Citrus Heights Respiratory And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Mesa, Arizona.
- Location
- 3130 East Broadway Road, Mesa, Arizona 85204
- CMS Provider Number
- 035193
- Inspections on file
- 22
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Citrus Heights Respiratory And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain and retain complete, accessible medical records and related documentation for numerous residents, particularly for periods before a change in ownership. Surveyors found that care plans, nursing progress notes, incident reports, five‑day investigations, grievance logs, and other records were missing or unavailable for residents involved in altercations, falls, and alleged financial misappropriation, even though federal assessment data confirmed those residents had been admitted and assessed at the facility. Staff acknowledged that records for residents admitted and discharged before the ownership change, and some records for current residents admitted earlier, were not available, and that incident and investigative records from those periods were also missing, contrary to facility policies requiring long‑term record retention and complete documentation of care and events.
Opioid medications were administered outside ordered pain parameters for three residents. MAR review showed oxycodone given when pain scores were below the physician-ordered ranges, including for a resident with severe cognitive impairment, a cognitively intact resident dependent on staff for all ADLs, and a resident with severe cognitive impairment and a femur fracture. Staff interviews confirmed nurses were expected to assess pain, follow the ordered parameters, and document the pain score at the time of administration; the DON stated the administrations for one resident did not meet expectations.
The facility failed to implement its abuse, neglect, and misappropriation policy by not maintaining investigation reports and contemporaneous clinical documentation for multiple allegations involving several residents. State records showed reports of lost personal property, financial misappropriation, resident‑to‑resident altercations, and alleged inappropriate sexual contact, often involving residents with dementia, traumatic brain injury, psychiatric disorders, and significant physical impairments. In numerous cases, the facility could not produce five‑day investigation reports, nursing progress notes, care plans, MDS assessments, or even basic identifying records for the timeframes of the incidents, and in some instances denied that an involved resident had ever lived there. Leadership acknowledged that records and investigation documents from before a change of ownership were not available, despite a stated retention expectation of ten years, resulting in noncompliance with the written abuse prevention and documentation policy.
Surveyors found that the facility lacked required clinical and investigation records for multiple residents involved in alleged abuse, resident‑to‑resident altercations, and misappropriation of property. For several residents with dementia, psychiatric disorders, traumatic brain injury, and other comorbidities, there were no care plans, nursing progress notes, MDS assessments, or 5‑day investigation reports covering the time of the alleged incidents. In some cases, the facility’s EHR contained no record of the alleged victim or alleged perpetrator, and staff stated that records for residents and incidents occurring before a change of ownership were not available, despite policies requiring long‑term retention of health records and abuse investigations and immediate reporting of all allegations to the Administrator and state and federal agencies.
The facility failed to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation involving several residents with complex medical and psychiatric conditions. In numerous cases of alleged resident-to-resident altercations, loss or misuse of funds, and inappropriate sexual contact, the facility could not produce five-day investigation reports, contemporaneous nursing notes, care plans, or even basic clinical records for the residents involved. Facility leadership acknowledged that records and investigation reports from before a change of ownership were unavailable, despite policy and record-retention expectations, resulting in an inability to verify that required abuse investigations were completed in accordance with the facility’s abuse prevention policy.
A cognitively intact resident with multiple chronic conditions had a bottle of Zinc 50 mg labeled with their name and room number and a bag of menthol cough drops on the bedside table, which the resident reported having since admission. Review of the EHR, physician orders, and care plan showed no assessment or authorization for self-administration and no orders for zinc or cough drops. Staff, including a CNA, RN, unit manager, and DON, acknowledged that prescribed and OTC items such as vitamins and cough drops are considered medications and should not be kept at bedside without a self-administration order, assessment, documentation, and appropriate storage, none of which were in place for this resident.
Food items in the kitchen and nourishment refrigerators were found unlabeled, undated, and improperly stored. Observations showed opened whipped cream without visible dates, bacon and frozen burger patties left exposed in partially closed boxes, and multiple resident food items in nourishment fridges with no room numbers or dates. Staff also found staff lunch items mixed with resident food, unidentifiable food in containers, and dirty refrigerator surfaces with food residue.
A CNA handled a resident and then delivered a lunch tray without performing hand hygiene, and the unit lacked visible hand sanitizer dispensers. In a separate event, a housekeeper cleaned a room previously under contact precautions for C. diff while wearing gloves only, with no isolation signage posted outside the room. The resident had diagnoses including C. diff, renal dialysis dependence, and acute respiratory failure with hypoxia, and staff described the room as having been deep cleaned the prior night, though no documentation was available.
A resident with severe cognitive impairment and diagnoses including a left femur fracture and encephalopathy was documented as verbally consenting to influenza, pneumococcal, and COVID-19 vaccines, but the pneumococcal vaccine was not offered, no MD order was present, and no MAR/TAR evidence showed it was given during the admission. The Infection Preventionist later stated this was a nursing error and that she had not been informed the resident needed the pneumococcal vaccine.
The facility failed to maintain required medical records for a resident admitted in 2022 who had moderate cognitive impairment and multiple chronic conditions, including ESRD, diabetes, seizure disorder, and mental health diagnoses. When surveyors requested the resident’s chart, including the facesheet, diagnoses, physician orders, MAR/TAR, progress notes, care plan, census information, and self-reports, facility staff reported they could not provide any records from before a change in ownership because they had no access to the prior EMR system after the previous owner stopped paying for it. The Medical Records Director and DON acknowledged that records are required to be retained for 10 years, and facility policies on medical record content and record retention also required long-term maintenance of resident records and investigations, which was not achieved due to the lack of access to historical records.
A resident did not receive prescribed antibiotics for eight days due to the facility's failure to obtain the medications as ordered. The resident, with a history of severe sepsis, was discharged from the hospital with orders for cefiderocol and gentamicin. Despite attempts to resolve the issue, including contacting the pharmacy and notifying the DON, the medications were not administered until eight days later, highlighting a breakdown in the facility's medication administration process.
A facility failed to update its infection control policies in line with CDC guidelines, leading to improper use of PPE during wound care. A resident with a pressure ulcer did not receive care with the recommended gown and gloves, as the facility's policy only required gowns for stage III or greater wounds. The DON, acting as the Infection Preventionist, lacked proper certification, and the facility's policy was outdated.
