and ED both stated that the facility substantiated the allegation of verbal abuse between the visitor and the resident. Facility policies in place at the time, including “Protection of Resident’s During abuse Investigations,” directed staff not to allow unsupervised visits with a resident if the alleged perpetrator is a family member or visitor, and the “Trauma Informed Care” policy required identification of history of trauma or interpersonal violence as part of the comprehensive assessment when possible. Despite these policies, the resident experienced verbal abuse from his son during an unsupervised visit, leading to the cited deficiency for failure to protect the resident from abuse.
Late Completion of Admission MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive Minimum Data Set (MDS) assessment within the required 14-day timeframe after admission for Resident #3. The resident was admitted with needs for assistance with personal care, malignant neoplasm of the prostate, uncomplicated substance abuse, long-term use of anticoagulants, and acute cystitis without hematuria. The admission MDS had an Assessment Reference Date (ARD) of January 6, 2026, and showed a BIMS score of 15, indicating intact cognition. However, the RN Assessment Coordinator’s signature verifying completion was dated January 28, 2026, which was six days past the latest allowable completion date of January 22, 2026, based on the established ARD. Review of the resident’s chart confirmed that the MDS was not completed within the required 14-day timeframe. During interviews, the MDS Coordinator stated she is responsible for tracking ARDs, completion dates, and submission dates for all required MDS assessments and that accurate and timely completion is essential for correct Medicare billing and identifying resident needs through Care Area Assessments. She reported relying primarily on a manual pencil-and-paper tracking system because the electronic record system does not consistently reflect accurate completion dates, and noted that she completes approximately 60 MDS assessments per week without a dedicated MDS assistant, with current support hours focused on care plan documentation rather than direct MDS completion. She also described system and staffing limitations, lack of coverage during her absences, delays in receiving required documentation from multiple departments, and challenges related to the resident’s multiple hospitalizations, which complicated interviews and determination of changes. The DON stated that MDS completion is monitored by a corporate MDS nurse rather than directly by her, and that staffing limitations and absences can affect workflow and contribute to backlog. Facility policy requires that the MDS be completed within 14 days after admission and within 14 days after a significant change or annually, which was not met for Resident #3.
Unattended Computer Screen Exposes Resident PHI
Penalty
Summary
Surveyors identified a deficiency related to failure to maintain confidentiality of resident-identifiable information when an unattended computer workstation displayed personal records for Resident #29. On January 29, 2026, at 10:45 a.m., the workstation was observed with resident records actively visible on the monitor and no staff present or monitoring the area. The information on the screen included personal and identifiable dietary information for Resident #29. At 10:46 a.m., a non-employee walked down the hallway and passed directly by the monitor with the resident’s information visible, and no staff intervened to shield or secure the information. At 10:47 a.m., the DON (Staff #85) approached the unattended workstation and immediately logged off the computer. In an interview at that time, the DON confirmed that the computer contained private resident information and acknowledged that leaving resident information visible on an unattended workstation could constitute a HIPAA violation and did not meet facility expectations for confidentiality. Review of facility documentation showed staff training on PHI, closing screens, not leaving information exposed, confidentiality, HIPAA, and resident and family notification, with 31 staff members having signed acknowledgment. A review of the facility’s Resident Rights policy, revised January 1, 2025, stated that residents have the right to secure and confidential personal and medical records and that the facility is responsible for safeguarding resident information from unauthorized access or disclosure.
