Haven Of Scottsdale
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsdale, Arizona.
- Location
- 3293 North Drinkwater Boulevard, Scottsdale, Arizona 85251
- CMS Provider Number
- 035059
- Inspections on file
- 22
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Haven Of Scottsdale during CMS and state inspections, most recent first.
A cognitively impaired, high‑fall‑risk resident with a Foley catheter had a long history of yelling out, agitation, attempts to self‑ambulate, and repeatedly pulling on the catheter, with multiple physician and psychiatry notes stating that the resident needed more supervision and recommending environmental and behavioral interventions. Despite this, the resident was left alone in a gerichair near the nurses’ station without a call light, with the Foley bag attached to the chair, and with no structured activity, while repeatedly yelling for help and requesting toileting; staff intermittently responded but did not provide toileting assistance, often walked past without intervening, and left the resident unsupervised even after he stated he might try to walk and could hurt himself. Video showed the resident attempting to stand from an inadequately secured gerichair, causing the chair to roll and the Foley bag to fall, and later standing and walking unsteadily away from the chair, which pulled the Foley tubing taut and resulted in the catheter and balloon being dislodged, significant bleeding, and transfer to the hospital, demonstrating a failure to provide adequate supervision and prevent accident hazards.
Two residents with significant medical conditions reported abuse-related incidents, including one alleging rough physical treatment by a CNA and another reporting sexually inappropriate comments from another resident while on the smoking patio. Although staff documented the allegations, notified internal leadership, and suspended the implicated CNA, there was no evidence that either allegation was reported to law enforcement or APS, no documentation of a thorough investigation, and no submission of investigation results to the State Agency within required timeframes. The DON and administrator reported that investigations could not be located and referenced a record retention policy, while staff interviews and the written abuse prevention policy described expectations for immediate protection, investigation, and external reporting that were not demonstrated in these cases.
Two residents with significant medical conditions reported separate abuse-related allegations, including rough treatment by a CNA resulting in claims of prior broken bones and threatening behavior, and sexually inappropriate comments from another resident while on the smoking patio. Although initial self-reports were submitted to the SA and one CNA was suspended, there was no documented evidence that these allegations were reported to APS or law enforcement as required, nor that completed investigation results were submitted to the SA within 5 working days for either incident.
Two residents reported separate abuse incidents, including rough treatment by a CNA resulting in alleged injuries and threatening behavior, and sexually inappropriate comments from another resident while on the smoking patio. Both residents had ADL care plans noting self-care deficits and were documented as alert and oriented. The facility submitted initial reports to the SA describing the allegations and suspended the implicated CNA, but later could produce no evidence that thorough investigations were conducted or maintained. Leadership, including the DON and administrator, acknowledged they could not locate investigation records and cited internal record-retention timeframes, despite facility policies requiring identification, investigation, and reporting of all abuse allegations.
A resident with end stage renal disease, type 2 DM, and an ESBL E. coli UTI was on ordered contact isolation with a care plan requiring PPE use, dedicated or disinfected equipment, and adherence to transmission-based precautions. A CNA entered the resident’s isolation room with a vitals cart, did not perform hand hygiene, did not don gown or gloves, took vital signs, then exited without disinfecting the equipment and moved the cart to the therapy gym. The CNA later acknowledged that contact precautions require gown, gloves, and equipment disinfection, but reported missing the isolation sign and not knowing where sanitizing wipes were located or about disposable vital-sign equipment. Other nursing staff and the DON described expectations consistent with facility policies, which require signage, PPE use, hand hygiene, and dedicating or disinfecting non-critical equipment for residents on transmission-based precautions.
A resident with dementia, anxiety, urinary retention, and a Foley catheter had documented moderate to severe cognitive impairment, frequent yelling, confusion, and poor recall, with care plans directing staff to anticipate needs, use calm redirection, and provide positive interaction. Over the course of a morning, the resident was left in a gerichair in front of the nurses’ station without a call light, repeatedly yelled for help, requested to use the bathroom, asked for water, and asked to call his family, while staff intermittently responded without assisting with toileting or changing and sometimes told him there was no reason for his yelling or that it was too early to call his family. With no staff nearby, the resident attempted to stand and walk while still connected to the Foley bag attached to the chair, causing the catheter to be pulled out and prompting loud cries of pain; a CNA then approached, grabbed his arm without reassurance, tried to pull him toward the chair, and repeatedly ordered him in a rude tone to sit, including during toileting, while the resident asked her not to be rude. These actions and inactions, along with the lack of timely implementation or updating of behavior-related care plan interventions, resulted in a failure to honor the resident’s rights to dignity, respect, self-determination, and communication as required by the facility’s resident rights and dignity policy.
Two residents were discharged home after skilled stays, one with metabolic encephalopathy, COPD, and anxiety and the other with speech language deficits and type II diabetes, with documentation showing IDT discharge planning, physician orders for discharge, discharge summaries, and progress notes confirming stable discharge with medications and family support. Despite this, there was no evidence that the Ombudsman was notified or provided copies of the discharge notices for either resident, and the DON reported that while residents and representatives are typically given written discharge information and Ombudsman contact details, the facility’s transfer/discharge policy did not include a requirement to notify the Ombudsman.
A resident admitted with multiple comorbidities and an existing coccyx pressure ulcer was care planned for skin impairment and ordered for weekly skin checks, but the initial wound assessment lacked required details such as measurements, drainage, and surrounding skin condition, and there was no documented wound treatment until two days after admission. When the wound was later documented as unstageable, specific measurements, drainage, necrotic tissue, and a treatment regimen with Medihoney, alginate, foam dressing, and an air mattress were recorded and transcribed to the TAR and wound record. Interviews with the MDS nurse, an RN, and the DON confirmed that facility expectations and policy require immediate provider notification, prompt initiation of ordered wound care, and complete documentation for each treatment, and that the absence of documentation means treatment was not provided, which did not occur as expected in this case.
