Haven Of Lakeside
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakeside, Arizona.
- Location
- 3401 North Lockwood Drive, Lakeside, Arizona 85929
- CMS Provider Number
- 035277
- Inspections on file
- 25
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Haven Of Lakeside during CMS and state inspections, most recent first.
A resident admitted with multiple complex wounds, including a sacral/coccygeal pressure ulcer, did not receive timely, physician-ordered treatment for that pressure injury. Admission skin assessments and the care plan identified a coccyx/sacrum pressure ulcer, but no corresponding provider orders for sacral wound care, Santyl, zinc, or specific dressings were entered into the EMR for an extended period. The ADON created handwritten wound treatment plans and logs, including use of Santyl and sacral foam dressings, but these were not integrated into the EMR and were unsupported by prescriber orders. Nursing notes documented repeated refusals of “wound care” without specifying which wounds or treatments were refused, and there was no documentation of resident education or provider notification. The admission MDS inaccurately coded that the resident had no pressure ulcers or pressure-ulcer care, despite existing documentation of a coccyx/sacrum ulcer. MAR/TAR records showed no sacral wound treatments until a late physician order for coccyx care was finally entered and started, resulting in a cited deficiency for failure to provide appropriate pressure ulcer care and timely treatment according to physician orders.
A resident with dementia, osteomyelitis, multiple DFUs, and a sacral/coccyx pressure ulcer was admitted with complex wound needs, but the facility failed to maintain a complete and accurate medical record for the sacral wound. Although a care plan identified a coccyx pressure ulcer and the wound nurse created handwritten treatment plans involving Santyl, zinc, and sacral dressings, these documents were not incorporated into the EMR and lacked physician orders. Early physician orders addressed wound vac care and foot and heel wounds but omitted the sacral/coccyx ulcer, and wound care notes and late entries referenced refusals and treatments without specifying which wounds were involved or what care was actually provided. The admission MDS documented no pressure ulcers or pressure-ulcer care despite the existing coccyx ulcer care plan, the sacral pressure ulcer diagnosis was not added until later, and TAR documentation for coccyx wound care did not begin until after a delayed physician order was entered, resulting in an incomplete, inconsistent, and non–policy-compliant record of the resident’s sacral pressure ulcer and its treatment.
A resident with a history of sexually inappropriate behavior and no cognitive impairment was reported by staff to have placed his hands down the pants of another resident with severe cognitive impairment while they were kissing, and to have previously made sexually explicit comments in common areas. The alleged victim’s record contained no documentation of the incident, and the facility did not report the allegation to the State Agency, Ombudsman, or law enforcement. The DON and Administrator reviewed video footage, concluded the interaction was behavioral rather than abuse, did not identify the involved female resident, allowed the footage to be auto-deleted, and did not conduct or document a thorough investigation as required by the facility’s abuse reporting and investigation policy.
The facility failed to report an allegation of abuse involving two residents and did not submit investigation results to the State Agency within the required timeframe. A resident with a history of sexually inappropriate behavior and no cognitive impairment was reported by staff to have placed his hands inside the back of another cognitively impaired resident’s pants while they were kissing. A NP documented the staff report and later documented, based on information from the DON after video review, that the residents were holding hands and that the alleged perpetrator had placed a hand on the other resident’s thigh. The alleged victim’s record contained no documentation of the incident. The ADON, DON, and Administrator acknowledged awareness of the allegation and review of camera footage but did not identify the involved resident and determined the event was a behavior rather than abuse, choosing not to report it to the State Agency, Ombudsman, or law enforcement, contrary to facility policy and regulatory requirements.
The facility failed to thoroughly investigate an allegation that a cognitively intact resident with a history of sexually inappropriate behavior placed his hands down the pants of a severely cognitively impaired resident and engaged in kissing. Although the NP documented the staff report and the DON and Administrator later stated that video footage showed the residents holding hands and one resident’s hand on the other’s thigh, there was no incident documentation in the alleged victim’s record, no clear identification of the reporter or the involved female resident, and no evidence of a comprehensive investigation as required by facility policy. The DON characterized the event as a behavior rather than abuse, did not report it to the SA, and indicated an investigation was unnecessary because it occurred on a behavior unit, contrary to the written abuse reporting and investigation procedures.
Multiple residents did not receive medications in accordance with physician orders and professional standards. One resident with depression and dementia had a lidocaine 4% patch still on the leg despite the MAR indicating it had been removed the prior evening, and was given 50 mg of sertraline when the active order and MAR required 100 mg. Another resident with chronic pain had a lidocaine patch applied to the ankle each morning without any ordered or documented removal schedule, and an LPN was observed removing an existing patch and immediately applying a new one. A third resident with hypertension and UTI had a lidocaine patch ordered for the shoulder in the morning, but no removal time was ordered or transcribed, and an RN was observed removing an old patch and applying a new one without a defined wear interval. A fourth resident on furosemide for edema had an order for 20 mg BID without specified times, yet the MAR scheduled and staff administered doses at approximately 8:00 and 12:00, only about 3.5–4 hours apart, even though neither the provider nor the pharmacist had ordered or recommended that timing and facility policy required adherence to written orders and established medication schedules.
Surveyors found that the facility’s activities program was directed by an Activities Director whose personnel file and resume did not demonstrate that she met the qualification requirements outlined in the State Operations Manual. The job description for the position only required basic employment clearances and English proficiency, omitting the federally required professional qualifications, and there was no facility hiring policy provided. HR and the DON reported that they relied on this incomplete job description to vet the candidate, and HR confirmed that the Activities Director had no prior activities position experience and was still in the process of obtaining Activity Director Certification while already overseeing resident activities.
The facility failed to ensure that its Daily Staff Posting accurately reflected actual nurse staffing and resident census. On multiple weekend dates, posted numbers and hours for CNAs, LPNs, RNs, CMAs, and valets did not match signed assignment sheets or time-clock punch details, including instances where staff called off, an RN was listed as an LPN, and staff worked different shifts than posted. The Daily Staff Posting at the reception desk was also observed without the census, and leadership initially provided an incorrect census before later confirming the correct number. Staff interviews confirmed that the posting is supposed to show how many staff are working and the census, and that accurate posting is important for compliance and for informing families and the public.
Surveyors identified multiple medication administration and transcription errors that resulted in a medication error rate at or above 5%. One resident with depression and dementia received a lidocaine 4% patch that remained on beyond the documented removal time, and was given sertraline 50 mg despite an active order and MAR documentation for 100 mg daily. Other residents with pain orders for lidocaine 4% patches had physician orders and MARs that lacked clear removal schedules, and staff were observed removing an existing patch and immediately applying a new one without documented timing parameters. Another resident receiving furosemide 20 mg BID for edema had the order transcribed on the MAR as 8:00 AM and 12:00 PM, and staff administered doses approximately 3.5–4 hours apart, even though the original physician order did not specify times and interviews with clinical staff, the provider, and the pharmacist indicated that BID furosemide is typically spaced further apart.
The facility did not ensure that several staff members received and documented required Disaster training, as mandated by its staff development policy and facility assessment. Personnel files for an RN, two LPNs, and a CNA contained signed job descriptions and orientation acknowledgements but no clear evidence of completed Disaster training. Review of the electronic training system and in-service logs with HR confirmed that Disaster training was either not assigned or not completed for these staff. Rosters later submitted by the facility listed staff names with handwritten check marks for Disaster-related education but lacked specific completion dates. Interviews with HR, an LPN, a CNA, and the DON described reliance on an electronic training system, monthly in-services, and annual computer-based training, and confirmed that Disaster and Emergency Preparedness education is expected but was not documented as completed for the affected staff.
The facility did not ensure that staff completed required Resident Rights education. Review of personnel files and in-service logs for an RN and an LPN showed no documented completion of Resident Rights training despite signed job descriptions requiring participation in mandatory education and a policy and facility assessment identifying Resident Rights as a required competency. HR acknowledged that Resident Rights training had not been assigned or was assigned but not completed, and that the training system was not consistently loading required courses. An LPN and a CNA reported that while in-services and computer-based training occur, Resident Rights training was not consistently provided, and the DON stated that Resident Rights education is expected during orientation and periodically thereafter to prevent knowledge deficits that could delay responses and impact care.
The facility failed to ensure that multiple staff members and an NA student received and had documented education on abuse, neglect, exploitation, and the Elder Justice Act. Personnel files, in-service logs, and the electronic training system for several RNs, LPNs, CNAs, and the activity director lacked evidence of Elder Justice Act training, and one RN also had no documented abuse training. Orientation acknowledgments and job descriptions did not specify training content, and later rosters provided by the facility listed staff names with handwritten check marks but no dates or clear proof of completion. An NA student in a free CNA class had only a TB test on file and no Elder Justice Act training documentation, as the facility did not treat class participants as employees for training purposes. Staff interviews confirmed that some newer staff had not received abuse or Elder Justice Act training, while facility policies and the facility assessment required abuse-related education and, in the abuse policy, explicitly mandated Elder Justice Act education during orientation and annual in-services.
A resident with multiple chronic conditions and on hospice had conflicting documentation of code status across the clinical record. A Prehospital Medical Care directive signed by the representative indicated DNR, but a later advance directive form signed by the resident had no selection for Full Code or DNR, and the code status was not reflected in the care plan or physician orders. Staff reported that the EHR banner showed DNR, while the hard chart form with no selection was interpreted as Full Code by default, even though a signed DNR was also present in the hard chart. This inconsistency in documentation did not align with facility policy requiring written changes, MDS and care plan updates, and physician notification for appropriate orders.
A resident with documented diagnoses of depression, anxiety disorder, bipolar disorder, schizoaffective disorder, psychotic disorder with hallucinations, and schizophrenia, and who was receiving antipsychotic and antidepressant medications, was not referred for a Level II PASRR evaluation. Care plans identified psychosocial issues related to multiple mental health conditions and included an intervention to initiate referrals as needed. Multiple Level I PASRR screenings, completed by the hospital and later in the facility, listed only anxiety and depression and indicated no Level II referral was necessary, despite the clinical record showing serious mental illness. Staff interviews revealed that the case manager did not perform PASRR screenings, the resident relations manager handled PASRRs but did not initiate a Level II referral for this resident, and the administrator confirmed there was no Level II PASRR referral, contrary to facility policy requiring such referrals when potential mental illness is present.
