Haven Of Safford
Inspection history, citations, penalties and survey trends for this long-term care facility in Safford, Arizona.
- Location
- 1933 Peppertree Drive, Safford, Arizona 85546
- CMS Provider Number
- 035172
- Inspections on file
- 16
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Haven Of Safford during CMS and state inspections, most recent first.
A resident with a history of behavioral issues and prior attempts to hit staff became agitated after family left the building and later confronted another resident with quadriplegia and intact cognition in a hallway. Witnesses, including staff and another resident, reported that the aggressive resident yelled at and then physically struck the disabled resident, and while being escorted away, also struck a second resident with dementia and moderate cognitive impairment who was seated in a doorway. The second resident was later observed with reddish/grey marks and a documented scratch/abrasion on the forearm, but the clinical records for both victims contained no incident documentation, despite multiple staff and resident accounts and police involvement. The DON and social services staff confirmed that the aggressive behavior constituted abuse under the facility’s abuse-prevention policy and acknowledged that required documentation in the clinical records was not completed, resulting in a failure to protect residents from abuse and to properly document the events and injuries.
A resident with moderate cognitive impairment and multiple comorbidities asked a staff member to help set up a checking account not linked to family, resulting in two $500 transfers intended to establish a new account in the resident’s name. The account was never created, and the funds were instead sent to the staff member, who minimized the issue when the resident repeatedly requested the money back. The resident reported feeling abused, taken advantage of, embarrassed, and betrayed, while the DON and an RN acknowledged that the incident met the definition of financial abuse under the facility’s abuse, neglect, exploitation, and misappropriation prevention policy.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in a bed with one resident’s shirt off and the other hovering over them. Staff acknowledged that both residents were not alert and oriented and could not consent, and one nurse had previously documented kissing behavior between them and recommended separating or moving them. Despite this, the facility did not revise either resident’s care plan to address the sexual behaviors, did not document the incident in progress notes beyond a single behavior entry, did not change room assignments even though their rooms were directly across from each other, and did not submit a facility-reported incident to the state agency, contrary to its abuse, neglect, and exploitation prevention policy requiring investigation, reporting, and protection of residents during investigations.
Two cognitively impaired residents, one with severe Alzheimer’s and one with dementia and a history of sexually inappropriate behavior, were housed in rooms directly across from each other. One day, staff later documented that one resident was found in the other’s bed with her shirt off while the other resident hovered over her, after prior notes had described kissing and the need for close supervision and redirection. Multiple staff acknowledged that the resident in bed could not consent to sexual activity, yet the abuse coordinator and DON concluded there was no abuse and did not report the incident as an allegation of abuse to the State Agency, despite a facility policy requiring investigation and reporting of any allegations within federal timeframes. Care plans for both residents were not revised to address the documented sexual behaviors, and progress notes lacked documentation of the incident and the female resident’s tendency to expose her breasts, leading to a cited deficiency for failure to timely report suspected abuse and the investigation results to proper authorities.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in one resident’s room, with one resident in bed, shirt off, and the other hovering over her after staff briefly lost sight of them. Staff acknowledged that neither resident could consent, but documentation in the clinical record lacked detailed notes about the incident, additional skin assessments around the time of the event, or revisions to either resident’s care plan to address sexual behaviors. The facility’s internal investigation was limited to a few staff statements, did not reflect broader evidence collection as outlined in the SOM, did not result in documented protective measures despite staff concerns about room proximity, and the incident was not reported to the State Agency as required by facility policy and federal guidelines.
Surveyors identified that the facility did not consistently follow procedures for controlled substance reconciliation, as multiple narcotic count sheets and shift change sign-off sheets were missing one or both required nurse signatures over several weeks. Interviews with nursing staff and the DON confirmed that the expected process of dual-nurse counts and signatures was not reliably performed, resulting in incomplete documentation for controlled substances.
Surveyors identified failures in infection control practices, including uncovered soiled laundry, improper handling of dirty linens, and unlabeled medications and insulin pens in medication carts. Staff were observed drawing insulin from multi-dose pens without proper labeling, and home medications were stored in medication carts against policy. Interviews confirmed staff uncertainty and non-compliance with established infection prevention protocols.
A resident with cognitive and communication impairments was repeatedly subjected to loud arguments and profanity by a CNA, including being told to "shut the fuck up." Multiple staff and a student CNA witnessed or overheard these interactions, and the resident reported that such incidents were frequent. Despite facility policies prohibiting such behavior, staff often failed to report or intervene, and the CNA had a history of unprofessional conduct.
