Desert Cove Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Chandler, Arizona.
- Location
- 1750 West Frye Road, Chandler, Arizona 85224
- CMS Provider Number
- 035095
- Inspections on file
- 22
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Desert Cove Nursing Center during CMS and state inspections, most recent first.
An LPN signed out multiple doses of opioid medications for five residents on controlled substance records without corresponding entries on the MAR, including PRN oxycodone and hydromorphone orders and one discontinued oxycodone order. One resident reported not receiving narcotic medication despite a signed-out dose, and another had a discontinued narcotic documented as administered. A scheduled oxycodone ER dose was documented as wasted without a second nurse co-signature. Staff interviews confirmed that narcotics were sometimes not documented on the MAR and that required dual signatures for wasting were not consistently obtained, resulting in unresolved discrepancies between narcotic logs and medication records.
A resident with muscle weakness and neurological impairment did not receive a physician-ordered speech evaluation due to an order entry error that marked the order as completed before services were provided. The speech therapist was not notified of the order, and the resident confirmed never receiving speech therapy.
A resident with multiple health conditions, including bilateral below-the-knee amputations and a high risk for falls and skin breakdown, was left unattended in the shower room for about an hour after the assigned CNA became ill and left the facility. Although the CNA attempted to notify other staff, the information was not effectively communicated, resulting in the resident being left alone without a call light. Facility policy requiring staff to remain nearby during showers and check on residents every 5 to 10 minutes was not followed, and the resident was only discovered when they moved themselves to the door and were found by staff.
A CNA was observed emptying a resident's indwelling urinary catheter bag while wearing gloves but not a gown, contrary to facility policy and Enhanced Barrier Precautions (EBP). The CNA admitted to skipping the gown due to being in a hurry, despite having received infection control training. Interviews with an LPN and the DON confirmed that both gloves and a gown are required for catheter care, as outlined in facility policies.
A resident who was fully dependent on staff for bathing did not consistently receive scheduled showers as outlined in their care plan, with multiple missed or undocumented bathing events and no evidence of refusals. Staff interviews revealed confusion over assignments and improper documentation practices, including the use of another staff member's login credentials. Facility policies required regular assistance and documentation for ADLs, but these were not followed, resulting in unmet hygiene needs.
A resident with a urinary catheter did not consistently receive care and monitoring as ordered by the physician, with multiple instances of missing documentation for catheter emptying and urine output. The resident reported that the catheter bag was sometimes not emptied for extended periods, and staff interviews confirmed lapses in following care protocols and documentation requirements.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of the investigation to the proper authorities as required.
A resident with multiple comorbidities, including diabetes and ulcers, did not receive wound care as ordered by the provider on several occasions, with no documentation to support that care was provided or refused. Interviews with staff and review of records confirmed that wound care was not consistently performed or recorded, contrary to facility policy and physician orders.
A resident with moderate cognitive impairment was inappropriately touched by another resident during a Christmas party, despite existing interventions for the latter's history of inappropriate behavior. The facility's policies on preventing abuse and ensuring consent were not effectively implemented, as no immediate psychiatric evaluation or care plan revision was conducted for the affected resident.
A facility failed to provide adequate supervision, resulting in multiple resident altercations. A resident with severe cognitive impairment and a history of aggression was involved in incidents where they hit other residents, despite care plan interventions requiring staff presence. Another resident with Alzheimer's exhibited aggression, striking a peer in the dining room. A third resident, with moderate cognitive impairment, was a victim of aggression due to lack of staff supervision during transitions. Staff interviews highlighted inconsistent adherence to care plans, contributing to these incidents.
The facility failed to provide necessary services for personal hygiene and meal assistance for two residents. One resident received fewer showers than required, and another did not receive consistent feeding assistance, as documented and confirmed by staff interviews.
The facility failed to ensure the environment remained free of accident hazards by leaving medications unattended. A medication cup with a red capsule was observed on a medication cart with no staff present. The DON disposed of the medication, and interviews confirmed that the RN had left it unattended after being called away.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. Staff schedules for January and March 2023 showed no RN coverage for 8 consecutive hours on at least 4 days each month, and in November and December 2023, there was no RN coverage for one day each month. Interviews with the staffing coordinator and DON confirmed awareness of the regulations but indicated inconsistent compliance. The census was 63 residents.