A resident on hospice for terminal pancreatic cancer had a hospital plan for an indefinite full liquid diet, but in the facility was placed on a regular/regular diet with thin liquids and no documented food preferences on the tray ticket. CNA logs showed frequent meal refusals and low intake, and progress notes repeatedly documented nausea, abdominal pain, very poor appetite, and pain or difficulty swallowing, yet there was no evidence that hospice or the facility provider was notified of these changes or that comfort‑focused dietary interventions were implemented. The resident reported that meals were too hard to eat and that alternate soft or liquid foods were not consistently provided, while meal observations showed regular‑texture items such as toast, crispy bacon, and hot dogs. The resident also sustained a fall with a head abrasion, with documentation inconsistently reflecting whether hospice was notified, and the hospice clinical director later reported hospice had not been informed of the fall or intake issues, despite a hospice agreement and facility policies requiring notification and coordinated care planning.
A resident with dementia, prior CVA, and right-sided hemiplegia initially had normal upper extremity ROM per early OT/PT evaluations but later developed a persistently flexed right wrist and fingers, observed multiple times while the resident used only the left hand for eating and mobility, without any splint or brace in place. Over an extended period, NP notes, nursing summaries, therapy screening, MDS coding, and IDT documentation did not identify or assess upper extremity ROM limitations, did not document ROM services, and did not include a care plan with ROM interventions. A CMA reported the resident could not move the right arm or fingers, that the wrist and fingers were stiff and hard, that the resident was not on therapy or an RNA program, and that prior therapy and splints had reportedly been refused, though these refusals and any ROM program were not documented in the record. The DON and rehab director described expectations for assessment, provider notification, and therapy screening, but there was no evidence of ongoing ROM assessment, documented refusals, or restorative interventions, leading to a deficiency for failure to provide appropriate ROM care.
Surveyors found that an LPN stored a bottle of lactobacillus acidophilus (probiotic) in an uncovered gray basin with ice packs on top of a locked medication cart, rather than in locked storage, and used it during a medication pass. Staff interviews revealed this was a standard practice: probiotics and certain supplements were kept on ice in a basin or ice bucket on top of the cart, covered with a towel to keep them out of residents’ view, instead of being locked in the medication cart or medication room. Another LPN acknowledged that any medication not locked could be accessed by a resident without a physician’s order, while the DON stated that probiotics, though ordered by a physician, were treated as supplements and stored on ice on top of the cart according to manufacturer instructions, and he did not believe there was risk beyond spoilage.
The facility failed to ensure that clinical staff received and had documented mandatory infection control education as required by its own policies and facility assessment. A RN and an LPN had personnel files showing signed job descriptions and general orientation acknowledgments, but no clear evidence of infection control training being assigned or completed, and the training system confirmed no such training for them. A later annual education roster listed these staff with handwritten check marks but did not specify when training was completed. Additional staff interviews revealed that a CNA had not received infection control training despite on-the-job orientation, while an LPN described general in-services and CBTs. The DON stated that infection control education is required at hire and annually, consistent with written policies, but the documented training for these staff did not meet those requirements.
Surveyors found that several RNs, LPNs, and CNAs lacked clear, documented Dementia Care training despite facility expectations and a facility assessment stating that Dementia competencies begin at orientation and are completed shortly after hire and annually. Personnel files typically contained job descriptions and orientation acknowledgements but did not specify Dementia Care content, and neither the electronic training system nor in-service logs showed completed Dementia training for these staff at the time of review. A later-submitted annual education roster listed these staff with handwritten check marks next to Dementia-related topics but did not indicate when the training was actually completed. Staff interviews confirmed that some employees had not received Dementia Care training and highlighted reliance on general orientation, monthly in-services, and computer-based modules without specific documentation of Dementia education.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents sustained burns after a smoking-related accident involving supplemental oxygen. One resident, with multiple medical conditions and a history of burns, was allowed to smoke independently and caught fire when his cigarette ignited his clothing and oxygen tubing. Another resident, also assessed as a safe smoker, was burned while attempting to help extinguish the fire. Facility policy required oxygen to be turned off before smoking, but this was not verified, and staff did not supervise the residents at the time of the incident.
A resident with multiple chronic conditions experienced a significant change in condition that was recognized and reported by therapy staff, but nursing staff initially dismissed the symptoms and delayed assessment and emergency intervention. The resident was eventually hospitalized with severe infection and sepsis. A staff member who reported concerns of neglect was later asked to alter her documentation and was terminated, and the facility did not investigate or report the incident as required by policy.
A resident with multiple chronic conditions experienced a significant change in mental and physical status that was observed by therapy and nursing staff, as well as family, but staff delayed assessment and transfer to emergency services. Despite repeated notifications, some staff dismissed the symptoms, and the provider delayed action until after completing documentation. The resident was later hospitalized with severe infection and respiratory failure. Additionally, the resident received oxygen therapy on several occasions without a physician order or care plan, contrary to facility policy.
A resident with multiple respiratory conditions received oxygen therapy on several occasions without a provider order, care plan, or documentation of the oxygen dose. Facility staff confirmed that required documentation and orders were missing, and facility policies for oxygen administration and recordkeeping were not followed.
Multiple residents with cognitive and behavioral impairments engaged in repeated verbal and physical altercations, including object throwing and slapping, resulting in injuries such as skin tears and bruising. Despite staff awareness and recommendations for separation, facility leadership did not implement timely room changes, allowing the abuse to continue. Care plans and safety checks were in place, but administrative decisions overrode staff efforts to prevent further incidents.
A resident with severe cognitive impairment and behavioral symptoms was physically abused by another cognitively impaired resident with a history of aggression. Staff were aware of escalating behavioral issues and prior verbal altercations between the two, but failed to update care plans or document the incident and related behaviors, resulting in inadequate prevention of further abuse.
The facility failed to protect residents from abuse, as incidents involving physical altercations between residents occurred. A resident with cognitive impairments was punched by another resident, and two residents with severe cognitive impairments engaged in a physical altercation. Staff interviews revealed inconsistencies in supervision, contributing to the deficiency.
The QAA committee failed to ensure the DON's attendance at meetings from February to May 2024, as required by facility policy. The DON position saw multiple personnel changes, with the ADON, an LPN, acting as DON during this period. Interviews confirmed the absence, and the facility could not provide documentation of the DON's presence at these meetings.
A resident with moderate cognitive impairment was unable to make choices about their bathing schedule, leading to missed showers. Despite expressing a preference for daytime showers, staff continued to schedule them at night, resulting in refusals and missed opportunities. Facility policies on accommodating resident preferences were not effectively implemented.
A resident with severe cognitive impairments experienced an unwitnessed fall resulting in a major injury, including a forehead laceration and a broken finger. Despite the severity and the resident's inability to explain the incident, the facility did not report it to the Department of Health Services as required. The interdisciplinary team presumed the injuries resulted from the fall and decided not to report, contrary to the facility's policy on prompt reporting and investigation of suspected abuse or injuries of unknown origin.
A resident with myotonic muscular dystrophy and other conditions did not receive necessary personal hygiene services, as the facility failed to document or attempt scheduled showers. Despite being dependent on staff for hygiene, the resident reported not having a shower or bed bath for a month, and observations confirmed poor hygiene. Staff interviews revealed inconsistencies in documentation and a preference for bed baths, which were not accommodated.
A resident with a history of aggression hit another resident, resulting in a deficiency. Despite interventions in place, the aggressive resident admitted to the incident, which was unwitnessed but documented. The affected resident confirmed being hit, and staff interviews revealed known triggers for the aggressive resident's behavior. The facility's abuse prevention policy was not effectively implemented, leading to the deficiency.
Failure to Obtain and Implement Timely Physician-Ordered Care for Sacral Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and treat a sacral/coccygeal pressure ulcer and to obtain and implement physician-ordered treatment for that wound. A resident was admitted with multiple serious conditions, including dementia, osteomyelitis, sepsis, diabetic foot ulcers, a right heel deep tissue injury, and a history of left great toe amputation. On admission, a weekly skin check and wound assessment documented multiple wounds, including a pressure injury on the coccyx/sacrum, and the care plan initiated the same day identified a pressure ulcer to the coccyx with interventions such as pressure-relieving mattress, weekly skin assessments, and monitoring and reporting changes. An audit of the skin assessment showed that an LPN initially documented a pressure injury on the coccyx, which was later edited by the ADON/RN to indicate a pressure injury on the sacrum. Despite this, there was no corresponding physician order in the electronic record for wound care to the coccyx/sacrum at admission or in the days immediately following. Handwritten paper documents created by the ADON, including a Treatment Plan and Evaluation of Care dated the day after admission and a Formal Wound Assessment log, described cleansing the sacral wound, applying Santyl, oil emulsion, skin prep, sacral dressing, and zinc oxide if full treatment was refused, and referenced enzymatic debridement and sacral foam protection. These documents also contained notations about the resident refusing daily changes and being confused, and later entries indicated refusals of wound assessment and treatment on several consecutive days. However, these handwritten records were not part of the electronic medical record, did not show clearly what wound care was actually performed, and there was no evidence of a physician order for Santyl, zinc, or specific sacral dressing changes during that period. The facility’s standing wound orders did not include Santyl, and the ADON, who lacked prescriptive authority, stated she believed she had told the physician about her treatment recommendations but there was no documented provider order. Late-entry notes by nursing staff documented that the resident refused wound care on multiple days, but did not specify which wounds or treatments were refused, and there was no documentation of resident education, multiple attempts, or provider notification regarding these refusals. Further documentation inconsistencies contributed to the deficiency. A Pressure Ulcer Documentation assessment for the sacral wound, showing an unstageable ulcer measuring 4.3 cm by 5.2 cm with significant slough and moderate exudate, was created and signed more than a week after the admission date and described the visit as an initial assessment. Another pressure ulcer assessment created later again documented the same unstageable sacral ulcer with similar measurements and noted zinc and sacral foam dressings and that new orders for daily Santyl were placed, yet no corresponding physician order was found in the clinical record for that date. The admission MDS, completed by the MDS coordinator using EMR data, recorded that the resident had no pressure ulcers and no pressure-ulcer care, despite the care plan and nursing documentation indicating a coccyx/sacrum pressure ulcer. The MDS coordinator acknowledged that the pressure ulcer appeared to have been missed. Review of the MAR/TAR showed no sacral/coccygeal wound treatments documented for the remainder of the admission month and into the following month until a physician order for coccyx wound care, including Santyl and specific dressing steps, was finally entered with a start date nearly two weeks after admission, and treatments to the coccyx began on that start date. Interviews with nursing staff, the ADON, and the DON confirmed that the resident had an unstageable sacral pressure ulcer on admission, that the ADON kept separate handwritten wound records, that floor nurses did not consistently recognize or document the sacral wound, and that the DON relied on standing wound orders despite the absence of specific physician orders for the sacral pressure ulcer treatment. The facility’s own policies required full assessment and documentation of pressure ulcers, including measurements and exudate description, and required that wound treatments and topical agents be ordered by a physician or other authorized prescriber and recorded as written, dated, and signed orders. Policies also required that wound care documentation include the type of wound care given, date and time, resident position, staff performing the care, changes in condition, and detailed assessment data. In this case, there was no evidence of timely, complete sacral wound assessment in the EMR at admission, no timely physician orders for sacral wound treatment, incomplete and delayed documentation of the sacral pressure ulcer, and missing or nonspecific documentation of wound care actually provided. The combination of undocumented or late-entered assessments, lack of provider orders for Santyl and other sacral treatments, inaccurate MDS coding omitting the pressure ulcer, and absence of MAR/TAR entries for sacral wound care until well after admission constituted the actions and inactions that led to the cited deficiency in providing appropriate pressure ulcer care and preventing further ulcer development. The facility’s standing orders and wound care policies were reviewed and showed that while standard wound preparation, cleaning, and non-sharp debridement techniques were authorized, the use of prescription enzymatic debridement agents such as Santyl required a specific provider order, which was not present for the sacral wound during the relevant period. The ADON’s reliance on handwritten treatment plans and separate wound logs, not integrated into the EMR and not supported by provider orders, further contributed to the lack of clear, timely, and authorized treatment for the sacral pressure ulcer. Interviews with staff revealed confusion about the presence and location of the sacral wound, with at least one LPN stating he did not believe the resident had sacral wounds, and the DON acknowledging that terms like coccyx and sacrum were used interchangeably, which may have affected documentation clarity. Collectively, these documented failures in assessment, physician ordering, EMR documentation, and implementation of wound care for the sacral pressure ulcer formed the basis of the deficiency.
