Granite Creek Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Prescott, Arizona.
- Location
- 1045 Scott Drive, Prescott, Arizona 86301
- CMS Provider Number
- 035131
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Granite Creek Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and incontinence was admitted without documented skin problems but was identified as at risk for pressure ulcers and ordered to receive frequent repositioning, barrier cream, weekly skin evaluations, and weekly Braden Scale assessments. Within days, CNAs, therapy staff, and nurses documented redness, rashes, open areas, and bleeding on the sacral/coccyx and perineal regions, while provider notes continued to describe the skin as warm and dry without wounds, and there was no evidence that early sacral redness and breakdown were promptly communicated to a provider. Required weekly skin assessments and Braden Scales were missed or incompletely documented, physician orders for barrier cream and repositioning were not consistently recorded as completed on the MAR/TAR, and detailed wound measurements and descriptors for MASD were delayed and backdated. Staff interviews confirmed that the resident experienced severe pain with pericare, that sacral skin was raw, red, and bleeding, that staffing shortages sometimes prevented turning and changing every two hours, and that documentation and communication about the MASD and sacral wound did not meet facility expectations or policy requirements.
The facility failed to provide required written transfer/discharge notices and to notify the State LTC Ombudsman for three residents who were either transferred to the hospital or discharged home. One resident with multiple comorbidities, including dementia and failure to thrive, was sent to the ED at a family member’s request, but there was no documentation of Ombudsman notification. Two cognitively intact residents with complex medical histories had planned discharges home with complete discharge paperwork, including medication lists and personal effects inventories, yet no Ombudsman notification was documented. The Ombudsman office reported not receiving discharge notices for an extended period, the Social Services Manager admitted she had not been formally notifying the Ombudsman, and the DON acknowledged the facility was unaware that notification must be in writing; the written discharge/transfer policy did not address resident notice content or Ombudsman notification.
The facility failed to ensure that meals were palatable, appealing, and consistently served at appetizing temperatures. Multiple residents reported that food was cold, repetitive, mushy, tasteless, or otherwise unappealing, and group interviews revealed concerns about food quality, portion sizes, and being told the kitchen was out when requesting more food. A test tray showed hot items at acceptable temperatures but with overcooked, grayish broccoli, stale bread, and unappealing chicken in the pasta. Staff, including CNAs, an LPN, and the DON, acknowledged that residents had complained about cold and unappetizing food and that staffing shortages contributed to delayed meal delivery. Facility records, including grievance logs and Resident Council minutes, documented ongoing dietary concerns, while written policies addressed food temperatures and nutritional adequacy but did not address the requirement that food be appetizing or appealing.
Surveyors found that medications were left at the bedside for two residents without provider orders or completed self-administration assessments, contrary to facility policy. One resident with pneumonia, AFib, and HTN had Metoprolol and a probiotic left on the bedside table; the resident delayed taking them while on the phone, spilled the pills, and required repeated nurse involvement to replace doses. Another resident with GERD had multiple Tums tablets left in a cup at the bedside, which the resident reported nurses routinely left for self-use. An LPN acknowledged leaving the Tums despite knowing there was no self-administration assessment, while a CNA, RN, and DON all stated that medications should not be left at the bedside without a specific order and proper assessment, and facility policies required locked storage and formal evaluation before self-administration.
Staff failed to consistently follow hand hygiene and TBP protocols. On multiple halls, CNAs and other staff entered and exited resident rooms, handled items such as breakfast trays, beds, and call lights, and moved between rooms without performing hand hygiene, despite stating in interviews that they understood hand hygiene should be done when entering and leaving rooms and before and after resident care. In a shared room with two residents, both EBP and Contact Precaution signs were posted, but a RN did not know which applied to which resident, and a CNA believed the precautions did not apply and therefore did not follow them. Staff entered this room to provide hygiene supplies without PPE or hand hygiene, and the RN later removed both precaution signs and placed them on an isolation cart. The IP and DON reported that posted TBP signs are to be followed until clarified, that stricter precautions should be used when there is conflicting information, and that staff are expected to know and follow TBP and standard precautions for their assigned residents.
The facility failed to protect residents from abuse, leading to incidents where a resident repeatedly entered others' rooms without clothes, causing fear and distress. Despite complaints, the facility's response was inadequate, resulting in continued intrusions. Additionally, a physical altercation between two residents resulted in injuries, highlighting the facility's failure to prevent and address abuse effectively.
A resident, initially assessed as low risk for wandering, repeatedly entered other residents' rooms uninvited, causing distress and fear. Despite reports to the administration, the facility failed to provide adequate supervision or update care plans, leading to ongoing incidents.
The facility failed to maintain a homelike environment for residents, with issues such as scraped paint, damaged drywall, and a ceiling crack with a liquid stain. Residents expressed dissatisfaction with these conditions, which were not addressed in a timely manner despite the facility's policy to maintain a clean and well-repaired building.
The facility failed to secure a medication cart and controlled substances properly. A medication cart was left unlocked in a hallway while a nurse attended to a resident, and backup e-kit boxes containing controlled substances were not double-locked as required. The DON confirmed the expectation for medication carts to be locked and acknowledged the malfunctioning e-kit, with backup boxes awaiting pickup by the pharmacy.
The facility failed to maintain safe food temperatures, risking foodborne illnesses. Observations showed improper food temperatures during lunch service, with staff failing to sanitize temperature rods between uses. The dietary manager acknowledged the lack of a policy for maintaining appropriate food temperatures.