A resident's privacy was compromised when their personal and medical information was left visible on an unattended medication cart. Despite the facility's policies and staff training on maintaining confidentiality, staff acknowledged the breach, which went against professional standards.
A resident with severe cognitive impairment was subjected to inappropriate behavior by another resident with a history of verbal and sexual misconduct. Despite staff awareness and documentation of the incidents, the facility failed to take adequate action to prevent further occurrences. The facility's policy on abuse prevention was not effectively implemented, leading to a deficiency identified by surveyors.
A resident with severe cognitive impairment was subjected to inappropriate behavior by another resident with a history of verbal and inappropriate sexual behaviors. Despite multiple incidents, the facility failed to report these behaviors to the state agency as required by their abuse prevention policy. Staff were aware of the behaviors and reported them internally, but the Administrator was not informed of a specific incident and acknowledged it should have been reported as abuse.
A resident with severe cognitive impairment was subjected to inappropriate sexual behavior by another resident, also with severe cognitive impairment, in an LTC facility. Despite multiple documented incidents of inappropriate behavior, the facility failed to report these incidents to the state agency. Staff, including LPNs, CNAs, and the DON, were aware of the behavior, but the facility's administration did not adhere to its policy requiring the reporting of abuse allegations.
A facility failed to investigate and report an allegation of abuse involving a resident with severe cognitive impairment and a history of inappropriate sexual behaviors. Despite staff awareness and documentation of the resident's misconduct, the administration did not take appropriate action, leading to a deficiency in abuse prevention and reporting.
The facility failed to administer medications according to physician orders for two residents, leading to potential negative outcomes. One resident received Tramadol outside the prescribed pain scale, while another was given Midodrine despite high blood pressure. Staff interviews and record reviews confirmed these deviations from professional standards and facility policy.
A resident with left-sided paralysis and cognitive impairment was found without access to a call light, despite their care plan requiring it to prevent falls. The call light cord was inaccessible, sandwiched between the mattress and wall, leading to the resident's inability to communicate with staff. Staff confirmed the deficiency, acknowledging the importance of accessible call lights for all residents.
The facility failed to protect residents from abuse, resulting in incidents where a resident with cognitive impairment was hit by another resident, and another resident was inappropriately touched. Despite having care plans and interventions in place, these measures were insufficient to prevent the incidents, highlighting issues such as understaffing and inadequate implementation of preventive measures.
A resident with moderate cognitive impairment physically abused two other residents, resulting in injuries. The aggressive resident's care plan lacked interventions for wandering and physical behaviors, contributing to the incidents. Staff interviews indicated escalating behaviors and challenges in managing the resident's aggression.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident and to properly assess and document the incidents in the clinical records. One victim, Resident #10, had hemiplegia, a history of CVA, dementia, and moderate cognitive impairment (BIMS 10), and was care-planned for behavior problems related to impaired cognition and safety awareness. Another victim, Resident #20, had diagnoses including cerebral ischemia, COPD, quadriplegia, TIA, and depression, with an intact cognition (BIMS 15) and a care plan noting that this resident had previously been the recipient of physical and verbal behaviors from another resident, with interventions to provide for safety and prevent such interactions. Despite these care plans, there were no progress notes in either Resident #10’s or Resident #20’s clinical records documenting any incident involving Resident #50. Resident #50, identified as the perpetrator, had vascular dementia and other medical conditions, with a BIMS score of 15 and a care plan for behavior problems including impaired safety awareness, physical and verbal behaviors, and resistance to care. Prior documentation for Resident #50 included a note that this resident had attempted to hit staff during a separate elopement incident and required 24-hour supervision for safety. On the day of the incident, multiple witnesses, including residents, staff, and the Ombudsman, described escalating behavior by Resident #50 after becoming upset about family leaving the facility. Staff reported that Resident #50 was yelling, pushing a wheelchair with blankets, and verbally agitated. Staff #45 and a nurse initially redirected Resident #50 back to her room, but shortly thereafter, commotion was heard in the hallway where Resident #50 was observed yelling at Resident #20. According to interviews, Resident #50 began physically striking Resident #20 while staff attempted to intervene. Resident #20, who is disabled and unable to walk, reported that Resident #50 grabbed and hit