Incomplete and Inaccurate Documentation of Sacral Pressure Ulcer and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete, accurate, and readily accessible medical record for a newly admitted resident with multiple complex wounds, including an unstageable pressure ulcer of the sacrum/coccyx. The resident was admitted with dementia, Alzheimer’s disease, osteomyelitis, sepsis, multiple diabetic foot ulcers, a pressure-induced deep tissue injury of the right heel, a nephrostomy tube, and an acquired absence of the left great toe. A weekly skin check and wound assessment documented numerous skin impairments, including a pressure injury on the sacrum, but did not provide details or measurements for that sacral wound. A care plan initiated on admission identified a pressure ulcer to the coccyx and called for weekly skin assessments and treatments as ordered, yet there was no corresponding, timely, or complete documentation of physician orders or wound treatments for the sacral/coccyx ulcer in the electronic medical record. Handwritten paper documents created by the ADON, including a Treatment Plan and Evaluation of Care and a Formal Wound Assessment dated shortly after admission, described a sacral wound treatment regimen involving Santyl, oil emulsion dressings, zinc oxide as an alternative if the resident refused full treatment, and sacral dressings. These documents also referenced resident refusals of daily dressing changes and confusion. However, these handwritten records were not part of the electronic medical record, lacked a physician signature or order, and did not clearly document what wound care was actually provided on specific dates. The Formal Wound Assessment log noted refusals of wound assessments and treatment objectives on several days, but did not specify which treatments were refused or what, if any, care was completed. Late-entry notes by nursing staff documented that the resident refused “wound care” on multiple days without identifying which wounds or treatments were involved, and there was no evidence of documented education, multiple attempts, or provider notification regarding these refusals. Physician orders in the record addressed wound vac care and wound care to the left foot and right heel but did not initially include any orders for treatment of the sacral/coccyx pressure ulcer. A pressure ulcer documentation assessment and related wound notes for the sacral wound were entered as late entries in early January, describing an unstageable sacral pressure ulcer measuring 4.3 cm by 5.2 cm with significant slough and exudate, and referencing daily Santyl treatments and zinc and sacral foam dressings, despite the absence of corresponding physician orders for Santyl or zinc at that time. The resident’s diagnosis list did not include a sacral pressure ulcer diagnosis until early January, and the admission MDS assessment documented no pressure ulcers or pressure ulcer care, even though the care plan already identified a coccyx pressure ulcer. Wound care to the coccyx did not appear on the treatment administration record until several days into January, after a physician order for coccyx wound care was finally entered. Interviews with nursing, MDS, and leadership staff confirmed inconsistent recognition and documentation of the sacral wound, reliance on separate handwritten wound records not integrated into the EMR, late entries due to the wound nurse being behind on paperwork, and a lack of clear, physician-ordered, and properly documented wound care for the sacral/coccyx pressure ulcer during the initial period after admission, contrary to facility policies on charting, skin/wound management, and physician orders.
Failure to Report and Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, exploitation, and misappropriation reporting and investigation policy after an allegation of sexual abuse between two residents. One resident, identified as having dementia, a history of traumatic brain injury, anxiety disorder, major depressive disorder, transient ischemic attack, and cerebral infarction, was care planned for behavior problems including wandering, refusing care, eating other residents’ food, and being sexually inappropriate. A Nurse Practitioner (NP) note documented that staff reported this resident had his hands inside the back of another resident’s pants while both residents were kissing, and that this resident was a registered sex offender with a history of making sexually explicit comments in common areas and becoming upset when redirected. The facility’s policy required immediate reporting of suspected abuse to the administrator and state and local agencies, and a thorough investigation, but this did not occur as required. The alleged victim was a resident with schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer’s disease, who had severe cognitive impairment as evidenced by a BIMS score of 00. This resident’s care plan identified communication problems related to impaired cognition and hearing deficit, and interventions such as anticipating needs, maintaining consistent routines, and using strategies to reduce confusion. Despite the NP note describing staff reports that the alleged perpetrator had his hands down this resident’s pants and that both residents were kissing, there was no documentation in the alleged victim’s clinical record of an incident with another resident on the date in question. There was also no documentation that the incident was reported to the State Agency, Ombudsman, or law enforcement, and no evidence that a thorough investigation was completed and reported within 5 working days as required by facility policy. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator, and other staff further demonstrated that the facility did not implement its abuse reporting and investigation policy. The ADON acknowledged awareness of a report that the alleged perpetrator put his hands down a female resident’s pants and stated it was reported to the DON and Administrator, but she did not know who witnessed the incident and did not review the camera footage. The DON and Administrator stated they reviewed video footage and concluded the residents were holding hands and that on one occasion the alleged perpetrator placed his hand on the alleged victim’s thigh; they considered the event a behavior rather than abuse and did not report it to the State Agency. They also stated they did not know the identity of the female resident involved, and the video footage was no longer available due to automatic deletion after 72 hours. The DON stated it would only be considered abuse if the psychiatric provider said so and that no preventive measures were in place because the sexually inappropriate conduct was considered a behavior. The NP reported he did not witness the incident or review the footage and wrote a second note after the DON described what he saw on the video. Other staff reported hearing about the incident but did not witness it. These actions and omissions show the facility did not follow its own policy requiring immediate reporting, preservation of evidence, identification and interview of involved parties and witnesses, and complete documentation of the investigation. The facility’s written policy on Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating required that all reports of resident abuse, including suspected abuse and injuries of unknown origin, be immediately reported to the administrator and to state and local agencies, including the state licensing/certification agency, Ombudsman, adult protective services (where applicable), and law enforcement. The policy also required that the administrator initiate and ensure a thorough investigation, including review of documentation and evidence, review of the resident’s medical record and condition, observation of the alleged victim, interviews with the reporter, witnesses, the resident or representative, physician as needed, staff on all shifts, roommates, family, visitors, and other residents cared for by the accused, as well as complete documentation of the investigation. In this case, there was no evidence that these required steps were carried out, that the alleged victim was assessed or interviewed as appropriate, that witnesses were identified and interviewed, or that evidence such as video footage was preserved and protected from destruction. The failure to follow these policy requirements in response to the allegation of sexual abuse between residents constitutes the cited deficiency.
Failure to Report Alleged Resident-to-Resident Sexual Abuse and Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse involving two residents to the State Agency, Ombudsman, and law enforcement, and failure to submit the results of the investigation to the State Agency within 5 working days as required by regulation and facility policy. One resident, identified as the alleged perpetrator, had diagnoses including dementia, history of traumatic brain injury, anxiety disorder, major depressive disorder, and cerebrovascular disease, and had a care plan noting behavior problems such as wandering, refusing care, eating other residents’ food, and being sexually inappropriate. This resident’s MDS showed a BIMS score of 15, indicating no cognitive impairment. The other resident, identified as the alleged victim, had schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer’s disease, with care plans documenting impaired cognition, hearing deficit, and neurocognitive disorder, and an MDS BIMS score of 0, indicating severe cognitive impairment. On the date of the alleged incident, a NP note documented that staff reported the alleged perpetrator had his hands inside the back of the pants of the alleged victim and that both residents were kissing. The note also documented that the alleged perpetrator was a registered sex offender and had a history of sexually explicit verbal behavior and difficulty with redirection. A later NP note, written after the DON reviewed camera footage, stated that the initial staff report was inaccurate and that the video showed the residents holding hands, with one occasion where the alleged perpetrator placed his hand on the alleged victim’s thigh. The clinical record for the alleged victim contained no documentation of the incident between the two residents on the date in question. Interviews with the ADON, DON, Administrator, and other staff confirmed that an allegation had been made that the alleged perpetrator placed his hands down a female resident’s pants, but the DON and Administrator could not identify which staff member reported it and did not know which female resident was involved, despite having reviewed video footage. The DON stated that the incident was discussed in an IDT meeting, that the video showed hand-holding and a hand on a thigh, and that the incident was considered a behavior and not abuse, leading to the decision not to report it to the State Agency. The Administrator stated that intent to cause harm would constitute abuse, and the DON stated it would only be considered abuse if the psychiatric provider said so. There was no evidence in the records or facility documentation that the allegation was reported to the State Agency, Ombudsman, or law enforcement, and no evidence that the results of any investigation were reported to the State Agency within 5 working days, despite facility policy requiring immediate reporting of suspected abuse and a follow-up investigation report within 5 business days.