The facility failed to follow its controlled substance reconciliation protocols, allowing diversion of narcotic medications for two residents. One resident with osteomyelitis and hip pain had an order for PRN oxycodone 5 mg that was not transcribed onto the MAR, while a narcotic audit later showed 58 tablets dispensed with incomplete audit documentation. Another resident with cardiac disease and osteomyelitis had an order for PRN oxycodone‑acetaminophen 10‑325 mg that was transcribed and intermittently administered, but a narcotic audit showed 20 tablets dispensed with the entry highlighted and marked as not applicable. An internal investigation and camera footage showed a registry RN accepting a medication cart with narcotics and count sheets present, later handing off the cart without the oxycodone‑acetaminophen bubble pack or count sheet, and appearing on video to conceal bubble packs in her scrubs. Staff interviews and policy review confirmed that two‑nurse shift‑to‑shift narcotic counts, reconciliation of declining inventory records, and immediate reporting of discrepancies were required but did not prevent or promptly detect the diversion involving these residents’ controlled medications.
A resident with advanced dementia, severe cognitive impairment, and persistent yelling and agitation had a PRN order for concentrated morphine solution to be given every 4 hours for pain or shortness of breath. On one day, the controlled drug record showed two morphine doses given 2 hours and 10 minutes apart, while the MAR showed no morphine administrations and progress notes did not specify dose times or number of doses. Staff interviews and facility policies confirmed that medications, including controlled substances, must be administered according to prescriber time parameters and documented on the MAR and controlled substance records, but in this case the narcotic was not administered and documented in accordance with the physician’s order.
Surveyors found that the facility failed to properly label and store food items in both the main kitchen and a nourishment refrigerator. An expired container of cooking wine and undated vegetables in a freezer were observed, and the nourishment refrigerator near a nurse station was overcrowded and disorganized, containing multiple unlabeled and undated items such as fruit, bread, prepared meals, soup, and visibly spoiled berries. Staff interviews showed conflicting accounts of who was responsible for labeling and cleaning nourishment refrigerators, and revealed that food brought in by families was not consistently labeled and dated as required. These practices did not align with facility policies mandating that all refrigerated and outside food be covered, labeled, dated, and monitored.
A resident with dementia, anxiety, CHF, cardiomyopathy, and pneumonia had care plans addressing pain and behavioral symptoms, and PRN orders for morphine and lorazepam for pain, SOB, and anxiety-related restlessness. On one day, behavior notes and individual controlled drug records showed that two doses each of morphine and lorazepam were given when the resident was yelling and not responding to redirection. However, the MAR contained no entries showing that these PRN doses were administered, and no anxiety or restlessness episodes were recorded, despite facility policy and staff statements that all administered medications and related symptoms must be documented on the MAR in accordance with professional standards.
A resident with COPD did not receive prescribed doses of Tyvaso DPI as ordered, despite the medication being supplied by the family and available on site. Nursing staff were unaware of the medication's source and failed to administer it consistently, with multiple missed doses documented as 'on order' or unavailable. Facility policy required medications to be given per prescriber orders, but this was not followed, resulting in the deficiency.
Two residents experienced verbal abuse from a CNA, who was loud, intimidating, and disrespectful. Despite multiple grievances, the facility initially failed to recognize these incidents as reportable abuse, leading to a deficiency in protecting residents from harm.
Two residents reported verbal abuse by a CNA, who entered their room abruptly, yelled, and acted intimidating. Despite grievances filed, the facility did not report the incidents to the state agency as required. The facility's abuse policy defines such behavior as abuse, yet prior complaints involving the same CNA were also not reported.
Three residents in an LTC facility reported verbal abuse by a staff member, who was rude and refused assistance. The residents, with no cognitive impairments, filed grievances about the staff's behavior, which included refusing to help and making inappropriate comments. The facility's policy defines such actions as abuse, causing mental anguish.
The facility failed to implement its abuse prevention policy, as evidenced by incidents involving three residents and CNA #42. A resident reported CNA #42's refusal to assist due to her age, while another resident experienced rudeness over bed sheet changes. A third resident, requiring assistance due to a TLSO brace, reported verbal abuse. Despite these grievances, the incidents were not reported or investigated per policy, and the DON did not consider them reportable unless discomfort was explicitly stated.
The facility failed to report alleged abuse involving three residents by a CNA, staff #42. The residents, who had no cognitive impairments, filed grievances against staff #42 for inappropriate comments and refusal to assist with care. Interviews with staff revealed differing views on whether the incidents constituted abuse, but the facility did not report the incidents as required by policy.
The facility failed to investigate and report alleged abuse by a staff member involving three residents. The incidents included inappropriate comments and refusal to assist residents, all of whom had no cognitive impairment. Despite the facility's policy requiring immediate reporting and investigation of abuse, these incidents were not addressed in a timely manner, leading to a deficiency.
Three residents in an LTC facility received pain medication outside of physician-ordered parameters, with no provider notification or post-administration assessments documented. This included a resident with COPD and chronic pain, another with opioid dependence, and a third with acute osteomyelitis. The DON attributed some errors to a nurse's inexperience.
The facility failed to ensure that CNAs maintained valid CPR and first aid certifications, as required by their job descriptions. Personnel file reviews showed that three CNAs lacked evidence of CPR or First Aid certifications. Despite a policy requiring a CPR-certified team, the Director of Nursing confirmed that no CNAs had such certifications. A new job description intended to make CPR certification a preference was not properly implemented, leading to inconsistencies in compliance.
A resident's cell phone went missing, and the facility's investigation was inconclusive. The resident, with intact cognition, reported the missing phone, and a CNA was suspected but could not be contacted due to a false phone number. Another resident also reported missing property during this time. The facility's policy on resident rights was not upheld, and the investigation did not resolve the issue.
A resident's husband reported concerns about care quality, including water damage and inappropriate dressing, to the facility staff and executive director. Despite these concerns, the facility did not document or investigate the grievance as required by policy, citing the husband's refusal to fill out a grievance form and his insistence on discharging the resident. This represents a failure to honor the resident's right to voice grievances without discrimination or reprisal.
