Desert Haven Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 2645 East Thomas Road, Phoenix, Arizona 85016
- CMS Provider Number
- 035062
- Inspections on file
- 20
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Desert Haven Care Center during CMS and state inspections, most recent first.
A resident with dementia, moderate cognitive impairment, behavioral symptoms, and hearing loss was seated in the dining room when another cognitively intact resident with schizophrenia, behavioral disturbances, and a history of aggression entered, asked about a blue folder, became agitated, and repeatedly struck the seated resident in the face with a closed fist before CNAs could separate them. The injured resident sustained bilateral nasal bone fractures, a laceration to the ear requiring sutures, and extensive facial bruising, with blood observed on his face, ear, and the surrounding area. Both residents had existing behavior care plans and psychiatric assessments addressing behavioral issues and the need to protect the rights and safety of others, but the interaction in the dining room escalated into physical abuse, which the facility’s investigation and DON confirmed met the definition of abuse under the facility’s Abuse Guidelines policy.
A resident with a history of psychosis-related behaviors and verbal aggression created a cardboard gun, covered his face with a bandana, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not be quiet, causing the threatened resident to become intimidated and withdraw to bed. Staff, including a CNA and an LPN, witnessed the event and described the aggressor as intimidating and aggressive, particularly around women, and the LPN reported the incident to a unit manager and wrote a statement. However, there was no documentation of the incident in either resident’s clinical record, no self-report or grievance logged for the period, and the DON reported having no knowledge of the event, despite facility policy requiring immediate reporting and documentation of suspected abuse, including resident-to-resident abuse.
The facility failed to implement its abuse policy after an incident in which a resident with a history of aggressive behaviors created a cardboard gun, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not quiet down. Staff, including a CNA and an LPN, witnessed the event, described it as resident-to-resident emotional abuse, and reported it verbally to a unit manager, but there was no documentation of the incident in either resident’s clinical record, no incident report, and no evidence of an investigation or required notifications. The DON, who is responsible for abuse coordination and reporting, was unaware of the event, despite facility policy requiring immediate reporting, documentation, resident examination, and notification of state agencies, the physician, and the resident representative for any suspected or alleged abuse.
The facility failed to report and document a resident-to-resident abuse incident in which a cognitively intact resident with a history of psychosis-related behaviors created a cardboard gun, covered his face, entered another cognitively impaired resident’s room, and threatened to shoot him if he did not be quiet. A CNA and an LPN witnessed the event, with the LPN stating the threatened resident appeared intimidated and became unusually withdrawn afterward. The LPN reported the incident and the cardboard gun to a unit manager and was told to write a statement, but the DON and unit manager later denied knowledge of or action on the incident. Review of clinical records, internal reports, and the state complaint database showed no documentation or external reporting of the event, despite facility policy and staff statements that abuse, including intimidation and resident-to-resident abuse, must be reported immediately and documented in progress notes and incident reports.
The facility failed to investigate and document an alleged resident-to-resident abuse incident in which a cognitively intact resident with a history of verbal aggression and threatening behaviors entered the room of a severely cognitively impaired resident while holding a cardboard gun, covered his face with a bandana, and threatened to shoot the other resident if he did not quiet down. Staff, including a CNA and an LPN, reported that they witnessed the event, considered it abuse, and informed a unit manager, but there was no documentation of the incident in either resident’s clinical record, no evidence of a self-report, grievance, or investigation, and the DON reported having no knowledge of the event. This inaction conflicted with the facility’s Abuse Guidelines policy, which required immediate reporting, documentation, examination, and investigation of all suspected abuse, including resident-to-resident abuse.
A resident with type 1 diabetes and a history of diabetic ketoacidosis experienced repeated failures in blood glucose monitoring and insulin administration, including missed and undocumented blood sugar checks, lack of provider notification for abnormal readings or refusals, and insufficient monitoring for symptoms of hypo- or hyperglycemia. These deficiencies led to the resident's hospitalization in the ICU for hyperglycemia and diabetic ketoacidosis.
A resident with type 1 diabetes had multiple physician orders for frequent blood glucose (BS) checks and insulin administration, including use of both fingerstick and continuous glucose monitoring devices. Despite these orders, staff failed to consistently document BS readings in the medical record, with many values missing or only noted as 'high' or 'low' without specifics. Interviews revealed the facility lacked a specific BS monitoring policy, and staff did not always ensure orders were properly reflected in the MAR, leading to incomplete and inaccurate medical records.