Failure to Thoroughly Investigate Alleged Sexual Abuse Between Residents
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a cognitively intact resident with known sexually inappropriate behaviors and a severely cognitively impaired resident. The alleged perpetrator had dementia, a history of traumatic brain injury, and a care plan identifying sexually inappropriate behavior, with interventions such as removal from situations and explanation of inappropriate behavior. On the date of the incident, a staff member reported to the NP that this resident had his hands inside the back of another resident’s pants and that both residents were kissing. The NP documented that the resident was a registered sex offender and had a history of making sexually explicit comments in common areas and becoming upset when redirected. A later NP note, based on information from the DON after review of camera footage, stated that the initial report was inaccurate and that the residents were holding hands, with one instance of the alleged perpetrator placing his hand on the alleged victim’s thigh. The alleged victim was a resident with schizoaffective disorder, dementia, bipolar disorder, obsessive compulsive behavior, anxiety disorder, and Alzheimer’s disease, with a care plan noting impaired cognition, hearing deficit, and neurocognitive disorder. The resident’s MDS showed a BIMS score of 0, indicating severe cognitive impairment, and interventions included anticipating needs, maintaining consistent routines, and facilitating communication. Despite the reported incident between these two residents, there was no documentation in the alleged victim’s clinical record of the event on the date it was reported. The facility’s records contained no evidence that a formal incident report or a comprehensive investigation specific to this allegation was completed or documented. Interviews with the ADON, DON, Administrator, and other staff further demonstrated that the allegation was not thoroughly investigated in accordance with facility policy. The ADON and DON acknowledged awareness of a report that the resident placed his hands down a female resident’s pants but could not identify who reported it, and neither could identify the female resident involved, despite the DON and Administrator stating they had reviewed video footage. The DON stated the incident was considered a behavior and not abuse and therefore was not reported to the State Agency, and he indicated that an investigation was not needed because the incident occurred on the behavior unit. The NP confirmed he did not witness the incident or review the video and wrote a second note based on the DON’s description. Review of the facility’s abuse policy showed that all allegations of abuse must be thoroughly investigated and reported, including review of records, interviews with reporters, witnesses, the resident, and others, and complete documentation of findings, which was not evidenced in this case, nor was there evidence that the results of any investigation were reported to the State Agency within 5 working days.
Medication Administration Not Consistent With Physician Orders and Standards of Practice
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders and professional standards for multiple residents. For one resident with hypertension, depression, and non-Alzheimer’s dementia, the care plans required that opiate and antidepressant medications be administered as ordered. During a medication pass observed with an LPN, the nurse removed a lidocaine 4% patch from the resident’s left lower leg just before applying a new patch, despite the Medication Administration Record (MAR) indicating the previous patch had been removed the prior evening. The physician’s order for the lidocaine patch specified application to the knee once daily for pain but did not include application and removal times, and there was no evidence of a physician order specifying the schedule that had been transcribed on the MAR. In the same observation, the LPN administered a 50 mg sertraline tablet even though the current physician order and MAR required 100 mg once daily. A CMA later stated that the resident’s dose had been increased from 50 mg to 100 mg, that a new 100 mg bubble pack had recently arrived, and that she had given two 50 mg tablets the previous day because she had not yet seen the new 100 mg pack. For another resident with hypertension, anxiety disorder, and depression, the care plan directed that opiate analgesics be administered per orders. The physician ordered a lidocaine 4% patch to be applied to the ankle once daily for pain, but the order did not specify when to apply or remove the patch. The MAR transcribed the order as application in the morning without any removal schedule. During an observed medication pass, an LPN removed an existing lidocaine patch from the resident’s right ankle and immediately applied a new patch to the same site, with no documented or ordered time frame for how long the prior patch had been in place. A third resident with hypertension and a UTI had a physician order for a lidocaine 4% patch to the right shoulder in the morning for pain, again without a specified removal time. The MAR showed administration of the patch, but no removal schedule was transcribed. During an observed medication pass, an RN removed a lidocaine patch from the resident’s right shoulder and applied a new patch below the right shoulder, again without any documented or ordered removal interval. A fourth resident with hypertension, depression, PTSD, morbid obesity, and edema was receiving diuretic therapy with furosemide. The care plan required medications to be administered as ordered, with monitoring for side effects and attention to dosing and potential need for modification. The physician order summary showed furosemide 20 mg by mouth twice daily for edema, with no specific administration times. The MAR, however, listed the doses at 8:00 AM and 12:00 PM, approximately four hours apart, without any corresponding physician order specifying those times. The MAR documented administration at 8:00 AM on one survey day, and an LPN was observed administering another 20 mg dose at 11:28 AM, about three and a half hours after the prior dose. Nursing staff interviewed stated that twice-daily furosemide is usually given in the morning and late afternoon or evening, and one RN stated that giving it at 8:00 AM and 12:00 PM could cause excessive urination and increase the risk of dehydration. The provider later stated that standard practice for twice-daily furosemide is morning and evening and that he does not advise morning and noon dosing, while the pharmacist stated that furosemide is usually given 6–8 hours apart and that administration times are normally set by the facility unless specified by the provider. Facility policies required medications to be administered only upon written order, with orders consistent with safe and effective order writing, and established that BID medications are to be given according to a routine schedule unless a physician specifies otherwise or an alternate schedule is documented, but the BID furosemide schedule for this resident had been set and followed without a corresponding physician instruction in the record.
Unqualified Activities Director and Inadequate Position Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the activities program was directed by a qualified professional as required by federal regulations. Personnel file review showed that the Activities Director was hired to manage all aspects of the activities program, including development, implementation, supervision, evaluation, completion of the activities component of the comprehensive assessment, and development of related care plan goals and approaches. The facility job description for this position listed only basic employment requirements such as background check, fingerprint clearance, TB clearance, post-hire health screening, and English proficiency, and did not include the qualification requirements specified in the State Operations Manual for an Activities Director. Review of the Activities Director’s resume showed prior employment as a Senior Research Associate/Administrative Director and educational credentials including a Master in Education and a Bachelor of Arts in Music Therapy, Music Education, and Psychology, but did not demonstrate that the individual met the specific qualification requirements outlined in the State Operations Manual. The personnel file indicated that the Activities Director applied for Activity Director Certification several months after hire and that the application was still under review. HR staff confirmed that the Activities Director had not previously held an activities position and that her role at the facility included overseeing activities for residents. HR and the DON both stated that they rely on the job description to determine qualifications and that there was no hiring policy in place, and the facility did not provide a hiring policy when requested by surveyors.
Inaccurate Daily Nurse Staffing and Census Posting
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the Daily Staff Posting accurately reflected the actual number and type of direct care nursing staff on duty and the current resident census. Surveyors reviewed PBJ staffing data, Daily Staff Postings, signed staffing/assignment sheets, and time clock punch details for multiple weekend dates and found repeated discrepancies. On several reviewed dates, the number of CNAs, LPNs, RNs, CMAs, and valets listed on the Daily Staff Posting did not match the actual staff who worked, and the total hours posted did not match the hours recorded in the punch details. The facility’s own assessment indicated a licensed capacity of 112 residents, an average daily census of 90, and a staffing plan specifying numbers of nurses/CMAs and direct care staff per shift, but the posted staffing information did not consistently align with actual staffing. On June 30, 2024, the Daily Staff Posting showed 5 CNAs and 60 CNA hours for the night shift, while the signed staffing sheet and punch details showed only 4 CNAs worked, with 50.23 actual hours after one CNA called off. On September 21, 2024, the posting showed no valets on the day shift, one RN and two LPNs on the night shift, and 5 CNAs on the night shift, but punch details showed 2 valets worked part of the day shift, no RN worked the night shift, 3 LPNs worked the night shift for 37.74 hours, and only 4 CNAs worked the night shift for 49.49 hours. On December 29, 2024, the posting showed 2 LPNs and 24 LPN hours on the day shift and 5 CNAs and 60 CNA hours on the night shift, but the assignment sheet showed one LPN called off and an RN erroneously listed as an LPN, and one CNA called off for the night shift; punch details confirmed only 1 LPN worked 12.40 hours on days and 4 CNAs worked 41 hours on nights. On March 8, 2025, the posting listed 9 CNAs and 108 CNA hours and 5 valets and 60 valet hours on the day shift, and 6 CNAs and 72 CNA hours on the night shift, but the assignment sheet showed only 7 CNAs scheduled for days with one CNA calling off on days and one CNA calling off on nights. Punch details showed 8 CNAs actually worked 95.39 hours on days, 4 valets worked 42.61 hours on days, one CNA scheduled for nights worked days instead, and only 4 CNAs worked 48.76 hours on nights. On May 4, 2025, the posting showed 24 CMA hours and 9 CNAs with 108 CNA hours on the day shift, but the assignment sheet documented 2 CNAs called off; punch details showed 22.80 CMA hours and 8 CNAs working 91.86 hours. During the survey entrance, the Daily Staff Posting at the reception desk lacked the census, the charge nurse could not state the current census, and the ED initially gave an incorrect census that differed from the CMS-671 form before later confirming the correct number. On the following day, the Daily Staff Posting again lacked the census until it was later updated. Interviews with the staffing coordinator, HR, and DON confirmed that the Daily Staff Posting is intended to show how many staff are working and the census, and they acknowledged that accurate posting is important for compliance and for informing the public, but the postings reviewed were not accurate or consistently completed.