The facility's kitchen was found unsanitary, with grease build-up, debris, and undated food items, risking foodborne illnesses. Six residents received incorrect meals, not matching their dietary needs or preferences. The facility lacked policies for personal food preferences and proper diet execution.
The facility failed to adhere to infection control policies during food preparation and resident care. In the kitchen, staff did not use proper hygiene practices, such as wearing beard coverings and sanitizing equipment, leading to food being served at improper temperatures. Additionally, a nurse did not follow Enhanced Barrier Precautions while caring for a resident with multiple diagnoses, including end-stage renal disease, by failing to wear a gown during medication administration.
A resident with congestive heart failure and other conditions was observed receiving oxygen without a physician's order upon admission to the facility. The facility's records lacked documentation of the initiation or administration of oxygen, and staff interviews revealed no communication with the provider regarding the resident's respiratory status. The facility's policy required physician orders for oxygen therapy, which were not obtained in a timely manner.
A resident with multiple health issues experienced prolonged dental pain due to the facility's failure to ensure timely dental consultations and follow-ups. Despite physician orders and ongoing reports of pain, the resident's clinical records lacked documentation of dental appointments or treatments. Interviews with staff revealed a lack of communication and coordination in managing the resident's dental care, leading to a deficiency in meeting the facility's policy for providing necessary dental services.
A resident with a gluten allergy did not receive appropriate dietary accommodations, as the facility failed to update the care plan and menu options to reflect the need for a gluten-free diet. Despite evaluations indicating the allergy, staff were unaware and did not provide suitable meal alternatives, leading to resident dissatisfaction and potential health risks.
A resident with multiple health issues, including a recent surgery, did not receive physician-ordered wound care services due to a failure in the facility's admission process. The care plan omitted necessary wound vac instructions, and the order was not entered into the system. Staff interviews revealed miscommunication and a lack of oversight, resulting in a delay in applying the wound vac. The facility's policy on implementing orders was not followed, leading to a deficiency in care.
A resident with a seizure disorder did not receive their prescribed clonazepam due to unavailability, resulting in a seizure and the resident leaving the facility AMA. Staff interviews revealed that the facility's emergency kits and pyxis machine did not have the correct dose, and the LPN did not notify the provider about the delay. The facility's policy requires medications to be administered as prescribed.
A resident with lung cancer and dyspnea had their oxygen tubing fall on the floor, and staff failed to replace or sanitize it, violating infection control guidelines. Despite the facility's policy to replace fallen tubing, staff did not notice or address the issue, as confirmed by interviews with an LPN and the ADON.
The facility did not provide written notification to a resident regarding changes in charges for services during their stay, as required by the Admission Agreement. The resident, undergoing IV antibiotic therapy, was discharged without being informed of a $2,800 bill and the expiration of their insurance coverage. Staff interviews revealed confusion and lack of documentation about the resident's financial responsibility, including the issuance of necessary notices like the Advance Beneficiary Notice of Non-Coverage (ABN) or Notice of Medicare Non-Coverage (NOMNC). The resident was verbally informed about the copay requirement but did not receive a formal letter, leading to a deficiency in communication and documentation.
A resident with multiple diagnoses, including ischemic cardiomyopathy and stage 4 chronic kidney disease, was found unresponsive on the toilet by a hospitality aide (HA) who lacked lift and transfer training. The HA assisted the resident without using the call light, contrary to protocol. Interviews with LPN and CNA revealed unclear understanding of HA duties and limitations, indicating communication gaps regarding roles and responsibilities in resident care.
The facility failed to maintain resident shower rooms in good repair, with only 2 out of 5 functional stalls in the Area 100/200 shower room and 3 out of 5 in the Area 300/400 shower room. Observations revealed dirty, stained, and cracked tiles, inadequate water pressure, and potential mold. Staff interviews confirmed the need for deep cleaning and repairs, but no work orders were found addressing these issues.
A resident with multiple diagnoses was not administered prescribed oxyCODONE as ordered, with MAR indicating the resident was sleeping without corresponding notes. Staff interviews and policy review confirmed the deficiency in medication administration and documentation.