her, hurt her arm, mocked her, and made her feel afraid and abused. Resident #10, who was nearby, reported seeing Resident #50 return down the hall and hit Resident #20 in the head, prompting Resident #10 to yell for help. Staff #25 (a CNA) placed herself between the residents and reported being hit while acting as a barrier. After staff began escorting Resident #50 away, Resident #50 then approached Resident #10, who was sitting in her doorway, and struck her in the arm and head. Resident #10 later showed reddish/grey marks on her right forearm, which she attributed to the incident, and a skin assessment documented a small scratch/abrasion on that arm without any cause noted. Staff interviews, including with the DON and social services director, confirmed that Resident #50 physically struck both residents and that no documentation of the incident, its details, or the resulting injuries was entered into the victims’ clinical records, despite the DON acknowledging that this conduct met the facility’s definition of abuse and that policy requiring documentation was not followed. The Ombudsman, who was in the building at the time, reported hearing screaming and being told by staff that Resident #50 had struck two residents, and was aware that police came to the facility. Staff #45 confirmed that she saw Resident #50 yelling at and then swinging on Resident #20, and later saw Resident #50 swing at Resident #10 while the DON attempted to block the contact. The CNA corroborated that Resident #50 and Resident #20 had a history of not getting along, that arguments tended to escalate, and that during this incident Resident #50 physically struck both residents. Resident #20 became visibly distraught and tearful when recounting the event to the surveyor and stated ongoing fear of Resident #50. Despite these events and the facility’s written policy stating residents have the right to be free from abuse, neglect, and related mistreatment, the clinical records for Residents #10 and #20 contained no incident documentation, and the single skin assessment for Resident #10 lacked any explanation of the cause of the injury, demonstrating a failure to protect residents from abuse and to document the abusive incidents in accordance with facility policy. A review of the facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program” effective January 1, 2024, stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. The DON acknowledged that the events involving Resident #50 and the two residents constituted abuse under this policy and that the policy was not followed with respect to documentation in the clinical records. The lack of contemporaneous clinical documentation of the incidents, injuries, and assessments for the victims, despite multiple staff and resident witnesses and involvement of law enforcement, was a central factor leading to the cited deficiency. In summary, the facility failed to prevent resident-to-resident physical abuse by a known behaviorally challenging resident and failed to document the incidents and resulting injuries in the victims’ clinical records, contrary to the facility’s own abuse prevention policy and standard documentation practices. This failure was established through clinical record review, interviews with the victims, staff, the Ombudsman, and observation of physical findings on Resident #10’s arm, as well as the absence of any incident-related entries in the clinical records of Residents #10 and #20.
Failure to Protect Resident From Financial Misappropriation by Staff
Penalty
Summary
The facility failed to protect a resident’s right to be free from misappropriation of property when a staff member became involved in the resident’s personal finances and received funds that were never used for their intended purpose. The resident, who had hemiplegia, CVA, dementia, UTI, type 2 DM, and sepsis, had a BIMS score of 10 indicating moderate cognitive impairment and required assistance and supervision with ambulation and various ADLs. According to the resident, she asked a staff member (identified as staff #200) to help her set up a checking account, and two monthly transfers of $500 each were arranged, for a total of $1,000. The resident reported that the account was never set up, that her son discovered the transfers and involved the police, and that she repeatedly asked the staff member for the money back. The resident stated that the staff member minimized the situation by saying it was “only money,” and that she felt abused, taken advantage of, embarrassed, and betrayed. The DON confirmed awareness of the incident and stated that the resident had requested an account not linked to her family and that staff #200 agreed to assist, with the understanding that the payments would be used to establish a new account in the resident’s name. The DON reported that the account was never created and that their investigation confirmed the money had been sent to staff #200. A registered nurse, when interviewed, stated that based on the details, the situation constituted abuse and defined abuse to include financial abuse as a violation of resident rights. The facility’s policy on abuse, neglect, exploitation, and misappropriation states that residents have the right to be free from misappropriation of resident property and exploitation, including financial abuse. Despite this policy, the resident’s funds were misappropriated by a staff member who had agreed to manage the resident’s financial transaction and did not carry out the agreed purpose.