Multiple Medication Administration and Transcription Errors Exceeding Acceptable Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication error rates were below 5%, as evidenced by multiple observed and documented errors in medication administration and order transcription. For one resident with hypertension, depression, and non-Alzheimer’s dementia, surveyors observed an LPN administer a lidocaine 4% patch after first removing an existing white patch from the resident’s left lower leg, despite the MAR documenting that the previous day’s patch had been removed the prior evening. The physician’s order for the lidocaine patch specified application to the knee once daily for pain but did not include instructions for when to remove the patch. The MAR showed the lidocaine patch transcribed with an 8:00 AM application and 8:00 PM removal schedule, with documentation indicating that the patch had been removed the previous night, which conflicted with the presence of a patch still on the resident’s leg at the time of observation. For the same resident, a physician order for sertraline 100 mg once daily was in place and had been transcribed to the MAR, with documentation showing administration of 100 mg daily since the order date, yet during observation the LPN dispensed and administered only 50 mg. Further review and interviews revealed additional details about the sertraline dosing error. A CMA stated that the resident had previously received 50 mg sertraline, and that the dose had been increased to 100 mg. She produced a new bubble pack of sertraline 100 mg and explained that it must have arrived two days earlier. She reported that she had administered two 50 mg tablets the previous day because she had not seen the new 100 mg bubble pack until then. The DON stated that when a psychotropic medication dose is changed, facility policy requires a new assessment and consent, and that the old 50 mg bubble pack should be returned to the pharmacy once the 100 mg dose is ordered. He also stated that staff are expected to follow physician orders at all times during medication administration. Additional residents were involved in lidocaine patch administration issues. One resident with hypertension, anxiety disorder, and depression had a physician order for a lidocaine 4% patch to be applied to the ankle once daily for pain, without any schedule for removal. The order was transcribed on the MAR to be applied in the morning, but no removal time was documented. During observation, an LPN removed an existing patch from the resident’s right ankle and immediately applied a new patch to the same site. Another resident with hypertension and a UTI had a physician order for a lidocaine 4% patch to be applied to the right shoulder in the morning for pain, again without removal instructions. The MAR did not include a removal schedule, and during observation an RN removed a patch from the resident’s right shoulder and applied a new patch just below the shoulder. The DON later reviewed a lidocaine 4% patch package, which stated it was for single use, to be used for up to 12 hours and then discarded, while also stating that if no removal instructions were provided, nurses might use clinical judgment or manufacturer guidelines. A separate medication error involved the administration schedule of furosemide for a resident with hypertension, depression, PTSD, morbid obesity, and edema. Provider progress notes documented a plan to increase furosemide to 20 mg twice daily for edema, and the physician order summary reflected furosemide 20 mg twice daily without specified administration times. However, the MAR for the month showed the order transcribed as 20 mg twice daily at 8:00 AM and 12:00 PM. On the survey date, furosemide was administered at 8:00 AM and again at approximately 11:28 AM, about 3.5 hours apart. There was no evidence in the clinical record of any physician order specifying the 8:00 AM and 12:00 PM schedule. Interviews with nursing staff, the provider, and the pharmacist indicated that standard practice for twice-daily furosemide is to space doses further apart (e.g., morning and late afternoon/evening), and the pharmacist noted that furosemide is usually given 6–8 hours apart. The LPN who administered the medication stated she had been giving it at 8:00 AM and 12:00 PM since the order was written, based on her understanding that this was how the provider wanted it scheduled, while also stating that she would normally question such a schedule. The DON confirmed that the electronic record set the twice-daily schedule and that, in this case, staff were expected to give the second dose four hours after the first, consistent with how it had been entered.
Failure to Provide and Document Required Disaster Training for Multiple Staff
Penalty
Summary
The facility failed to ensure that multiple staff members received required Disaster training as part of its staff development and emergency preparedness program. Personnel records and training documentation for four staff members showed no evidence that Disaster training had been completed, despite facility policies and the facility assessment stating that Emergency Preparedness, including Fire and Disaster training, was a mandatory topic and that such competencies were to be started during orientation and completed within the first few weeks of hire and then annually. New Employee Orientation Acknowledgements and signed job descriptions for these staff members referenced participation in required trainings and events but did not specify the content or confirm completion of Disaster training. For a registered nurse hired in August 2024, the personnel file contained a signed job description and a New Employee Orientation Acknowledgement, but there was no documentation that Disaster training had been completed. Review of the in-service training log and the electronic training system, conducted with the HR representative, confirmed that Disaster training was neither assigned nor completed for this nurse at the time of survey. After survey exit, the facility submitted a Clinical Staff Annual Education roster listing this nurse’s typed name with a handwritten check mark under a training complete section and indicating Disaster as a topic, but the roster did not clearly show when the training was actually completed. For an LPN hired in 2016, the personnel file similarly lacked evidence of completed Disaster training, although the job description required participation in all required trainings. The HR representative stated that the training system is supposed to assign courses and that Disaster training was assigned to this LPN but had not been completed, and the in-service training log did not show completion. A Clinical Staff Annual Education roster later provided by the facility listed the LPN’s typed name with a handwritten check mark and indicated Elder Justice Act among the topics, but again without clear dates of completion. For a CNA hired in February 2025 and another LPN hired in 2019, personnel files, orientation records, the training system, and in-service logs all lacked documentation of Disaster training. Subsequent rosters submitted after survey exit showed their typed names with handwritten check marks but no clear indication of when the Disaster training was completed. Interviews with staff further described the facility’s training practices and expectations. The HR representative explained that the electronic training system is responsible for assigning courses and acknowledged that, based on the records reviewed, some courses were not being assigned and that certain staff had no Disaster training documented in either the system or orientation. An LPN reported that staff receive training via monthly in-services and yearly computer-based modules and stated that training on Disaster topics is important so staff know what to do and how to care for residents in such situations. A CNA who identified as a relatively new employee reported receiving on-the-job training but no other training yet, and was told there would be online training to complete within two months. The DON stated that staff are expected to follow facility policy by completing general orientation and periodic education throughout the year, and emphasized that Disaster training is important so staff know how to evacuate and respond in emergencies and be prepared to protect residents, noting that lack of training could lead to a knowledge deficit and delayed responses that impact care.
Failure to Ensure Staff Completion of Resident Rights Training
Penalty
Summary
The facility failed to ensure that staff were educated on resident rights and facility responsibilities, as evidenced by missing or incomplete training documentation for multiple staff members. A personnel file review for an RN hired on August 1, 2024 showed a signed job description requiring participation in all required trainings, but no evidence that this RN had completed Resident Rights training. Review of the in-service training log also did not show Resident Rights training for this RN, and the HR representative confirmed that the Resident Rights course had not been assigned or completed for this staff member at the time of the survey. Similarly, the personnel file for an LPN hired on September 20, 2016 contained a signed Resident's Rights Summary from the date of hire and a signed job description requiring participation in trainings, but there was no evidence of current Resident Rights training. The in-service training log did not show completion of Resident Rights training for this LPN, and HR stated that while the training had been assigned, it was not completed. HR also reported that the training system was responsible for assigning courses and that there were issues with required courses not being assigned or loaded in a standardized way for all staff. Additional staff interviews supported that Resident Rights training was not consistently provided. An LPN reported that staff receive monthly in-services and yearly computer-based training and stated that training on Resident Rights is important so staff can recognize when something inappropriate is occurring and know what to do. A CNA who identified as a relatively new employee stated that although on-the-job training was provided, Resident Rights training had not been provided, and that they were told there would be online training to complete within two months and had only started some Resident Rights training online. The DON stated that the expectation is that staff complete general orientation and periodic education, including Resident Rights, and that lack of such training could lead to a knowledge deficit, delayed responses, and impact care. Facility policy and the facility assessment both identified Resident Rights as a mandatory topic and a required competency to be started during orientation and completed within the first weeks of hire and annually, but the documentation and interviews showed this was not consistently occurring.
Failure to Provide and Document Required Abuse and Elder Justice Act Training for Staff and NA Student
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multiple staff members received required education on abuse, neglect, exploitation, and the Elder Justice Act, as well as failure to ensure one staff member received abuse education and one NA student received Elder Justice Act training. Surveyors requested personnel files and proof of abuse and Elder Justice Act training for several identified staff and one NA student. For a registered nurse hired in August 2024, the personnel file contained a signed job description and a new employee orientation acknowledgment, but there was no documentation specifying what training was covered, and no evidence in the personnel file, in-service logs, or the training system that abuse or Elder Justice Act training had been completed. Later, a clinical staff annual education roster provided by the facility listed this RN’s typed name with a handwritten check mark, but without any clear indication of when the training was actually completed. For an LPN hired in 2016, the personnel file showed a Preventing and Reporting Resident Abuse and Elder Justice Act form signed at hire, but there was no evidence of current Elder Justice Act training in the personnel file, in-service logs, or the training system. The HR representative confirmed that the Elder Justice Act course was not indicated in the system for this LPN and acknowledged that required courses were not being consistently assigned or loaded. Similar findings were documented for the activity director, a CNA, another CNA, and an LPN, all of whom had signed job descriptions and orientation acknowledgments that did not specify training content, and none had documented Elder Justice Act training in their personnel files, the training system, or in-service logs. For some of these staff, the facility later produced a clinical staff annual education roster with typed names and handwritten check marks, but again without dates or clear evidence of when or if the Elder Justice Act training was completed, and in some cases the staff member’s name did not appear on any relevant roster. For another RN hired in February 2025, the personnel file contained a signed job description and orientation acknowledgment, but no documentation of Elder Justice Act training in the file, training system, or in-service binder. HR confirmed the absence of this training and stated that courses would need to be added to the system. Additionally, for an NA student participating in a free CNA class, the facility stated that the individual was not an employee and that only a TB test was on file; items requested as part of a personnel record, including Elder Justice Act training, were not obtained for non-employee participants. There was no documentation of Elder Justice Act training completion for this NA student in the in-service logs or email attachments. Staff interviews supported these findings: one LPN described that training is provided via monthly in-services and yearly computer-based modules and emphasized the importance of abuse training, while a CNA reported receiving on-the-job training but no abuse or Elder Justice Act training and being told that online training would need to be completed later. Facility policies and the facility assessment indicated that abuse, neglect, and exploitation are mandatory topics and that employees are to receive education on the Elder Justice Act during orientation and annual in-services, but there was no specific mention of Elder Justice Act training in the staff development program policy, and the documented training for the cited staff did not align with these expectations. The facility’s own documents further highlighted inconsistencies between policy and practice. The Staff Development Program policy required all personnel to participate in initial orientation and regularly scheduled in-service training classes and identified abuse as a mandatory topic, but did not reference Elder Justice Act training. The facility assessment stated that competencies, including abuse, neglect, and exploitation, are started during orientation and completed within the first few weeks of hire and then annually, without specific mention of Elder Justice Act. In contrast, the Abuse Policy explicitly required that all employees receive education on the Elder Justice Act, including contact and reporting information, and that education on abuse prevention, recognition, and reporting be provided during new hire orientation, annual in-services, and as needed. The lack of documented training for the cited staff and the NA student, despite these written requirements, formed the basis of the deficiency. Interviews with HR and leadership corroborated the documentation gaps. HR repeatedly acknowledged during joint reviews with surveyors that the training system had not assigned or loaded Elder Justice Act courses for several staff and that there was no documentation of completion in either the system or orientation records. HR suggested checking in-service binders, which did not show evidence of the required training for the cited staff. The DON stated that the expectation is for staff to complete onboarding orientation covering general education and to receive periodic education throughout the year, and emphasized the importance of abuse and Elder Justice Act training so staff know how to identify, report, and understand residents’ rights. Despite these stated expectations and policies, the survey findings showed that at least one staff member lacked abuse education and multiple staff and an NA student lacked documented Elder Justice Act training, leading to the cited deficiency.