Failure to Maintain and Retain Required Resident Medical Records and Incident Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and readily accessible medical records and related documentation for multiple residents, as required by professional standards and the facility’s own record retention policies. During the survey, records dated prior to March 1, 2025 were largely unavailable in the electronic health record (EHR) system, despite evidence from State Authority (S.A.) MDS submissions that numerous residents had been admitted and resided in the facility before that date. Surveyors requested care plans, nursing progress notes, five‑day investigation reports, and other clinical documentation for sampled residents, but the facility repeatedly stated it was not in possession of these records. For several residents involved in alleged incidents or complaints, including resident‑to‑resident altercations, falls, and alleged misappropriation of funds, the facility could not produce contemporaneous care plans, nursing progress notes, incident reports, or five‑day investigative reports. Examples included a resident‑to‑resident altercation where one resident’s earliest care plan and nursing notes in the EHR began approximately a year after the reported event, and another resident involved in the same altercation had no clinical record in the EHR at all. In other cases, residents with documented admissions in the S.A. MDS had no EHR record, no care plans, and no nursing progress notes corresponding to the timeframes of reported incidents or allegations. The facility also reported that it did not possess grievance logs for entire prior years and for early months of a subsequent year, despite a record request for those periods. Additional discrepancies were identified when the facility asserted that certain residents had never resided there, while iQIES data and MDS submissions showed those residents had been admitted with various diagnoses and documented BIMS scores. For multiple such residents, there was no evidence of any medical record in the facility’s EHR. Interviews with the Medical Records Supervisor and the Administrator confirmed that there were no medical records available for residents admitted and discharged prior to March 1, 2025, and that some records for current residents admitted before that date might also be missing. They acknowledged that incident reports and five‑day investigations prior to the ownership change were not available, and that they had no access to paper records from the previous owner. Facility policies reviewed by surveyors required maintaining resident medical records for 10 years and investigations for 5 years, and required documentation to provide a complete account of residents’ care, treatment, and progress, which was not met in these cases. The deficiency also encompassed the facility’s inability to provide complete MDS, care plans, and progress notes for specific timeframes related to allegations of resident‑to‑resident aggression, falls, and financial misappropriation. For example, for a resident who reported being attacked by another resident, the earliest MDS and care plan on record did not cover the period of the alleged event, and requested progress notes and care plans for the months surrounding the allegation were not available. For another resident with an alleged misappropriation of benefit funds, no records could be located in the EHR, and the facility stated it did not possess information for incidents occurring before March 1, 2025. Across these cases, the survey findings consistently showed that required clinical and investigative documentation was missing or incomplete for residents whose presence and clinical status at the facility were documented in federal assessment systems, demonstrating a systemic failure to retain and maintain medical records and related documents in accordance with policy and accepted standards. Interviews further clarified that the lack of records was linked to a change of ownership on March 1, 2025, after which the new Administrator reported having no access to prior physical records, including medical records, incident reports, and five‑day investigations. The Medical Records Supervisor, who assumed her role months after the ownership change, stated she had no knowledge of what the previous owners had done with the paper records and confirmed that no paper copies of incident reports or five‑day investigations for alleged incidents were available. Both staff members acknowledged that the expectation was to maintain resident medical records for 10 years and investigations for 5 years, and that upon transfer of ownership, the facility should have had access to all resident records within the required retention timeframe. Despite these expectations and written policies, the facility did not have the historical records necessary to provide a complete account of residents’ care and prior incidents. The surveyors’ review of facility policies titled “Documentation and Charting” and “Record Retention Schedule” showed that the facility’s own standards required a complete account of residents’ care, treatment, response, signs and symptoms, and progress, and mandated retention of resident medical records for 10 years and investigations for 5 years. The absence of records for numerous residents, including those with documented admissions and MDS assessments, and the lack of incident reports, five‑day investigations, and grievance logs for multiple years, directly conflicted with these policies. The facility’s inability to produce these records during the survey, despite multiple requests and the presence of corresponding data in iQIES and S.A. MDS, formed the basis of the cited deficiency for failure to safeguard and maintain complete medical records in accordance with accepted professional standards. The Administrator and Medical Records Supervisor both acknowledged during interviews that the facility did not have medical records for residents admitted and discharged prior to the ownership change, and that some records for current residents admitted before that date were also missing. They also confirmed that incident reports and five‑day investigations prior to the change of ownership were not available, and that they could not reach the previous owners, who had relocated to another country. These statements, combined with the documented absence of records in the EHR and the facility’s written responses to record requests, demonstrated that the facility lacked the required historical documentation for a significant number of residents and events, leading to the cited deficiency. The survey findings also highlighted that, despite the facility’s dispute of the citation, the objective evidence from iQIES and S.A. MDS data showed that residents for whom the facility claimed no records or no residency had, in fact, been admitted and assessed at the facility. The lack of corresponding medical records, care plans, nursing notes, incident reports, five‑day investigations, and grievance logs for these residents and timeframes was inconsistent with both regulatory expectations and the facility’s own policies. This systemic absence of historical resident documentation and investigative records formed the core of the deficiency related to safeguarding and maintaining resident‑identifiable information and medical records. Overall, the deficiency was based on the facility’s failure to ensure the presence of complete and readily accessible medical records for a large portion of the sampled residents, including those involved in reported incidents and complaints, and its failure to retain required records such as incident reports, five‑day investigations, and grievance logs for the mandated retention periods. The surveyors’ observations, record reviews, and staff interviews collectively demonstrated that the facility did not have the necessary historical documentation to meet accepted professional standards for medical record maintenance and retention.
Opioid medications administered outside ordered pain parameters
Penalty
Summary
The facility failed to ensure that three residents received opioid medications according to physician orders. Review of clinical records, MARs, care plans, and staff interviews showed that oxycodone was administered to Residents #4, #50, and #90 when the documented pain scores were outside the ordered parameters. The deficiency involved medication administration for residents with pain-related diagnoses and included both scheduled care plan interventions and PRN opioid orders. Resident #4 was admitted with diagnoses including nontraumatic subdural hemorrhage, extradural and subdural abscess, and cognitive communication deficit. The resident had a BIMS score of 0, indicating severe cognitive impairment, and required moderate to maximum assistance with ADLs. The care plan identified opioid use for pain in the head and abdomen and directed staff to administer the opioid as prescribed and follow the pain scale. The physician ordered oxycodone HCl 5 mg every 6 hours as needed for pain rated 4 through 10. The MAR showed multiple administrations when the recorded pain scores were 0 or 1, including several doses in February and March 2026. Resident #50 was re-admitted with diagnoses including lymphedema, generalized muscle weakness, and hereditary and idiopathic neuropathy. The resident had a BIMS score of 14 and was dependent on staff for all personal cares and ADLs. The care plan identified opioid use for pain in the right thigh and knee and directed staff to administer opioid medications. The physician ordered oxycodone HCl 10 mg every 4 hours as needed for pain rated 5 through 10. The MAR showed administrations when the recorded pain scores were 0, 1, or 2, including multiple doses in February and March 2026. Resident #90 was admitted with diagnoses including a left femur neck fracture, encephalopathy, and generalized muscle weakness. The resident had a BIMS score of 3 and required maximum assistance or was fully dependent for personal care and ADLs. The care plan directed staff to administer opioid medications as prescribed and to follow the pain scale. The physician ordered oxycodone HCl 5 mg, one tablet every 6 hours as needed for pain rated 4 through 6, and oxycodone HCl 5 mg, two tablets every 6 hours as needed for pain rated 7 through 10. The MAR showed administrations of one tablet when the pain score was 3 or 1, and two tablets when the pain score was 0 or 1. Staff interviews confirmed that nurses were expected to assess pain, follow ordered parameters, and document the pain score at the time of administration. The DON stated that medications should not be administered outside of parameters and that documentation and administration for Resident #4 did not meet expectations.
Failure to Implement Abuse and Misappropriation Investigation Policy and Maintain Required Records
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and misappropriation policy by not conducting or maintaining thorough investigations and related clinical documentation for multiple allegations of abuse, neglect, and theft involving 11 residents. State Agency (SA) records showed that various incidents, including misappropriation of property, resident‑to‑resident altercations, and alleged sexual contact, had been reported and that the facility had indicated investigations were conducted. However, during the survey, the facility was unable to produce investigation reports, five‑day reports, or contemporaneous clinical documentation such as nursing progress notes, care plans, and Minimum Data Set (MDS) assessments for the timeframes of the allegations, despite policy requirements to identify, document, and investigate abuse, neglect, exploitation, and misappropriation. For one resident who reported loss of personal property allegedly involving a nurse aide, SA records indicated the facility conducted an internal investigation immediately after the incident, but the facility could not provide the investigation report and denied that the resident had ever resided there, even though SA MDS data showed an admission. Another resident with dementia, bipolar disorder, anxiety, depression, and mobility issues had an allegation of misappropriation by a payee; yet the EHR contained no care plan, nursing notes, or task records for the relevant month, and the facility stated it did not possess any supporting documentation. In a documented resident‑to‑resident altercation where one resident struck another’s hand in the dining room, the facility reported that staff separated the residents and conducted an investigation, but later could not produce a five‑day report, a face sheet for one of the residents, or nursing documentation for the time of the incident. Additional SA‑reported resident‑to‑resident altercations and misappropriation allegations similarly lacked corresponding facility records. In one case, a resident with traumatic brain injury, anxiety, and depression was reportedly struck on the shoulder by another resident with schizoaffective disorder, traumatic brain injury, and multiple psychiatric diagnoses, but there were no nursing progress notes for either resident for the period of the incident and no five‑day investigation report. Another resident with hypertension, prior transient ischemic attack, and adjustment disorder had an alleged misappropriation of financial resources, yet there was no care plan for the year of the allegation, no progress notes for that period, and no investigation report. A resident with traumatic brain injury, legal blindness, seizures, and serious mental illness reported being attacked by another resident, but the facility lacked MDS, care plans, and progress notes for the months surrounding the allegation. Further, an allegation of inappropriate sexual contact between roommates was reported, but the facility’s EHR contained no record for the alleged perpetrator, and for the alleged victim there was no MDS or care plan on or before the date of the incident and no nursing notes until much later. Another resident who discovered that insurance catalog benefits had been nearly depleted was not found in the EHR at all, and the facility stated it did not have records for residents or incidents prior to a change of ownership. The Administrator reported that the facility did not have access to medical records, five‑day investigation reports, or self‑reported incidents from before the ownership change, and the Medical Records Supervisor stated that such records should be retained for ten years but that no paper records existed for residents prior to that date. These inactions and missing records demonstrate that the facility did not follow its abuse prevention policy requiring immediate reporting, protection of alleged victims, and thorough identification and documentation of abuse, neglect, exploitation, and misappropriation. The facility’s written policy on abuse prevention and prohibition stated that each resident has the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that staff with knowledge of actual or potential violations must report them immediately to the Administrator. The policy further required the facility to identify and document abuse, neglect, exploitation, and misappropriation, including through assessments and review of occurrences, patterns, and trends such as resident‑to‑resident altercations, and to respond immediately to protect alleged victims and preserve the integrity of investigations, including examination of alleged victims for signs of injury via physical and/or psychosocial assessment. The absence of investigation reports, contemporaneous clinical documentation, and retained records for the cited residents and incidents shows that these policy requirements were not implemented for the 11 sampled residents associated with the SA‑reported allegations.