A resident with dementia, muscle weakness, type 2 DM, and unstageable pressure ulcers to the sacrum and right ischium had active orders for wound care that required cleansing with wound cleanser, patting dry, applying skin prep, then packing with Dakin’s-soaked gauze and covering with a dry dressing. During an observed treatment, an LPN removed old dressings and packed both wounds with Dakin’s-soaked gauze without cleansing them first, despite the orders. The LPN reported being told by the wound provider not to clean the wounds and was unsure if this was correct. The DON referenced an unsigned statement suggesting Dakin’s did not require prior cleansing, which was not supported by the manufacturer’s article cited, while the wound physician later clarified that wounds should be cleansed at treatment and that Dakin’s could be used to cleanse and then separately to pack the wound, consistent with facility policy requiring medications to be administered per orders.
Surveyors observed kitchen staff preparing food without required hair nets and beard covers while a pot of vegetables was actively cooking on the stove. The Food Service Director later confirmed that the item being prepared was buttered spinach for a meal service and acknowledged that staff are required by facility policy to wear hair restraints and facial hair guards to prevent hair from getting into food. The Administrator also stated that staff are expected to follow infection control policies, including use of appropriate PPE such as hair nets and facial hair covers during food prep, consistent with the written personal hygiene and sanitation policy.
A resident with severe cognitive impairment and mobility issues was found with a call light out of reach, leading to distress and inability to call for help. Observations revealed the call light was improperly placed, and the facility lacked a Call Light Policy, contributing to the deficiency.
A resident with a high risk of wandering and a history of elopement exited the facility unsupervised after a nurse was distracted by a medication delivery. Despite being on 1:1 monitoring, the resident managed to leave when the alarm was triggered. The resident was found the next day with blisters on both feet, indicating a lapse in supervision and monitoring.
The facility failed to maintain a dignified dining experience by using disposable dishware and utensils due to a lack of dishwashing staff on certain nights. A resident noted that Styrofoam was used occasionally, and the dietary director confirmed this practice occurred monthly. The Executive Director was unaware of the staffing issue until recently and expected a homelike dining environment.
The facility failed to update the PASRR for two residents with new psychiatric diagnoses, potentially impacting their care. One resident had a new diagnosis of anxiety disorder, and another was diagnosed with schizoaffective disorder, but their PASRR screenings were not updated. Interviews with staff confirmed the oversight, despite the facility's policy requiring such updates.
The facility failed to properly label and store food items, as well as maintain the correct potency of the Quaternary Sanitizer solution. Observations revealed unsealed and undated food items, including bacon and various bread products, in the kitchen. The Dietary Director was uncertain about storage requirements, and the Executive Director confirmed the need for proper sealing and dating to prevent oxidation. Additionally, the Quat solution was found to be too strong, requiring adjustment to meet the recommended 200 ppm.
A facility failed to implement enhanced barrier precautions (EBP) for a resident with a PEG tube, risking the transmission of multi-drug resistant organisms. Despite the resident's severe cognitive impairment and the presence of a PEG tube, no EBP signs or PPE were visible. Staff interviews revealed a lack of adherence to EBP guidelines, with the DON expressing disagreement with the guidelines due to concerns about maintaining a homelike environment.
The facility failed to maintain a safe and clean environment, with broken window blinds, stained walls, and dusty vents observed in residents' rooms. Staff interviews revealed that maintenance issues were not consistently reported or addressed, despite expectations for prompt action. The maintenance director acknowledged that housekeeping should have cleaned the affected areas.