The facility failed to administer pain medication within the prescribed pain scale parameters for two residents, leading to potential overmedication. One resident was given 10 mg of oxycodone for pain levels 0 to 3, and another was given 5 mg of oxycodone for pain levels 0 to 6, contrary to physician orders. Staff interviews and the MAR confirmed these discrepancies, which did not meet the facility's policies and expectations.
The facility failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, and did not enforce the use of beard guards/nets for staff with facial hair. Observations revealed multiple instances of staff not washing hands after touching unsanitary surfaces and not wearing beard guards, which was confirmed by staff interviews and a review of facility policies.
The facility failed to ensure proper infection control practices, as an X-Ray Technician performed an ECG on a resident without PPE despite enhanced barrier precautions, and a nurse improperly sanitized a glucometer between uses. The Infection Preventionist and DON emphasized the importance of adhering to infection control policies.
A resident with multiple diagnoses was found with medications at the bedside without proper assessment or physician orders. Interviews with staff revealed a lack of adherence to the facility's policy on self-administration of medications, and the DON confirmed that the resident had not been assessed or authorized to self-administer medications.
A resident with ESRD and a dialysis shunt in the left arm had blood pressure measured from the shunt arm on seven occasions, contrary to the care plan and facility policy. Interviews revealed inconsistent understanding among RNs about the policy, potentially risking harm to the resident.
The facility failed to ensure unused medications were disposed of according to accepted professional standards. A red capsule was found unattended on a medication cart and was improperly disposed of in an uncovered bin by the DON. Interviews with staff confirmed that this practice was against facility policy and posed a risk to residents.
Unreconciled Narcotic Documentation and MAR Omissions Across Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete documentation of controlled substance administration on the Medication Administration Record (MAR) for five residents, despite entries on the Individual Resident Controlled Substance Records. For one resident with major depressive disorder, anemia, and sepsis, an order for PRN oxycodone 5 mg every 8 hours was in place, and the resident’s care plan included evaluation of pain medication effectiveness. The controlled substance record showed that an LPN (staff #777) documented administering oxycodone on a specific date, but the MAR for that month showed no administration recorded for that date. A second resident with muscle weakness, cardiomyopathy, and cellulitis had a care plan for pain relief and an order for PRN oxycodone 5 mg every 6 hours. The controlled substance record showed that staff #777 documented administering oxycodone on the same date as above, but the MAR did not show the medication as given on that date. A witness statement documented that this resident reported not having taken any narcotic pain medication since a date several weeks earlier. A third resident with chronic kidney disease, anxiety disorder, and heart failure had a care plan addressing pain and an order for PRN hydromorphone 1 mg/mL every hour. The controlled substance record showed staff #777 signed out oxycodone 5 mg for this resident on the same date, while the MAR for hydromorphone did not show administration on that date, and the hydromorphone order had been discontinued. A fourth resident, re-admitted with pneumonia, muscle weakness, and hyperlipidemia, had an order for PRN oxycodone 5 mg every 4 hours that had been discontinued weeks earlier. Despite this discontinuation, the controlled substance record showed that staff #777 signed out oxycodone for this resident on the same date in March. A fifth resident with depression, hyperlipidemia, and muscle falls had an order for scheduled oxycodone ER 10 mg twice daily for moderate to severe pain, and the controlled substance record showed that staff #777 documented wasting a 10 mg oxycodone dose at 2100 on that same date. Facility documents noted that this waste was recorded without a required second nurse co-signature. Interviews with staff and the alleged perpetrator confirmed that narcotics were signed out on controlled substance records without corresponding MAR documentation, that one narcotic dose was disposed of without a second nurse’s signature, and that the nurse acknowledged sometimes not documenting on the MAR, leading to discrepancies between the narcotic logs and the MAR for all five residents.
Failure to Implement Physician-Ordered Speech Services Due to Order Entry Error
Penalty
Summary
The facility failed to ensure that professional standards of care were followed regarding the implementation of physician-ordered speech services for a resident. The resident was admitted with multiple diagnoses, including muscle weakness and a neurological disorder, and was assessed as cognitively intact. A physician order was entered for a one-time speech evaluation due to increased weakness in the resident's voice. However, the order was incorrectly entered with a one-day stop date, causing it to be automatically marked as completed in the system, even though the evaluation was never performed. The speech therapist did not receive notification of the order and therefore did not conduct the evaluation. The Director of Nursing confirmed that the speech evaluation was not completed and could not be located. The resident reported never receiving speech therapy, and the speech therapist stated he was unaware of any new orders for the resident. Facility documentation and interviews revealed that the failure to properly enter and communicate the physician's order resulted in the resident not receiving the required speech evaluation as ordered.