Missing Abuse and Misappropriation Investigation Records After Ownership Change
Penalty
Summary
The deficiency involves the facility’s failure to ensure that allegations of abuse, neglect, and misappropriation of resident property were properly documented and that related investigation records were available, as required by policy and regulation. Surveyors found that for 11 sampled residents, there were missing clinical records, care plans, nursing progress notes, and investigation reports associated with reported or alleged incidents. The facility repeatedly stated it was not in possession of requested records, including 5‑day investigation reports and self‑reports, for events that had been reported to the State Agency (SA) or were alleged by residents. One resident was reportedly involved in an altercation with a nurse aide regarding loss of personal property, but the facility could not produce an investigation report or any clinical records for that individual and asserted that the resident had never resided there. Another resident had an allegation of misappropriation of funds by a payee, yet there was no care plan, nursing progress notes, or task documentation for the relevant time period in the EHR, and the facility reported it did not have those documents. In a separate resident‑to‑resident altercation, one resident with dementia and multiple psychiatric diagnoses remained in the facility, but the earliest nursing notes in the EHR were dated long after the alleged incident, and the facility could not provide the 5‑day report or records for the other resident allegedly involved, stating it did not possess those records. Additional SA‑reported resident‑to‑resident altercations and misappropriation allegations were also not supported by contemporaneous documentation in the facility’s records. For two residents involved in a reported altercation, nursing progress notes only began more than a year after the incident, and no investigation report was available. For a resident with hypertension and cerebrovascular history, there was no care plan for the year of a reported misappropriation allegation and no progress notes or 5‑day report for the months surrounding the event. A resident with traumatic brain injury and psychiatric diagnoses reported being attacked by another resident, but the MDS and care plan for the relevant period were missing, and the facility could not provide requested progress notes or care plans for the months before and after the alleged event. In another allegation, a resident reported that his roommate fondled his genitals; however, there was no documentation for the alleged roommate in the EHR, and the facility stated that person had never resided there. The resident’s own MDS and care plan did not cover the date of the alleged incident, and the earliest care plan and nursing notes were dated more than two years later. A separate resident who alleged misuse of insurance catalog benefits could not be located in the EHR at all, and the facility stated it did not have records if the resident or incident pre‑dated a change of ownership. The Medical Records Supervisor stated that medical records and incident/5‑day investigation reports should be retained for 10 years, and the Administrator confirmed there were no medical records or access to medical records, including 5‑day investigations and self‑reports, for residents prior to the change of ownership date. Facility policies required retention of resident health records for 10 years and facility investigations for 5 years, and required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and appropriate state and federal agencies, but the facility lacked the records to demonstrate compliance for the cited residents and events.
Failure to Investigate and Document Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and maintain documentation for multiple allegations of abuse, neglect, and misappropriation of property as required by its own abuse prevention policy. For one resident who allegedly accused a nurse aide of loss of personal property, state agency records showed the resident had been admitted to the facility, but the facility denied the resident had ever resided there and could not provide a five-day investigation report or any clinical records. In another case involving an alleged misappropriation of funds by a resident’s payee, the facility’s EHR contained no care plan, nursing progress notes, or task records for the relevant time period, and the facility stated it did not possess the requested records, preventing confirmation that the allegation was investigated. Additional deficiencies were identified in several resident-to-resident altercations and other abuse-related complaints. In one incident, a resident reportedly struck another resident’s hand in the dining room; staff stated the residents were separated and an investigation was conducted, but the facility could not produce a five-day investigation report or nursing documentation for the time of the incident. One of the involved residents did not appear in the EHR at all, and the facility reported having no documentation for that resident. In another altercation, a resident was observed striking another resident on the shoulder, but there were no nursing progress notes for either resident for the time frame of the incident, and the facility could not provide an investigation report. Further, the facility lacked documentation for allegations of misappropriation of financial resources, physical attacks by other residents, and inappropriate sexual contact between roommates. For one resident alleging misappropriation of financial resources, there was no care plan for the year of the allegation and no nursing progress notes until nearly two years later, and the facility could not provide investigation reports or contemporaneous records. For another resident who reported being physically attacked by another resident, the MDS and care plans for the relevant period were unavailable. In a complaint of inappropriate sexual contact, the alleged perpetrator did not appear in the EHR and the facility stated that person had never resided there, while the complainant’s MDS, care plan, and nursing notes for the time of the allegation were missing. In an additional case of alleged misuse of insurance benefits, the facility had no records for the resident and stated it did not possess information for residents or incidents prior to a change of ownership. Interviews with the Administrator and the Medical Records Supervisor confirmed that the facility did not have access to medical records, incident reports, or five-day investigation reports for residents prior to a change of ownership, despite the Medical Records Supervisor stating that such records should be retained for ten years following discharge. Both acknowledged that no paper records existed for residents prior to the ownership change and that this absence resulted in a lack of resident history and incomplete understanding of residents’ needs. Review of the facility’s abuse prevention policy showed that all allegations of abuse, neglect, misappropriation, and exploitation were to be promptly reported, thoroughly investigated, and fully documented, but the facility’s inability to produce investigation reports and contemporaneous clinical documentation for the cited residents demonstrated noncompliance with this policy.
Unauthorized Medications Kept at Bedside Without Self-Administration Assessment or Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored and administered according to policy for one cognitively intact resident. The resident was admitted with multiple diagnoses including major depressive disorder, anxiety disorder, neuromuscular bladder dysfunction, ventilator dependence, morbid obesity, obstructive sleep apnea, polyneuropathy, chronic diastolic CHF, chronic respiratory failure with hypoxia, and bradycardia. A quarterly MDS showed a BIMS score of 15, indicating intact cognition. Review of the physician’s orders, care plan, and EHR showed no evidence of an order authorizing the resident to self-administer medications and no documented assessment for self-administration, despite facility policy requiring IDT assessment and documentation when a resident participates in self-administration of medications. During an observation in the resident’s room, surveyors noted a bottle of Zinc 50 mg and a bag of Halls cherry-flavored menthol cough drops on the bedside table. The bottle of zinc was labeled with the resident’s name and room number. The resident stated that both items had been at the bedside since admission. There was no evidence in the EHR of any physician order for oral zinc or for cough drops for this resident. The presence of these items at bedside occurred without the required assessment, orders, or care plan entries for self-administration, and without secure storage as required for medications. Interviews with staff confirmed that the zinc and cough drops were considered medications that should not be kept at bedside without a self-administration order. A CNA stated that medications include prescribed and OTC items, including vitamins, and that residents cannot have medications at bedside unless authorized to self-administer; she acknowledged that zinc and cough drops at the bedside should not have been there. An RN similarly stated that medications can be prescribed or OTC and include oral, topical, inhaled, or injected forms, and confirmed there were no orders for zinc or cough drops for this resident. The unit manager and DON both stated that residents may not have medications at bedside unless assessed and authorized for self-administration, with documentation and appropriate storage, which had not occurred for this resident.