Failure to Prevent Resident‑on‑Resident Physical Abuse Resulting in Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in significant facial trauma. One resident with dementia, moderate cognitive impairment (BIMS score of 8), behavioral symptoms, a history of falling, and hearing loss was care planned for behavior problems such as placing himself on the floor, banging his head, yelling, paranoia, refusing care and medications, verbal and physical aggression, territorial behavior in the dining room, and making false accusations. His care plan included anticipating his care needs before he became overly stressed and implementing interventions as needed to protect the rights and safety of others. On the day of the incident, he was seated in his wheelchair in the dining room watching television when another resident approached him. The other resident, who was cognitively intact (BIMS score of 15) and had diagnoses including schizophrenia, mild neurocognitive disorder with behavioral disturbance, psychoactive substance use disorder, anxiety disorder, insomnia, suicidal and homicidal ideations, and schizoaffective disorder bipolar type, had a care plan for behavioral problems including self-isolation, aggression, and a history of suicidal and homicidal ideation. Interventions for this resident included intervening as needed to protect the rights and safety of others, approaching him calmly, diverting his attention, and removing him from situations as needed. A psychiatry assessment recommended maintaining firm boundaries regarding appropriate and acceptable communication and behavior and consideration of a two-person assist for safety and accountability. On the day of the incident, this resident approached the nurse at the medication cart asking to speak with the unit manager about paperwork, was informed the manager had left, stated he did not need assistance, and then walked into the dining room. Shortly after entering the dining room, the cognitively intact resident approached the resident with dementia and asked about a blue folder. Due to hearing loss, the seated resident responded that he did not have the folder or said “what,” and the interaction quickly became confrontational. Two CNAs in the dining room observed the resident who had entered calmly become agitated and strike the seated resident with a closed fist. Staff reported that, due to the size and strength of the aggressor, it required significant effort to separate them, and the aggressor was able to strike the other resident multiple times (approximately five times) before they were fully separated. A nurse, alerted by CNA yelling, arrived after the residents had been separated and found the injured resident in his wheelchair with blood dripping from his nose, blood coming from his left ear, a hematoma near his left eyebrow, and blood on the floor and surrounding area, with his hearing aids in his hand. The injured resident was transported to the hospital, where CT imaging revealed mildly displaced bilateral nasal bone fractures and a 1.5 cm laceration to the left ear that required suture repair. Upon return, he was noted to have a swollen nose, bruising around the nose and left eye, and later two black eyes, with ongoing bruising and discoloration documented in weekly skin assessments. He reported that his hearing aids were damaged by his attacker and stated he had been beaten up by another resident. The facility’s investigation, including staff interviews and review of the incident, concluded that the allegation of physical abuse was verified. The DON stated that the incident met the definition of physical abuse under the facility’s Abuse Guidelines policy, which defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish and requires assessment and care planning for residents with behavioral problems to protect the rights and safety of others.
Failure to Recognize, Document, and Report Resident-to-Resident Abuse Involving Threats with a Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident and to recognize, document, and report the incident as required by policy. One resident had a documented history of behavioral problems related to psychosis, including delusions, refusing care, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances toward females. Care plans identified these behaviors and included an intervention to protect the rights and safety of others. Behavior progress notes over several weeks documented multiple episodes of verbal aggression, threats toward peers and staff, and at least one incident where the resident physically placed his hands on another resident’s arms while attempting to redirect him, leading to an argument that required staff separation. Despite this pattern of escalating behaviors, there was no documentation in the clinical record regarding a later resident-to-resident incident that occurred on January 20, 2026. The other resident involved had vascular dementia with severe cognitive impairment, as evidenced by a BIMS score of 03, and a care plan that identified behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and educating the resident on appropriate behaviors when on the patio with peers. The clinical record for this resident also lacked any documentation of the resident-to-resident incident on January 20, 2026. When surveyors requested the facility’s self-reports, grievances, and investigations for the prior four months, the facility reported that there had been no incidents or grievances during that period, despite staff accounts of a serious resident-to-resident event. Multiple staff interviews described the unreported incident and the facility’s failure to follow its abuse policy. A CNA stated that the aggressive resident had a pattern of trying to intimidate people, especially when women were present, and reported that within the prior week he made a cardboard gun, covered his face with a bandana, entered the cognitively impaired resident’s room, and threatened to “teach [him] a lesson” if he did not be quiet. An LPN reported witnessing the same event, stating that the resident held a pretend cardboard gun, told the other resident to go to sleep or he would shoot him, and that the threatened resident appeared intimidated and later stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, saw it had been colored to look more realistic, but returned it to the resident because she was afraid of what he might do. She reported the incident to the unit manager and was told to write a statement, but the DON later stated she was unaware of any such abuse incident, and the unit manager stated she did not recall the incident being reported and had not investigated it. The facility’s abuse policy required immediate reporting of suspected abuse to the DON and administrator and documentation of incidents, but there was no evidence of documentation, self-reporting, or investigation of this resident-to-resident abuse. The DON stated that allegations of abuse were expected to be documented in an incident report and progress note and reported within two hours to applicable state agencies, physicians, case managers, and family, and that resident-to-resident physical or verbal abuse was considered reportable. The unit manager similarly stated that staff were expected to document all progress notes, including incidents of abuse or allegations, and that allegations should be reported immediately, but no longer than two hours, to the DON. Despite these stated expectations and the written Abuse Guidelines policy defining abuse as willful infliction of injury, intimidation, or punishment causing physical harm, pain, or mental anguish, and requiring immediate reporting of suspected abuse, the incident involving the cardboard gun and threats was not documented in either resident’s clinical record, not entered as a self-report or grievance, and not brought to the DON for investigation. This failure to follow policy and to recognize and report the resident-to-resident intimidation and threats constituted the identified deficiency.
