Diamondback Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 3000 N 91st Avenue, Phoenix, Arizona 85037
- CMS Provider Number
- 035302
- Inspections on file
- 13
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Diamondback Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified a failure to follow food safety standards when multiple opened food items in the kitchen, including liquid eggs, frozen chicken tenders, frozen tilapia, and hot dog buns, were found without labels indicating when they were opened. The facility’s policy required all foods to be labeled and dated, and both the Dietary Manager and the RD confirmed that all products should be labeled upon delivery, storage, and opening so that staff know when items were received, stored, and opened.
A resident with C. difficile was on ordered single-room contact precautions with clear care plan interventions and posted signage requiring PPE use. Despite an isolation cart stocked with gowns, gloves, masks, and wipes, a CNA was observed exiting the resident’s contact isolation room after delivering a meal tray without performing hand hygiene, then handling another meal tray on the shared food cart, which continued to be used for meal service. In interviews, the CNA, an LPN, the Administrator, and the IP all acknowledged that PPE, hand hygiene, and other contact precaution measures are required for such residents, including during meal delivery. The facility’s IPCP policy required appropriate hand hygiene and PPE use, and the facility also failed to document community infection control surveillance mapping as part of its infection control program.
An unattended computer workstation was observed with a resident’s personal dietary information actively displayed on the monitor while no staff were present. A non-employee walked past the exposed screen without any staff attempt to shield or secure the information. The DON later returned to the workstation, logged off, and acknowledged that leaving PHI visible on an unattended workstation could violate HIPAA and did not meet facility expectations, despite existing policies and staff training on confidentiality and protection of resident records.
Two residents were transferred to the hospital for acute changes in condition, including unresponsiveness and hypotension, with documentation in nursing notes, physician visit notes, transfer forms, and discharge MDS assessments indicating hospital transfers with return anticipated, but no written transfer/discharge notices containing required elements were found in their records. One resident had multiple serious conditions including acute respiratory failure, heart failure, and pneumonia; the other had ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, and severe cognitive impairment. Staff interviews revealed that Social Services was not involved in notifications, the Medical Records Director only began tracking notifications months after the events and was unsure how mailed notices were tracked, and the liaison who visited residents in the hospital did not provide any transfer/discharge forms. The Medical Records Director confirmed no transfer/discharge notices existed for the two residents and that the form in use contained incorrect appeal and ombudsman contact information, while the Administrator stated she was unaware that this version of the form was being used. Review of the facility’s discharge/transfer policy showed it addressed bed-hold review after emergent transfers but did not address providing written transfer/discharge notices or the required content.
A resident admitted on an antipsychotic (olanzapine 2.5 mg daily) with moderate cognitive impairment and no documented behavioral symptoms had the medication discontinued, as reflected on the MAR, but the discontinuation and rationale were not accurately documented in provider progress notes. A PA’s psychiatric note stated no medication changes were made and did not mention stopping olanzapine, while a telephone discontinue order was entered by an LPN and no further doses were given. Behavioral monitoring tied to the antipsychotic remained active with no recorded behaviors, and subsequent NP notes incorrectly documented that the resident would continue olanzapine, even though it was no longer administered and was not included on discharge prescriptions, resulting in inconsistent and inaccurate clinical documentation.
A resident with severe cognitive impairment and a history of bradycardia was repeatedly administered antihypertensive medications despite physician orders to hold these medications if the heart rate was below 60 bpm. Nursing staff and the DON confirmed awareness of the medication parameters, but the MAR showed multiple instances where medications were given outside of these parameters, contrary to facility policy and provider instructions.
A resident with severe cognitive loss and multiple diagnoses was found to have a bruise on the left foot, later confirmed as a fracture. Despite the spouse's request for an X-ray and hospital evaluation, the facility did not report the injury as required by their Abuse Policy. Staff interviews revealed that the facility did not consider the incident reportable, leading to a deficiency in reporting and investigating the injury.