Food Items Not Labeled, Dated, or Stored Properly
Penalty
Summary
The facility failed to ensure food items in the kitchen and nourishment refrigerators were labeled, dated, and stored correctly. During a kitchen observation with the Dietary Supervisor, six piping bags of whipped cream were found in the refrigerator, including one opened bag with no visible dates. Also observed were a partially closed cardboard box holding bacon strips in a clear plastic bag in the refrigerator and a partially closed cardboard box containing a clear plastic bag of frozen burger patties in the freezer, both open and exposed to air. In the nourishment refrigerator on Station 1, multiple items were observed with no room number or dates, including Trader Joe's buffalo chicken dip, a small container of Fritos bean dip, a black container of white rice, a reused sliced peaches jar filled with soup, and a Hillshire Farms roasted turkey breast deli meat container filled with bologna slices. The refrigerator also had a brown crusted and sticky substance on the floor, a white sticky substance on the shelving, and small brown food crumbs in the freezer. In the nourishment refrigerator on Station 4, two lunch totes had no names, labels, or dates, a glass container with a pink lid held unidentifiable food, and a Redbull energy drink had no names, labels, or dates. Staff interviews confirmed that the observed food items were not acceptable practice, that staff lunches should be stored elsewhere, and that food items were expected to have received, opened, and discard dates.
Hand Hygiene and Contact Isolation PPE Lapses
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices were followed for hand hygiene and for the use of PPE when entering and cleaning a contact isolation room. During an observation in the locked unit dining room, a CNA moved a basket of laundry, redirected a resident by placing a hand on the resident’s shoulder, and then immediately handled and delivered a lunch tray without performing hand hygiene between resident contact and contact with the food tray. During the same observation period, there were no hand sanitizer dispensers on the hallway walls, in resident rooms, or at the nurse’s station on the unit. The CNA stated she was not used to working on that unit and was reminded by another staff member to perform hand hygiene. Another CNA confirmed there were no hand sanitizer dispensers on the unit and stated that each staff member carried a personal hand sanitizer bottle. Resident #84 was admitted with diagnoses including enterocolitis due to C. diff, dependence on renal dialysis, and acute respiratory failure with hypoxia. A physician order dated February 27, 2026, directed contact precautions for C. diff, with all therapies, treatment, cares, and meals in a single occupancy room every shift. A later physician order dated March 9, 2026, prescribed strict contact isolation precautions related to C. diff and directed staff to wear a gown and gloves and to wash with soap and water before leaving the room. When the resident’s room was observed being cleaned, there was no signage outside the room identifying the transmission-based precaution status or the occupant of the room. A housekeeper was observed cleaning the floor and removing trash while wearing gloves only and no other PPE. The housekeeper stated the resident had been transferred to another room and that she was cleaning the room because a new admission was being assigned later that day. She stated there had been no sign posted outside the room before she entered, although she knew the room had been a transmission-based precaution room the day before. The housekeeping supervisor stated staff should wear the PPE indicated on the signage outside the door, but was unaware how this was communicated if nursing staff removed signs without informing housekeeping. The ADON/IP stated the room had been deep cleaned the night prior by another nurse, but she was unable to provide documentation confirming that the room was deep cleaned.
Missed Pneumococcal Vaccination
Penalty
Summary
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations resulted in one resident not receiving a pneumococcal vaccination during the current admission. The resident was admitted with diagnoses including fracture of the left femur, encephalopathy, and need for assistance with personal care. A consent form dated January 2, 2026 documented verbal consent for influenza, pneumococcal, and COVID-19 vaccination, and the form was signed by two nurses, including the Infection Preventionist. The resident did not sign that consent, and the Medicare 5-Day MDS showed a BIMS score of 3, indicating severe cognitive impairment. The MDS also showed that the pneumococcal vaccination was not offered.
Failure to Maintain Required Resident Medical Records After Ownership Change
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident medical records for the required retention period, specifically for one resident whose admission MDS was submitted and accepted in early April 2022. The MDS documented that this resident had moderate cognitive impairment with a BIMS score of 11, exhibited verbal and other behavioral symptoms, and had multiple active diagnoses including hypertension, diabetes mellitus, end-stage renal disease, hyperlipidemia, seizure disorder or epilepsy, anxiety, depression, and bipolar disorder. When surveyors requested the resident’s facesheet, diagnoses list, physician orders, MAR/TAR for the full stay, progress notes, completed MDS, care plan, census list, and self-reports or investigations, the facility responded that the resident was not in the facility after March 1, 2025, and that they were unable to provide any records for this resident. Interviews with the Medical Records Director, Clinical Resource, RN Unit Manager, and DON confirmed that the facility did not have access to any paper or electronic records for this resident, or for any residents prior to March 1, 2025, unless they remained in the facility on or after that date. Staff stated that medical records were expected to be maintained for 10 years and described the contents of a complete medical record, but reported that they could not access prior records because the previous owner had stopped paying for the EMR system and no one could figure out how to access it. The facility also reported they could not provide a list of self-reports from 2022 for the same reason. Review of facility policies showed that the “Medical Record, Content of” policy required a separate medical record for each resident with specific identification data, and the “Record Retention Schedule” policy required resident medical records to be retained for 10 years and investigations for 5 years, which was not met in this case.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's medications were obtained and administered as ordered by the physician, resulting in a delay in treatment. The resident, who was admitted following a hospital stay, had a history of severe sepsis and was prescribed antibiotics cefiderocol and gentamicin upon discharge. However, these medications were not administered for eight days due to issues with obtaining them from the pharmacy. The facility's physician orders indicated that the antibiotics were to start on February 13, 2025, but the Medication Administration Record showed no doses were given until February 19, 2025. Nursing notes documented that the medications were on order and unavailable, with the provider and family being informed. Despite attempts to resolve the issue, including contacting the pharmacy and notifying the Director of Nursing (DON), the medications remained unobtained for several days. Interviews with staff and pharmacy personnel revealed communication issues and insurance authorization problems that contributed to the delay. The first pharmacy could not fill the order due to insurance constraints, and the second pharmacy was unable to provide the medications as they were outside their formulary. The DON was aware of the situation and attempted to address it, but the delay persisted, highlighting a breakdown in the facility's medication administration process.
Deficient Infection Control Practices in Wound Care
Penalty
Summary
The facility failed to ensure that their enhanced barrier precaution (EBP) policies, specifically regarding the use of personal protective equipment (PPE) during wound care, were up-to-date with professional standards of practice. During an observation of wound care for a resident with a pressure ulcer on the right hip, the Certified Wound Nurse/LPN did not wear a protective gown, only gloves, as the procedure was classified as clean. The nurse stated that according to the facility's policy, gowns were only required for wounds classified as stage III or greater, which was confirmed as the current practice by the staff. The Director of Nursing, who was also the designated Infection Preventionist, confirmed that the facility's EBP practice was based on their policy, which only required gowns for stage III or greater wounds. However, the Director of Nursing did not hold any qualifying infection prevention certification or training at the time. A review of the facility's policy revealed it was based on CDC guidance, which recommends gown and glove use for high-contact resident care activities, especially for residents with wounds or indwelling medical devices. The facility's policy had not been updated to reflect the CDC's recommendations, which were last updated in July 2022.
Latest citations in Arizona
Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
Two residents with known behavioral issues and cognitive/neurologic conditions were involved in a patio altercation where one resident struck another on the head after a verbal interaction and dispute over a book. Care plans for both residents already identified behavioral disturbances, including verbal and physical aggression, and outlined interventions such as providing a calm environment, diverting attention, and intervening to protect others. Despite these plans and prior documented episodes of verbal aggression and a previous physical altercation involving one of the residents, staff‑witness accounts and later review of video footage confirmed that one resident approached and hit another on the head, causing the victim to report pain and fear, demonstrating a failure to protect residents from physical abuse.