Failure to Prevent, Assess, and Treat MASD and Sacral Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to prevent, assess, and treat moisture associated skin damage (MASD) for one resident in accordance with physician orders, facility policy, and professional standards. The resident was admitted with multiple comorbidities, including a periprosthetic fracture around an internal prosthetic left knee, left femur fracture, COPD, pneumonia, atrial fibrillation, breast cancer, and a need for assistance with personal care. An initial admission assessment documented no skin problems, and a care plan and physician orders were put in place for pressure ulcer risk, including frequent repositioning, barrier cream to the perineal area every shift, weekly skin evaluations, and weekly Braden Scale assessments. Early documentation on daily skilled notes and Braden assessment indicated no skin issues and low risk for pressure-related skin impairment, despite the resident being dependent for toileting hygiene and having incontinence. Within days of admission, multiple staff documents and shower sheets began to note redness and abnormal skin color on the lower back and coccyx area, as well as redness, rashes, open areas, and skin tears in the genital and sacral/coccyx regions. These findings were recorded on March 7, 8, and 12 by CNAs and nurses, and an Occupational Therapist documented decubitus ulcers on the inner thighs, vagina, buttocks, and right heel, along with improper healing of a pelvic incision. However, there was no evidence that the redness and skin changes on the lower back and coccyx were communicated to the physician at those times, and provider progress notes repeatedly described the skin as warm and dry without rashes, lesions, or wounds. There was also no evidence of detailed skin assessments or change-of-condition monitoring orders when significant redness, rashes, open areas, and bleeding were documented on shower sheets. Nursing documentation was inconsistent, with several days lacking daily skilled notes, and some weekly skin assessments and non-pressure ulcer assessments created later and backdated, omitting the sacral/coccyx issues. Physician orders for skin care, including barrier cream to the perineal area every shift and frequent repositioning, were not consistently documented as completed on the MAR/TAR for multiple day shifts. Required weekly skin evaluations and Braden Scale assessments were missed or not documented as completed according to the orders, with only the initial Braden assessment and one later assessment recorded. When a coccyx skin injury/ulcer and MASD to the coccyx and upper rear thighs were eventually documented, there were no early measurements or detailed descriptors, and the onset date for the sacro-coccyx MASD wound was later recorded as March 19 with a 6 cm x 5 cm partial thickness wound and peripheral tissue edema. Staff interviews revealed that CNAs and nurses were aware of raw, red, painful, and bleeding skin on the perineal and sacral areas, and that the resident experienced excruciating pain during pericare. Staff also reported that there were times when there were not enough staff to change and reposition the resident every two hours as expected, and that management had been informed of staffing concerns. The wound nurse acknowledged that, based on the documentation, he could not determine when he first assessed the wound, its progression, or whether it was improving or worsening, and the ADON confirmed that the documentation did not meet expectations for identifying, assessing, and treating the resident’s skin condition. Throughout this period, multiple provider progress notes continued to state that the resident’s skin was warm and dry without rashes, lesions, or wounds, even on days when other documentation or staff interviews indicated significant MASD, excoriation, open areas, and bleeding on the sacral/coccyx and perineal regions. The facility’s own policies on wound management, physician orders, documentation and charting, and change of condition reporting required comprehensive assessments, accurate transcription and implementation of orders, complete documentation of care and resident status, and prompt communication of changes in condition to the physician. The clinical record and staff interviews showed that these processes were not consistently followed for this resident, resulting in delayed and incomplete assessment and treatment of MASD and related skin breakdown. The CNA task log for turning and repositioning showed missing entries for required repositioning on certain shifts, and staff interviews indicated that CNAs were expected to check incontinent residents at least every two hours and that nurses were to perform weekly skin checks and notify the wound nurse of any issues. Despite these expectations, there were gaps in documentation of repositioning, missed or incomplete weekly skin assessments, and delayed or absent communication to the provider and wound nurse about the resident’s worsening sacral and perineal skin condition. The ADON and wound nurse both acknowledged that the available documentation did not allow them to determine the wound’s progression or whether interventions were effective, and that the documentation and response to the resident’s MASD did not meet their expectations for quality of care and prevention of worsening skin conditions.
Failure to Provide Required Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written transfer/discharge notices and to notify the State Long-Term Care Ombudsman of resident transfers and discharges, as required by the State Operations Manual Appendix PP. For one resident with failure to thrive, dementia, right-sided hemiplegia, and other comorbidities, the clinical record showed a decline in oral intake, facial and eye twitching, inability to follow commands, and abnormal vital signs. The family requested transfer to the emergency room, and the resident was sent to the hospital; however, there was no documentation in the clinical record or facility documentation that the Ombudsman was notified of this transfer. Two other residents experienced planned discharges home without documented Ombudsman notification. One resident with dysphagia, dysarthria, chronic ischemic heart disease, type 2 diabetes mellitus, parkinsonism, and other conditions had a physician order for discharge home with remaining narcotics, a discharge summary and post-discharge plan of care, and a signed transfer/discharge report including personal effects and medication information. The resident was cognitively intact per a BIMS score of 15 and was discharged home, but the record contained no documentation of Ombudsman notification, and no separate facility documentation of such notification was available. Another cognitively intact resident with paroxysmal atrial fibrillation, neuropathy, and morbid obesity had a planned discharge home documented by physician order, discharge nursing summary, MDS discharge assessment, and a signed transfer/discharge report with personal effects and medication details. Again, there was no documentation of Ombudsman notification in the clinical record or elsewhere. Email correspondence from the Ombudsman office indicated they had not received discharge notices from the facility since June 2024. The Social Services Manager acknowledged she had not been notifying the Ombudsman in the required manner, and the DON stated her expectation that Social Services notify the Ombudsman but admitted the facility did not know the notification had to be in writing. Review of the facility’s discharge/transfer policy showed it did not address transfer/discharge notification to residents or their representatives, did not specify required notice content, and did not state that the Ombudsman must be notified.
Failure to Provide Palatable, Appealing Meals at Appropriate Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food items were palatable, appealing, and consistently served at safe and appetizing temperatures. Review of the 2025 grievance log showed multiple food-related grievances across several months, including general dietary concerns, food temperature concerns, and food preference issues. Resident Council minutes from multiple months documented ongoing concerns about menu variety, food portions, dietary restrictions, and the need to educate residents on proper food serving temperatures. These documented concerns indicate that residents had been voicing dissatisfaction with various aspects of the food service over an extended period. During resident interviews conducted on January 4, 2026, multiple residents reported that the food was cold, repetitive, unappealing, and sometimes not edible despite appearing so. Several residents specifically stated that the food was always cold, not good, or “yucky,” and one resident reported having constantly complained to staff about the food. A lunch test tray observed on January 5, 2026 showed that hot food temperatures were within acceptable ranges, but the steamed broccoli appeared grayish-green, bland, overcooked, and mushy; the chicken in the fettucine alfredo resembled tuna flakes; and the garlic breadstick tasted stale. In a group interview with approximately 12 residents, attendees reported that food was unappealing, mushy, and tasteless, that requests for more food were sometimes met with statements that the kitchen was out of the item, and that double portions appeared the same as regular portions. Staff interviews further confirmed that residents had ongoing concerns about food quality and temperature. The Social Services Manager acknowledged that food concerns had previously been trending in Resident Council meetings, though she believed complaints had decreased. The Dietary Supervisor stated that dietary staff attend Resident Council meetings and that food concerns are usually brought up there or via nursing staff, and she described her practice of checking food temperatures when issues are reported, but she stated she had not received complaints about food not being appealing or appetizing. CNAs and an LPN reported that residents had complained about food being cold, not appetizing, or not appealing, and one CNA attributed cold food to insufficient staffing delaying meal delivery. The DON and other staff recognized that food should be edible, nutritious, hot, and at appropriate temperatures, and acknowledged that unappealing or non-appetizing meals could result in residents not eating enough. Review of facility policies showed guidance on food temperatures and menus meeting nutritional needs and resident choices, but no policy content addressing the requirement that food be appetizing or appealing.