Failure to Provide Required Written Transfer/Discharge Notices and Accurate Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notifications to residents and/or their representatives when residents were transferred to the hospital. For one resident with acute respiratory failure with hypoxia, a left femur fracture, pulmonary hypertension, heart failure, and pneumonia, the record showed admission on a specified date and a subsequent transfer to the hospital on a later date due to unresponsiveness and rapid decline in mental status. The face sheet identified the husband as responsible party and the daughter as emergency contact, with phone numbers listed, and documented that the resident was discharged to the hospital. A physician visit note confirmed the emergent transfer, and a discharge MDS coded as a discharge-return anticipated indicated the resident was sent to the hospital. However, there was no order in the Order Summary Report for the hospital transfer and no documentation in the clinical record of a written transfer notice containing the required elements being provided to the resident or resident representative. For another resident originally admitted with ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, type II neurofibromatosis, respirator dependence, visual loss, and pleural effusion, the face sheet listed the resident’s mother as emergency contact with a phone number. An eINTERACT transfer form documented a hospital transfer for hypotension, and a nursing note recorded a blood pressure of 84/65, that the POA was at bedside, the provider was notified, and 911 was called for transport per physician’s orders. The Order Summary Report contained a physician’s order to transfer the resident to the ER for hypotension, and a discharge MDS coded as discharge-return anticipated documented that the resident, who had severe cognitive impairment, was sent to the hospital. Despite this, the clinical record contained no documentation that a written transfer notice with the required information was provided to the resident or resident representative. Interviews and policy review further described gaps in the facility’s process for transfer/discharge notifications. The social worker reported that Social Services/Case Management was not involved in transfer/discharge notifications and identified Medical Records as responsible. The Medical Records Director stated she began tracking transfer/discharge notifications around October 2025, that a transfer/discharge form was created at that time, and that completed forms were to be scanned into the clinical record if provided to her, but she was unsure how mailed notifications were tracked. She confirmed there were no transfer/discharge notifications in the records of the two residents and acknowledged that the form in use contained incorrect appeal and ombudsman contact information. The Admissions Coordinator/Clinical Liaison stated he visited residents in the hospital but did not provide any transfer/discharge form or packet and was unfamiliar with the form. The Administrator stated that transfer notices are provided three days prior to discharge and that there is a notification for each level with a checklist, but when shown the facility’s transfer/discharge notification form, she said it did not look like the one she approved and she was unaware her team was using it. Review of the facility’s Discharge/Transfer policy showed it addressed reviewing the bed-hold policy with the POA within 24 hours of an unplanned emergent transfer but did not address providing transfer/discharge notifications to residents or representatives or specify the required information, despite State Operations Manual requirements for written notice including reasons, effective date, destination, appeal rights, and advocacy contact information.
Failure to Accurately Document Discontinuation of Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the discontinuation of an antipsychotic medication and the rationale for that change in a resident’s clinical record. The resident was admitted from the hospital with an order for olanzapine 2.5 mg daily and had moderate cognitive impairment with no documented behavioral symptoms during the MDS assessment period. Facility physician orders showed olanzapine was started with an indefinite end date, and the MAR reflected administration for several days, with the medication discontinued on November 11, 2025, at 11:41 a.m. A behavioral monitoring order related to olanzapine, initiated the day before, remained active through the resident’s discharge, and no behavioral symptoms were documented during that time. On the same day olanzapine was discontinued, a psychiatry progress note by a PA documented that this was the initial psychiatric visit and stated that no medication changes were recommended, without noting the discontinuation of olanzapine and directing staff to refer to the MAR for non-pharmacologic interventions. A telephone discontinue order for olanzapine was entered by an LPN as a telephone order from the same PA, and the MAR confirmed no further doses were given after that date. Subsequent nurse practitioner notes on two later dates documented that the resident would continue olanzapine and benztropine for psychosis, despite the medication having been discontinued and not provided, and the resident was ultimately discharged without a prescription for olanzapine. Interviews with nursing and pharmacy staff, as well as the PA, confirmed that the discontinuation was not documented in the progress note and that behavioral monitoring and alert charting were not updated, contrary to facility policies requiring accurate documentation of physician-ordered services and nursing documentation of treatment and order changes.
Failure to Care Plan for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing anticoagulant therapy for a resident who was receiving Enoxaparin Sodium for DVT prevention. The resident had a history of falling, unspecified dementia, and unspecified anemia, and an MDS assessment showed a BIMS score of 02, indicating severe cognitive impairment. The MDS also documented that the resident was receiving an anticoagulant. A physician order directed daily subcutaneous Enoxaparin Sodium injections for 19 days, and the MAR showed the medication was administered on multiple days in January in the resident’s abdomen. Despite this ongoing anticoagulant therapy, the clinical record and care plan report contained no anticoagulant therapy focus area or anticoagulant-specific interventions, contrary to the facility’s anticoagulation management policy requiring that anticoagulant use be reflected in the care plan. During interviews, a CNA stated that staff rely on the care plan to identify resident-specific needs and that residents on blood thinners require extra caution due to prolonged bleeding and easy bruising, with monitoring for bruising and blood in urine being important. An RN confirmed that staff depend on care plans to identify resident-specific risks and interventions, acknowledged that anticoagulant therapy requires individualized care planning, and verified that there was no anticoagulant-related care planning in the resident’s record. A rehab staff member stated that residents on anticoagulants are at higher risk for bleeding and bruising and that care plans should include monitoring vital signs, symptoms, and blood loss, and coordination among departments to minimize fall risks. The DON stated that care plans are expected to guide staff in implementing fall prevention interventions and to be reviewed and revised after any incident, and confirmed that the resident who experienced a fall while on Enoxaparin had no care plan interventions addressing anticoagulant therapy, which did not meet facility expectations or its care planning and anticoagulation management policies.