Failure to Implement Abuse Policy After Resident-to-Resident Threat with Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy following a resident-to-resident abuse incident involving two residents. The facility’s own "Abuse Guidelines" policy requires that any suspected or actual abuse, including intimidation and resident-to-resident abuse, be immediately reported to facility management, that the DON and administrator be notified, that the resident be examined by a physician or licensed nurse with findings documented in the medical record, and that an unusual occurrence form and written witness statements be completed with an immediate investigation. Despite these requirements, there was no documentation in either resident’s clinical record of the alleged abuse incident that occurred on January 20, 2026, and the DON reported having no knowledge of any recent abuse incident between the two residents. One of the residents involved, identified as Resident #89, had a history of behavioral issues documented in the clinical record. Diagnoses included mild neurocognitive disorder, major depressive disorder, and other chronic medical conditions. Care plans noted behavior problems related to psychosis, including delusions, verbal aggression, intrusiveness, wandering, and inappropriate sexual advances, with interventions to protect the rights and safety of others. Behavior notes over several weeks documented repeated episodes of verbal aggression, threats toward staff and peers, and at least one incident where he physically placed his hands on another resident’s arms during an argument. However, there was no behavior note or other documentation regarding the cardboard gun incident on January 20, 2026, despite staff describing it as resident-to-resident abuse. The other resident, identified as Resident #78, had vascular dementia with severe cognitive impairment (BIMS score of 03) and multiple chronic conditions. His care plan documented behavioral symptoms related to dementia, including physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Staff interviews revealed that within the week prior to the survey, Resident #89 created a cardboard gun, entered Resident #78’s room, and threatened him, telling him to be quiet or he would "teach [him] a lesson" and stating "go to sleep, or I am going to shoot you." Staff witnesses, including a CNA and an LPN, described the incident as resident-to-resident emotional abuse and reported that Resident #78 appeared intimidated and frightened afterward, staying in bed and not wanting to do anything. The LPN who witnessed the event stated she reported the incident to the unit manager and was instructed to write a statement, but the unit manager later stated she did not recall the incident being reported and did not investigate it. The facility’s records showed no self-reports, grievances, or investigations for the prior four months, and there was no clinical documentation or formal reporting of this abuse incident as required by the facility’s abuse policy. Interviews with multiple staff members further demonstrated the breakdown in implementing the abuse policy. The CNA described Resident #89 as aggressive and intimidating, especially around women, and confirmed that the cardboard gun incident occurred and that he considered it resident-to-resident abuse. The LPN who witnessed the incident stated that abuse incidents should be documented in progress notes and reported immediately to the DON or administrator, and that she did report the event to the unit manager and requested that the cardboard gun be taken away. The DON stated that allegations of abuse must be documented in the clinical record and reported to state agencies within two hours, and that resident-to-resident verbal or physical abuse is reportable, yet she was unaware of the incident. The unit manager stated that abuse allegations should be reported immediately and documented, but she denied having recently reported anything and said she only learned of the cardboard gun situation minutes before her interview and did not investigate it. This combination of absent documentation, lack of reporting to the DON and state agencies, and failure to initiate an investigation after a witnessed resident-to-resident abuse incident constitutes the core deficiency in implementing the facility’s abuse policy.