Failure to Supervise High‑Risk Resident Leads to Traumatic Foley Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accident hazards for a cognitively impaired, high‑fall‑risk resident with a Foley catheter, resulting in accidental catheter dislodgement and transfer to the hospital. The resident had multiple diagnoses including advanced vascular dementia, non‑Alzheimer’s dementia with behavioral disturbance, anxiety, depression, altered mental status, CHF, cardiomyopathy, pneumonia, and urinary retention. From admission onward, clinical documentation repeatedly described the resident as confused, oriented only to self, very forgetful, encephalopathic, and at high risk for falls, with ongoing behaviors of yelling out, agitation, attempts to self‑ambulate, and repeatedly pulling on his Foley catheter. The care plans and multiple physician and psychiatry notes documented that the resident needed more supervision, had impaired safety awareness, and was at risk for catheter‑related trauma, with goals that the resident remain free from such trauma. Despite these documented needs, the record showed that the resident continued to yell out instead of using the call light, frequently requested toileting, and pulled on his Foley catheter on numerous occasions, with notes of bloody urine after pulling on the catheter. Providers and psychiatry repeatedly recommended increased supervision and nonpharmacologic strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for agitation, and a consistent sleep routine. Behavior notes also documented multiple attempts by the resident to self‑ambulate to leave the facility, and staff reports that the resident was constantly yelling, shouting, and difficult to redirect. However, there was no evidence that the facility implemented new or enhanced supervision interventions in response to these escalating behaviors, nor evidence that the recommended nonpharmacologic strategies were put in place. Review of the MAR/TAR further showed that a PRN antianxiety medication ordered for anxiety and restlessness was not documented as administered, and no target behaviors were recorded over several days. On the morning of the incident, observations and video footage showed the resident seated alone in a gerichair across from the nurses’ station with his Foley bag attached to the chair, no call light or call bell within reach, and no television or activity available. Over an extended period, he repeatedly yelled for help, requested water, and requested assistance to use the bathroom. Staff intermittently approached but did not provide toileting assistance, repeatedly left him alone, and at times did not respond at all while he continued to yell loudly. The resident stated he might try to walk and could hurt himself, attempted to stand multiple times, and at one point the unlocked gerichair rolled backward when he partially stood, causing the Foley bag to fall to the floor; staff rehung the bag and again left him seated without continuous supervision. Later, while no staff were in the immediate area, the resident stood and took unsteady steps away from the chair, causing the Foley tubing to pull taut and the catheter with balloon to be dislodged and fall to the floor. The resident yelled in pain and was later found with significant bleeding and clots, leading to his transfer to the emergency department. The surveyors concluded that, despite clear documentation of the resident’s need for increased supervision and his ongoing behaviors of yelling, pulling on the Foley, and attempting to self‑ambulate, the facility failed to implement and maintain adequate supervision and environmental safeguards to prevent this accident. Additional observations and interviews supported the pattern of inadequate supervision and response to the resident’s behaviors. Video review showed prolonged periods during which the resident yelled for help dozens of times without staff response, and instances where staff walked past him while he requested bathroom assistance without intervening. The gerichair was observed with wheels not securely locked when the resident attempted to stand, contributing to instability. Other residents reported that the man’s yelling had been ongoing and affected their sleep. A CNA reported that the resident had gotten up from his chair before and screamed all the time, and that caring for residents with behaviors was very hard because the facility was understaffed. Throughout the record, there was continued documentation that the resident needed more supervision and might not be appropriate for the facility due to agitation, yet no corresponding increase in supervision or implementation of recommended nonpharmacologic safety measures was documented prior to the catheter‑related injury.
Failure to Report and Investigate Abuse Allegations per Policy
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse reporting and investigation policy for two residents who made abuse-related allegations. For one resident with a history of a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain, documentation showed that the resident was alert, oriented, and able to verbalize events. After admission following a ground-level fall at home, the resident experienced a fall in the facility and later expressed dissatisfaction with the facility without initially providing details. A late entry incident note documented that the resident reported being treated roughly and refused further care from a CNA who had worked the morning shift, prompting notification of the ED, DON, physician, and family. The initial facility report to the State Agency stated that this resident told an unnamed therapist that he did not want care from a CNA assigned to him and alleged that this CNA had caused multiple broken bones, was going to kill him, and was out to get him. The resident provided a physical description of the CNA, and facility documentation indicated that there was a CNA who best fit that description. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that he hit his face on the wall while being turned during care. The report noted that the CNA was immediately suspended and that the facility was contacting other agencies. However, there was no evidence in the clinical record or facility documentation that this allegation was reported to law enforcement or APS, that a thorough investigation was conducted, or that the results of the investigation were submitted to the State Agency within five working days. For a second resident with diagnoses including chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, care plans and notes indicated the resident was encouraged to participate in ADLs and was documented as alert and oriented. Psychology notes referenced an “incident last week” and stated there was no evidence of psychological harm and no further conflicts, but did not describe the incident. An initial facility report to the State Agency later documented that this resident reported to the ED that another resident made sexual comments toward her while she was sitting on the smoking patio. As with the first case, there was no evidence that this allegation was reported to law enforcement, that a thorough investigation was completed, or that the results of the investigation were submitted to the State Agency within five working days. Interviews with the DON, administrator, RNs, and the social services director confirmed that investigations related to these two residents were not available and that the facility followed a record retention policy under which incident reports and self-reports were only kept for 12 months and grievances for three years. The DON and administrator stated they could not locate any evidence of the investigations for these incidents, and the DON referenced that the requested investigations were “outside the guidelines” for document retention. Staff interviews described the facility’s general procedures for responding to abuse allegations, including ensuring resident safety, separating alleged perpetrators, suspending staff when implicated, and reporting to the ED, DON, Ombudsman, police, physician, family, and State Agency. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program required identification, investigation, and reporting of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property within required federal timeframes and protection of residents from further harm during investigations, but the documentation for these two residents did not demonstrate that these policy requirements were carried out.