Failure to Honor Resident’s Right to Personal Cellphone and Independent Communication
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to communication and personal possessions by not facilitating her access to a personal cellphone. The resident, who had diagnoses including type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington’s disease, was her own responsible party and had a BIMS score of 15, indicating she was cognitively intact. Her care plans identified risks for altered mood and psychosocial well-being related to panic disorder and emphasized encouraging alternative communication with visitors and family via phone or video calls, as well as promoting independence and assessing for lower levels of care as needed. Despite these documented needs and goals, the resident had been without a cellphone for several months after her previous phone broke, and she repeatedly expressed that she needed a cellphone. Facility documentation and staff interviews showed that the resident had financial resources available and the cognitive ability to express her needs, yet her request for a replacement cellphone was not acted upon. A behavioral health note documented that the resident complained about her phone and asked staff to use their online account to buy her a new one, and she was told that the business office and social services would be notified. The business office manager confirmed that the resident had a trust fund balance of $543.00 and stated that the resident could verbalize her needs and had requested a cellphone, but the manager was waiting for the resident’s sister to decide because the resident had previously spent $1000.00 on food using her debit card via her cellphone. The business office manager also stated that she only handled the resident’s trust fund and that the resident’s finances were otherwise managed by a third party, with the sister acting as surrogate decision maker, even though the resident’s public fiduciary petition had been denied due to her intact cognition. Additional interviews revealed that the resident did not know how to obtain another cellphone, did not have her sister’s contact number, and had not spoken with her sister since the previous year, while believing the facility had made her sister her power of attorney. The social service director acknowledged that everyone is allowed a cellphone but stated that this resident’s cellphone was considered a safety concern due to a hot phone charger, significant weight gain from ordering food, and related safety issues, and confirmed that the resident had not had a cellphone for several months. The director stated that the resident’s access to a phone was limited to using the facility phone at the nurses’ station or in the unit. The DON stated that residents with a BIMS score of 15 have the right to have their own phone and that social services and the business office should assist them in purchasing one with their own money. The facility’s Resident Rights policy affirmed residents’ rights to keep and use personal possessions and to have reasonable access to a telephone for private conversation, but the resident’s ongoing lack of a personal cellphone, despite her expressed wishes, available funds, and intact cognition, demonstrated the facility’s failure to honor her rights to communication and personal possessions as outlined in policy and regulation. The facility’s own documentation further showed that the resident’s care plan interventions included encouraging alternative communication with visitors and family members via phone and other electronic means, and encouraging participation in supportive visits and activities important to the resident. However, the resident was observed sitting somewhat apart from other residents during an activity, interacting with staff who were showing her products on a cellphone, while she herself did not have a phone. Staff interviews indicated inconsistent awareness of the resident’s cellphone status, with one CNA stating that the resident’s phone had broken the previous month and an LPN stating she did not know if the resident had a cellphone. The combination of the resident’s documented need for communication to support her psychosocial well-being, her repeated verbal requests for a cellphone, her available personal funds, and the facility’s decision to defer to a sister who was not actively involved, resulted in the resident being without a personal cellphone and without independent access to persons and services outside the facility, contrary to her rights and the facility’s own policies.