Failure to Report and Document Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to timely report and document a resident-to-resident abuse incident involving intimidation and threats, as required by its abuse policy and staff expectations. One resident, identified as having mild neurocognitive disorder, major depressive disorder, and a history of psychosis-related behaviors including verbal aggression, intrusiveness, and inappropriate sexual advances, had multiple prior behavior notes documenting verbal aggression and threats toward peers and staff. Another resident, diagnosed with vascular dementia and severe cognitive impairment, had a care plan identifying behavioral symptoms such as physical aggression, verbal outbursts, hallucinations, wandering, and refusal of care. Despite these known behavioral risks, there was no documentation in either resident’s clinical record regarding the specific resident-to-resident incident that occurred on January 20, 2026. Staff interviews revealed that within the week prior to the survey, the first resident created a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” An LPN reported witnessing the resident holding the pretend cardboard gun and telling the other resident to go to sleep or he would shoot him, and stated that the second resident appeared intimidated and subsequently stayed in bed and did not want to do anything, which was not his usual behavior. The LPN stated she picked up the cardboard gun when it fell, then returned it to the resident because she was afraid of what he might do to her. She further stated that she reported the incident to the unit manager, was instructed to write a statement on paper, and requested that the unit manager take the cardboard gun from the resident. Despite this report, the DON stated she was unaware of any recent abuse incident between these two residents and only knew that the first resident had been verbally aggressive to staff over a recent weekend. The unit manager initially stated that she had not reported anything recently and only learned shortly before her interview that the resident had made a cardboard gun and was playing with staff and the other resident; she stated she did not recall the incident being reported to her and did not investigate or report it. Review of the facility’s self-reports, grievances, and investigations for the prior four months showed no reported incidents or grievances, and review of the State Agency complaint database showed no evidence that the incident had been reported. This inaction occurred despite the facility’s written Abuse Guidelines policy, which required immediate reporting of suspected abuse, including intimidation, to facility management, immediate notification of the administrator, and prompt notification of state agencies, the ombudsman, the resident representative, APS, and the physician, as well as documentation in incident reports and progress notes. The facility’s own policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and explicitly stated that resident abuse by anyone, including other residents, would not be condoned. Staff interviews confirmed that they understood reportable incidents to include physical, verbal, and resident-to-resident abuse, and that such incidents were to be reported immediately to the DON, administrator, or designated supervisor, and documented in the clinical record. Nonetheless, there was no evidence of progress notes, incident reports, or external notifications related to the cardboard gun incident, and the DON and unit manager both denied having reported or investigated it. This lack of reporting and documentation of a witnessed resident-to-resident abuse incident constituted the deficiency identified by the surveyors.
Failure to Investigate Alleged Resident-to-Resident Abuse Involving Threats with a Cardboard Gun
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an alleged incident of resident-to-resident abuse involving two residents. One resident had a history of behavioral issues, including psychosis-related behaviors, verbal aggression, intrusiveness, and inappropriate sexual advances, with care plan interventions to protect the rights and safety of others. Behavior notes over several weeks documented multiple episodes of verbal aggression, threats toward peers, and menacing behavior toward staff, including threatening language and attempts to put hands on another resident. Despite this pattern, there was no documentation in the clinical record regarding a specific resident-to-resident incident that occurred on January 20, 2026. The other resident involved had vascular dementia with severe cognitive impairment, as indicated by a BIMS score of 03, and a care plan identifying behavioral symptoms such as physical aggression, verbal aggression, hallucinations, wandering, and refusal of care. Interventions included psychoactive medications as ordered, recording behavioral symptoms, and education on appropriate behaviors. This resident’s MDS also showed frequent verbal behaviors. However, similar to the first resident, there was no documentation in this resident’s clinical record regarding the alleged resident-to-resident incident on January 20, 2026. Staff interviews revealed that a CNA described the first resident as aggressive and intimidating, particularly around women, and reported that within the prior week the resident made a cardboard gun, covered his face with a bandana, and entered the second resident’s room, telling him that if he did not be quiet, he would “teach [him] a lesson.” The CNA stated that staff removed the resident from the room and that he considered the event resident-to-resident abuse, and that two nurses present reported it to their supervisor. An LPN separately reported witnessing an incident in which the same resident entered the other resident’s room with a cardboard gun and threatened to shoot him if he did not quiet down, stating, “go to sleep, or I am going to shoot you,” and that the other resident felt intimidated. This LPN reported the incident to the unit manager and was instructed to write a statement, but did not know if it was reported further or investigated. The DON, who is responsible for abuse coordination, investigation, and reporting, stated she was unaware of any recent abuse incident between these residents, and the unit manager stated she did not recall the incident being reported to her and did not investigate the cardboard gun incident. Review of facility records showed no self-reports, grievances, or investigations for the prior four months, and the facility’s Abuse Guidelines policy required immediate reporting, documentation, examination, and investigation of suspected abuse, including resident-to-resident abuse, which did not occur in this case. The facility’s Abuse Guidelines policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and stated that the facility would not condone abuse by anyone, including other residents. The policy required employees, consultants, and physicians to immediately report suspected abuse to the DON or, in her absence, to the nurse supervisor, and required immediate notification of the administrator, state licensing agency, ombudsman, resident representative, adult protective services, and the resident’s physician when an allegation or suspected case of mistreatment or abuse was reported. It further required that a physician or licensed nurse immediately examine the resident, record findings in the medical record, complete an unusual occurrence form with written witness statements, and conduct an immediate investigation with a copy provided to the administrator. Despite these policy requirements and staff accounts of a threatening resident-to-resident interaction involving a cardboard gun and verbal threats, there was no evidence that the incident was documented in either resident’s clinical record, reported to the DON or administrator, or investigated in accordance with facility policy.