Medications Left at Bedside Without Orders or Self-Administration Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were not left at the bedside for two residents without a provider order and without completion of a self-administration assessment, contrary to facility policy and professional standards. For one resident with pneumonia, atrial fibrillation, hypertension, and a need for assistance with personal care, orders were in place for Metoprolol Tartrate 12.5 mg twice daily for high blood pressure and Saccharomyces boulardii 250 mg twice daily as a probiotic. The resident’s BIMS score indicated that she was cognitively intact and she was independent with eating and oral hygiene, but there was no documentation in the clinical record of an assessment for self-administration or a physician order allowing medications to be left at the bedside. The MAR showed that both medications were administered at the scheduled morning time. During an observation later that same morning, the resident’s medications were found left on her bedside table. As the resident attempted to take the pills, she knocked over the medicine cup, causing both pills to spill. She reported that she was able to retrieve the white probiotic capsule but could not find the small pill for her irregular heart rate, and explained that she had not taken the medications immediately when the nurse brought them because she was on the phone with her brother. Over the next several minutes, a CNA and an LNA entered the room, and the resident informed them that the medication cup had flipped; both staff members indicated they would inform the nurse. When an LPN entered the room, the resident again reported that the medication cup had gone flying. The LPN stated she would provide another pill, then returned with Metoprolol 12.5 mg and also reported finding the other pill in the trash can. While the LPN was present, the resident dropped another pill from her mouth, and the LPN left again to obtain another dose. Interviews with the LPN charge nurse and the DON confirmed that facility expectations were that nurses observe residents swallow medications and do not leave medications at the bedside unless there is a specific order and a completed self-administration assessment, which were not present for this resident. For a second resident with acute posthemorrhagic anemia, atrial fibrillation, GERD without esophagitis, and alcohol dependence, the care plan included a focus on GERD related to medication use, with interventions to give medications as ordered and monitor side effects and effectiveness. The resident’s BIMS score indicated that she was cognitively intact. A physician order directed that Calcium Carbonate (Tums) 500 mg be given by mouth before meals for GERD, and the MAR showed that the medication was documented as administered as ordered. However, there was no evidence in the clinical record from admission through the date of observation that the resident had been assessed for self-administration of medications, and there was no physician order authorizing self-administration of Tums. During an observation, the resident was seen in bed with a glass of water and a clear cup containing three pink circular pills at the bedside. The resident identified the pills as Tums that she takes for stomach issues and stated that nurses leave them there for her to take when needed. An LPN confirmed that the pills were Tums and acknowledged that they were usually left on the bedside table for the resident to take independently, and that she had left them there that day even though the resident did not have a self-administration assessment and medications should not be left at the bedside. A CNA and an RN both stated that no medications, including Tums, should be left at the bedside without a physician order, and the RN noted that if there were an order for self-administration, the medication should be stored in an appropriate container. The DON similarly stated that no medication should be left at the bedside without a physician order for self-administration and that leaving medications such as Tums at the bedside could pose a risk to the resident or others. Facility policies on Medication Access and Storage and Self-Administration of Medications required that drugs be stored in locked compartments accessible only to authorized personnel and that self-administration be based on an interdisciplinary assessment and provider order, conditions that were not met in these instances.