A resident with multiple comorbidities, intact cognition, and a care plan requiring two-person assistance for toileting repeatedly requested help for a brief change using the call light and by wheeling to the nurses’ station. A CNA, who had documented training on professional language and abuse prevention, allegedly failed to respond to the call light, refused to assist because a second staff member was not available, and used profanity toward the resident in the context of the resident’s complaints about delayed care, causing the resident to cry and feel unsafe. Another staff member reported seeing the CNA on her phone while call lights were on, hearing the profane statement directed at the resident, and later comforting the resident, while additional staff confirmed the resident’s report that the CNA was rude and blamed her for not receiving care. The facility’s abuse policy defined mental and verbal abuse to include profane, insulting, or degrading language and depriving a resident of care, which aligned with the described interaction.
A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with hemiplegia, psychiatric diagnoses, and dependence on staff for ADLs required assistance with toileting hygiene and bathing per the care plan and MDS, which documented bilateral extremity impairment and wheelchair use. CNA task logs for bowel/bladder and toilet use contained multiple blank shifts, leaving it unclear whether toileting and hygiene care was provided or refused, despite the EHR having specific codes for refusals and unavailability. Behavior and NP notes described the resident’s verbal aggression, sexually inappropriate comments, resistance to care, shower refusals, and repeated complaints that peri care was inadequate, while a nurse documented finding the peri area clean after one such complaint. A CNA and an LPN both stated that blank entries likely reflected a failure to chart and that all ADL care should be documented, consistent with facility policies requiring provision and documentation of ADL services. Surveyors concluded that the facility failed to ensure and document necessary ADL care, specifically toileting hygiene, for this resident.
A resident with spinal conditions, a history of lumbar compression fracture, and documented ADL self-care deficits was care planned and Kardexed for two-person maximum assist transfers for bathing and wheelchair transfers. Despite this, a CNA transferred the resident alone multiple times between a recliner, wheelchair, and shower chair using only a gait belt, during which the resident reported the CNA was rough, fast, and caused pain. An LPN received the resident’s complaint that the CNA was not caring and was the only staff present, while another CNA and a regional clinical specialist confirmed that the Kardex required two-person assist and that the CNA had performed the transfers without assistance, in violation of the plan of care and facility expectations.
Two residents with known behavioral issues, one with severe cognitive impairment and one cognitively intact, were involved in a resident-to-resident physical altercation. A resident with a history of behavioral problems, including prior physical altercations, entered another resident’s room and allegedly punched him multiple times in the face and twisted his arm, resulting in a black eye, skin tears, bruising, and minor cuts. Staff later observed the injured resident approaching the nurses’ station with these injuries, and leadership confirmed via camera review that the aggressor had entered the victim’s room and that a physical altercation occurred, despite an existing abuse policy intended to protect residents from abuse.
The facility failed to prevent resident-to-resident verbal and physical abuse involving two separate pairs of residents with known psychiatric and behavioral issues. In one case, a cognitively intact resident with a history of agitation and verbal aggression insulted another cognitively intact resident with schizoaffective disorder and intermittent explosive disorder during dinner; after repeated verbal exchanges, the second resident stood up, shoved the table, and punched the first resident in the eye, resulting in an orbital fracture and retrobulbar hemorrhage. In another case, a resident with schizophrenia, bipolar disorder, and documented verbal aggression argued over a soda with a peer who had borderline personality disorder and a care plan for bullying and physical aggression; the argument escalated from name-calling to one resident standing and swinging at the other, with the alleged victim later reporting facial and chin pain despite no visible injury on assessment. In both incidents, residents with identified behavior risks and existing behavior plans engaged in escalating verbal conflicts in common areas that were not effectively de-escalated before they became physical or attempted physical assaults.
Multiple residents with dementia and other psychiatric conditions physically abused other residents in common areas and on an outside ramp when staff supervision was inadequate. In one case, a resident with schizoaffective disorder and a known history of verbal and physical aggression, already agitated over smoking restrictions and having threatened and struck staff, was allowed to remain in a common area and struck another resident on the shoulder. In another incident, a resident with dementia and documented combative behavior picked up a folded tray table and hit a non-verbal resident who was seated nearby, while scheduled CNAs and an LPN later reported they did not witness the event and trainees described the assault. In a third event, a resident with violent behavior blocked a narrow ramp and pushed another resident’s wheelchair backward using his hands and feet, causing the wheelchair to flip and the resident to fall and hit his head, with the incident observed and reported by housekeeping rather than direct care staff. These events reflect failures to provide continuous observation and to prevent resident-to-resident physical abuse despite known behavioral risks.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a notice of discharge to the State Ombudsman for one resident. Resident #59 was admitted with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension, and the hospital discharge summary showed the resident was transferred to the facility for therapy services. The discharge planning and discharge progress notes dated 2/15/2026 documented that the resident arrived with family, and the family expressed concern that the assigned room did not have adequate space for the resident's belongings. The same documentation showed the family elected to take the resident home against medical advice, and the electronic medical record, including the AMA Release Form dated 2/15/2026, showed the resident was discharged home with the responsible party. During record review, the Administrator was asked to provide documentation of discharge notices sent to the Ombudsman for the prior 6 months. The Administrator documented that the Ombudsman did not require the facility to send discharge notices directly to her, while also acknowledging that discharge notices had not been sent and that the facility would send notices for discharged residents moving forward. The Ombudsman stated she had periodically received discharge notices in the past but had not received discharge notices from the facility after 12/4/2026, and confirmed the facility is required to provide discharge notices per regulation.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. One resident had multiple diagnoses including cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment, with a BIMS score indicating severe cognitive impairment. This resident had care plans addressing impaired cognitive function and behavioral disturbances, including verbal and physical abuse, with interventions such as providing a calm environment, diverting attention, and intervening as necessary to protect the rights and safety of others. Despite these identified needs and planned interventions, this resident was involved in a resident‑to‑resident altercation on the patio in which another resident struck him on the head after a verbal interaction. The second resident involved had diagnoses including metabolic encephalopathy and pain, and a care plan for behavioral disturbances such as refusal of care, refusal of medication, and verbal and physical abuse. This care plan also included interventions to document behaviors, reinforce why inappropriate behavior is unacceptable, and intervene as necessary to protect the rights and safety of others, including removing the resident from situations as needed. Prior to the incident on the patio, this resident had a documented history of involvement in a physical altercation with another resident, where he was described as the non‑aggressor, and had ongoing behavioral charting for verbal aggression and argumentative behavior. Behavior notes documented episodes of verbal aggression, cursing at staff, and yelling related to environmental changes. On the date of the incident leading to the deficiency, an internal incident report documented that the second resident slapped the first resident on the back of the head on the patio after a verbal confrontation. Witness accounts varied: the activities assistant reported hearing a loud slapping sound and seeing the second resident standing, then intervening, while another resident witness stated she saw the second resident hit the first resident on the head with a book because of a dispute over ownership of the book, and that there had been no argument beforehand. The DON reported that camera footage showed the two residents conversing about three feet apart on the smoking patio, then the second resident wheeled up to the first resident and hit him on the head, which the DON characterized as physical abuse. The administrator also acknowledged that video footage showed the second resident tapping the first resident’s head. The first resident later indicated he was in pain afterward and felt scared. These events occurred despite existing behavior care plans and interventions intended to prevent such incidents, resulting in a failure to ensure residents were free from physical abuse by another resident.