Failure to Follow Physician Orders for Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that physician orders for blood glucose monitoring and insulin administration were consistently followed for a resident with type 1 diabetes mellitus and a history of diabetic ketoacidosis. Despite multiple physician orders specifying the use of a Dexcom G7 sensor, scheduled blood glucose checks four times daily, and specific insulin administration parameters, the clinical record revealed repeated lapses. Blood glucose monitoring was not performed or documented as ordered, and the physician's order for scheduled checks was not transcribed onto the medication or treatment administration records for several months. There were also numerous instances where blood sugar readings were not recorded prior to insulin administration, and low or high blood sugar values were not consistently addressed or reported to the healthcare provider as required. The documentation showed that the resident frequently refused blood glucose checks and insulin administration, but there was no evidence that the physician was notified of these refusals or that the resident was monitored for signs and symptoms of hypo- or hyperglycemia following missed doses. On several occasions, the resident's blood sugar readings were outside of the ordered parameters, including both hypoglycemic and hyperglycemic episodes, yet there was no documentation of follow-up actions, rechecks, or provider notification. The care plan did not include specific interventions for blood sugar monitoring with either fingerstick or continuous glucose monitoring devices, and there was a lack of documentation regarding monitoring for symptoms or implementing change in condition protocols when abnormal readings occurred. Ultimately, the deficient practice resulted in the resident being admitted to the hospital's intensive care unit with hyperglycemia and diabetic ketoacidosis. The clinical record detailed that the resident was found with altered mental status, high blood sugar readings, and symptoms such as vomiting, tachypnea, and diaphoresis. Emergency services were called, and the resident was transferred to the hospital, where a diagnosis of diabetic ketoacidosis and acute encephalopathy was made. The failure to follow physician orders, monitor and document blood glucose levels, and notify the provider of abnormal findings directly contributed to the resident's acute medical deterioration.
Incomplete Documentation of Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure that the medical record for a resident with type 1 diabetes was complete and accurate regarding blood glucose (BS) monitoring. The resident had multiple physician orders for frequent BS checks and insulin administration, including the use of both fingerstick (accucheck) and a continuous glucose monitoring device (Dexcom G7). Despite these orders, there was a lack of consistent documentation of BS readings in the medical record, including the Medication Administration Record (MAR), progress notes, and vitals log. On numerous occasions, BS values were either missing, not recorded as numerical values, or only noted as 'high' or 'low' without further detail. There were also instances where the resident refused BS checks or insulin, but the attempts and outcomes were not always fully documented. Interviews with nursing staff and the DON revealed that the facility did not have a specific policy for BS monitoring and relied on physician orders to guide practice. Staff reported that BS values should be recorded on the MAR, but review of the MAR for the relevant months showed no such documentation. Staff also indicated that the process for ensuring BS monitoring orders were properly reflected in the MAR was not always followed, as the nurse practitioner entering the order did not select the necessary options to trigger MAR documentation. Additionally, there was confusion among staff regarding the interpretation of the Dexcom device readings and when to notify providers of abnormal results. The resident involved had a complex medical history, including type 1 diabetes, cerebral infarction, and dementia, and required close monitoring of blood glucose levels. The care plan did not include specific interventions for BS monitoring with either the accucheck or Dexcom device. Throughout the period reviewed, there were multiple days with missing or incomplete BS documentation, and on several occasions, there was no evidence that providers were notified of abnormal BS readings or that appropriate follow-up occurred. The lack of complete and accurate documentation could result in an incomplete medical record for the resident.
Failure to Cleanse Pressure Ulcers Before Applying Dakin’s-Soaked Dressings
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in accordance with physician orders and professional standards for a resident with pressure ulcers. The resident was admitted with diagnoses including dementia with mood disturbance, muscle weakness, and type 2 diabetes mellitus, and had an unstageable right ischial wound and an unstageable sacral wound. The care plan included an intervention to provide wound care as ordered by the physician. Active physician orders for both the right ischium and sacrum directed staff to cleanse the wounds with wound cleanser, pat dry, apply skin prep to the surrounding area, pack with Dakin’s soaked gauze, and cover with a dry dressing daily and as needed. During an observed wound care treatment, the LPN serving as the wound care nurse prepared Dakin’s half-strength solution and soaked gauze, stating she had been told by the wound provider not to clean the wound and expressing uncertainty about the correctness of this method. The LPN removed the old dressings, performed hand hygiene, donned clean gloves, and then packed both the sacral and right ischial wounds with Dakin’s soaked gauze without cleansing either wound beforehand, contrary to the physician’s orders. A 6x6 dressing was applied to the sacral wound and a 4x4 dressing to the right ischial wound. Interviews with another LPN and the DON confirmed that nurses are expected to follow provider orders and receive training from the wound nurse, while the DON referenced an unsigned statement suggesting Dakin’s solution did not require prior cleansing, which was not supported by the manufacturer’s article cited. The wound physician later clarified that nurses should follow his orders, that wounds should be cleansed at the time of treatment, and that Dakin’s solution could be used as a cleanser but should be used first to clean and then separately to pack the wound. Facility policy required all medications to be administered in accordance with orders.