Failure to Report and Complete Abuse Investigations Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of abuse to Adult Protective Services (APS) and law enforcement, and failure to submit the results of abuse investigations to the State Agency (SA) within 5 working days for two residents. For one resident with a history of a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain, the care plan identified risk for ADL self-care performance deficit and encouraged participation in care. This resident was admitted after a ground level fall at home and later sustained a fall in the facility, after which he was found on the floor by the toilet, alert and oriented, and able to describe the event. On the same day, documentation showed the resident expressed unhappiness with the facility and, in a late entry incident note, reported being treated roughly and refusing further care from a specific CNA. The initial facility report to the SA for this resident stated that he told an unnamed therapist he did not want care from a CNA assigned that day, alleging that this CNA had caused at least three broken bones, was going to kill him, and was out to get him. He provided a physical description of the CNA, and the facility identified a CNA who best fit that description. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that he hit his face on the wall while being turned during care. The CNA was immediately suspended, and the report indicated the facility was contacting other agencies. However, review of the clinical record and facility documentation revealed no evidence that this allegation was reported to law enforcement or APS, and no evidence that the results of the investigation of the alleged abuse were submitted to the SA within 5 working days of the incident. For the second resident, admitted with chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, the ADL care plan also identified risk for ADL self-care performance deficit and included interventions to praise self-care efforts and encourage participation. Documentation showed the resident was alert and oriented, with psychology notes indicating no evidence of psychological harm related to an unspecified incident the prior week and no concerns or changes since that occurrence. An initial facility report to the SA later documented that this resident reported to the executive director that another resident made sexual comments toward her while she was sitting on the smoking patio. Despite this allegation of sexual comments by another resident, review of the clinical record and facility documentation showed no evidence that the allegation was reported to law enforcement, and no evidence that the results of the investigation of the alleged abuse were submitted to the SA within 5 working days of the incident.
Failure to Maintain and Document Thorough Investigations of Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of abuse. For the first resident, an individual admitted with a displaced intertrochanteric fracture of the left femur, osteoporosis, and chronic pain had an ADL care plan indicating risk for self-care performance deficits and encouragement to participate in care. This resident experienced a fall in the facility bathroom, was found on the floor by the toilet, and was documented as alert and oriented and able to verbalize what happened. Later that same day, documentation showed the resident expressed unhappiness with the facility without elaborating. A late entry incident note then recorded that the resident reported being treated roughly and refused further care from a CNA who had worked the morning shift, with a skin assessment showing no new findings. The facility’s initial report to the State Agency documented that the resident told an unnamed therapist he did not want care from a CNA assigned that day and alleged that this CNA had caused at least three broken bones, was going to kill him, and was out to get him. The resident provided a physical description of the CNA, including age range, hair color, glasses, tattoos, and clothing, and later clarified the clothing color and tattoo location, which the facility noted matched a specific CNA. The resident further alleged that the CNA wheeled him too fast, bumped his feet on walls, made him feel like a horse while being showered, and that during turning for care he hit his face on the wall. The CNA was immediately suspended, and the facility reported that it was contacting other agencies. Despite these detailed allegations, review of the clinical record and facility documentation revealed no evidence that the facility conducted or maintained a thorough investigation into this abuse allegation. The second resident involved was admitted with diagnoses including chronic embolism, hemiplegia and hemiparesis, restless leg syndrome, and other specified brain disorders, and had an ADL care plan noting risk for self-care performance deficits with interventions to praise self-care efforts and encourage participation. A health status note documented that this resident was alert and oriented, and a late entry NP note indicated a long history of daily smoking. Psychology progress notes on two consecutive days stated that observations and conversations with the resident showed no evidence of psychological harm related to an incident the prior week, but did not describe the incident itself, only noting no concerns or changes and no further conflicts. The facility’s initial report to the State Agency later specified that the resident had reported to the ED that another resident made sexual comments toward her while she was sitting on the smoking patio. As with the first case, review of the clinical record and facility documentation showed no evidence that this allegation of abuse was thoroughly investigated. Interviews with facility leadership and review of facility policies further clarified the deficiency. The DON stated she did not know where the investigations related to these two residents were and referred to them as being "outside the guideline," explaining that this meant outside the facility’s document retention timeframes. The administrator similarly stated he could not find any evidence of investigations for these incidents and cited a facility memo on record retention that limited how long incident reports, self-reports, and grievances were kept. The DON also described the facility’s abuse policy and the expected process for responding to abuse allegations, including ensuring resident safety, suspending involved staff, reporting to the abuse coordinator and external agencies within required timeframes, and conducting interviews with the victim, alleged perpetrator, and witnesses. However, despite these stated procedures and policies emphasizing identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation, there was no documentation available to demonstrate that thorough investigations were completed or maintained for the abuse allegations involving these two residents.