Failure to Implement Abuse Prohibition Policy After Alleged Sexual Incident Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prohibition policy and to investigate and report an allegation of possible sexual abuse between two cognitively impaired residents. One resident had early onset Alzheimer’s disease, aphasia, depression, a BIMS score of 00 indicating severe cognitive impairment, and a care plan noting behavior problems including poor safety awareness, wandering, exit seeking, and later, lifting her shirt and exposing her breasts. Despite this, the care plan interventions were not revised when the behavior of lifting her shirt was added, and there were no progress notes documenting this behavior or the alleged incident. The second resident had dementia with behavioral disturbances, type 2 diabetes, depression, a BIMS score of 09 indicating moderate cognitive impairment, and a care plan that identified sexually inappropriate behavior, but the care plan was not revised after the incident to reflect modified interventions related to sexual behaviors. Progress notes for the second resident showed that he was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note documented that he was observed kissing the first resident and that the first resident was reciprocating, but no additional progress notes were found related to this alleged incident. An observation showed that the two residents’ rooms were directly across the hallway from each other. Review of the state agency complaint portal revealed that no facility-reported incident had been submitted regarding these two residents, despite the facility’s policy requiring investigation and reporting of allegations of abuse within required timeframes and protection of residents from further harm during investigations. Multiple staff interviews revealed inconsistent and incomplete responses to the incident and a failure to treat it as a reportable allegation of abuse. A CNA stated that suspected abuse should be reported to the administrator, described the first resident as nonverbal and unable to give consent due to cognitive impairment, and expressed concern that having the residents’ rooms across from each other was not safe. An RN reported being told at shift change that there had been inappropriate behavior between the two residents but was unsure what occurred and noted that the residents should be moved. Another RN stated she had been told that the male resident was kissing the female resident on the cheek and that she had recommended moving them but was told only to keep them separated. The DON reported that both residents were found in the male resident’s room with the female resident’s shirt up, that they were separated, and that the facility concluded no sexual abuse had occurred; she acknowledged the incident was not reported to the state and could not say with 100% certainty that nothing had happened. The administrator, serving as abuse coordinator, confirmed that staff reported the residents were in bed together, fully clothed, and that the female resident could not consent, yet he did not consider the situation abuse and did not report it. The written statement from the witnessing RN described the female resident in bed with her shirt off and the male resident hovering over her; this RN stated she separated them and reported the incident because both residents were not alert and oriented and could not consent, but she personally did not label it as sexual abuse. Despite the facility’s policy defining abuse to include sexual abuse and requiring investigation and reporting of allegations, the incident was not reported to the state, the residents were not clearly protected through care plan revisions or room changes, and the facility did not fully implement its abuse prohibition policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Agency as required by its own policy and federal requirements. One resident, identified as Resident #5, had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00, indicating severe cognitive impairment. Her care plan, initiated in August 2025, documented behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, the care plan was updated to note that she lifted her shirt and exposed her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to this behavior or to the alleged incident. Another resident, identified as Resident #8, had dementia with behavioral disturbances, type 2 diabetes, and depression, and a BIMS score of 09, indicating moderate cognitive impairment. His care plan, revised in August 2025, documented behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to protect the rights and safety of others. Behavior notes from early January 2026 showed that he was placed on 1:1 activity for increased supervision and required redirection and supervision around other residents. A behavior note documented that he was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this incident, and his care plan was not revised after the incident to reflect modified interventions for sexual behaviors. Staff interviews and the facility’s internal investigation revealed that a nurse (Staff #9) found Resident #5 in Resident #8’s room, in his bed, with her shirt off and Resident #8 hovering over her after she had briefly lost sight of them. Staff #9 separated the residents and reported the incident to the DON (Staff #17). Multiple staff, including a CNA and RNs, stated that Resident #5 was not able to give consent due to cognitive impairment, and the abuse coordinator (Staff #2) confirmed that Resident #5 could not consent to being in bed with another person because she was not alert and oriented. Despite this, the abuse coordinator and DON concluded, based on staff statements and their belief that there was insufficient time for sexual contact, that no sexual abuse had occurred and therefore did not report the incident as an allegation of abuse to the State Agency. The abuse coordinator stated he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse, even though Resident #5 could not consent. Review of the State Agency complaint portal showed no facility-reported incident related to these residents, and the facility’s policy required investigation and reporting of any allegations within required federal timeframes. Resident room placement was also relevant to the events leading to the deficiency. Observations showed that the rooms of Resident #5 and Resident #8 were directly across the hallway from each other. Staff interviews indicated concerns about this proximity, with a CNA stating that this arrangement was not safe for Resident #5 because Resident #8 could easily access her, and RNs reporting that they had raised concerns and suggested moving the residents to different rooms. Nonetheless, the residents remained in close proximity. The combination of documented cognitive impairment, inability to consent, prior sexually inappropriate behavior, the observed incident of one resident in bed with clothing removed and another hovering over her, and the facility’s decision not to treat this as a reportable allegation of abuse led to the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities, contrary to the facility’s abuse prevention policy. The facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” effective January 1, 2024, required the facility to investigate and report any allegations within timeframes required by federal requirements. Despite this policy, the DON acknowledged that she could not say with 100% certainty that nothing took place between the two residents during the time they were unsupervised. The abuse coordinator described the situation as merely a nurse reporting an incident and maintained that there was no allegation of abuse, even though he acknowledged that Resident #5 could not consent. The investigative report, which documented that Resident #5 was in bed with her shirt up and Resident #8 hovering or leaning over her, was not part of the clinical record and was initially characterized as a quality measurement document. These facts demonstrate that an allegation of potential sexual abuse involving a resident who could not consent was not reported to the State Agency as required, constituting the deficiency. Review of the State Agency’s complaint portal confirmed that no facility-reported incident related to these residents had been submitted. Staff interviews consistently described the internal reporting chain, with suspected abuse to be reported to the administrator/abuse coordinator or the DON, who would then determine whether to report to external agencies. In this case, although staff recognized that both residents were not alert and oriented and that Resident #5 could not consent, the leadership determined that the situation did not constitute abuse and did not submit a report. This failure to report an allegation of sexual abuse, despite the circumstances and the facility’s own policy requiring reporting of any allegations, is the central deficiency identified by the surveyors.