Failure to Use Required Hair and Beard Restraints During Food Preparation
Penalty
Summary
The deficiency involves failure to maintain proper sanitary conditions in the kitchen during food preparation, specifically related to required use of hair restraints and facial hair covers. During a kitchen observation at 8:10 a.m. on September 2, 2025, one cook (Staff #107) was observed working in the kitchen without a hair net. Another cook (Staff #51) was observed in the kitchen without a hair net and with visible facial hair that was not covered by a beard guard/net. At the same time, a small pot containing a green substance resembling vegetables was observed boiling on the stove. In subsequent interviews, the Food Service Director (Staff #125) confirmed that staff working in the kitchen are required to wear hair nets and facial hair guards and acknowledged that failure to do so can result in hair getting into food, stating that the staff "know better." The Administrator (Staff #5) stated that expectations are for staff to follow facility policy and procedure to prevent cross contamination in the kitchen, including proper PPE such as hair nets and facial hair covers during food preparation. In a later interview, the Food Service Director identified the boiling green food observed during the initial kitchen observation as buttered spinach being prepared for lunch service and confirmed it is started early in the day for slow cooking. Review of the facility’s “Personal Hygiene and Health Reporting” policy showed that hair restraints must be worn around exposed foods in kitchen and food service areas, and that beards must be restrained with beard covers when around exposed foods.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, which could result in a preventable accident and the resident being unable to meet their needs. The resident, who was admitted to the facility with severe cognitive impairment and multiple diagnoses including atherosclerotic heart disease and bipolar disorder, was observed on two occasions with the call light out of reach. The resident has both upper and lower impairment on both sides and requires assistance with activities of daily living due to spinal stenosis and impaired mobility. On the day of observation, the call light was found in the resident's top dresser drawer and later pinned on the resident's lap, both positions out of reach. The resident was observed screaming for help, indicating distress and inability to access assistance. Interviews with the CNA and DON revealed that the call light should have been placed on the resident's upper chest for accessibility. The facility lacked a Call Light Policy, as confirmed by the DON, which contributed to the oversight in ensuring the call light was within reach.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was at high risk for wandering. The resident, who had a history of elopement and was diagnosed with conditions such as post-traumatic stress disorder, aphasia, and vascular dementia, was admitted to the facility with an incomplete minimum data set assessment. Despite being identified as a high risk for wandering, the resident was able to exit the facility when a nurse was distracted by a medication delivery and the exit door alarm was triggered. The resident was found the next day by a family member and returned to the facility with blisters on both feet. Interviews with staff revealed that the resident was initially on 1:1 monitoring, which was removed shortly before the elopement occurred. The staff were aware of the resident's elopement risk, and interventions were in place to distract the resident from wandering. However, the lapse in supervision allowed the resident to leave the facility unnoticed. The facility's policy required all nursing personnel to report and investigate missing residents, but the incident highlighted a failure in maintaining adequate supervision and monitoring of the resident's movements.
Use of Disposable Dishware in Dining Room
Penalty
Summary
The facility failed to ensure that residents were treated with dignity during dining by using disposable cutlery and dishware. During a dining observation, it was noted that seven residents were served their meals in Styrofoam containers, cups, and bowls, and were using plastic utensils. A resident mentioned that Styrofoam was used sometimes, but not consistently. This practice was attributed to the absence of dishwashing staff, as the dietary director explained that meals were served on Styrofoam when there was an emergency or when the dishwasher staff called off. The dietary director admitted that the use of Styrofoam dishware occurred on a monthly basis due to the lack of dishwashing staff on Monday nights, and the administrator was aware of this situation. The Executive Director (ED) stated that he supervises the dietary manager and was informed about the kitchen staffing needs. However, he did not review the kitchen staff schedule and was unaware of the dishwasher staffing issue on Monday nights until just before the interview. The ED expressed that it was his expectation for the facility to provide a homelike environment in the dining room and that Styrofoam dishware should not be used. The facility's policy on Dining Room Service emphasized maintaining a comfortable and attractive atmosphere in the dining room, which was not upheld in this instance.