Resident Left Unattended in Shower Room Due to Staff Communication Failure
Penalty
Summary
A deficiency occurred when a resident with significant medical complexities, including bilateral below-the-knee amputations, chronic heart failure, diabetes, chronic respiratory failure, and muscle weakness, was left unattended in the shower room for an extended period. The resident's care plan identified them as being at risk for falls and impaired skin integrity, requiring maximal assistance with bathing and toileting, and the use of a motorized wheelchair with orthotics/prosthetics. During a bathing session, the assigned CNA became ill and was sent home by the DON, who instructed the CNA to notify other staff about the resident. The CNA reported informing an LPN and another CNA, but the information was not effectively communicated, resulting in the resident being left alone in the shower room without a call light nearby. The resident reported being left in the shower room for approximately an hour, during which time they were seated in a shower chair and eventually had to pull themselves toward the door to seek assistance. Facility policy required staff to stay nearby during showers and check on residents every 5 to 10 minutes, but this protocol was not followed. Interviews with staff confirmed that residents should not be left unattended in shower chairs due to the risk of injury, yet the resident was left alone, and the incident was only discovered when a staff member found the resident after they had moved themselves to the door.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A Certified Nursing Assistant (CNA) was observed entering a resident's room and emptying the resident's indwelling urinary catheter bag while wearing gloves but not a gown, as required by the facility's infection control policies. The resident had a medical history that included infection and inflammatory reaction due to an indwelling urethral catheter, urinary tract infection, and obstructive and reflux uropathy. The CNA acknowledged during an interview that she should have worn a gown in addition to gloves but failed to do so because she was in a hurry, despite having received infection control training and having access to personal protective equipment. Further interviews with an LPN and the Director of Nursing confirmed that Enhanced Barrier Precautions (EBP), including the use of gloves and a gown, are required when providing catheter care or emptying a catheter, in accordance with facility policy. Review of the facility's policies on indwelling urinary catheter management and transmission-based precautions also specified the need for gloves and gowns during manipulation of the catheter or high-contact resident care activities. The failure to follow these infection control practices was identified through clinical record review, observation, and staff interviews.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with paraplegia and a history of chronic pain, hypertension, and recent infection was not provided assistance with bathing or showering according to their care plan and preferences. The resident was assessed as cognitively intact and fully dependent on staff for bathing, with a care plan specifying two showers per week. Facility records and shower schedules indicated multiple missed or undocumented showers over a period of several weeks, with no evidence of resident refusal or proper documentation in the clinical record for those dates. Interviews with the resident and various staff members revealed inconsistencies in the assignment and documentation of bathing tasks. The resident reported not receiving scheduled showers and recounted a previous period of four weeks without a shower. Staff interviews confirmed that showers were to be documented on shower sheets and in the electronic record, with refusals also to be documented. However, several staff members either did not offer showers as scheduled or were not assigned to the resident, and one staff member's electronic documentation was found to be completed by someone else using their login credentials while they were not present in the facility. Review of facility policies confirmed that residents are to receive assistance with ADLs, including bathing, in accordance with their care plan and professional standards. Documentation of showers, including skin condition and refusals, was required but not consistently completed. The lack of proper documentation and failure to provide scheduled showers as per the resident's care plan constituted a failure to meet the resident's needs and preferences for personal hygiene.