Failure to Follow Hand Hygiene and Transmission-Based Precaution Protocols
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently followed hand hygiene protocols when entering and exiting resident rooms and after contact with resident environments. On one unit, a CNA entered a resident’s room, removed a breakfast tray, then went into another resident’s room, touched the bed and call light, exited, and proceeded directly into a third resident’s room without performing hand hygiene at any point. On another unit, a staff member entered a resident’s room, turned off the call light, and exited without using hand sanitizer or washing hands before or after room entry. A similar observation on a different hall showed another staff member entering and exiting a resident’s room without performing hand hygiene. These observations occurred despite staff interviews confirming their understanding that hand hygiene should be performed when entering and leaving resident rooms and before and after resident care or contact with resident belongings and surfaces. The deficiency also includes failure to follow posted Transmission-Based Precaution (TBP) signage and protocols. In one room with two female residents, two different precaution signs were posted on the door: one for Enhanced Barrier Precautions (EBP) and one for Contact Precautions, with the Contact Precaution sign specifying that gloves and gowns must be worn before entering and discarded before exiting. A RN assigned to the area stated he did not know which TBP posting applied to which resident and deferred to management for clarification. A CNA later stated that one sign was intended for the resident in bed A and the other for the resident in bed B, but he did not know why the residents were on precautions and believed the precautions did not apply, so he did not think the posted signs needed to be followed. Further observations showed that staff entered the same room with the two female residents to provide hygiene supplies without wearing any PPE and without performing hand hygiene prior to entry. Shortly afterward, another staff member also entered the room without PPE or hand hygiene. The RN subsequently removed both the EBP and Contact Precaution signs from the door and placed them on top of the isolation cart across from the room. The Infection Preventionist later stated that two residents with different TBP are not usually placed in the same room, that the stricter TBP should be followed if this occurs, that posted signs must be followed until confirmed otherwise, and that signs should not be removed without consulting her. The DON stated that staff were expected to follow TBP signage unless told otherwise, that nurses should know the TBP status and infection-related information for their assigned residents, and that staff must follow standard precautions, including hand hygiene and the most stringent TBP when there is conflicting information.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of three residents to be free from abuse, resulting in incidents of resident-to-resident abuse. Resident #22, who had intact cognition and was on anti-anxiety medication, reported multiple instances of resident #60 entering her room without clothes, causing her fear and distress. Despite notifying the administrator and director of nursing, no effective action was taken to address the inappropriate behavior of resident #60, leading to further emotional harm to resident #22. Resident #54 also experienced similar intrusions by resident #60, who entered her room and attempted to get into her bed, causing her to feel unsafe. The facility's response was inadequate, as resident #60 continued to roam into other residents' rooms, including resident #54's, despite a red label ribbon being placed on the door. Resident #89 was involved in a physical altercation with his roommate, resident #238, resulting in visible bruising and scratches on resident #89's face. The incident occurred after a disagreement over the television, and although the facility separated the residents and documented the incident, the response did not prevent the initial harm. The facility's investigation revealed that resident #238 had poked resident #89 in the face, causing the injuries. Despite the altercation, the facility's response was limited to documenting the incident and monitoring the injuries, without addressing the underlying issues that led to the altercation. Interviews with staff, including the CNA and the DON, highlighted a lack of effective measures to prevent and address abuse within the facility. The facility's policy on abuse prevention and prohibition was not effectively implemented, as evidenced by the repeated incidents involving resident #60 and the altercation between residents #89 and #238. The facility's failure to create a safe environment and adequately respond to grievances and incidents of abuse resulted in emotional and physical harm to the residents involved.
Inadequate Supervision Leads to Resident Wandering
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to incidents where the resident wandered into other residents' rooms uninvited. Resident #60, who was initially assessed as low risk for elopement or wandering, exhibited behaviors that were not documented in the clinical record, such as entering other residents' rooms without clothing. Despite being care planned for potential dementia-related behaviors, there was no documentation of the supervision required for the resident. Multiple residents reported feeling scared and unsafe due to Resident #60's behavior. Resident #22 expressed fear and distress after Resident #60 entered her room unclothed and attempted to lie on her bed. She reported these incidents to the facility's administration, but felt that her concerns were not adequately addressed. Similarly, Resident #54 reported that Resident #60 repeatedly entered her room, drank her beverages, and watched her sleep, causing her to feel unsafe. Interviews with staff revealed that the facility's response to these incidents was inadequate. The CNA and social service director acknowledged the residents' grievances but did not ensure their safety. The DON and administrator were aware of the residents' concerns but failed to take effective action to prevent further incidents. The facility's policy on elopement and unsafe wandering was not properly implemented, as evidenced by the lack of updated care plans and interventions for Resident #60.
Facility Fails to Maintain Homelike Environment for Residents
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for seven sampled residents, as observed through various deficiencies in room conditions. In the case of two residents, the paint on the walls behind and surrounding the headboards of their beds was scraped off, revealing white patches against the tan wall color. Despite the room being vacated and a new resident moving in, the paint damage remained unrepaired. The new resident expressed that the unsightly condition of the room was bothersome. In another room, two residents experienced similar issues with paint scraped off the walls behind their beds, along with additional damage to the drywall below the window. Another resident's room had a significant area of paint scraped off the wall, with visible damage to the drywall, easily seen from the doorway. These conditions were noted during observations and interviews with the residents, who expressed dissatisfaction with the state of their living environment. Additionally, two residents in another room were affected by a crack in the ceiling above one of the beds, accompanied by a liquid residue stain. The residents reported that the crack had been present for an extended period, with one resident stating it had been there since before their admission over a year ago. Interviews with the Maintenance Director revealed that daily walk-throughs were conducted, but room checks were only done weekly. Despite the facility's policy to maintain a homelike environment, these deficiencies were not addressed in a timely manner, leading to resident dissatisfaction.
Medication Security Deficiencies
Penalty
Summary
The facility failed to ensure that a medication cart was locked when unattended, as observed on October 1, 2024. A medication cart was left unlocked in the hallway of the 400 unit while a nurse was attending to a resident in a room across the hall. The nurse acknowledged leaving the cart unlocked during medication administration. The Director of Nursing (DON) confirmed that it is expected for medication carts to be locked if a nurse leaves their assigned cart. Additionally, the facility did not properly secure controlled medications in the medication storage room. On October 2, 2024, it was observed that two brown plastic storage containers, identified as backup e-kit boxes, were not locked and could be easily opened. These boxes contained various controlled substances, including tramadol, hydrocodone, hydromorphine, methadone, and temazepam, which were not stored under double lock as required by facility policy. The DON stated that the e-kit was malfunctioning, and the pharmacy provided backup boxes that needed to be picked up.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food within safe serving temperatures, which could result in foodborne illnesses among residents. On October 1, 2024, during the lunch tray line observation, the initial temperatures of the food were recorded: meat at 149 degrees Fahrenheit, starch at 178 degrees Fahrenheit, and pasta salad at 70 degrees Fahrenheit. Staff #123 mentioned that the pasta salad would be put on ice to cool it to the desired temperature range. Later, a test tray was monitored throughout the facility, and the final temperatures were recorded as follows: meat at 96.4 degrees Fahrenheit, tater tots at 95.7 degrees Fahrenheit, and pasta salad at 75.6 degrees Fahrenheit. Staff #11 was observed temping each food component without sanitizing the temperature rod between uses. Interviews with staff revealed that the temperatures of the food were not up to professional standards, and there was an expectation for proper sanitization of the temperature rod between temping food components. The dietary manager, staff #14, stated that the expectation for food storage, preparation, distribution, and serving is to label and date food, keep areas clean, wash hands, and maintain appropriate temperatures. However, a review of the kitchen policies showed no policy in place for maintaining appropriate food temperatures, contributing to the deficiency.