Failure to Thoroughly Investigate and Respond to Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an allegation of possible sexual abuse between two cognitively impaired residents and to take steps to correct the situation. Resident #5, who had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00 indicating severe cognitive impairment, had a care plan initiated in August 2025 for behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, this care plan was updated to note that Resident #5 lifted her shirt exposing her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to the alleged incident or to Resident #5’s tendency to lift her shirt and expose her breasts. Resident #8 had dementia with behavioral disturbances, type 2 diabetes, depression, and a BIMS score of 09 indicating moderate cognitive impairment. His care plan, revised in August 2025, identified behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to intervene as necessary to protect the rights and safety of others. After the incident involving Resident #5, there was no indication that his care plan was revised to reflect modified interventions related to sexual behaviors. Behavior notes documented that Resident #8 was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note on January 2, 2026, documented that Resident #8 was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this alleged incident. Interviews and the facility’s investigative documentation revealed inconsistencies and gaps in the investigation of the incident. Staff reported that Resident #5 and Resident #8 resided in rooms directly across from each other, and multiple staff expressed concern that this proximity was not safe for Resident #5. The DON stated that both residents were found in Resident #8’s room with Resident #5’s shirt up and that the residents were separated, and she reported that they concluded no sexual abuse had occurred, though she could not say with 100% certainty that nothing took place. The abuse coordinator stated that he was told the residents were in bed together with clothes on and that they liked to flirt, and he did not consider Resident #5 having her shirt up with Resident #8 hovering over her to be abuse, even though he acknowledged Resident #5 could not consent. The written investigation consisted only of statements from the witnessing RN, a CNA who did not witness the event, and the DON, with no evidence of broader interviews, additional observations, or further record review around the time of the incident, including no additional skin assessments beyond those dated December 22, 2025 and January 5, 2026. The incident was not reported to the State Agency’s complaint portal, despite facility policy and the State Operations Manual requiring investigation and reporting of allegations within required timeframes and the collection of evidence through observations, interviews, and record reviews, as well as immediate measures to protect residents from further abuse during the investigation. Further, the RN who witnessed the incident later described finding Resident #5 in Resident #8’s room, in bed with her shirt off and Resident #8 hovering over her, after hearing giggling and having lost sight of them for a few minutes. She separated the residents and reported the situation to the DON, acknowledging that both residents were not alert and oriented and could not consent, which was why she intervened. She stated that she did not personally consider it sexual abuse because she believed they were two consenting adults and that there was not enough time for anything to happen, but she recognized that determining whether it was abuse and whether to report it was the responsibility of leadership. Review of the State Agency’s complaint portal showed no facility-reported incident related to these residents, and the facility’s own policy on abuse, neglect, exploitation, and misappropriation prevention required investigation and reporting of any allegations within federal timeframes. The combination of incomplete documentation, limited investigative steps, lack of care plan revisions, and failure to report the allegation to the State constituted the deficient practice identified by surveyors. The facility also did not document any additional protective measures or environmental changes in the clinical record related to the proximity of the residents’ rooms, despite staff concerns that having the two residents directly across from each other was unsafe for Resident #5. CNA and RN staff interviews indicated that suspected abuse was to be reported to the administrator or DON, and that this process was followed in terms of initial reporting, but the subsequent investigation did not include comprehensive evidence collection as outlined in the State Operations Manual. The investigative report was treated as a quality measurement document and not part of the clinical record, and it did not demonstrate that the facility had thoroughly collected evidence through broader staff interviews, resident observations, or expanded record review around the time of the incident. These actions and omissions led to the finding that the facility failed to thoroughly investigate the allegation of abuse and to take steps to correct it.