Failure to Follow Contact Isolation and Equipment Disinfection for ESBL-Positive Resident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility’s infection prevention and control program and contact isolation policies for a resident with an active ESBL E. coli urinary tract infection. The resident was admitted from a short-term general hospital for IV infusions with contact isolation and had diagnoses including end stage renal disease and type 2 diabetes mellitus. Physician orders documented contact isolation due to ESBL for a defined period, and the care plan identified an active ESBL infection with interventions such as contact/droplet isolation precautions, staff and resident education on infection containment, use of disposable or dedicated equipment, appropriate cleaning and disinfection of non-disposable equipment, and provision of independent or 1:1 activities. On the day of the survey observation, a CNA entered the resident’s room, which had a contact isolation sign posted on the right side of the doorway and an isolation cart with PPE outside the room. The CNA pushed a vitals cart into the room without performing hand hygiene and without donning a gown or gloves, despite the posted contact isolation precautions. The CNA proceeded to take the resident’s vital signs using the blood pressure cuff on the resident’s ankle while the resident was in bed, then closed the door and later exited the room without sanitizing the vitals cart. The CNA then pushed the unsanitized vitals cart down the hallway to the therapy gym and left it there. In a subsequent interview, the CNA stated that staff identify isolation rooms by signs on the door indicating the type of precautions and required PPE, and that for contact precautions, staff are required to wear a gown and gloves. The CNA also stated that equipment brought into an isolation room and then used for other residents should be sanitized with sanitizing wipes, but she did not sanitize the vitals cart because she did not know where wipes were located and none were present in the isolation cart. She reported she had not received verbal report at shift change about which rooms were on isolation, did not initially realize the room was an isolation room because the sign was posted to the side of the door rather than in the center, and was unfamiliar with disposable or single-use blood pressure cuffs or stethoscopes. When the room was re-observed with the CNA, she acknowledged the contact isolation sign. Other nursing staff, including an RN/unit manager, an LPN, and the DON, described expectations consistent with facility policy: observing isolation signage, donning required PPE before entry, performing hand hygiene before leaving the room, dedicating or disinfecting equipment with sanitizing wipes before reuse, and maintaining PPE and supplies in or near the room, and they stated that failure to follow these practices could result in spread of infection. Review of facility policies on "Managing Infections: Isolation - Categories of Transmission-Based Precautions" and "Managing Infections: Isolation - Initiating Transmission-Based Precautions" showed that transmission-based precautions are to be initiated for residents with transmissible infections or laboratory-confirmed infections at risk of transmission. Policies require appropriate signage on the room entrance door and chart, use of standard precautions at all times, and additional contact precautions for residents known or suspected to be infected with organisms transmitted by direct or indirect contact. The policies specify that non-critical resident-care equipment such as stethoscopes, sphygmomanometers, and thermometers should be dedicated to a single resident when possible, or cleaned and disinfected before use with another resident if reuse is necessary. They also require gloves and disposable gowns upon entering the room, removal of PPE and performance of hand hygiene before leaving the room, and ensuring that PPE and necessary supplies, including appropriate waste and linen containers, are maintained in or near the resident’s room. The observed staff actions did not align with these written requirements.
Failure to Treat Cognitively Impaired Resident With Dignity and Respond to Repeated Requests for Help
Penalty
Summary
The deficiency involves the facility’s failure to treat a cognitively impaired resident with dignity and respect and to respond appropriately to his repeated requests for assistance. The resident had acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention, and was admitted with a Foley catheter. Assessments and therapy notes documented moderate to severe cognitive impairment, poor orientation, poor recall, confusion, and frequent yelling out for help or for his wife. Care plans identified behavior problems related to impaired cognition, including yelling out instead of using the call light, and directed staff to anticipate and meet needs, provide positive interaction, explain procedures, identify triggers, and use calm approaches and redirection. Multiple clinical notes from nursing, therapy, psychiatry, neurology, and pulmonary providers documented ongoing confusion, anxiety, constant yelling, inability to verbalize needs, and repeated pulling on the Foley catheter. On the morning of the incident, video footage and surveyor observations showed the resident seated in a gerichair in front of the nurses’ station with a Foley catheter bag attached to the chair and no call light or call bell available. From shortly after 6:00 a.m. onward, the resident repeatedly yelled for help, requested to use the bathroom, and asked for water and to call his family. Staff responses were intermittent and did not address his toileting requests; one staff member told him he had a catheter and did not assist him to the bathroom, another told him to remain reclined until breakfast, and others walked past without responding while he continued to call out loudly dozens of times. When he reported having had a bowel movement, he was told to wait until staff could be found, and no one assisted him with toileting or changing for an extended period. Staff also told him there was no reason for his yelling, that he was waking everybody up, and that it was too early to call his family, without addressing his expressed needs. Later that same morning, with no staff nearby, the resident attempted to stand and walk unassisted while still connected to the Foley catheter bag attached to the gerichair. As he took small, unsteady steps, the catheter tubing became taut and ultimately the catheter balloon and tubing were observed on the floor after being pulled out, and the resident yelled out loudly in pain. A CNA then approached and, without reassuring the resident or explaining her actions, grabbed his arm with both hands and attempted to pull him back toward the chair while he said “No” and tried to walk in the opposite direction. The CNA then positioned the gerichair in front of him and repeatedly ordered him in a rude, firm tone to “sit down here” and “sit in there,” without explanation, while the resident questioned what the chair was. During toileting assistance in the bathroom, the CNA’s firm and rude tone continued, and the resident was overheard asking her not to be rude. Interviews with staff and leadership confirmed awareness of the resident’s ongoing yelling behaviors and confusion, and the facility’s own policy required that residents be treated with kindness, respect, and dignity and be free from abuse and neglect, which was not followed in this case. The facility’s care plans and provider recommendations called for consistent routines, environmental modifications, structured activities, task segmentation, frequent redirection, and calm, respectful communication to address the resident’s impaired cognition and behaviors. Despite