A resident with multiple diagnoses, including anoxic brain damage, was found to have a bruise on the left foot, later revealed to be a fracture. The facility failed to report this injury of unknown origin within the required timeframe, as they did not consider it reportable. Interviews with staff indicated that unusual marks are typically reported and assessed, but the facility's policy on reporting was not followed in this case. The absence of a list of reportables and 5-day reports was noted by the new administrator.
A resident with multiple diagnoses, including Alzheimer's and dysphagia, experienced a worsening pressure wound due to repeated loose stools. Despite physician orders for Imodium, it was only administered once, and the facility failed to manage the resident's condition effectively. Inadequate communication between CNAs and nursing staff contributed to the deficiency, as the facility did not adhere to its policies on resident condition changes and incontinence care.
The facility failed to ensure adequate staffing for residents requiring ventilator and tracheostomy care, leaving LPNs to manage care beyond their scope. The absence of a scheduled RT for the night shift resulted in residents not receiving necessary trach care, vent checks, or suctioning. Interviews revealed that LPNs were not comfortable or trained to handle ventilator settings or emergent situations, posing a significant risk to resident safety.
Failure to Label and Date Opened Food Items in Kitchen Storage
Penalty
Summary
The deficiency involves the facility’s failure to ensure that opened food items were labeled and dated in accordance with professional food safety standards and the facility’s own policy. During a kitchen observation conducted with the Dietary Manager, surveyors found two liquid egg cartons in the refrigerator without an opened date label, as well as one bag of chicken tenders and one bag of tilapia in the freezer without opened date labels. In addition, one bag of hot dog buns was found without an opened date label. The facility’s written policy, titled “Food Safety Requirements,” stated that all foods will be labeled, dated, and monitored, including refrigerated foods and leftovers, so that they are used by their use‑by date. In interviews, the Dietary Manager stated that food should be labeled with the date it is opened and the expiration date, and that if food has no opened date or expiration date label, kitchen staff should dispose of it immediately because eating from open, undated food could pose a risk to residents. The registered dietitian stated that the expectation was that all food products are properly labeled and dated upon delivery and storage, and again once items are opened, noting that the risk included not knowing when the food was received, stored, or opened. These observations and statements show that staff did not consistently follow the facility’s established food safety requirements for labeling and dating opened food items.
Failure to Follow Contact Precautions and Document Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement proper infection prevention and control practices for a resident on contact precautions and to document community infection control surveillance mapping. A resident admitted with diagnoses including C. difficile enterocolitis, urinary tract infection, and psychoactive substance abuse had a comprehensive care plan and physician order requiring single-room contact precautions, including use of gowns and gloves for high-contact care, gowns and masks when changing contaminated linens, and conducting all care, therapies, and activities in the room. Signage outside the resident’s room indicated contact precautions and the need for PPE, and an isolation cart with gowns, gloves, masks, and sanitizing wipes was present. Surveyors observed a CNA exiting this contact isolation room after delivering a meal tray without performing hand hygiene. After exiting, the CNA handled another meal tray on the food cart and pushed it back into the cart, and there was no evidence that this tray was discarded while staff continued to pass meal trays from the same cart. In interviews, the CNA acknowledged exiting the room without hand hygiene and stated that staff are required to don gowns and gloves when entering, doff them before exiting, use disposable meal trays, perform hand hygiene, and disinfect reusable items for residents on contact precautions. An LPN and the Administrator, along with the Infection Preventionist, confirmed that proper PPE use and adherence to contact precautions are required, including when delivering meal trays. The facility’s IPCP policy required hand hygiene per facility procedures and use of PPE according to policy, but these practices were not followed in this instance, and the facility also failed to document community infection control surveillance mapping as part of its infection prevention and control program.