Sanitation and Dietary Compliance Issues in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could lead to foodborne illnesses among residents. During an observation, the stove and stacked oven were found with grease build-up and burned debris, and crackers and an applesauce cup were on the floor in the dry storage room. The dietary supervisor stated that cleaning occurs daily, but the cleaning logs lacked initials to confirm task completion. Additionally, yellow square slices were left unattended and undated near a preparation sink, and the kitchen refrigerator had hardened ice collecting on the floor. Cooking and baking sheet pans were stacked with a wet-like substance between them, and the wall behind them had chipped paint. An opened brown bag with a powder substance was also found near the preparation station. The facility also failed to provide meals according to residents' dietary needs and preferences. During a tray line observation, six residents received items not listed on their meal tickets or not in accordance with their prescribed diets. For example, residents with mechanical soft diets were given regular diets, and some residents received items they disliked. Staff reported that in the event of a non-gluten diet, residents receive non-gluten pasta and bread, but they forgot to provide a gluten-free option for burgers and pasta salad. The dietary manager stated that staff is expected to label and date food, keep areas clean, wash hands, and maintain appropriate temperatures. The review of kitchen policies revealed no policy addressing personal preferences or the execution of following established diets as stated on a resident's meal ticket. The policy titled 'Sanitization of Dining and Food Service Areas' requires staff to initial tasks as they are completed, but this was not done. The dietary manager acknowledged the risk of improper temperatures and the impact of not adhering to dietary restrictions, which can upset residents and affect their mood.
Infection Control Deficiencies in Food Handling and Resident Care
Penalty
Summary
The facility failed to adhere to infection control policies during food preparation and distribution, as well as in the care of a resident. In the kitchen, the dietary supervisor was observed without a beard covering, and a cook was seen rinsing hands without using soap before meal preparation. Additionally, a dietary aide did not sanitize the temperature rod between checking different food components, leading to food being served at temperatures below professional standards. These practices could result in foodborne illnesses among residents. Regarding the care of a resident with multiple diagnoses, including metabolic encephalopathy and end-stage renal disease, the facility did not follow Enhanced Barrier Precautions (EBP) as required. A registered nurse entered the resident's room, performed hand hygiene, and donned gloves but failed to wear a gown while administering medications through the resident's feeding tube. The nurse was initially unaware of the EBP requirements and had to refer to the posted precautions to recall the necessary procedures. The Director of Nursing confirmed that EBP involves wearing a gown and gloves when providing direct care to residents with indwelling medical devices or a history of multi-drug resistant organism infections. The facility's infection prevention and control program, revised in July 2023, mandates that all personnel conduct themselves in a way that minimizes the spread of infection. However, the observed deficiencies in both food handling and resident care indicate a failure to adhere to these established protocols.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to ensure that respiratory services were provided according to professional standards for a resident who was admitted with diagnoses including congestive heart failure, hypertension, and coronary artery disease. Upon admission, there were no orders for oxygen use in the resident's hospital discharge orders. Despite this, the resident was observed receiving oxygen via nasal cannula on multiple occasions without a corresponding physician order documented in the facility's records until several days later. The facility's records, including the resident's care plan and progress notes, lacked documentation of the initiation or administration of oxygen. Interviews with staff revealed that there was no communication with the provider regarding a change in the resident's respiratory status or the need for oxygen. The facility's policy required that oxygen therapy be administered as ordered by a physician or as an emergency measure until an order could be obtained, but this protocol was not followed. Observations and interviews indicated that the resident was unsure of the oxygen dose and the reason for its administration. Staff interviews highlighted a lack of adherence to the facility's policies on documentation and communication regarding changes in the resident's condition. The Director of Nursing confirmed the absence of timely documentation and emphasized the importance of such documentation for continuity of care across shifts.
Failure to Address Resident's Dental Needs
Penalty
Summary
The facility failed to ensure that the dental needs of a resident were met, leading to a deficiency in care. The resident, who was cognitively intact, was admitted with multiple diagnoses including subluxation of the right shoulder joint, sequelae of cerebral infarction, hypertension, major depressive disorder, hyperlipidemia, and acute kidney failure. Despite a physician's order for a dental consultation and treatment as needed, the resident's clinical records did not show any documentation of a dental referral or visit, even after the resident reported teeth pain and was prescribed antibiotics for a teeth infection. The resident's clinical records revealed multiple instances where dental issues were noted, yet no follow-up actions were documented. A physician's progress note indicated the resident's need for a dental consultation due to teeth pain, and subsequent notes showed the resident was experiencing ongoing pain and was prescribed antibiotics. However, there was no evidence of a dental appointment being scheduled or conducted, and the resident continued to report pain during assessments. The facility's failure to document and follow through with necessary dental care resulted in the resident experiencing prolonged discomfort and potential complications from untreated dental issues. Interviews with facility staff highlighted a lack of communication and coordination regarding the resident's dental care. The Director of Social Services and the Case Manager were unsure of their roles in managing dental follow-ups, and the Unit Secretary noted that the resident was last seen for dental care in August, with no further information on treatment needs. The Director of Nursing expressed that staff should alert providers to dental issues and ensure follow-up appointments are scheduled, emphasizing the importance of oral health in overall resident care. Despite these expectations, the facility's policy to provide access to dental services was not effectively implemented, resulting in the deficiency.