this, there was no evidence of updates or revisions to the behavior-related care plan interventions after mid-December, even as documentation showed escalating yelling, anxiety, and inability to be redirected. On the day of the incident, staff did not implement the planned interventions such as anticipating and meeting needs, providing one-to-one interaction, or promptly assisting with toileting, and instead left the resident unattended in the hallway for prolonged periods while he loudly and repeatedly called for help, the bathroom, water, and his family. The combination of failing to respond to his expressed needs, leaving him without a call system or supervision despite known impulsivity and unsteady gait, and interacting with him in a rude and non-reassuring manner constituted a failure to honor his rights to dignity, respect, self-determination, and communication as outlined in the facility’s resident rights and dignity policy. Other residents and staff interviews corroborated that the resident frequently screamed and that he likely wanted someone to talk to or an activity to calm him. CNAs and nurses described appropriate approaches they would generally use for confused, yelling, or restless residents, such as sitting with them, holding their hand, providing activities, or placing them near the nurses’ station with close supervision. However, on the morning in question, these approaches were not consistently applied to this resident. The Director of Nursing acknowledged awareness of his yelling and impulsivity and stated expectations for calm approaches, redirection, and offering comfort measures, while the Administrator acknowledged that staff could have done a better job addressing his requests to use the bathroom. The documented events, observations, and interviews collectively show that the resident’s rights to be treated with dignity and respect and to have his needs assessed and addressed were not upheld. The facility’s written policy on Resident Rights/Dignity required employees to treat all residents with kindness, respect, and dignity and guaranteed residents the right to a dignified existence, to be treated with respect, kindness, and dignity, to be free from abuse and neglect, and to exercise self-determination and communication with people and services. The observed failure to respond to the resident’s repeated requests for toileting and assistance, the lack of a call light, the prolonged periods without staff attending to him while he yelled for help, and the CNA’s rude tone and physical handling of his arm were inconsistent with these policy requirements. These actions and inactions formed the basis of the cited deficiency for failure to ensure the resident was treated with dignity and respect.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide the Ombudsman with a copy of the written notice of discharge for two residents who were discharged from skilled care. For the first resident, admitted with metabolic encephalopathy, COPD, and anxiety for post‑operative rehabilitation, the clinical record showed ongoing discharge planning toward return to home, later updated to discharge to home with hospice services. Multiple documents, including skilled needs reviews, IDT care plan conference notes, therapy notes, a discharge summary, a discharge transfer evaluation, physician orders, and a discharge MDS, confirmed that the resident was discharged home on a specified date. However, there was no evidence in the clinical record that the Ombudsman was notified or provided a copy of the discharge notice for this resident. For the second resident, admitted with speech language deficits and type II diabetes, the record contained physician orders indicating completion of the skilled inpatient stay and discharge to home, an IDT care plan conference note documenting a plan to discharge home with family, a discharge summary confirming the discharge date and that the resident would be discharged with medications, and a progress note stating the resident was discharged home in stable condition with family and belongings. Despite this documentation of discharge, there was no evidence that the Ombudsman was notified or given a copy of the discharge notice for this resident. In an interview, the DON explained the usual process for notifying residents and/or representatives in writing about discharge, including appeal rights, bed‑hold policy, and Ombudsman contact information, but the facility’s written policy on transfer or discharge notice did not include a requirement to notify the Ombudsman.
Failure to Initiate and Document Timely Pressure Ulcer Treatment on Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and complete pressure ulcer care and assessment for a resident admitted with an existing coccyx wound. The resident was admitted with multiple comorbidities, including a left tibia fracture, type II diabetes with hyperglycemia, pulmonary fibrosis, shortness of breath requiring oxygen, and bowel and bladder incontinence. An admission Braden scale showed a score of 15, and a progress note on the admission date documented a stage 4 coccyx ulcer with foul odor. The care plan identified existing and at-risk skin areas, including the coccyx, and called for treatments as ordered, weekly skin assessments, and adherence to facility policies for prevention and treatment of skin breakdown. A physician order for weekly skin checks was also in place. Despite the identification of a stage 4 coccyx ulcer on admission, the weekly skin check and wound assessment note for that date did not include required wound descriptors such as measurements, odor, drainage, tunneling, or description of surrounding skin and wound edges/bed. The clinical record showed no evidence that any wound treatment was initiated on the admission date, and there was no documentation of wound care being provided until two days later. On the subsequent weekly skin check, the coccyx wound was documented as an unstageable pressure ulcer present on admission, with specific measurements, drainage, odor, necrotic tissue, and surrounding slough, and treatment orders including Medihoney, alginate, and foam dressing were documented at that time. A low air loss mattress was requested, and an order for an air mattress and specific wound care regimen was entered and transcribed onto the treatment and wound administration records on that later date. Interviews with facility staff confirmed that the documented practice did not align with facility expectations and policy. The MDS nurse and an RN stated that upon admission, a head-to-toe skin assessment is performed, the provider is notified for orders if a wound is identified, and treatment is expected to begin as soon as orders are received, with each treatment documented; they both indicated that if there is no documentation, the treatment is considered not done, and that a delay of two to three days in treatment would not meet expectations. The DON stated that nurses are expected to assess and document wound characteristics on admission, transcribe any existing wound orders, and notify the provider if no orders exist, and that wound care documentation must include details of the care provided and resident response. The DON and corporate resource both acknowledged that they found no documentation that wound treatment was provided to this resident prior to the later date. The facility’s written policy required full assessment and documentation of pressure ulcers, including location, stage, size, exudate, necrotic tissue, pain, mobility status, current treatments, and support surfaces, and required that newly admitted residents be examined for existing pressure ulcers so that the physician could order appropriate wound treatments and pressure reduction surfaces, which was not fully carried out for this resident on admission.