Failure to Ensure Accurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to ensure proper safeguards and systems for the accurate reconciliation and accounting of controlled substances on one of three medication carts. During an observation of a medication cart with an LPN, surveyors reviewed narcotic count reconciliation sheets and shift change sign-off sheets for several months. Multiple entries were found to be missing one or both required nurse signatures, with some days having no entries at all. The facility was unable to provide all requested medication cart logs, submitting only the shift change sign-off sheets. Interviews with nursing staff and the DON confirmed that the established procedure requires two nurses to count and sign for controlled substances at each shift change, but this was not consistently followed as evidenced by the missing signatures and incomplete documentation. The facility's policy requires that both the nurse receiving and the person delivering controlled substances count and sign together, and that the consultant pharmacist routinely monitors these records. Despite this, the review of documentation revealed repeated failures to obtain the necessary signatures and maintain complete records for controlled substances over multiple weeks. Staff interviews acknowledged that these omissions did not meet facility expectations and that the dual-nurse count is intended to ensure accuracy and accountability for narcotic medications.
Infection Control Deficiencies in Laundry and Medication Management
Penalty
Summary
The facility failed to adhere to infection control guidelines in multiple areas, including laundry services, medication preparation, and medication storage. In the laundry area, surveyors observed several deficiencies: dirty linen carts and storage containers were left uncovered or improperly covered, soiled blankets with visible debris were found under machines, and trash containers were not properly lidded. Additionally, a leaking washing machine was managed by placing blankets on the floor, which were replaced only when visibly soiled. Staff interviews revealed uncertainty and inconsistency regarding the requirement to keep dirty laundry covered and the proper handling of soiled items, with some staff unaware of the facility's expectations. In the area of medication preparation and storage, surveyors found open multi-dose insulin vials and insulin pens in medication carts without resident identifiers. Some insulin pens were being used as a substitute for unavailable insulin vials, with staff drawing insulin from the pens using syringes after swabbing the cartridge tops. This practice was described as common by nursing staff, despite facility policy prohibiting the use of multi-dose pens for more than one resident and requiring clear labeling with resident identifiers. Additionally, a cluttered medication cart contained a pill organizer and various medication bottles without proper labeling, and home medications were stored in the cart due to renovations, contrary to policy. Interviews with staff, including the DON and Infection Preventionist, confirmed that these practices did not meet infection control expectations. The DON acknowledged that dirty laundry should be bagged and tied at the source, kept covered, and separated from clean laundry, and that trash cans should be lidded. The DON also stated that insulin pens must be labeled and used only for the assigned resident, and that the observed medication storage practices were not compliant with facility policy. The facility's own policies require strict labeling and storage procedures for medications and biologicals, and prohibit transferring medications between containers or using multi-dose pens for multiple residents.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with multiple medical and cognitive conditions, including cerebral infarction, legal blindness, chronic pain syndrome, and moderate cognitive impairment, was not protected from verbal abuse by a staff member. The resident had a documented history of communication impairment and behavioral challenges, including agitation, use of profane language, and making false accusations. Despite these challenges, the care plans in place directed staff to anticipate and meet the resident's needs, maintain effective communication, and support the resident's comfort and dignity. On several occasions, staff and witnesses reported that a CNA engaged in loud arguments and used profanity toward the resident, including telling the resident to "shut the fuck up." Multiple interviews with staff, a student CNA, and the resident confirmed that such interactions were not isolated incidents but rather frequent occurrences. The resident consistently reported that CNAs yelled and used profanity, and a student CNA and other staff corroborated hearing the CNA argue and use inappropriate language. Facility documentation and interviews revealed that staff often did not report these incidents, considering them unprofessional but not necessarily abuse, and some staff justified the loud tone due to the resident's hearing deficit. The facility's own policies strictly prohibited demeaning, intimidating, or harassing behavior, including swearing and shouting, and required staff to treat residents with kindness, respect, and dignity. Despite these policies, the CNA in question had a documented history of unprofessional conduct, including previous incidents of arguing with residents and staff. The facility's investigation into the verbal abuse allegations was ultimately inconclusive, but firsthand accounts and interviews indicated that the resident was subjected to repeated verbal abuse, and staff failed to consistently recognize, report, or intervene in these situations as required by policy.