Unattended Computer Screen Exposes Resident PHI
Penalty
Summary
Surveyors identified a deficiency related to failure to maintain confidentiality of resident-identifiable information when an unattended computer workstation displayed personal records for Resident #29. On January 29, 2026, at 10:45 a.m., the workstation was observed with resident records actively visible on the monitor and no staff present or monitoring the area. The information on the screen included personal and identifiable dietary information for Resident #29. At 10:46 a.m., a non-employee walked down the hallway and passed directly by the monitor with the resident’s information visible, and no staff intervened to shield or secure the information. At 10:47 a.m., the DON (Staff #85) approached the unattended workstation and immediately logged off the computer. In an interview at that time, the DON confirmed that the computer contained private resident information and acknowledged that leaving resident information visible on an unattended workstation could constitute a HIPAA violation and did not meet facility expectations for confidentiality. Review of facility documentation showed staff training on PHI, closing screens, not leaving information exposed, confidentiality, HIPAA, and resident and family notification, with 31 staff members having signed acknowledgment. A review of the facility’s Resident Rights policy, revised January 1, 2025, stated that residents have the right to secure and confidential personal and medical records and that the facility is responsible for safeguarding resident information from unauthorized access or disclosure.
Failure to Provide Required Written Transfer/Discharge Notices and Accurate Information
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notifications to residents and/or their representatives when residents were transferred to the hospital. For one resident with acute respiratory failure with hypoxia, a left femur fracture, pulmonary hypertension, heart failure, and pneumonia, the record showed admission on a specified date and a subsequent transfer to the hospital on a later date due to unresponsiveness and rapid decline in mental status. The face sheet identified the husband as responsible party and the daughter as emergency contact, with phone numbers listed, and documented that the resident was discharged to the hospital. A physician visit note confirmed the emergent transfer, and a discharge MDS coded as a discharge-return anticipated indicated the resident was sent to the hospital. However, there was no order in the Order Summary Report for the hospital transfer and no documentation in the clinical record of a written transfer notice containing the required elements being provided to the resident or resident representative. For another resident originally admitted with ventilator-associated pneumonia, sepsis, respiratory failure with hypercapnia, type II neurofibromatosis, respirator dependence, visual loss, and pleural effusion, the face sheet listed the resident’s mother as emergency contact with a phone number. An eINTERACT transfer form documented a hospital transfer for hypotension, and a nursing note recorded a blood pressure of 84/65, that the POA was at bedside, the provider was notified, and 911 was called for transport per physician’s orders. The Order Summary Report contained a physician’s order to transfer the resident to the ER for hypotension, and a discharge MDS coded as discharge-return anticipated documented that the resident, who had severe cognitive impairment, was sent to the hospital. Despite this, the clinical record contained no documentation that a written transfer notice with the required information was provided to the resident or resident representative. Interviews and policy review further described gaps in the facility’s process for transfer/discharge notifications. The social worker reported that Social Services/Case Management was not involved in transfer/discharge notifications and identified Medical Records as responsible. The Medical Records Director stated she began tracking transfer/discharge notifications around October 2025, that a transfer/discharge form was created at that time, and that completed forms were to be scanned into the clinical record if provided to her, but she was unsure how mailed notifications were tracked. She confirmed there were no transfer/discharge notifications in the records of the two residents and acknowledged that the form in use contained incorrect appeal and ombudsman contact information. The Admissions Coordinator/Clinical Liaison stated he visited residents in the hospital but did not provide any transfer/discharge form or packet and was unfamiliar with the form. The Administrator stated that transfer notices are provided three days prior to discharge and that there is a notification for each level with a checklist, but when shown the facility’s transfer/discharge notification form, she said it did not look like the one she approved and she was unaware her team was using it. Review of the facility’s Discharge/Transfer policy showed it addressed reviewing the bed-hold policy with the POA within 24 hours of an unplanned emergent transfer but did not address providing transfer/discharge notifications to residents or representatives or specify the required information, despite State Operations Manual requirements for written notice including reasons, effective date, destination, appeal rights, and advocacy contact information.