Failure to Reconcile and Safeguard Controlled Medications Resulting in Narcotic Diversion
Penalty
Summary
The deficiency involves the facility’s failure to follow its own protocols for reconciliation and control of narcotic medications, resulting in undetected diversion of controlled substances for two residents. For one resident with acute osteomyelitis of the right ankle and foot, infection and inflammatory reaction due to an internal left hip prosthesis, and left hip pain, the admission evaluation and care plan documented high‑risk medications and pain management needs. A physician order was in place for oxycodone 5 mg by mouth every 6 hours as needed for pain rated 4–10, along with an order for pain evaluation using a 1–10 pain scale every shift. However, this oxycodone order was not transcribed onto the February MAR. A narcotic card audit conducted by the DON showed that 58 oxycodone 5 mg tablets had been dispensed for this resident, and the audit documentation for this medication was highlighted and incomplete, with no indication that the medication was in the cart or scanned. For another resident admitted with atherosclerotic heart disease, muscle weakness, and acute hematogenous osteomyelitis of the right ankle and foot, there was a physician order for oxycodone‑acetaminophen 10‑325 mg, one tablet by mouth every 6 hours as needed for pain level 1–10. The care plan documented that the resident was on an opiate and required medications to be administered as ordered, and there was also an order for pain evaluation using a 1–10 pain scale every shift. The MAR for February showed that the oxycodone‑acetaminophen order was transcribed and documented as administered on two dates. Provider notes indicated that the resident complained of leg pain and that pain control was adequate, with a plan to continue the current pain regimen. Despite this, the narcotic card audit revealed that 20 tablets of oxycodone‑acetaminophen 10‑325 mg had been dispensed, but the audit entry was highlighted, lacked a check mark, and was marked as not applicable. The facility’s internal investigation documented that two nurses on consecutive shifts completed medication reconciliation for the second resident’s oxycodone‑acetaminophen and that both the bubble pack and narcotic count sheet were present at that time. The following day, a registry RN accepted the cart from the night shift nurse and identified that the narcotics and count sheet were present, but when that RN later passed the cart to the next nurse, the narcotic sheet and bubble pack for the oxycodone‑acetaminophen were no longer present. The investigation stated that the registry RN concealed this information and did not properly report it during handoff. Camera footage reviewed by the facility showed the registry RN entering the medication room, pretending to place medications into a cabinet, and instead stuffing medication bubble packs down the front of her scrubs. During an audit of all residents on controlled medications, the facility determined that this RN had removed the first resident’s oxycodone 5 mg, totaling 58 tablets, which were from a discontinued order set for destruction. The facility substantiated misappropriation of medications based on this evidence. Interviews with nursing staff and review of the facility’s controlled substances policy confirmed that the established process required two‑nurse narcotic counts each shift, reconciliation of declining inventory records with MARs and access records, and immediate reporting and investigation of discrepancies, but these controls did not prevent or timely detect the diversion involving these two residents’ narcotics. Additional staff interviews further described the expected practices that were not effectively implemented in this incident. An RN stated that it was never acceptable to use one resident’s controlled medication for another and that two nurses were to conduct narcotic counts at shift change, with any discrepancies immediately reported to the DON. An LPN explained that the oncoming nurse was to count all controlled medication cards, bottles, and syringes for every resident, with two nurses verifying that all medications were accounted for, and that any discrepancy would prompt review of the previous three shifts and notification of the DON. The DON described the reconciliation process in which the oncoming and outgoing nurses compare the narcotic sheet with the physical bubble packs, first by card count and then by pill count, and notify her of any mismatch for investigation and possible notification of the administrator and consultant pharmacy. Despite these written policies and described procedures, the documented diversion of oxycodone and oxycodone‑acetaminophen for the two residents occurred, and the missing narcotics and associated documentation were not identified and addressed at the time of shift‑to‑shift reconciliation.
Failure to Administer and Document PRN Morphine per Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer and document narcotic medication according to a physician’s order for a resident with dementia and significant behavioral symptoms. The resident had multiple diagnoses including acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention. Assessments and provider notes over time documented moderate to severe cognitive impairment, advanced dementia with behaviors, and near constant yelling, screaming, and agitation that were difficult to redirect. Care plans identified pain, behavior problems, and impaired cognitive function, with interventions that included administering medications as ordered, monitoring for side effects and effectiveness, and using non-pharmacological interventions prior to PRN medications. On a specified date, a physician ordered Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, to give 0.25 ml every 4 hours as needed for pain or shortness of breath. A behavior note from that same date documented that the resident continued to yell throughout the day, that redirection had no effect, and that PRN lorazepam and morphine were administered into the resident’s cheek pocket, pending effectiveness. The Individual Control Drug Record for the resident’s morphine 5 mg pre-filled syringe (0.25 ml/5 mg) showed that two doses were administered that day, one at 10:00 a.m. and another at 12:10 p.m., which was 2 hours and 10 minutes after the first dose, rather than at or after the ordered 4-hour interval. Despite the controlled drug record indicating two morphine doses, the January Medication Administration Record (MAR) contained no evidence that any doses of morphine sulfate oral solution were administered. Progress notes referenced that morphine was given but did not specify how many doses or the exact times of administration. Interviews with nursing staff and the DON confirmed that facility practice and policy require medications to be administered in accordance with prescriber orders, including required time frames, and to be documented on the MAR, with controlled substances also documented on individual controlled substance records. The DON reviewed the morphine order and narcotic reconciliation sheet and stated that administering morphine at 10:00 a.m. and again at 12:10 p.m. did not meet her expectations for following the physician’s order, and staff interviews emphasized that failure to document on the MAR creates a risk of not knowing when a medication was given and of administering another dose too soon. Facility policies on administering medications and controlled substances required that medications be administered as prescribed, that medication errors be documented and reported, and that the individual administering the medication record the date, time, dosage, route, indications, results, and their signature in the medical record or EMAR. The controlled substances policy required accurate individual controlled substance records and reconciliation using MARs and declining inventory records. In this case, the discrepancy between the controlled drug record, the MAR, and the physician’s order, along with incomplete documentation in progress notes, demonstrates that the resident’s narcotic medication was not administered and documented according to the physician’s order and facility policy.
Failure to Properly Label and Store Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure food was labeled and stored in accordance with professional standards. During a kitchen observation, a container of cooking wine was found in the walk-in dry storage with a use-by date of August 25, 2025, indicating it was past its use-by date at the time of the survey. In the large three-door freezer, peas and sliced carrots were stored in a blue plastic bag without any date labeling. Further observations of a nourishment refrigerator near a nurse station showed it was almost full and unorganized, with multiple food items that were unlabeled and undated. These included a plastic container with diced fruit in liquid, individual snacks and two triangle-shaped pieces of bread, a rectangular container with two round yellow substances on a white substance with dark speckles, a black container with pancakes and bacon, a styrofoam cup with what appeared to be vegetable soup with ice formation on top, and a large fruit cup with grapes, watermelon, and cantaloupe that had a past sell-through date but no facility-applied label. Additional items included a light blue container with what appeared to be meatballs and pasta with only “August 26” on the container and no complete date, and a black container with raspberries covered with light brownish fuzz mixed with blueberries that was also unlabeled and undated. Interviews with staff revealed inconsistent understanding and practices regarding responsibility for labeling and cleaning nourishment refrigerators. One cook stated the expired cooking wine was no longer good and acknowledged using the undated peas and carrots from the blue bag to prepare food the previous night. The cook also stated that CNAs were responsible for cleaning and discarding expired food from the nourishment refrigerator, while the Kitchen Dietary Director stated that specific kitchen staff were responsible for cleaning nourishment refrigerators on designated days. A dietary aide reported that she and the Dietary Director were responsible for cleaning all refrigerators and that food brought in by families should be labeled, dated, and used within 5 to 7 days. A CNA, however, stated that maintenance staff were responsible for cleaning nourishment refrigerators and that staff or families would label and date food brought in for residents. Facility policies reviewed by surveyors required that all refrigerated food be covered, labeled, dated, and monitored, and that foods brought from outside sources be labeled with the resident’s name and date and stored separately from facility food, which was not consistently followed in these observations.