Resident Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the privacy of a resident during medication administration, which was observed during a survey. Resident #23, who has a history of Non-St Elevation Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Atherosclerotic Heart Disease, and Gastrointestinal Hemorrhage, was affected by this deficiency. The resident's information, including their name, date of birth, photo, and medications, was left visible on a device atop an unattended medication cart. This incident occurred despite the facility's policy and staff training emphasizing the importance of resident privacy and confidentiality. Interviews with staff, including a Registered Nurse and Unit Manager, a Licensed Practical Nurse, and the Director of Nursing, revealed that the facility's expectations were not met. Staff acknowledged that leaving resident information exposed and unattended was against professional standards. The facility's policy on resident rights and dignity clearly states that residents have the right to privacy and confidentiality regarding their medical records, and any breach of this policy could lead to further violations of resident privacy.
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 #128, who has severe cognitive impairment and depression, was subjected to inappropriate behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. On July 7, 2024, Resident #128 was found yelling for Resident #66 to stop touching her, as staff witnessed Resident #66 reaching for her and attempting to expose himself. This incident was documented in progress notes, indicating that Resident #66 frequently engaged in inappropriate behavior towards female residents. Despite being aware of Resident #66's behavior, the facility's staff, including CNAs, LPNs, and the DON, failed to adequately address the situation. Interviews with staff revealed that Resident #66 had a history of touching female residents inappropriately and making sexual comments. Staff reported these incidents to their supervisors, but the facility did not take sufficient action to prevent further occurrences. The facility's policy on abuse prevention was not effectively implemented, as the administrator was unaware of the July 7 incident until it was brought to his attention during the survey. The facility's response to Resident #66's behavior was inadequate, as evidenced by the continued inappropriate conduct documented in subsequent progress notes. Staff interviews indicated that Resident #66's behavior persisted, with reports of him touching other female residents and making inappropriate comments. The facility's failure to report the July 7 incident to the state agency and to implement effective interventions to prevent further abuse contributed to the deficiency identified by the surveyors.
Failure to Report and Address Inappropriate Resident Behavior
Penalty
Summary
The facility failed to follow its abuse policy for a resident, leading to a deficiency. Resident #128, who has severe cognitive impairment due to dementia, was subjected to inappropriate behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. Despite multiple incidents of Resident #66 attempting to touch female residents inappropriately, including Resident #128, the facility did not adequately address or report these behaviors as required by their abuse prevention policy. Resident #66 was admitted to the facility with a history of dementia and depression and exhibited inappropriate sexual behaviors towards staff and residents. The facility's care plan for Resident #66 included interventions such as anticipating needs, identifying behavior triggers, and referring to a psychiatric provider. However, despite these measures, Resident #66 continued to engage in inappropriate behaviors, including touching female residents' private areas and making inappropriate comments. These incidents were documented in progress notes, but the facility failed to report them to the state agency as required. Interviews with staff revealed that they were aware of Resident #66's behaviors and had reported them to supervisors, including the Director of Nursing and the Administrator. However, the Administrator admitted to not being aware of the July incident involving Resident #128 and acknowledged that it should have been reported as abuse. The facility's policy requires immediate reporting of suspected abuse to the state agency, but this was not done, resulting in a deficiency in following the abuse prevention policy.
Failure to Report Resident Abuse
Penalty
Summary
The facility failed to report an incident of abuse involving two residents to the state agency, as required by professional standards. Resident #128, who has severe cognitive impairment due to dementia, was subjected to inappropriate sexual behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. Despite multiple documented incidents of Resident #66's inappropriate behavior towards female residents, including touching and groping, the facility did not report these incidents to the state agency. The deficiency was identified through clinical record reviews, staff and resident interviews, and facility documentation. Staff members, including LPNs, CNAs, and the DON, were aware of Resident #66's behavior, which included touching female residents inappropriately and making sexual advances. Despite being aware of these behaviors, the facility's administration, including the DON and the administrator, failed to report the incidents to the state agency. The administrator acknowledged that the incident involving Resident #66 and Resident #128 should have been reported as abuse but was not. The facility's policy requires the identification, investigation, and reporting of any allegations of abuse within the timeframes required by federal requirements. However, the facility did not adhere to this policy, as evidenced by the lack of reporting of Resident #66's behavior. The failure to report these incidents could result in further unreported incidents of abuse, neglect, or exploitation, as the facility did not follow its own protocols for preventing and identifying abuse.