Failure to Provide Catheter Care and Output Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide care and services for a urinary catheter according to physician orders for a resident with paraplegia, neurogenic bladder, and a history of sepsis and catheter-related infection. The resident had physician orders to have the catheter emptied and urine output recorded three times daily, with documentation required in the electronic clinical record. Review of the Medication and Treatment Administration Record (MAR/TAR) revealed multiple instances across several months where the required documentation was missing, indicating that the catheter may not have been emptied or the output recorded as ordered. There was no evidence in the clinical record that the resident refused care on these occasions. Interviews with the resident confirmed that the catheter bag was not always emptied as scheduled, with reports of the bag not being emptied for 12-14 hours at times, and the resident having to empty the bag himself. Staff interviews corroborated that both CNAs and nurses are responsible for catheter care and output monitoring, and that failure to empty the catheter bag as ordered could lead to complications. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of adhering to physician orders for catheter care and recognized that the lack of documentation meant there was no way to confirm if care was provided as required. Facility policy required regular emptying of catheter bags and documentation to prevent infection and ensure proper care. The policy also specified the use of clean containers and ongoing monitoring for signs of infection. The review of records and staff interviews demonstrated that the facility did not consistently follow these protocols, resulting in a failure to provide care and services in accordance with physician orders and established standards.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Provide and Document Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident received wound care in accordance with physician orders. The resident, who had diagnoses including heart failure, cellulitis, diabetes with ulcers, obesity, and muscle weakness, was admitted with a care plan requiring treatment as ordered and weekly skin checks. Physician orders specified detailed wound care steps for ulcers on the left lower extremity and right inner calf, to be performed daily or twice daily. However, clinical record review showed that wound care for both areas was not documented as performed or refused on multiple identified dates. Interviews with facility staff confirmed that wound care was the responsibility of licensed nurses, and that refusals or missed treatments were to be documented and reported. The Director of Nursing acknowledged that there was no evidence in the Treatment Administration Record to support that wound care was provided or refused on the specified dates, and that facility expectations for documentation and care were not met. Facility policies required accurate documentation of care and resident condition, as well as resident participation in care planning.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in an incident where one resident was inappropriately touched by another resident. Resident #26, who has moderate cognitive impairment due to dementia, was involved in an incident at a Christmas party where Resident #13, also with moderate cognitive impairment, was observed with his hand down Resident #26's pants. This incident was witnessed by the Admissions Assistant, who noted that Resident #26 did not appear distressed at the time. Resident #13 has a history of inappropriate sexual behavior, including making inappropriate comments and touching staff. His care plan included interventions for these behaviors, such as monitoring and supervision. Despite these measures, the incident with Resident #26 occurred, indicating a failure in the facility's ability to prevent such interactions between residents. The facility's policies on intimacy and abuse prevention were not effectively implemented, as evidenced by the lack of immediate psychiatric evaluation or care plan revision for Resident #26 following the incident. The Director of Nursing acknowledged that both residents lacked the capacity to consent to sexual activity, yet the facility did not take adequate steps to prevent the abuse or address the aftermath appropriately.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident abuse, as evidenced by incidents involving three residents. Resident #1, who has severe cognitive impairment and a history of physical aggression, was involved in multiple altercations. Despite care plan interventions requiring staff presence and maintaining distance from other residents, Resident #1 was observed hitting another resident in the hallway. This incident occurred without staff escorting Resident #1, contrary to the care plan requirements. Resident #2, diagnosed with Alzheimer's Disease and severe cognitive impairment, exhibited physical aggression towards peers. An incident was documented where Resident #2 struck another resident in the dining room. The care plan for Resident #2 included interventions to manage aggression, such as allowing extra time for responses and maintaining a consistent routine, but these measures were not effectively implemented to prevent the altercation. Resident #3, with moderate cognitive impairment, was a victim of physical aggression by Resident #1. Despite being aware of Resident #1's aggressive tendencies, the facility did not ensure staff supervision during transitions in and out of the dining room, leading to Resident #3 being hit. Interviews with staff revealed a lack of consistent supervision and adherence to care plan interventions, contributing to the incidents of resident-to-resident aggression.
Deficiencies in Personal Hygiene and Meal Assistance
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for one resident and assistance with meals for another resident. Resident #39, who has multiple diagnoses including paraplegia and chronic pain, was documented to have received only one shower during the week of January 24, 2024, despite the care plan indicating a need for two showers per week. Interviews with staff revealed that the facility had been short-staffed for the past 3 to 4 weeks, leading to delays in providing showers. The Director of Nursing confirmed that a 6-day gap between showers did not meet the facility's expectations and acknowledged the potential risk of infection due to lack of hygiene. Resident #10, diagnosed with quadriplegia and other conditions, required assistance with feeding as per the care plan. However, documentation revealed inconsistencies in the assistance provided, with several instances where the resident did not receive the necessary help during meal times. An interview with the resident confirmed that she did not receive assistance with her meal on the morning of February 5, 2024. Staff interviews indicated that the resident required extensive assistance with all meals, and the Director of Nursing acknowledged that the documentation did not meet expectations, suggesting a possible documentation error. The facility's ADL policy, reviewed in August 2023, mandates that residents receive assistance with activities of daily living, including bathing and feeding. The failure to adhere to this policy for residents #39 and #10 highlights deficiencies in the facility's ability to provide consistent and necessary care, potentially compromising the residents' health and well-being.