Verbal Abuse and Failure to Respond to Resident’s Request for Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by a CNA. The resident, who had type 2 diabetes mellitus with foot ulcers, absence of the left foot, morbid obesity, and a mood disorder, was care planned for ADL self-care deficits and required maximum assistance for toileting and two-person dependent assistance with transfers. A quarterly MDS showed the resident had a BIMS score of 14, indicating intact cognition, and required substantial assistance for toilet transfers. On the morning in question, an event note documented that the resident was wheeling herself in her wheelchair in the hallway to the nurses’ station to request assistance with a brief change when a CNA seated at the nurses’ station heard her, turned around, and made an inappropriate comment, after which the resident began crying. The facility’s investigation materials described differing accounts of the interaction but consistently referenced the use of profanity by the CNA in the context of the resident’s request for care. The resident reported that she had not received care that morning, had urinated on herself, and had activated her call light, but the CNA would not answer it. The resident stated that when she told the CNA she was going to notify someone about the lack of assistance, the CNA became angry, stood up, and told her, “it’s your fucking fault,” which made her cry and feel unsafe. A staff member (Staff #118) provided a written statement and interview indicating that around 5:15 a.m. he observed multiple call lights on, including the resident’s, and saw the CNA sitting at the nurses’ station on her phone. He stated that the resident came out of her room begging for help with a brief change, that the CNA refused because she did not have a second person to assist, and that at one point the CNA told the resident, “it was [the] resident’s fucking fault,” after which the resident went back to her room crying. The CNA involved had documented training on professional language and on abuse, neglect, exploitation, resident rights, respect in the workplace, and prevention of abuse, including mental and verbal abuse. Her written statement acknowledged that the resident’s call light had been on since about 4:00 a.m. and that the resident later came out of her room angry about the wait; she claimed she agreed with the resident and went downstairs to get another CNA, and admitted she may have used the term “fuck” but denied directing it at the resident. Another CNA (Staff #24) stated that the resident was on “cares in pairs” because she accused staff of not helping her, that the resident used her call light frequently and wanted care immediately, and that delays could occur due to the need for two staff, though communication about delays could ease the situation. A staff member (Staff #38) reported that the resident later said she had a rough morning because she needed help and the CNA was rude and blamed her for not getting care due to the “cares in pairs.” The facility’s abuse policy defined mental and verbal abuse as conduct, including the use of profanity, that can cause humiliation, intimidation, fear, shame, agitation, or degradation, and included mocking, insulting, ridiculing, and threatening residents, including depriving a resident of care, as examples of mental and verbal abuse. The facility’s documentation also showed that the CNA had signed an education acknowledgment form stating she was trained to use professional language and that profanity was prohibited at work. The investigation report and staff interviews consistently placed the resident in a position of repeatedly requesting assistance for incontinence care, with her call light on and her coming into the hallway to seek help, while the CNA did not provide the requested care and used or was alleged to have used profanity in response to the resident’s complaints. The DON acknowledged receiving a report that the CNA was not helping the resident and had sworn at her, and stated that verbal abuse of residents can affect a resident’s psychological well-being. The combination of the resident’s report, corroborating staff statements, and the facility’s own policy definitions formed the basis for the finding that the resident was not kept free from verbal abuse.
Failure to Follow Physician-Ordered Cut-Up Diet Leads to Fatal Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered diet specifying that a resident’s food be cut into bite-sized pieces, and to ensure that this requirement was consistently communicated and implemented by nursing and dietary staff. Resident #9 had multiple diagnoses including heart failure, chronic atrial fibrillation, chronic kidney disease, and moderate vascular dementia with anxiety. A physician order dated December 23, 2024, prescribed a regular diet with regular texture, thin liquids, and explicitly directed that food be cut into bite-sized pieces with large protein portions. The facility’s nutrition care plan initiated on December 30, 2024, referenced the regular diet with large protein portions but did not include the requirement to cut food into bite-sized pieces. The cognition and ADL care plans addressed cognitive impairment and self-care deficits but did not incorporate the ordered cut-up diet or any specific swallowing precautions, despite the resident’s cognitive impairment and upper extremity limitations documented on the MDS. The dietary management and electronic systems in use contained the cut-up order, but this information was not reliably translated into practice. The Menu Wizard tray card history, as reviewed by the senior menu specialist, showed a diet order of regular, regular, thin liquids with notes to cut food into bite-sized pieces and provide large protein portions, and this instruction had been in place since December 23, 2024. The dietary manager stated that dietary staff are responsible for cutting food and that bite-sized pieces would include items like burritos, with food expected to arrive on the unit already cut. However, he also indicated he could not retrieve prior diet slips after discharge and relied on nursing to relay changes. The DON asserted that the “cut into bite-sized pieces” language was a preference rather than part of the actual diet order and stated that only the basic diet components (regular texture, thin liquids) transfer to the kitchen, while additional information such as cutting food does not cross over. In contrast, the prescribing physician confirmed that he ordered regular food, thin liquids, cut into bite-sized pieces, and large protein portions as a single diet order and expected the entire order, including cutting food into bite-sized pieces, to be followed. On the day of the choking event, breakfast trays were delivered to Resident #9’s room, and the resident was served an egg burrito, oatmeal, and cranberry juice. CNA staff reported that the burrito was cut in half but not further cut into bite-sized pieces, and CNA #6 stated she did not know the resident’s diet, did not recall reviewing the meal ticket, and believed his meals did not need to be cut up. She also stated she was unaware of any special instructions to cut the resident’s food into bite-sized pieces and that she typically relied on dietary and nursing to communicate such needs. Multiple CNAs and the charge nurse indicated they were not aware of any formal special diet instructions beyond a regular diet, although the charge nurse acknowledged knowing the family’s preference for cut-up food and finger foods and that dietary did not always cut up his meals, requiring nursing to do so. The resident’s family member reported repeated concerns to the dietary manager, charge nurse, DON, and CNAs about the resident’s food not being cut up, and stated that both she and a hired companion frequently found his meals served uncut despite his upper extremity weakness and motor decline. Later that morning, an LPN who had just started her shift and was not familiar with the resident found him in bed with his breakfast tray in front of him, food apparently eaten, and “mushy” food around and in his mouth. The resident appeared to be sleeping, did not respond to his name, and was grunting and moaning with snoring-type respirations. The LPN manually removed food from his mouth and began suctioning, and the charge nurse arrived with a suction machine and a LifeVac device. Staff observed egg on the resident’s chest and in his mouth, and suctioning removed egg and mucus secretions. EMS was called, and the resident was transported to the hospital. Hospital emergency department documentation recorded that the resident had been eating eggs, was later found choking and unresponsive, and presented with aspiration into the airway and respiratory failure with hypoxia and hypercapnia. The resident was documented as DNR/DNI and was ultimately pronounced deceased. The survey findings attribute this event to the facility’s failure to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and implemented by staff. The report also notes that for Resident #9 there were no active orders for PT/OT/ST evaluation or treatment on the Order Summary Report despite a NP/PA progress note planning for such services, and that the SLP evaluation focused on cognition and compensatory strategies rather than swallowing, with no active speech therapy orders in the diet context. Staff interviews revealed inconsistent understanding of the resident’s diet requirements, with some staff describing cut-up food and finger foods as a preference rather than an order, and others stating they had no knowledge of any special diet instructions. The grievance logs contained no formal grievances from the family member despite her statements that she had repeatedly complained about meals not being cut up and about the resident not being taken to the dining room as he preferred. Collectively, these documented actions and inactions show that the facility did not ensure the physician-ordered diet specifying cut-up, bite-sized food was integrated into the care plan, reliably communicated to dietary and direct care staff, or consistently implemented at the bedside for Resident #9, culminating in a choking and aspiration event requiring hospitalization and resulting in death.