Failure to Accommodate Gluten Allergy in Resident's Diet
Penalty
Summary
The facility failed to meet the dietary needs of a resident with a gluten allergy, which could lead to malnutrition and dissatisfaction with meals. The resident, who was admitted with multiple diagnoses including a gluten allergy, had a care plan that did not address this allergy. Despite quarterly nutrition evaluations indicating the need for a gluten-free diet, the resident's diet order was not consistently updated to reflect this requirement. The facility's menu and alternative options did not clearly indicate gluten-free items, and during a tray line observation, the resident was served food items that were not gluten-free. Interviews with the resident and staff revealed a lack of awareness and communication regarding the resident's dietary restrictions. The resident expressed dissatisfaction with the food options, stating that they were not offered appropriate gluten-free substitutions. Staff members, including a CNA and an LPN, were not aware of the resident's gluten allergy and did not ensure that the dietary restrictions were communicated or adhered to. The Dietary Supervisor admitted to forgetting to provide gluten-free options on a particular day, and the CNA indicated that it was the resident's responsibility to request alternative meals. The Director of Nursing expressed expectations that dietary restrictions should be documented and communicated, but acknowledged uncertainty about whether the resident's needs were being met. The facility's policies on menus and nutrition emphasized the importance of meeting residents' dietary needs, but these were not effectively implemented in practice. The lack of proper dietary accommodations for the resident with a gluten allergy highlights a deficiency in the facility's ability to provide appropriate nutritional care.
Failure to Implement Physician-Ordered Wound Care
Penalty
Summary
The facility failed to provide a resident with physician-ordered wound care services, specifically the use of a wound vac, as indicated in the hospital discharge orders. The resident, who was admitted with multiple diagnoses including acute kidney failure, diabetes, and a recent surgical history, had a care plan that did not include the necessary wound care instructions. The care plan only mentioned interventions such as floating heels and monitoring the skin injury, but omitted the wound vac instructions. Upon review of the clinical records, it was found that there was no order for wound care instructions and wound vac in the Point Click Care (PCC) system. Interviews with staff revealed a breakdown in the admission process, where the admission nurse failed to input the wound vac order into the system. The resident had a wound vac at the bedside and mentioned that it needed to be changed every other day, but the facility initially did not have one available. Further interviews with staff, including the LPN, admission nurse, and director of nursing, highlighted a lack of communication and oversight in ensuring the wound vac order was placed and followed. The wound nurse confirmed that the wound vac was not applied until two weeks after the resident's admission, due to a lack of supplies and miscommunication about the order. The facility's policy requires accurate implementation of orders, but this was not adhered to in this case, leading to a deficiency in care.
Medication Unavailability Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that medication was available for administration as ordered by the physician for a resident with a history of myoclonic seizures, hypertension, and neuropathy. The resident was admitted with a physician's order for clonazepam 1 mg at bedtime for anxiety, but the medication was not available at the time of administration. The electronic medication administration record noted that clonazepam was unavailable, and the pharmacy was contacted for delivery. The resident reported not receiving the medication during the scheduled medication pass, which led to a seizure and the resident leaving the facility against medical advice. Interviews with staff revealed that the facility had emergency kits, but they did not contain all medications, and the pyxis machine had clonazepam in a different dose than ordered. The LPN did not notify the provider about the delay in medication delivery, which could have medically impacted the resident. The Assistant Director of Nursing confirmed that clonazepam was available in the pyxis but in a different dose, and a new order from the doctor was needed to administer it. The Director of Nursing agreed that a new order was necessary to pull the medication from the pyxis. The facility's policy stated that medications should be administered as prescribed by the attending physician.
Infection Control Deficiency in Oxygen Use
Penalty
Summary
The facility failed to adhere to infection control guidelines related to oxygen use for a resident diagnosed with primary pulmonary adenocarcinoma and dyspnea. The resident had a physician order for oxygen therapy and a care plan that included continuous oxygen via nasal cannula. On a specific day, the resident's oxygen tubing was observed on the floor by her bed, and multiple staff members entered the room without addressing the fallen tubing. The resident later reported that staff picked up the tubing but did not sanitize it or provide new tubing, contrary to the facility's policy. Interviews with staff revealed a lack of awareness and adherence to infection control protocols. An LPN stated that new tubing should be provided if it falls on the floor, but admitted not noticing the incident. The ADON confirmed that staff should replace any tubing that falls on the ground and use hand sanitizer when entering and exiting resident rooms. The facility's policy on oxygen administration allows for tubing replacement as needed, and the infection prevention policy aims to decrease infection risk and correct problems related to infection control practices.