Inconsistent Documentation of Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that a resident’s advance directives were consistent and correctly documented throughout the clinical record. The resident, who had diagnoses including COPD, atrial fibrillation, and vascular dementia, was admitted to hospice and had a Prehospital Medical Care directive signed by the resident’s representative indicating a DNR (Do Not Resuscitate) status. However, an advance directive form signed by the resident several days later in the clinical record had no selection marked for either Full Code or DNR. There was no evidence that the resident’s code status was reflected in the care plan or in physician’s orders. During interviews, the Clinical Resource staff member acknowledged that the advance directive on file was not adequate because the resident’s choice was unclear on the signed form, which could cause confusion about the resident’s wishes. An RN explained that in an emergent code situation, staff would check the electronic chart banner and then the hard chart at the nurse’s station; for this resident, the electronic banner indicated DNR, while the signed form in the hard chart showed no code status selection, which the RN interpreted by default as Full Code. The RN noted that a signed DNR could be found elsewhere in the hard chart, but the lack of consistency across the resident’s clinical record could lead to confusion about which directive to follow. The facility’s policy stated that changes or revocations of advance directives must be in writing to the administrator, reflected in the MDS and care plan, and that the DON or designee would notify the attending physician so appropriate orders could be entered, but this was not consistently carried out for this resident.
Failure to Refer Resident With Serious Mental Illness for Level II PASRR Evaluation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple serious mental health diagnoses was referred for a Level II Pre-admission Screening and Resident Review (PASRR) as required. The resident was initially admitted and later readmitted with diagnoses including myocardial infarction, depression, anxiety disorder, bipolar disorder, schizoaffective disorder, psychotic disorder with hallucinations, and schizophrenia. Care plans dated in early January 2024 documented the resident’s use of antipsychotic and antidepressant medications related to schizoaffective disorder and identified psychosocial well-being problems related to anxiety, depression, psychosis, substance abuse, schizoaffective disorder, and bipolar disorder, with an intervention to initiate referrals as needed. A Level I PASRR dated March 8, 2024 indicated that the resident did not have a Serious Mental Illness such as schizophrenia, schizoaffective disorder, bipolar disorder, major depression, or paranoid disorder, and listed only anxiety disorder and depression as mental disorders, concluding that no Level II referral was necessary. However, the resident’s clinical record and subsequent assessments documented active diagnoses of anxiety disorder, depression, bipolar disorder, psychotic disorder with hallucinations, schizoaffective disorder, and schizophrenia, and confirmed ongoing use of antipsychotic and antidepressant medications. An MDS assessment showed the resident was cognitively intact and had active psychiatric diagnoses, and provider progress notes in May and September 2025 continued to list multiple serious mental health conditions and active psychotic symptoms. Interviews with staff revealed gaps in the PASRR process and responsibilities. The case manager reported she was not trained in PASRR screening and did not perform it, stating that the resident relations manager handled PASRRs. The resident relations manager, a CNA, stated she completes PASRRs on admission, ensures hospital PASRRs are in place, and initiates Level II referrals when indicated, such as when residents exhibit behaviors or are prescribed psychiatric medications. She acknowledged that multiple Level I PASRRs for this resident were completed by the hospital and that a subsequent Level I PASRR was done after the resident remained more than 30 days, but none identified Serious Mental Illness despite the record showing schizoaffective disorder, bipolar disorder, and psychotic hallucinations. She confirmed that no Level II PASRR referral was made for this resident and could not explain why, and the administrator documented that the facility did not have a PASRR Level II referral for this resident, despite facility policy stating that a Level II referral must be submitted when a resident is positive for potential mental illness.
Failure to Coordinate Hospice Care and Honor Diet Preferences for a Terminally Ill Resident
Penalty
Summary
The deficiency involves the facility’s failure to coordinate with hospice and follow physician orders and resident preferences for diet and symptom management for a hospice resident with terminal pancreatic cancer. The resident had a hospital plan of care for a full liquid diet to continue indefinitely, but upon admission to the facility, a physician order dated August 29, 2025 prescribed a regular diet with diabetic preference, regular texture, and thin liquids. Hospice respite documentation listed diet as “as tolerated,” and a care plan revised on August 29, 2025 identified hospice involvement for terminal pancreatic cancer with an intervention to maintain comfort through nutrition/hydration. A subsequent care plan revision on September 3, 2025 documented that the resident was at risk for decreased/variable intake, with goals to avoid unsatisfied hunger or thirst and interventions noting the resident preferred a pureed diet, liquified per preference, and food preferences to be honored. However, the admission nutrition assessment referred only to “see tray ticket” for food and fluid preferences, and the tray ticket lacked documented likes, dislikes, and beverage preferences. CNA task logs over a 30‑day look‑back period showed frequent refusals and low meal intake, with only two instances of 76–100% meal consumption and many episodes of refusal or 0–25% intake. Documentation of snacks offered was sparse, with entries on only 9 of 30 days. Progress notes on multiple dates, including September 4, 6, and 12, 2025, recorded that the resident had very poor appetite, nausea, abdominal pain, and difficulty or pain when swallowing mechanically altered diet, and on one day consumed only water and preferred to sleep. Despite these repeated observations of poor intake and swallowing difficulty, the clinical record did not show that hospice or the facility provider was notified of these issues, nor that specific comfort‑focused interventions were implemented in response. There was also no evidence in the record that the resident was actually on a mechanically altered diet at the time these complaints were documented. The facility also failed to consistently notify hospice of a fall and related change in condition. An incident report dated September 7, 2025 documented a fall with a head abrasion and indicated hospice was notified late that night, but progress notes and the IDT fall review on September 8, 2025 only referenced notification of providers and family, without specifying hospice. The hospice Director of Clinical Services stated that hospice had not been notified of the fall or of the resident’s food intake issues, and that such information should have been relayed. Interviews with staff showed inconsistent understanding and practice regarding hospice notification: an LPN stated hospice should be contacted for falls and eating pattern changes, while the DON stated that for hospice residents it was not always necessary to involve hospice if the facility physician was managing care. Observations of meals on September 16, 2025 showed the resident receiving regular‑texture foods (toast, crispy bacon, scrambled eggs, hot dog and chips) that the resident described as too hard to eat given his cancer and need for soft or liquid foods, and the dietary manager reported no known issues and no listed preferences, despite the care plan indicating pureed/liquified preferences. These actions and omissions occurred despite facility policies and a hospice agreement requiring notification of hospice for significant changes in condition, coordination of care plans, documentation of communication, and accommodation of resident food preferences and significant variations in intake.
Failure to Assess and Provide ROM Services for Resident With Post-Stroke Right-Sided Weakness
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to maintain or improve range of motion (ROM) for a resident with a history of cerebrovascular accident and right-sided weakness. The resident was admitted with dementia, hemiplegia/hemiparesis following cerebral infarction, cerebral atherosclerosis, dysphagia, and dysarthria. Initial OT and PT evaluations in 2021 documented functional deficits in ADLs, strength, functional mobility, cognition, bed mobility, transfers, gait, balance, strength, and endurance, but upper extremity ROM was within normal limits at that time. Subsequent clinical documentation over 2024 and 2025, including NP notes, IDT care conference notes, quarterly nursing summaries, therapy screening, and provider progress notes, did not identify or document any limitations in upper extremity ROM, any ROM treatment or services, or any decline in ROM. The annual MDS did not code for therapy, restorative nursing, or splint/brace use, and there was no care plan developed with interventions specifically addressing limited ROM. Surveyor observations in September 2025 showed that the resident consistently demonstrated significant right upper extremity posturing and apparent contracture-like positioning. During multiple observations, the resident was seen sitting in a wheelchair, eating independently with the left hand, while the right wrist was bent downward toward the underside of the forearm, and the right thumb and pointer finger were bent inward toward the palm. The right wrist and hand remained in this position during different activities, including self-propelling the wheelchair using the left hand and side rails, and there was no splint or brace in place on the right wrist or hand during any of these observations. Despite these visible limitations, the clinical record contained no assessment of the extent and limitations of joint movement since the 2021 therapy evaluations and no documentation that ROM services were provided, maintained, or declined. Interviews with staff further demonstrated the lack of appropriate ROM assessment and services. A CMA reported that the resident had a severe stroke, had right-sided weakness, could not move the right arm, open or close the right hand, or move the fingers, and that the right wrist and fingers were now stiff and hard. The CMA stated the resident was not currently on therapy or an RNA program, that therapy and splint devices had been offered in the past but reportedly refused by the resident, and that she occasionally attempted exercises during care but the resident would pull his arm away. She also stated she was not aware of any recent therapy screen for further ROM decline. The DON described expectations that staff assess residents when issues are identified, implement interventions, notify providers, and collaborate on care, and the director of rehabilitation stated that residents must be screened by therapists. However, the record lacked evidence of ongoing ROM assessment, documented refusals, or a care plan with interventions to address the resident’s limited ROM, resulting in the cited deficiency.