Unattended Medication on Cart
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards by leaving medications unattended. On February 08, 2024, at 9:34 A.M., a small clear plastic measuring cup with a red capsule was observed on top of a medication cart with no staff present. The Director of Nursing (DON) also observed the unattended medication on the cart and disposed of it in an uncovered bin located at the bottom end of the medication cart. The medication was identified as docusate belonging to a resident. Interviews conducted with a registered nurse (RN) and the DON confirmed that the medication was left unattended. The RN stated that they were called away and it slipped their mind to secure the medication. The administrator confirmed that medications should always be within view and not left unattended on carts, as they can be picked up by unauthorized individuals.
Failure to Maintain RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required by regulations. Review of staff schedules for January and March 2023 revealed that there were no RNs on duty for 8 consecutive hours for at least 4 days each month. Additionally, in November and December 2023, there were no RNs for 8 consecutive hours for one day in each month. Interviews with the staffing coordinator and the Director of Nursing (DON) confirmed awareness of the regulations but indicated that the facility did not consistently meet the requirement. The staffing coordinator mentioned that typically an RN, such as the Infection Preventionist or the DON, would be present, and the DON stated that she would cover if no licensed nurse was available within a 24-hour period. The census at the time was 63 residents, and this deficiency has the potential to affect resident care.
Failure to Administer Pain Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to administer pain medication within the prescribed pain scale parameters for two residents, leading to potential overmedication. Resident #39, who has diagnoses including paraplegia, chronic pain, and anxiety disorder, was administered 10 mg of oxycodone for pain levels ranging from 0 to 3, despite the physician's order specifying it should only be given for pain levels 4 to 10. This occurred at least seven times, as confirmed by the Director of Nursing (DON) and the Medication Administration Record (MAR). Interviews with staff revealed that the medication was administered outside the prescribed parameters, which did not meet the facility's expectations and policies. Similarly, Resident #17, with diagnoses including a displaced intertrochanteric fracture of the right femur and chronic back pain, was given 5 mg of oxycodone for pain levels 0 to 6, contrary to the physician's order for administration only for pain levels 7 to 10. This occurred on at least eleven occasions, as confirmed by the DON and the MAR. Staff interviews indicated that the medication was not administered according to the prescribed parameters, which could lead to serious health risks. The facility's policy on the administration of medications, reviewed in August 2023, mandates that medications be administered safely and appropriately per physician orders. The policy also emphasizes adherence to the 10 rights of medication administration. The DON acknowledged that the administration of oxycodone outside the prescribed parameters did not meet the facility's standards and posed potential risks to the residents.
Failure to Ensure Proper Hand Hygiene and Beard Guard Use
Penalty
Summary
The facility failed to ensure staff conducted appropriate hand hygiene during kitchen food preparation and dining services, as well as donning beard guards/nets in the presence of facial hair. During a kitchen observation, a dietary aide was seen with facial hair and not wearing a beard guard/net. Additionally, a cook was observed answering the kitchen phone and returning to puree preparation without conducting hand hygiene. In the dining room, the activities director was seen pulling up his pants, scratching his face, and then passing out dining trays without washing his hands. Similarly, the staffing coordinator was observed cutting up food for multiple residents without performing hand hygiene between each resident's utensils. The activities director was also seen wiping under his eyes and then delivering a food tray without washing his hands first. Interviews with staff confirmed that the expected hand hygiene practices were not followed. The dietary director and the executive director both acknowledged that the failure to adhere to proper hand hygiene and beard guard policies could lead to contamination of food and potential infection. A review of the facility's policies on Associate Conduct and Dress Code, as well as Handwashing and Glove Use, revealed that these practices were required to prevent contamination and ensure sanitary conditions in the kitchen and dining areas.