Failure to Accurately Document Discontinuation of Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the discontinuation of an antipsychotic medication and the rationale for that change in a resident’s clinical record. The resident was admitted from the hospital with an order for olanzapine 2.5 mg daily and had moderate cognitive impairment with no documented behavioral symptoms during the MDS assessment period. Facility physician orders showed olanzapine was started with an indefinite end date, and the MAR reflected administration for several days, with the medication discontinued on November 11, 2025, at 11:41 a.m. A behavioral monitoring order related to olanzapine, initiated the day before, remained active through the resident’s discharge, and no behavioral symptoms were documented during that time. On the same day olanzapine was discontinued, a psychiatry progress note by a PA documented that this was the initial psychiatric visit and stated that no medication changes were recommended, without noting the discontinuation of olanzapine and directing staff to refer to the MAR for non-pharmacologic interventions. A telephone discontinue order for olanzapine was entered by an LPN as a telephone order from the same PA, and the MAR confirmed no further doses were given after that date. Subsequent nurse practitioner notes on two later dates documented that the resident would continue olanzapine and benztropine for psychosis, despite the medication having been discontinued and not provided, and the resident was ultimately discharged without a prescription for olanzapine. Interviews with nursing and pharmacy staff, as well as the PA, confirmed that the discontinuation was not documented in the progress note and that behavioral monitoring and alert charting were not updated, contrary to facility policies requiring accurate documentation of physician-ordered services and nursing documentation of treatment and order changes.
Failure to Follow Medication Administration Parameters for Resident with Bradycardia
Penalty
Summary
The facility failed to ensure that medications were administered within the physician-ordered parameters for a resident with multiple diagnoses, including acute and chronic respiratory failure, hypotension, dependence on a ventilator, and bradycardia. The resident had severely impaired cognition and was prescribed several antihypertensive medications, all with specific instructions to hold administration if the systolic blood pressure was less than 110 mmHg or if the heart rate was less than 60 beats per minute. Despite these clear parameters, the medical records and Medication Administration Records (MAR) showed that nursing staff repeatedly administered Amlodipine, Carvedilol, Clonidine, Doxazosin, and Hydralazine on multiple occasions when the resident's heart rate was below 60 bpm. Interviews with staff confirmed that they were aware of the medication parameters and the risks associated with administering these medications outside of those parameters. A CNA stated that staff are instructed to notify a nurse if a resident's pulse falls below 60 bpm, and an LPN confirmed that medication orders with parameters are to be followed as written. The LPN also reviewed the MAR and acknowledged that medications were given when the resident's pulse was below the required threshold, stating that they should have been held on those days. The Director of Nursing (DON) stated that the facility's expectation is for nursing staff to follow provider orders when administering medications and recognized that bradycardia can be dangerous. The DON also noted that episodes of bradycardia should be reported to the provider and that such events qualify as a change of condition. The facility's Medication Administration policy directs staff to review medication records and adhere to the five rights of medication administration, but this was not followed in the case of this resident.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin and complete a 5-day written investigation as required by their Abuse Policy for a resident. The resident, who had severe cognitive loss due to anoxic brain damage, was found to have a bruise on the left dorsal foot below the second toe, which was later confirmed to be a fracture. The incident was not reported as the facility did not consider it a reportable incident, despite the resident's spouse requesting an X-ray and subsequent hospital evaluation. The resident was admitted with multiple diagnoses, including anoxic brain damage, respiratory failure, and epilepsy, and was always incontinent of bladder and bowel. The care plan indicated the resident had communication problems and potential skin integrity issues. On a specific date, the resident's spouse noticed a bruise and requested an X-ray, which led to the discovery of a fracture. The facility's staff, including a CNA and LPN, followed procedures to notify relevant parties and document the incident, but the facility did not report the injury as required. Interviews with staff revealed that the facility's Director of Nursing and Administrator did not believe the incident was reportable, citing the resident's condition and lack of an open wound. The facility's policy on abuse prevention and reporting was reviewed, which mandates reporting all alleged violations within specified timeframes. However, the facility did not adhere to these requirements, resulting in a deficiency in reporting and investigating the injury of unknown origin.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required timeframe for a resident, which may result in residents being abused or receiving untimely treatment and care. The resident, who was admitted with multiple diagnoses including anoxic brain damage and respiratory failure, was found to have a bruise on the left dorsal foot below the second toe. The resident's spouse informed the nurse of the bruise, and an X-ray was ordered, revealing a fracture. The resident was then transported to the hospital for evaluation and treatment. Interviews with staff revealed that unusual marks are typically reported to the nurse, who then observes the mark, notifies the DON, ADON, the doctor, and family members, and performs any orders received. However, in this case, the facility did not report the incident as they did not consider it reportable, understanding the patient's condition. The DON later acknowledged that in hindsight, the incident should have been reported. The facility's policy on abuse prevention and reporting was reviewed, which requires reporting of all alleged violations within specified timeframes. The report highlights that the facility did not have a list of reportables or 5-day reports available, as shared files were wiped from the system. The new administrator, who started on January 1, noted the absence of these files. The facility's failure to report the injury of unknown origin within the required timeframe constitutes a deficiency, as it may result in residents being abused or receiving untimely treatment and care.