Unsecured Probiotic Medication Stored on Top of Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure medications were secured and stored properly in locked compartments. During a medication pass observation with an LPN, a gray basin covered with a white towel was seen on top of the medication cart. The LPN removed a bottle of lactobacillus acidophilus (a probiotic) from the basin, took a capsule from the bottle, placed it in a medication cup, and administered it to a resident. The LPN stated that the basin contained applesauce, the probiotic, and Ensure, and that she kept the probiotic bottle in the basin on ice packs to keep it cold. She acknowledged that the probiotic was not locked in the medication cart because it needed to be kept on ice, and that the towel was used to keep it hidden from residents because “tempted eyes like to touch things.” Further observation and interviews confirmed that this was a standard practice at the facility. Another LPN explained that the facility had one locked medication room with refrigerators and a freezer for ice packs, and that medications requiring room temperature storage were kept in the medication room or cart, while refrigerated medications were kept in the medication refrigerator. She stated that lactobacillus, considered an OTC probiotic, was sometimes stored on top of the medication cart in a covered ice bucket with an ice pack and was not kept in locked storage, despite acknowledging that an unlocked medication could be accessed by a resident without a physician’s order. The DON confirmed that medication carts and the medication room were locked, but stated that probiotics such as lactobacillus, ordered by a physician and used as supplements, were stored on ice on top of the medication cart according to manufacturer’s directions and were not locked, and he did not believe there was any risk other than spoilage if manufacturer’s directions were not followed. Facility policy required that medication and treatment orders be consistent with principles of safe and effective order writing, but did not alter the observed practice of leaving the probiotic unsecured on the cart.
Failure to Provide and Document Required Infection Control Training for Clinical Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff received mandatory infection prevention and control education as required by its infection control program and staff development policies. A registered nurse hired in early August 2024 had a personnel file that included a signed job description and a general new employee orientation acknowledgment, but there was no documentation specifying what training topics were covered, and no evidence that infection control training had been completed. Review of the in-service training log and the facility’s electronic training system, confirmed by the HR representative, showed that infection control training was neither assigned nor completed for this nurse at the time of survey. A similar lack of documentation was found for an LPN hired in September 2016. The LPN’s personnel file contained a signed job description requiring participation in all required trainings, but there was no evidence of completed infection control training. The HR representative and surveyor verified in the training system that infection control training had not been assigned or completed for this LPN. After survey exit, the facility submitted an email with an attached “Clinical Staff Annual Education” roster listing both the RN and LPN with handwritten check marks indicating training completion, but the document did not clearly indicate when the training occurred or provide specific dates of completion. Additional staff interviews supported the finding that infection control education was not consistently provided or documented. An LPN reported that staff receive monthly in-services and annual computer-based training and stated that training on infection control is important so staff do not spread infections. A CNA, described as relatively new, reported receiving on-the-job training but no infection control training, and was told there would be online training to complete within two months. The DON stated that staff are expected to complete onboarding orientation and periodic education throughout the year, and emphasized that infection control training is important to prevent knowledge deficits that could delay responses and impact care. Facility policies and the facility assessment specified that infection control education is mandatory on hire and annually, and that infection control is a required competency to be started during orientation and completed within the first weeks of hire and then annually, but the documented practices for the identified staff did not align with these requirements.
Lack of Documented Dementia Care Training for Multiple Clinical Staff
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multiple staff members received and had documented Dementia Care training as required by the facility assessment and staff development expectations. Surveyors requested personnel files and proof of Dementia Care training for several staff, and for five staff members there was no clear evidence that such training had been completed. Personnel files commonly contained signed job descriptions and orientation acknowledgements stating that staff would participate in required trainings, but these documents did not specify that Dementia Care training had been provided or completed. For a registered nurse hired in August 2024, the personnel file included a job description and a new employee orientation acknowledgement, but no documentation of Dementia Care training. The in-service training log and the electronic training system also did not show assigned or completed Dementia Care training for this RN during the survey. After survey exit, the facility submitted a Clinical Staff Annual Education roster listing this RN’s typed name with a handwritten check mark next to a Dementia and Managing Behaviors to Prevent Abuse topic, but there was no indication of the actual date the training was completed. A similar pattern was found for an LPN hired in 2016: the personnel file and in-service binder lacked evidence of completed Dementia Care training, and although the training system showed Dementia Management training assigned, it was not completed at the time of review. The same Clinical Staff Annual Education roster later submitted also listed this LPN with a handwritten check mark but without a clear completion date. For a CNA hired in February 2025, the personnel file contained a job description and orientation acknowledgement, but neither specified Dementia Care content, and there was no documentation of Dementia Care training in the training system or in-service binder. For another LPN hired in 2019 and an RN hired in February 2025, personnel files, orientation documents, the training system, and in-service logs similarly lacked any documented Dementia Care training. In each of these cases, the post-survey Clinical Staff Annual Education roster showed the staff member’s typed name and a handwritten check mark for Dementia-related education, but without any clear indication of when the training was actually completed. Staff interviews corroborated gaps in Dementia Care training: an LPN reported that training is provided via monthly in-services and yearly computer-based modules and emphasized the importance of Dementia Care training, while a CNA described receiving on-the-job training but no Dementia Care training and being told there would be online training to complete within two months. The DON stated that staff are expected to complete general orientation and periodic education, and that Dementia Care training is important to prevent knowledge deficits. The facility’s Staff Development Program policy required initial orientation and regular in-services but did not specifically mention Dementia Care, while the facility assessment stated that Dementia training was part of staff competencies to be started during orientation and completed within the first weeks of hire and annually.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Smoking-Related Accidents Involving Oxygen Use
Penalty
Summary
The facility failed to ensure that two residents were free from injuries resulting from a preventable accident related to smoking while using supplemental oxygen. One resident, who had multiple medical diagnoses including myocardial infarction, acute respiratory failure, COPD, psychotic disorder, and burns, was assessed as a safe smoker and allowed to smoke independently. Despite a facility policy prohibiting smoking in areas where oxygen is administered or stored, the resident was outside smoking with oxygen tubing in place when he dropped his cigarette, igniting his clothing and oxygen tubing. The fire resulted in second and third degree burns to his right hip, thigh, and flank, requiring emergency medical attention. The resident stated he could not assist himself due to lack of legs, and friends had to intervene to extinguish the fire. Another resident, with diagnoses including orthostatic hypotension and COPD, was also assessed as a safe smoker and permitted to keep his own smoking materials. During the incident, this resident provided a cigarette to the first resident and attempted to extinguish the fire when it broke out, sustaining burns to his own hand in the process. Documentation showed inconsistencies in the evaluation and storage of smoking materials for this resident, as the evaluation indicated he did not require supervision, but also stated the facility would store his lighter and cigarettes. Interviews revealed that both residents were considered cognitively intact based on BIMS scores, and staff relied on these assessments to determine their ability to smoke safely without supervision. The facility's process for evaluating safe smokers involved observing residents' ability to handle cigarettes and lighters, and their cognitive awareness of smoking procedures. However, staff interviews indicated uncertainty regarding whether oxygen was turned off prior to smoking, and there was a lack of direct staff supervision during the incident. The facility's policy required oxygen to be turned off and nasal cannula removed before smoking, but this was not verified at the time of the accident. Additionally, residents and staff noted the absence of clear signage in the smoking area regarding oxygen safety, and residents expressed trauma and distress following the event.
Failure to Report and Investigate Alleged Neglect and Retaliation Against Reporter
Penalty
Summary
A deficiency occurred when facility staff failed to implement policies and procedures for reporting and investigating allegations of neglect for a resident with multiple chronic conditions, including COPD, post-polio syndrome, and chronic pain syndrome. On the day in question, the resident exhibited a significant change in mental and physical status, including confusion, lack of responsiveness, and abnormal movements. Therapy staff immediately recognized the change and reported it to nursing and the provider, but nursing staff initially dismissed the symptoms as typical behavior or faking. There was a delay in assessment and in sending the resident to the emergency room, despite repeated concerns raised by therapy staff and the resident's family. Documentation and interviews revealed that therapy staff, including a PTA and COTA, followed internal expectations by notifying nursing, the provider, and the Director of Rehab about the resident's change in condition. However, nursing staff did not promptly assess the resident, and the provider delayed evaluation. The resident's family also expressed concerns about the lack of timely response and communication from facility staff. Ultimately, the resident was sent to the hospital, where he was diagnosed with severe infection, sepsis, and required intensive care. Further, the facility failed to protect a staff member who reported concerns of neglect. The PTA who documented the events and raised concerns about nursing and provider response was later asked to alter her documentation and was terminated from her position. The facility did not initiate or document an investigation into the allegations of neglect, nor did it report the incident to mandatory reporting sources as required by policy. The facility's own policies require immediate reporting and protection from retaliation for reporters, but these were not followed in this case.
Failure to Timely Assess Change of Condition and Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to timely assess and respond to a resident's change of condition, resulting in a delay in transferring the resident to emergency services. The resident, who had a history of chronic obstructive pulmonary disease, post-polio syndrome, chronic pain syndrome, asthma, and dyspnea, exhibited significant changes in mental status and physical behavior that were observed by therapy staff, nursing staff, and the resident's family. Despite repeated notifications to nursing staff and the provider about the resident's altered state, including confusion, inability to follow directions, abnormal movements, and lack of responsiveness, there was a delay in both assessment and action. Multiple staff interviews revealed that concerns were either dismissed or not acted upon promptly, with some staff suggesting the resident was 'faking' symptoms. The provider and nursing leadership were eventually notified, but there was a further delay as the provider completed documentation before instructing that the resident be sent to the emergency room. The resident was ultimately transferred to the hospital, where he was found to have urosepsis, acute kidney injury, and acute respiratory failure, and required intensive care. Additionally, the facility failed to obtain a physician order for the administration of oxygen therapy for the same resident. Documentation showed that the resident received oxygen therapy on multiple occasions, as recorded in the O2 Sats Summary log, but there was no evidence of a corresponding physician order or care plan for oxygen use during the resident's stay. Interviews with the ADON and DON confirmed that oxygen was administered without a provider's order and that this was not in accordance with facility policy or professional standards. The lack of a physician order for oxygen therapy was acknowledged by facility leadership as not meeting expectations for continuity of care and appropriate care planning. Facility policy required prompt notification of providers and family for changes in condition, detailed assessment and documentation, and a physician order for oxygen administration. The investigation found that these policies were not followed in the case of this resident, as evidenced by the lack of timely assessment, delayed transfer to emergency services, and the absence of required physician orders for oxygen therapy.