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices were observed, leading to potential spread of infections. Resident #60, who was cognitively intact and had a foley catheter, was placed under enhanced barrier precautions to prevent urinary infections. However, an X-Ray Technician entered the resident's room and performed an ECG without donning appropriate PPE, despite the presence of CDC signage indicating the need for enhanced barrier precautions. The technician admitted to not seeing the signage and acknowledged the risk involved in performing high-contact procedures without PPE. The Infection Preventionist expressed uncertainty about the necessity of PPE for an ECG, but emphasized the importance of adhering to posted signage and inquiring when unsure about precautions. Additionally, during a medication pass observation, a registered nurse was seen returning a glucometer to the medication cart without properly sanitizing it between uses. The nurse was unsure of the policy regarding glucometer sanitization and used an alcohol pad instead of the required bleach wipes. The Director of Nursing later provided the correct policy for cleaning and disinfecting the glucometer, which mandates the use of EPA-registered bleach wipes to prevent the transmission of bloodborne pathogens. The DON stated that the nurse was reeducated on the proper cleaning procedures and emphasized the importance of following infection control policies. The facility's policies for standard precautions, handwashing, and glove use were reviewed, revealing that the infection prevention and control program includes systems for preventing, identifying, reporting, investigating, and controlling infections. The policies also specify the appropriate use of PPE, hand hygiene, and cleaning and disinfecting procedures. Despite these policies, the observed deficiencies in infection control practices highlight lapses in adherence to established protocols, potentially jeopardizing the health and safety of residents and staff.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medication. Resident #6, who was admitted with diagnoses including type 2 diabetes, spinal stenosis, heart failure, and essential hypertension, was observed with hydrocortisone ointment and Vicks Vaporub at the bedside without any staff present. The resident confirmed that staff were aware of the medications. Interviews with a CNA and an LPN revealed that there was no consistent understanding or adherence to the policy regarding self-administration of medications. The CNA was unaware of any policy and stated that medications found at the bedside were typically disposed of by the nurse. The LPN confirmed that all medications should be stored in the wound or medication cart and administered by a nurse, and acknowledged the existence of a policy for self-administration but noted it was not commonly practiced. The DON confirmed that the resident had not been assessed for self-administration, and there were no physician orders or care plan entries to support self-administration for this resident. The facility's policy, dated August 29, 2023, requires an interdisciplinary team assessment and a physician's order for residents to self-administer medications. However, this policy was not followed for Resident #6, as there was no evidence of an assessment or physician's order in the resident's records. The DON verified that the resident was not authorized to self-administer medications, highlighting a failure to adhere to the established policy and procedure, which could result in residents self-administering medications without proper assessment and authorization.
Failure to Follow Dialysis Care Policy for Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that a resident with end stage renal disease (ESRD) and a dialysis shunt in the left arm received safe monitoring of vital signs. Despite the care plan and facility policy explicitly stating that blood pressure should not be taken from the arm with the shunt, the resident's blood pressure was measured from the left arm on seven occasions between January 25, 2024, and February 7, 2024. This practice was contrary to the facility's Hemodialysis Offsite Policy, which was last reviewed on August 23, 2023, and could potentially lead to complications such as damage to the access site, clotting, or circulatory problems. Interviews with multiple registered nurses revealed a lack of consistent understanding and adherence to the policy. One RN incorrectly stated that it did not matter which arm was used for blood pressure measurements, while two other RNs correctly identified that using the arm with the shunt was inappropriate and could cause harm. The resident involved was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15, and had no documented issues with the right arm that would necessitate using the left arm for blood pressure readings.
Improper Disposal of Unused Medications
Penalty
Summary
The facility failed to ensure unused medications were disposed of according to accepted professional standards. On February 08, 2024, at 9:34 A.M., a small clear plastic measuring cup with a red capsule was observed on top of a medication cart with no staff present. The Director of Nursing (DON) also observed the unattended medication on the cart and disposed of it in an uncovered rectangular bin located at the bottom end of the medication cart. This action was contrary to the facility's policy and professional standards for medication disposal. An interview with a Registered Nurse (RN) revealed that unused medications should be disposed of in a sharps container to prevent access by unauthorized personnel or residents. The RN emphasized that discarding medications in an uncovered trashcan poses a risk, especially for residents who are not cognitively aware. The facility's administrator confirmed that the trashcan is not an approved method for medication disposal and that the facility's policy requires medications to be disposed of in a manner that limits access and complies with applicable laws and environmental regulations.
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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