Failure to Provide Written Notification of Payment Liability Changes
Penalty
Summary
The facility failed to ensure that Resident #3 was provided with a written notification of changes in charges for services during their stay. Despite the Admission Agreement stipulating that any changes in charges based on the resident's condition should be communicated in advance, there was no evidence that Resident #3 received written notice of a liability change for payment. The resident, who was on IV antibiotic therapy for an infected prosthetic knee joint, was discharged without being informed of a $2,800 bill received post-discharge and the expiration of their insurance coverage. Staff interviews revealed discrepancies in communication regarding the resident's liability for payment. The Assistant Business Office Manager indicated that the resident became responsible for a copay on the 21st day of their stay, but there was confusion about issuing a Notice of Medicare Non-Coverage (NOMNC) due to Medicare coverage dropping to 70%. The Business Office Manager acknowledged that there was a lack of documentation regarding discussions with Resident #3 about payor changes and the issuance of necessary notices like the Advance Beneficiary Notice of Non-Coverage (ABN) or NOMNC. The Business Office Manager mentioned that the resident was informed about the copay requirement verbally but admitted that no formal letter was given to Resident #3 regarding the liability change. Despite the resident expressing financial concerns and being unable to leave due to ongoing IV therapy, there was a delay in providing written notification of the payment liability change. The lack of proper communication and documentation regarding the resident's financial responsibility during their stay led to the deficiency in ensuring Resident #3 was adequately informed of potential liabilities for services not covered by Medicaid/Medicare.
Resident Care and Role Clarity Deficiency
Penalty
Summary
The facility failed to ensure that resident #5 received treatment and care in accordance with professional standards of practice. Resident #5 had pertinent diagnoses including Ischemic cardiomyopathy, atrial fibrillation, stage 4 chronic kidney disease, diabetes mellitus type 2, hypertension, and hyperlipidemia. On February 15, 2024, the resident was found unresponsive while sitting on the toilet by a hospitality aide (HA/staff #108) who did not have lift and transfer training. The HA, who was not a certified nursing assistant, assisted the resident to the bathroom without hitting the call light as promised, leading to the resident being found slumped over. The LPN and CNA interviewed were not clear on the duties and limitations of hospitality aides, indicating a lack of clarity and communication within the facility regarding roles and responsibilities in resident care.
Deficiencies in Shower Room Maintenance and Cleanliness
Penalty
Summary
The facility failed to ensure that all resident shower rooms were in good repair. During an initial observation and walk-through of both shower rooms, it was found that the Area 100/200 shower room had only 2 out of 5 shower stalls functional, and the Area 300/400 shower room had only 3 out of 5 shower stalls functional. Additionally, the Area 100/200 shower room had a dirty or stained/discolored tile floor, while the Area 300/400 shower room had cracked tiles on both the floor and lower wall of the shower stalls. Interviews with staff revealed that the maintenance director did not consider the limited number of functional shower stalls or the broken and discolored tiles to be a concern. However, CNAs reported that the shower rooms needed deep cleaning, the shower heads needed replacement, and the water pressure was inadequate. They also noted that the tiles were stained, the grout was dirty, and the cracked tiles posed a safety hazard for residents and staff. Further observations during a follow-up walk-through confirmed the issues reported by the CNAs. In the Area 300/400 shower room, there were missing floor tiles at the entrance/exit, stalls without shower heads and handles, brownish/gray material on the tile floor and bottom tile wall, cracked tiles with moist crevices containing dark/black unknown material, a broken shower head holder, a missing pull help string, and a cracked tub box with black material. In the Area 100/200 shower room, there was brownish/gray material on the tile floor, stalls used as storage, missing floor tiles at the entrance/exit, and a wet area under the sink with a brown unknown material spot. Interviews with additional staff confirmed that the shower rooms were dated and needed work, with concerns about mold and the safety hazards posed by the cracked tiles. Review of the facility's Shower Room Cleaning Log indicated that the shower rooms were cleaned weekly, including sweeping, mopping, and deep cleaning of walls and tiles with bleach. However, a review of work orders from September 24, 2023, to January 23, 2024, did not show any work orders related to the shower room issues. The facility's policy on Facility Maintenance stated that procedures should be established for routine and non-routine care to ensure the facility remains in good working order for resident and staff safety. Despite this policy, the facility failed to address the deficiencies in the shower rooms, leading to an unsafe and unsanitary environment for residents and staff.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered by the provider. Resident #350, who has diagnoses including urinary tract infection, chronic obstructive pulmonary disease, depression, gastro-esophageal reflux disease, hypertension, and convulsions, was prescribed oxyCODONE HCI oral tablet 5mg to be taken every 4 hours for pain. However, the Medication Administration Record (MAR) revealed that the medication was not administered on multiple occasions, with the reason coded as the resident was sleeping. There was no documentation in the eMAR progress notes indicating that attempts were made to wake the resident or that the medication was attempted to be administered as required by the facility's policy. Further review of the MAR indicated that the prescribed oxyCODONE was held multiple times, with progress notes stating that the medication was either on order or awaiting delivery from the pharmacy. An investigation report revealed that the resident had raised concerns about not receiving the medication, but the facility's review concluded that all medications had been administered per physician's orders, which was unsubstantiated. Interviews with staff confirmed that the proper procedure was not followed, as there were no corresponding notes to justify the coding on the MAR, and the medication should have been administered as scheduled or the resident should have been woken up. The Assistant Director of Nursing (ADON) confirmed that the facility's policy requires medications to be administered as prescribed and documented accurately. The ADON also noted that the mismatched codes and progress notes were unacceptable and that the resident not receiving the prescribed medication could lead to pain and loss of trust in the staff. The facility's policy on the administration of drugs emphasizes the importance of administering medications within the scheduled time frame and documenting any deviations accurately in the clinical record.
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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