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents, one of whom was identified as having severe cognitive impairment and a history of inappropriate sexual behaviors. The incident involved a resident with dementia and depression, who was observed reaching for another resident and attempting to expose himself. Despite being aware of the behavior, the facility did not report the incident to the state agency as required. The resident with inappropriate behaviors had a documented history of verbal and physical sexual misconduct towards female residents and staff. Multiple staff members reported witnessing these behaviors and had informed their supervisors, including the Director of Nursing and the Executive Director. However, the facility's administration did not take appropriate action to investigate or report these incidents, as evidenced by the lack of documentation and acknowledgment of the July incident involving the two residents. Interviews with staff revealed that the resident's behaviors were known and had been ongoing, yet the facility's response was inadequate. The Director of Nursing and the Administrator were not fully aware of the extent of the resident's behaviors, and the facility's policy on abuse prevention and reporting was not followed. This failure to act and report the abuse allegations could lead to further incidents of resident abuse.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, leading to potential negative outcomes. For one resident, who was admitted with conditions including surgical aftercare and end-stage renal disease, the facility administered Tramadol 50mg for a pain level of 4, which was outside the prescribed parameters of a pain scale of 6-10. This was confirmed through a review of the Medication Administration Record and staff interviews, where it was acknowledged that the medication was given out of order parameters, contrary to professional standards and facility policy. Another resident, admitted with diagnoses including hypotension and rheumatoid arthritis, received Midodrine 5mg despite having a systolic blood pressure greater than 130, which was against the physician's order. The Medication Administration Record showed multiple instances of this medication being administered outside the prescribed parameters. Interviews with staff, including a pharmacist and a unit manager, confirmed that the medication should have been given only within the specified parameters unless cleared by the provider. The facility's policies on medication administration and resident assessment emphasize adherence to physician orders and the importance of notifying the physician of any abnormal vital signs.
Resident Lacks Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident had access to a call light, which is crucial for communication with staff. The resident, who was admitted with diagnoses including left-sided paralysis, stroke, Type-2 Diabetes, repeated falls, and depression, was observed without access to a call light on multiple occasions. The resident's care plan specifically noted the need for the call light to be within reach to prevent falls and ensure prompt assistance. However, the call light cord was found sandwiched between the mattress and the wall, making it inaccessible to the resident. During interviews, the resident expressed concerns about not having a call light and mentioned previous falls. The resident's cognitive impairment and physical limitations further exacerbated the issue, as they were unable to reach the call light. Staff interviews confirmed that the call light was not easily accessible, and it was acknowledged that all residents should have easy access to their call lights. The deficiency was identified through observations, interviews, and a review of facility policies and resident records.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in injuries. Resident #15, who has moderate cognitive impairment, was hit in the head with a hairbrush by resident #50, who also has moderate cognitive impairment and a history of abusive behaviors. The incident was confirmed by staff interviews, but there were no detailed progress notes in resident #15's clinical record about the incident. Resident #50's behavioral care plan included interventions to prevent escalation of agitation, but these were not effectively implemented to prevent the incident. In another incident, resident #50 was inappropriately touched by resident #75, who has significant cognitive impairment and a history of inappropriate sexual behaviors. This incident was witnessed by staff and reported, but resident #50 expressed feeling abused by the encounter. Staff interviews revealed that resident #75 has a pattern of inappropriate behaviors, and there were interventions in place to identify behavior triggers and meet the resident's needs, but these measures were insufficient to prevent the incident. The facility's abuse policy acknowledges the challenges of preventing abuse among residents with dementia and mental illnesses, but the incidents indicate a failure to adequately protect residents from abuse. Staff interviews highlighted issues such as understaffing, which may have contributed to the inability to prevent these incidents. The Director of Nursing confirmed the incidents and noted that interventions were in place, but the incidents were considered outliers, suggesting a lack of consistent implementation of preventive measures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to injuries. Resident #30, who has significant cognitive impairment, was hit in the face by resident #90 after an incident involving a wheelchair. Resident #30 was admitted with diagnoses including gout, alcohol dependence, and hypertension, and had a care plan to maintain a consistent routine to reduce confusion. Despite these measures, resident #30 suffered a bruise to the right eye after being struck by resident #90. Resident #90, who has moderate cognitive impairment and a history of physical behaviors, was involved in multiple incidents of aggression. The resident's care plan noted risks of wandering and physical behaviors but lacked specific interventions to address these issues. Progress notes indicated that resident #90 had several angry outbursts and was difficult to redirect, culminating in the physical altercation with resident #30. Additionally, resident #90 was reported to have caused an abrasion on the face of resident #60, another resident with significant cognitive impairment. Interviews with staff revealed that resident #90's behavior had escalated over time, with incidents of physical aggression towards other residents. The facility's abuse policy acknowledges the challenges of preventing abuse among residents with dementia and other mental illnesses. However, the lack of effective interventions for resident #90's behaviors contributed to the incidents of abuse, highlighting a deficiency in ensuring resident safety.
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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