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notices to residents and to send copies of those notices to the Office of the State Long-Term Care Ombudsman for multiple residents. Surveyors found that the facility relied on the Notice of Medicare Non-Coverage (NOMNC) as its only discharge/transfer notice and did not use any separate form that met regulatory content requirements. The NOMNC used by the facility did not include the effective date of transfer/discharge, the location to which the resident would be transferred or discharged, the name, address, and telephone number of the State Long-Term Care Ombudsman, or contact information for protection and advocacy agencies for individuals with developmental disabilities or mental disorders. Staff interviews confirmed that the Resident Relations Manager and Business Office Manager considered the NOMNC to be the facility’s discharge/transfer notice and that they did not provide ombudsman information to residents or send copies of discharge/transfer notifications to the ombudsman. For Resident #107, who had hemiplegia and hemiparesis following cerebral infarction, systolic congestive heart failure, muscle issues, and gait and mobility abnormalities, the physician documented that the resident would transfer to another SNF at the family’s request, and a subsequent note showed the resident was discharged via transport van. The discharge MDS documented an unplanned discharge to a SNF. However, review of the clinical record revealed no evidence that a discharge notification was sent to the State Long-Term Ombudsman. The facility’s Admissions, Transfers and Discharges policy referenced reporting information in accordance with facility policy and professional standards but did not include requirements for notifying the ombudsman. For Resident #8, admitted with COPD, palliative care, and paroxysmal atrial fibrillation, the care plan included goals for pre-discharge planning. A discharge order and a discharge-transfer note/summary documented discharge home with oxygen equipment, home health services, narcotic medications, and a scheduled PCP appointment, and this summary was signed by the resident’s family. The documentation given to the family did not include the ombudsman’s contact information or an explanation of appeal rights. The discharge MDS showed an unplanned discharge home with return not anticipated, and there was no evidence in the clinical record that the ombudsman was notified of the discharge. An email sent about 19 days after discharge contained only a list of residents who were discharged, deceased, or transferred, and for this resident it listed a discharge/transfer to another hospital without the reason for discharge or the same information provided to the family. For Resident #12, admitted with atherosclerotic heart disease, the discharge MDS documented an unplanned discharge to hospice at home. A discharge/transfer/LOA form indicated discharge to the community with hospice services at a private home/apartment, initiated by the resident or representative, and a discharge summary and progress note documented discharge home with belongings, medications, and paperwork. There was no physician order for discharge in the order summary report, and the clinical record did not show that a copy of the discharge notification was sent to the ombudsman. In an interview, the Resident Relations Manager stated that a copy of the notification is not sent to the ombudsman and that ombudsman information is not provided to residents. For Resident #100, admitted with COPD, an order directed transfer to the ED for shortness of breath, and a discharge summary documented respiratory distress and transport via ambulance to an acute care hospital. A social services note stated that the resident or representative was provided written notice of transfer, bed-hold notice, readmission policy, ombudsman and appeals information. However, the clinical record contained no evidence that a copy of the transfer notice was sent to the State Long-Term Care Ombudsman. For Resident #102, admitted and later readmitted with hepatic encephalopathy, influenza, and cirrhosis, clinical documentation showed an anticipated discharge to the community, an NP note indicating discharge to prior living arrangements, and an unplanned discharge home/community on the MDS. A discharge/transfer/LOA form and discharge summary documented discharge to a private home/apartment without hospice, initiated by the resident or representative, and a social services note recorded that the family picked the resident up and took him back to the reservation. There was no physician discharge order, and no indication in the record that a copy of the discharge notification was sent to the ombudsman. Interviews with the ombudsman and facility staff further described the deficient practice. The ombudsman reported that their office previously received a list of discharged/transferred residents but had not received anything for recent months and that they were sent only a list, not copies of discharge/transfer notifications. The Resident Relations Manager and Business Office Manager stated that Resident Relations is responsible for presenting the notice of proposed discharge/transfer, that the notice is presented up to 72 hours prior to discharge, and that a copy of the notification is not sent to the ombudsman. They also stated they were unsure if any policy or guidance outlined what information must be included in the notice and confirmed that the NOMNC was the only form used as a discharge/transfer notice, even though it lacked ombudsman and advocacy contact information. The acting DON reported being unfamiliar with discharge/transfer notification requirements, and the Executive Director stated that the facility used only the NOMNC, believed no paper notice was required beyond that, and understood the facility’s obligation as sending a monthly list of discharged/transferred residents to the ombudsman, not copies of the actual transfer/discharge notifications.
Failure to Ensure and Document Toileting Hygiene Assistance for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident dependent on staff for ADLs, including toileting hygiene, consistently received and had documented assistance with these needs. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side, along with schizophrenia and major depressive disorder. The care plan identified the resident as being at risk for functional self-care deficits and functional mobility limitations and specified that he required assistance with toileting hygiene and bathing/showering, including washing, rinsing, and drying, with baths/showers to be provided per his schedule and preferences. The admission MDS documented that the resident was cognitively intact, had bilateral upper and lower extremity impairment interfering with daily function, used a wheelchair, and was dependent on staff for toileting hygiene, shower/bathing, oral and personal hygiene, dressing, and footwear. Review of the December CNA task logs for bowel and bladder and toilet use showed multiple shifts left unmarked/undocumented, meaning it was unclear whether toileting and bowel/bladder care were provided or refused on those shifts. The bowel and bladder task log had blank entries on several specific dates and shifts, and the toilet use task log also contained numerous blank entries across day, evening, and night shifts. A CNA explained that CNA care is documented in the EHR using specific codes, including codes for refusal and resident unavailability, and that if a task is left blank it likely means the CNA did not chart, making it questionable whether the care was provided. The CNA stated that blank areas mean one would not know if care was provided, and that everything should be charted so that care conferences and assessments have accurate data. An LPN similarly stated that blanks on the bowel and bladder task log made her think that either someone did not chart or the resident did not have a bowel movement, and that whoever was on shift should have charted appropriately so that others could determine whether care was provided. The resident’s record also contained multiple behavior and NP notes describing ongoing verbal aggression, sexually inappropriate comments, resistance to care, and specific complaints about how peri care and showers were provided. Notes documented that the resident sometimes refused showers, stated he only needed one shower a week, and complained that staff did not clean his peri area adequately after bowel movements, including an incident where he alleged staff did not clean under his penis despite a nurse finding his peri area and brief clean and dry. Another note described the resident demonstrating that he could clean his own peri area and then verbally abusing staff. Additional documentation described the resident’s frequent agitation, oppositional behavior, verbal aggression, and disruptive behavior during care interactions, including cursing at staff, making derogatory comments, and repeatedly activating the call light. Despite these behaviors and complaints, the facility’s own policies required that residents unable to carry out ADLs independently receive appropriate support and assistance with toileting and personal hygiene, and that all services provided, refusals, and care-specific details be documented in the medical record. The combination of the resident’s dependence on staff for toileting hygiene and the numerous undocumented shifts on CNA task logs led surveyors to determine that the facility failed to ensure ADL care such as toileting hygiene was provided and properly documented for this resident. Facility staff interviews reinforced the importance of ADL care and documentation and highlighted the gap between expectations and practice. The CNA familiar with the resident described him as a two-person assist due to behaviors, using briefs rather than the toilet, being very sexual, refusing care from male staff, and demanding extra wiping and frequent changes, which led staff to implement cares-in-pairs and show him wipes after each wipe to prove cleanliness. The CNA acknowledged that blank documentation entries likely meant CNAs did not chart and that this created uncertainty about whether care was provided. The LPN stated that residents should be rounded on at least every two hours for ADL care, emphasized that ADL care is important for dignity and to prevent skin breakdown, and confirmed that uncharted tasks prevent others from concluding whether care was provided. These findings, combined with the facility’s policies requiring provision and documentation of ADL services, formed the basis for the deficiency that the facility failed to ensure ADL care, specifically toileting hygiene, was provided and documented for this resident.