Failure to Manage Resident's Loose Stools and Pressure Wound
Penalty
Summary
The facility failed to provide care and services according to professional standards for a resident who was admitted with multiple diagnoses, including a traumatic hemorrhage of the cerebrum, Alzheimer's disease, dysphagia, and protein-calorie malnutrition. Upon admission, the resident was noted to have an unstageable pressure wound and moisture-associated skin damage (MASD) to the sacrum. Despite a physician's order for wound care, there was no evidence of proper wound measurements or consistent assessments for the risk of developing pressure ulcers. The resident experienced repeated episodes of loose stools, which were documented by CNAs but not effectively communicated to nursing staff, leading to inadequate management of the resident's condition. The resident's condition deteriorated as the pressure wound increased in size, attributed to the ongoing loose stools. Although Imodium was ordered to manage the loose stools, it was only administered once, despite the resident experiencing multiple episodes of diarrhea. The lack of communication between CNAs and nursing staff resulted in a failure to address the resident's loose stools promptly, contributing to the worsening of the pressure wound. The facility's policies on change in resident condition and incontinence care were not followed, as there was insufficient documentation and monitoring of the resident's medical status and interventions. Interviews with staff revealed inconsistencies in the awareness and management of the resident's condition. Some staff members were unaware of the resident's ongoing diarrhea, while others noted the need for frequent changes due to loose stools. The Director of Nursing acknowledged the importance of effective communication and the need for daily assessments of residents with loose stools. However, the facility's failure to adhere to its policies and ensure proper communication and intervention led to the deficiency in care for the resident.
Inadequate Respiratory Care Staffing
Penalty
Summary
The facility failed to ensure that staff had the necessary competencies or skills to provide care for eight residents who required ventilator and tracheostomy care. The facility's census was 75, and the deficiency was identified through personnel record reviews, facility documentation, staff interviews, and policy review. The absence of a scheduled Respiratory Therapist (RT) for the night shift on the ventilator/tracheostomy unit led to Licensed Practical Nurses (LPNs) being responsible for care beyond their scope of practice. This situation resulted in residents not receiving the required tracheostomy care, ventilator checks, or suctioning. The staff schedule revealed that no RT was scheduled for the night shift, leaving LPNs to manage the care of residents on ventilators and tracheostomies. Interviews with staff indicated that LPNs were not comfortable or adequately trained to handle ventilator settings, alarms, or emergent situations. The Director of Nursing acknowledged that LPNs were not able to assess trach or vent residents independently and were only able to assist RTs or RNs. The facility's policy stated that respiratory care should be provided consistent with professional standards, but the lack of trained personnel on the night shift contradicted this policy. Interviews with RTs and LPNs highlighted concerns about the risks associated with LPNs providing care without proper supervision or training. The RTs expressed that airway management is a high-risk task that should not be left to LPNs alone. The facility's failure to staff RTs or RNs for the night shift on the ventilator/tracheostomy unit resulted in inadequate care for residents, as evidenced by the state of the trach and vent patients when the daytime RT arrived. The deficiency posed a significant risk to the health and safety of the residents requiring specialized respiratory care.
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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