Failure to Document and Order Oxygen Therapy for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple respiratory diagnoses, including chronic obstructive pulmonary disease, asthma, and dyspnea. During the resident's stay, documentation showed that oxygen therapy was administered on several occasions, as recorded in the O2 Sats Summary log. However, there was no documentation of the specific dose of oxygen administered, no provider order for oxygen use, and no care plan addressing oxygen therapy for the entire period of the resident's admission. The admission MDS assessment also did not indicate that the resident was receiving oxygen therapy. Interviews with the ADON and DON confirmed that there were no physician orders for oxygen use and that the dose of oxygen was not documented in the clinical record. Both staff members acknowledged that facility policy requires a physician order for oxygen administration and that all treatments should be documented in the resident's medical record, including care-specific details such as the dose. The facility's own policies on documentation and oxygen administration were not followed, resulting in incomplete and inaccurate medical records for the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect four residents from physical abuse, specifically resident-to-resident abuse, as evidenced by multiple documented incidents involving verbal and physical aggression. In one case, a resident with severe cognitive impairment and a history of verbal aggression repeatedly engaged in altercations with her roommate, who had intact cognition but also exhibited behavioral symptoms. The incidents included the throwing of objects resulting in a skin tear, verbal altercations, and a physical slap. Despite ongoing conflicts and staff recommendations for room changes, the residents continued to be housed together for an extended period, with only temporary separations and 15-minute safety checks implemented. Staff interviews revealed that there were available rooms, but administrative decisions, influenced by the medical director and concerns about room availability for admissions, prevented timely room changes. Another set of incidents involved two residents with dementia and behavioral disturbances. One resident, known for antagonizing peers, repeatedly provoked another resident, leading to a physical altercation in which one resident struck the other multiple times with a closed fist. Documentation indicated that staff were aware of the ongoing behavioral issues and had care plans in place to monitor and separate residents at the first sign of agitation. However, the altercations still occurred, and in at least one instance, a skin assessment was not completed following the incident, despite evidence of redness and bruising. Throughout these events, staff consistently reported the incidents to facility leadership and followed protocols such as separating residents and implementing safety checks. However, the facility's leadership, including the administrator, DON, and medical director, often decided against permanent room changes or additional interventions, even when staff expressed concerns about escalating behaviors and resident incompatibility. The facility's abuse policy emphasizes the prevention of all forms of abuse and the immediate securing of resident safety, but the documented actions and inactions led to repeated resident-to-resident abuse and injuries.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Care Planning
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. One resident with severe cognitive impairment and behavioral symptoms was kicked in the leg by another resident, who also had severe cognitive impairment and a history of verbal aggression and physical posturing. Prior to the incident, staff were aware of ongoing verbal altercations and territorial behaviors between the two residents, but there was no evidence that these behaviors or the altercation were documented in the care plans of either resident. On the day of the incident, staff observed the aggressive resident accuse the other of taking personal items and then kick him in the leg. Although staff intervened quickly and conducted a skin assessment that revealed no injuries, the event was not documented in the progress notes or care plan for the resident who was kicked. Staff interviews revealed that behavioral issues had been escalating, and that staff were aware of the potential for conflict but did not implement specific interventions to prevent further incidents aside from increased observation. Subsequent to the altercation, there were additional incidents involving the same residents, including verbal aggression, physical posturing, and blocking access to rooms. Despite these ongoing behaviors, there was no evidence that the care plans were updated to reflect the incidents or to address the risk of further abuse. The facility's policy required prompt reporting and investigation of abuse, but the documentation and care planning did not reflect the actions needed to prevent recurrence.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, as evidenced by incidents involving residents #24, #15, #6, and #34. Resident #24, who has a history of physical and verbal aggression due to cognitive impairments, was involved in an altercation with resident #6. Resident #6, who is cognitively intact but has a history of inappropriate behaviors, punched resident #24 in the face during an encounter in the hallway. This incident was not documented in the clinical record, and the facility's response included placing both residents on 15-minute checks and notifying the police. In another incident, resident #34, who has severe cognitive impairment, was involved in a physical altercation with resident #15, who also has severe cognitive impairment. The altercation occurred after resident #15 accidentally bumped into resident #34's wheelchair, leading to both residents raising their fists at each other. A certified medication assistant intervened to separate the residents and informed them that fighting was unnecessary. Despite this intervention, a subsequent altercation occurred where resident #34 pushed resident #15 out of his wheelchair, causing him to fall. Interviews with staff revealed that there were inconsistencies in supervision and monitoring of residents in common areas. A CNA stated that staff were trained to prevent resident-to-resident abuse by providing supervision and separating residents when necessary. However, a registered nurse noted that there was not always staff available to monitor the hall and dining room areas. The Director of Nursing confirmed that staff were required to attend abuse training and that a staff member was assigned to supervise common areas, but the facility's policy acknowledged the challenges in preventing all incidents of abuse due to residents' proximity and unpredictable behaviors.
QAA Committee Lacks DON Attendance
Penalty
Summary
The Quality Assessment and Assurance (QAA) committee at the facility failed to ensure the attendance of the Director of Nursing (DON) at the QAA meetings, as required. During a survey conducted from June 3, 2024, to June 6, 2024, it was found that the DON's signature was missing from the QAPI Attendance Record for the months of February through May 2024. This absence was noted despite the facility's policy requiring the DON's presence at these meetings. The facility's documentation showed that the DON position experienced several changes in personnel during this period, with Staff #134 serving until March 8, 2024, followed by Staff #136 and then Staff #135, who resigned on May 20, 2024. Subsequently, the Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN), assumed the role of acting DON. Interviews conducted with the human resources manager and the executive director confirmed the absence of the DON from the QAA meetings during the specified months. The human resources manager indicated that the ADON, who is an LPN, was acting as the DON, which is permissible under state law for up to eight months. The executive director acknowledged that the QAA meetings are held monthly and require the attendance of the executive director, medical director, Infection Preventionist (IP), and DON. However, the facility could not provide documentation proving the DON's presence at the QAA meetings from February to May 2024, highlighting a deficiency in meeting the required attendance for quality assurance processes.
Failure to Accommodate Resident's Bathing Preferences
Penalty
Summary
The facility failed to ensure that a resident was able to make choices about their care, specifically regarding their bathing schedule. Resident #31, who has moderate cognitive impairment, was scheduled for showers on the night shift, which she did not prefer due to her long hair remaining wet when going to bed. Despite her requests for a different shower time, staff continued to mark her as refusing showers, resulting in her missing scheduled bathing opportunities. Over a three-month period, there were no documented showers for the resident, and 14 out of 18 scheduled bathing opportunities were not attempted. Interviews with staff revealed that while there is a policy to accommodate residents' preferences for shower times, this was not effectively implemented for Resident #31. The CNA staff mentioned that they try to accommodate different times if a resident refuses, but the LVN and ADON indicated that a shift change would be necessary to balance workloads. The facility's policy on personal care and resident self-determination emphasizes accommodating residents' preferences and identifying underlying causes for care resistance, which was not adhered to in this case.
Failure to Report Alleged Abuse Timely
Penalty
Summary
The facility failed to report an alleged violation involving abuse within the required timeframe for a resident who experienced an unwitnessed fall resulting in a major injury. The resident, who had severe cognitive impairments and was unable to communicate effectively, was found on the floor with a laceration to the forehead and a broken finger. Despite the severity of the injuries and the resident's inability to explain the incident, the facility did not report the event to the Department of Health Services as required. The interdisciplinary team reviewed the incident and determined it was not an injury of unknown origin, presuming it resulted from the fall. The facility's policy mandates prompt reporting and investigation of suspected abuse or injuries of unknown origin to ensure resident safety. However, the Executive Director stated that the team decided not to report the incident, as they believed it was not necessary due to the presumption that the injuries were from the fall. This decision was made despite the facility's policy emphasizing the importance of reporting and investigating such incidents to protect residents from potential abuse.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility failed to ensure that a resident received necessary services to maintain personal hygiene, which may lead to a decline in the resident's quality of life. The resident, who was admitted with diagnoses including myotonic muscular dystrophy, acute respiratory failure with hypoxia, and major depressive disorder, was dependent on staff for personal hygiene and mobility. Despite being scheduled for showers twice a week, documentation revealed that the resident did not receive any showers in the last 30 days, with 12 out of 18 scheduled bathing opportunities not documented as attempted. The resident reported not having received a shower or bed bath for a month, and observations confirmed poor personal hygiene. Interviews with staff indicated that the resident preferred bed baths over showers and that refusals were documented inconsistently between paper and electronic records. The facility's policy required staff to provide care to maintain or improve residents' ability to perform activities of daily living and to accommodate residents' preferences for shower times. However, the facility did not adhere to this policy, as evidenced by the lack of documented attempts to provide the resident with the necessary personal hygiene care.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #20, who has a history of cerebrovascular accident, epilepsy, traumatic brain injury, major depressive disorder, and schizoaffective disorder, was involved in an altercation with another resident, #304. Resident #20's care plan indicated a potential for physical and verbal aggression due to poor cognition and understanding of situations. Despite interventions such as cognitive assessments and psychiatric consultations, Resident #20 admitted to hitting Resident #304 on the cheek, an incident that was unwitnessed but documented by nursing staff. Resident #304, who has Alzheimer's disease, major depressive disorder, and bilateral hearing loss, was unable to provide a detailed account of the incident but confirmed being hit. The incident note documented that Resident #304's left cheek was reddish, indicating physical contact. The care plan for Resident #304 included interventions to address communication problems and cognitive impairment, but these measures did not prevent the altercation. Interviews with facility staff revealed that Resident #20 is known to become agitated by loud noises and has a history of verbal aggression. Staff members reported intervening in confrontations by redirecting residents and separating them to prevent further contact. However, the facility's policy on abuse prevention, which mandates protecting residents from abuse by anyone, including other residents, was not effectively implemented in this case, leading to the deficiency.
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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