Failure to Prevent Resident-to-Resident Physical Abuse by Known Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with a known history of aggression. The alleged victim, resident #911, had diagnoses including aphasia, hemiplegia, hemiparesis, dementia, major depressive disorder, and anxiety disorder, and resided on a secured unit due to vascular dementia. A recent MDS showed short- and long-term memory problems and moderate cognitive impairment in daily decision-making, with documented physical and verbal behavioral symptoms and wandering. Care plans identified risks for psychosocial well-being problems, cognitive problems, and abuse related to dementia, with interventions such as emotional support, calm reassurance, increased 1:1 activities, and monitoring for mood or behavior changes after incidents. On the date of the incident, an incident report and nursing documentation described a resident-to-resident altercation in a hallway in which another resident, identified as the occupant of room [ROOM NUMBER]B (resident #999), suddenly rose from his wheelchair and struck resident #911 twice on the nose with a closed fist. Resident #911 sustained a small, open, bleeding area across the bridge of the nose, reported pain at 5/10, and later developed bruising around the right eye. A wound care note and skin assessment documented an abrasion on the bridge of the nose, and subsequent nursing notes confirmed ongoing bruising and healing of the nasal abrasion. Social Services documented that resident #911, who had limited verbal communication and primarily responded by nodding or brief statements, recalled the incident and stated he was okay, appearing calm and without observable distress. The alleged perpetrator, resident #999, had diagnoses including dementia, anxiety disorder, schizophrenia, psychosis, and major depressive disorder, and had been placed on a secured unit due to psychosis and schizophrenia with verbal and physical aggression toward staff. Prior documentation showed a pattern of physical aggression: a nursing note from October 28, 2025 recorded that he hit another resident on the nose after claiming his wheelchair had been kicked, and a note from November 1, 2025 recorded that he hit a CNA’s hand, was verbally aggressive, and threw a bedside commode. These incidents were not reflected in care plans with specific interventions to prevent further incidents at the time they occurred. A behavioral care plan initiated later documented combative and aggressive behaviors such as yelling, hitting, and grabbing, with general interventions to monitor behaviors and protect others’ rights and safety. On the date of the abuse incident involving resident #911, an incident report and nursing notes documented that resident #999 approached resident #911 and punched him twice on the nose, later stating he did so because the other resident touched his girlfriend’s hand, although the girlfriend was not present in the hallway. The facility’s investigation, including witness and resident interviews, concluded that the allegation of abuse was verified. Facility policies on Abuse and Neglect and on Accident Hazards/Supervision/Devices required assessment, care planning, monitoring, identification of residents likely to be involved in altercations, and implementation of interventions to minimize resident-to-resident altercations, which were not effectively carried out for resident #999 despite his known aggressive history.
Failure to Protect Resident From Financial Misappropriation and Inadequate Documentation of Exploitation Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from financial misappropriation/exploitation of property by another resident and to ensure appropriate reporting of the incident. One resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including anemia, COPD, weakness, and major depressive disorder, reported that money was being taken after befriending another, younger resident. This resident had a care plan addressing depression and psychosocial risks, including monitoring for changes in mood and behaviors related to situational stressors. Documentation shows that the resident became upset and distressed after an encounter involving being robbed by a fellow resident, later experiencing increased anxiety, sadness, and a desire to move to another facility. The alleged perpetrator was also cognitively intact, with a BIMS score of 15, and had diagnoses including major depressive disorder, obesity, and life management difficulty, as well as a care plan for self-harmful ideation and poor impulse control. According to the facility’s incident follow-up report, the perpetrator stated that the victim initially gave permission to use her funds and then continued to use them without permission. Staff interviews revealed that the victim had given her debit card and cash to the other resident to hold, and that the other resident used the funds to buy clothes for herself and the victim, and to purchase coins for virtual slot games. Another staff member reported noticing boxes of purchases in the alleged perpetrator’s room and learning that the victim’s debit card was being used without permission. The deficiency is further supported by inconsistencies and gaps in the facility’s documentation and reporting of the event. The incident follow-up report did not include the names of the residents involved. During the onsite survey, when a self-report for the relevant month involving the victim was requested, the administrator provided documentation that did not include any self-report for that period. The business office manager stated she had no documentation of the incident other than an investigator’s card, and the administrator reported having no prior knowledge of the incident and being unable to locate the reportable event or investigation in the facility’s records. Although staff described the situation as abuse and financial exploitation and referenced notifications to external agencies, the lack of a self-report in the requested timeframe and incomplete internal documentation demonstrate the facility’s failure to properly document and maintain records of the misappropriation incident, contributing to the cited deficiency. The facility’s own Abuse and Neglect policy states that residents are to receive care in an environment free from misappropriation of property and exploitation, and that suspected abuse will be investigated based on facts, observations, and statements from the alleged victim and witnesses. In this case, the victim’s report of stolen money, the perpetrator’s admission of continued use of funds without permission, and staff observations of unusual purchases and changes in the victim’s demeanor all point to financial misappropriation by one resident against another. The absence of a complete, identifiable self-report and investigation record available for review, along with the omission of resident names in the incident follow-up report, shows that the facility did not fully adhere to its own policy requirements in documenting and tracking this substantiated misappropriation event.
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