Failure to Update PASRR for Residents with New Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was updated for two residents, which could result in residents not receiving the care and services they needed. Resident #73 was admitted with diagnoses including bipolar disorder, major depressive disorder, and severe intellectual disability. A new diagnosis of anxiety disorder was made, but the PASRR Level I screening was not updated to reflect this change. Interviews with the Social Services Director and the Director of Nursing confirmed that the PASRR should have been updated following the new diagnosis. Resident #22 was admitted with multiple diagnoses, including cerebral infarction and bipolar disorder. A PASRR Level I screening was completed, and a Level II determination was submitted. However, after a new diagnosis of schizoaffective disorder, the PASRR was not updated, nor was a Level II determination completed. The resident exhibited behavioral symptoms, and a behavioral care plan was revised, but the PASRR remained outdated. Interviews with the Director of Social Services and the Director of Nursing confirmed that the PASRR should have been updated and a Level II determination submitted. The facility's policy on PASRR, reviewed in July 2022, requires screening for all individuals being considered for admission to a Medicaid-certified nursing facility to determine if they have a mental illness, intellectual disability, or related condition. The policy aims to prevent inappropriate placement in nursing homes. Despite this policy, the facility did not update the PASRR for residents with new psychiatric diagnoses, as required by federal regulations.
Deficiency in Food Storage and Sanitizer Testing
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in accordance with professional standards. During an initial tour of the kitchen, it was observed that a 15-pound box of bacon was not stored in a sealed bag or container, and a bag of shredded lettuce was not sealed or dated. Additionally, various bread items, including wheat bread, hamburger buns, and Hawaiian sweet rolls, were found without open dates. The Dietary Director was unsure about the necessity of sealing the bacon and acknowledged that the shredded lettuce should have been sealed. The Executive Director confirmed that open products should be dated and sealed to prevent oxidation, which can affect the nutritive value and quality of the food. Furthermore, the facility did not adhere to the correct procedures for testing the Quaternary Sanitizer (Quat) solution. The Dietary Director tested the Quat solution and found it to be at 400 parts per million (ppm), which is higher than the recommended 200 ppm. The Director stated that the solution was too strong and required adjustment. The facility's policy on food storage and date marking specifies that leftover food should be stored in covered containers, clearly labeled, and dated if stored for over 24 hours, and used within seven days or discarded. The Quaternary Sanitizer Test Strip directions also require the solution to be tested at 200 ppm.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with a percutaneous endoscopic gastrostomy (PEG) tube, which could result in the transmission of multi-drug resistant organisms. The resident, who was admitted with diagnoses including hemiplegia, diabetes mellitus type 2, cerebral infarction, dementia, and gastrostomy status, had a severe cognitive impairment as indicated by a BIMS score of 03. Despite the resident's condition and the presence of a PEG tube, no signs related to EBP were posted outside the resident's room, and no personal protective equipment (PPE) was visible. Interviews with staff revealed a lack of adherence to EBP guidelines. A licensed practical nurse stated that no precautions were in use anywhere in the building, as it made it easier for staff to care for residents without having to gown up. The Director of Nursing also confirmed that no precautions were in use, expressing disagreement with the EBP guidelines due to concerns about maintaining a homelike environment. The facility's assessment indicated that infection prevention and control services were provided, yet the CDC and CMS guidelines for EBP, which include the use of gown and gloves during high-contact resident care activities for residents with indwelling medical devices, were not followed for the resident with a PEG tube.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and staff interviews. In one resident's room, the window blinds were broken, a light brown substance had dried on the walls, there was a strong odor of urine, and the plaster and paint were chipped off in multiple areas. Additionally, the bathroom ceiling vent was covered in brown dust and dirt. Another room was observed to have broken window blinds as well. Interviews with staff, including a CNA and an LPN, revealed that there was an expectation for maintenance issues to be reported and addressed promptly, but this was not consistently happening. Further observations with the maintenance director highlighted additional cleanliness issues, such as a bathroom vent emitting a puff of white and brown dust when poked, and a bathroom wall stained with a brown substance. The maintenance director acknowledged that these areas should have been cleaned by housekeeping. The facility's policy on maintenance services states that the maintenance director is responsible for ensuring that the building and equipment are maintained in a safe and operable manner, but the observations indicate that this policy was not being effectively implemented.
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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