Improper Single-Staff Transfer During Shower Contrary to Two-Person Assist Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was transferred in accordance with the care plan and transfer orders during bathing and showering. The resident had diagnoses including a wedge compression fracture of the 3rd lumbar vertebra, surgical aftercare, cauda equina syndrome, spinal stenosis, and a need for assistance with personal care. A care plan initiated on April 10, 2026 documented that the resident required assistance with bathing and showering and had an ADL self-care performance deficit. Interventions initiated on April 20, 2026 and resident task documentation revised on April 14, 2026 indicated that the resident required a two-person maximum assist for transfers to the wheelchair. Despite these documented requirements, a facility investigation dated April 22, 2026 revealed that a CNA (Staff #79) transferred the resident alone from a recliner to a wheelchair, from the wheelchair to a shower chair, and then back from the shower chair to the wheelchair and into bed, using only a gait belt and without a second staff member. The resident reported that the CNA was alone during all transfers, was very rough, and that the transfers were painful, and also stated that the CNA did not speak to him during the shower. An LPN (Staff #96) confirmed receiving a complaint from the resident that the CNA was not caring and was very fast during the shower, and that the CNA was the only staff member present. Another CNA (Staff #72) stated that the Kardex identifies the resident as a two-person assist and that she always obtains another person to help with transfers, noting that transferring the resident alone could cause pain and injury. The Regional Clinical Specialist (Staff #102) stated that CNAs are expected to follow the Kardex for transfer assistance levels and confirmed that the investigation determined the CNA had transferred the resident without assistance, contrary to policy and the plan of care.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. Resident #1 had severe cognitive impairment with a BIMS score of 05 and a care plan identifying behavioral problems, including taking others’ belongings, eating other residents’ food, inappropriate contact with other residents’ belongings and clothing, giving food to other residents without permission, refusing medication and care, and initiating a physical altercation with another resident. Despite these identified behaviors and the existence of a care plan focused on behavior problems, Resident #1 was able to enter Resident #2’s room and engage in a physical altercation. Resident #2 was cognitively intact with a BIMS score of 14 and had a care plan for behavior problems related to verbal and physical behaviors, including prior verbal altercations with other residents, use of profanity, striking another resident in the head, spitting water on staff, kicking at staff during care, cursing at staff, and refusing brief checks and changes. On the day of the incident, Resident #2 approached the nurses’ station with a hematoma to the left eye, a large skin tear to the right forearm, minor cuts to the nose, lip, and right hand, and bruising to the left hand. Resident #2 reported that Resident #1 had entered his room, punched him multiple times in the face, grabbed and twisted his arm, and then left the room. Staff interviews and facility documentation confirmed that no staff witnessed any verbal altercation between the two residents prior to the event, and that earlier in the day Resident #2 did not have any injuries. After the incident, staff observed Resident #2 with a swollen eye and face, bruising, and lacerations consistent with his report. The Administrator and DON stated that review of camera footage showed Resident #1 entering Resident #2’s room and that a physical altercation occurred, confirming that Resident #1 went into Resident #2’s room, hit him in the face, and then exited. The facility’s abuse policy stated an objective to provide a safe haven for residents through preventive measures that protect every resident’s right to freedom from abuse, but the documented resident-to-resident physical abuse occurred despite these stated objectives.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse by other residents. One incident involved a resident with borderline personality disorder, schizophrenia, major depressive disorder, generalized anxiety disorder, a history of traumatic brain injury, and chronic pain syndrome, who had intact cognition and documented patterns of agitation, aggression, yelling, cursing, and threatening others. While in the dining room during dinner, this resident verbally insulted another cognitively intact resident with schizoaffective disorder, bipolar type, intermittent explosive disorder, and personality change due to a physiological condition. Multiple accounts from staff and both residents indicate that after being told not to talk to him, the verbally aggressive resident continued speaking, and the other resident stood up, shoved the table, and struck him in the left eye with a closed fist. As a result of this altercation, the assaulted resident reported pain, nausea, and later requested psychiatric support and antidepressant therapy. Clinical documentation and hospital imaging confirmed an acute left inferior orbital wall fracture and retrobulbar hemorrhage, with visible bruising to the left eye. Prior to this event, the aggressor had known psychiatric diagnoses and was receiving multiple psychotropic and mood-stabilizing medications for mood swings, aggression, disorganized thinking, paranoia, and intermittent explosive disorder. The facility’s records show that the aggressor had behavior care plans related to behavior problems and intermittent explosive disorder, but there is no indication in the report that staff anticipated or intervened to prevent this specific escalation in the dining room before the physical strike occurred. A second incident involved two other residents with significant psychiatric and behavioral histories. One resident had schizophrenia, bipolar disorder, anxiety disorder, intellectual disabilities, and obesity, with a behavioral care plan noting verbal aggression, demanding behaviors, and instructions for staff not to provide requests when made in a rude, threatening, or aggressive manner. The other resident had borderline personality disorder, bipolar disorder, pseudobulbar affect, anxiety disorder, PTSD, and type 1 diabetes, with a behavioral treatment plan for bullying or physical aggression toward peers and interventions directing staff to intervene promptly, remind the resident of respectful behavior expectations, and separate and redirect her if needed. Despite these identified risks and care plan directives, the two residents engaged in a verbal argument over a soda at the nurses’ station, during which one resident called the other a “fat b****” and continued name-calling after being told to stop, leading the other resident to stand up and swing at her. Documentation from behavior notes, incident notes, and the facility’s investigation shows that both residents stood up from their wheelchairs and approached each other during the argument. One resident reported being slapped in the face and later complained of chin pain, while the other resident was documented as having swung her arm at the peer. A skin assessment performed shortly after did not show visible injury, redness, trauma, or swelling, and witnesses, including staff and another resident, reported seeing a swing but were unsure if physical contact occurred. The facility’s investigation ultimately concluded that it could not determine whether physical contact was made, but the event was characterized as a verbal altercation that escalated to at least an attempted physical strike. In both sets of incidents, residents with known behavioral risks and existing behavior plans engaged in escalating verbal conflicts that were not effectively de-escalated or prevented from becoming physical, resulting in at least one resident sustaining a confirmed serious injury and another reporting pain after an alleged slap. Across these events, the facility had identified behavioral risks for the involved residents and had documented care plans and behavior interventions addressing aggression, bullying, and inciting peers. However, during the actual incidents, residents engaged in escalating verbal abuse in common areas (dining room and nurses’ station) that progressed to physical aggression or attempted physical aggression. The report describes that staff were present in the vicinity and, in some cases, intervened only after the physical act occurred or as the residents were already standing and approaching each other. The survey findings conclude that the facility failed to ensure that the affected residents were free from physical or verbal abuse by other residents, as required, resulting in resident-to-resident altercations that included verbal insults, threats, and at least one confirmed physical assault causing an orbital fracture and retrobulbar hemorrhage.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Supervision in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents and to provide adequate supervision in common areas. One cognitively impaired resident with dementia and depression was struck on the right shoulder by another resident with schizoaffective disorder and a history of verbal and physical aggression. Prior to the assault, the aggressive resident had been up all night, repeatedly demanding cigarettes outside of scheduled smoking times, threatening staff, calling 911, grabbing a housekeeper’s keys and injuring her shoulder, and punching a CNA in the abdomen. Despite these escalating behaviors and the resident’s known behavioral care plan identifying verbal and physical aggression and exit-seeking, the resident remained in the common area where he randomly hit the other resident’s shoulder in passing. Staff and police were present on campus, but the aggressive resident was still able to make physical contact with the other resident before being removed. Another deficiency occurred when a resident with dementia, bipolar disorder, major depressive disorder, and anxiety, who had a behavioral care plan for combative behavior, severe agitation, cursing, striking out, and threats, struck another cognitively impaired, non-verbal resident with a tray table in a common area. The victim had dementia, diabetes, and a cognitive communication deficit, and was known to wander and exhibit other non-directed behavioral symptoms. The incident was reported as occurring while the two residents were in a common area, and multiple scheduled CNAs and an LPN assigned to that unit later stated they did not witness the event. Statements from trainees indicated they observed the aggressor pick up a folded wooden table, yell profanities, and launch it at the victim’s head while the victim remained seated and non-verbal. The DON acknowledged that no CNA was physically present in the common area at the time, that trainees were only observing, and that the nurse preparing medications did not provide full attention to supervising the residents, resulting in no staff supervision in the room when the altercation occurred. A further deficiency involved a resident with mild cognitive impairment and no documented behavioral symptoms who was pushed backwards in his wheelchair by another resident with dementia, anxiety disorder, and violent behavior. The incident occurred on a narrow, steep ramp outside the dayroom, where only one person at a time could pass. The aggressor, also in a wheelchair, blocked the ramp and told the other resident he could not come up, then pushed the resident’s shoulder with his hand and used his feet to kick the wheelchair, causing it to flip and the resident to fall to the ground and hit his head. A housekeeping/laundry staff member witnessed the event and reported that the aggressor refused to let the other resident pass and then pushed him down the ramp. The DON stated that CNAs conduct rounding outside every 15 minutes, but the report does not indicate that any direct care staff were present at the ramp when the altercation occurred, and the event was instead discovered and reported by non-nursing staff after the fall. Across these incidents, the facility’s own documentation and staff interviews show that residents with known histories of aggression, agitation, or violent behavior were able to physically assault other residents in common areas and on an outside ramp without effective, continuous supervision by assigned nursing staff. Behavioral care plans identified risks such as verbal and physical aggression, striking out, and threats, and the DON stated that when residents are in common areas there should always be a staff member observing them. However, in the described events, residents were either not directly supervised by CNAs in the common areas, or staff attention was divided, allowing aggressive residents to hit, push, or otherwise physically abuse other residents before staff intervened. These actions and inactions led to resident-to-resident altercations that constituted physical abuse under the facility’s own definitions and policies.
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