Failure to Accurately Document PRN Controlled Medications on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident. The resident was re-admitted with multiple diagnoses, including acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention. An admission MDS showed moderate cognitive impairment. The resident’s care plan included a focus on pain management, with interventions such as administering analgesics per orders, anticipating pain needs, monitoring for non-verbal signs of pain, and using non-pharmacological interventions before PRN medications. Another care plan focus addressed behavior problems related to impaired cognition and impaired safety awareness, including verbal behaviors such as yelling out and banging on the table, with interventions to administer medications as ordered and monitor and document side effects and effectiveness. Physician orders dated January 2, 2026, included PRN Morphine Sulfate oral solution (20 mg/ml, 0.25 ml every 4 hours for pain/shortness of breath) and PRN Lorazepam Intensol oral concentrate (2 mg/ml, 1 ml every 2 hours for anxiety evidenced by restlessness/agitation). A behavior note on the same date documented that the resident continued to yell throughout the day, that redirection was ineffective, and that PRN doses of lorazepam and morphine were administered into the resident’s cheek pocket, pending effectiveness. The Individual Control Drug Records showed that two doses of morphine and two doses of lorazepam were administered on that date, at 10:00 a.m. and again at 12:10 p.m. Despite these entries on the narcotic control records and in the behavior note, the Medication Administration Record (MAR) for January 2026 contained no documentation that any doses of morphine sulfate oral solution or 2 mg/ml lorazepam were administered to the resident. The MAR also showed no recorded episodes of anxiety or restlessness for any shift in January 2026 under target symptoms/behavior tracking. Interviews with an RN, an LPN, and the DON confirmed that facility practice and policy require nurses to document all administered medications on the MAR, including date, time, dosage, route, symptoms, and results, and that controlled substances must also be recorded on narcotic reconciliation sheets. The DON reviewed the records and acknowledged that, although the narcotic sheets showed administration of morphine and lorazepam at 10:00 a.m. and 12:10 p.m., the MAR did not reflect these administrations, which did not meet the facility’s documentation expectations and policies.
Failure to Administer Prescribed Inhalation Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) received the prescribed Tyvaso Dry Powder Inhaler (DPI) as ordered by the physician. The resident was admitted with multiple diagnoses, including COPD and acute respiratory failure, and had a care plan that required administration of aerosol or bronchodilators as ordered. Physician orders were in place for Tyvaso DPI at varying dosages over several weeks. However, clinical record review and medication administration records (MAR) revealed multiple missed doses of Tyvaso DPI, with documentation indicating the medication was 'on order' or unavailable, despite the resident's family having provided the medication to the facility and it being stored on site. Staff interviews revealed confusion among nursing staff regarding the source and administration of the medication. An LPN stated that medications were always ordered through the pharmacy and was unaware that the family had supplied the Tyvaso DPI. The Assistant Director of Nursing confirmed that the medication was never ordered through the pharmacy and that the family had brought it in, but due to confusion over titration and dosage, the administration was inconsistent and not all doses were given as ordered. The facility's policy required medications to be administered according to prescriber orders, but this was not followed in this case, resulting in missed doses and a failure to comply with physician instructions.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a Certified Nursing Assistant (CNA), identified as staff #67. Resident #5, who was admitted with a diagnosis of traumatic subdural hemorrhage and other conditions, reported an incident where CNA #67 entered the room abruptly, was loud, and threw items on the floor. The resident felt afraid and unsafe due to the CNA's behavior, which included yelling and calling the residents troublemakers. The resident's call light was also thrown under the bed by the CNA, further exacerbating the situation. Resident #30, who shared the room with Resident #5, corroborated the account of verbal abuse. This resident, admitted with a fracture and other health issues, reported that CNA #67 was loud and inconsiderate, waking them up and arguing with them. The CNA was described as being out of control, flailing her arms, and towering over Resident #5 in an intimidating manner. Both residents expressed a desire for the CNA not to return to their room due to her behavior. Interviews with other staff members revealed a pattern of complaints against CNA #67, including her reluctance to assist residents and her tendency to speak loudly and disrespectfully. Despite multiple grievances and reports of verbal abuse, the facility's administration initially treated these incidents as grievances rather than reportable abuse. The facility's policy defines verbal abuse as actions that cause mental anguish, which aligns with the residents' experiences. However, the administration failed to recognize and report these incidents as abuse, leading to a deficiency in protecting residents from verbal harm.
Failure to Report Alleged Abuse by CNA
Penalty
Summary
The facility failed to report alleged abuse involving two residents, which could lead to continued abuse. Resident #5, admitted with a diagnosis of traumatic subdural hemorrhage and other conditions, filed a grievance report on November 8, 2024, stating that a CNA entered her room abruptly, was loud, and threw items on the floor. The resident reported feeling afraid and unsafe due to the CNA's behavior, which included yelling and throwing the call light under the bed. The resident's care plan indicated she was at risk for falls and required assistance, which was not adequately provided. Resident #30, admitted with a fracture and other conditions, also filed a grievance report regarding the same CNA on November 8, 2024. The resident reported that the CNA was loud and verbally abusive, arguing with both residents and blaming them for using the call light. The resident described the CNA as being out of control, flailing her arms, and intimidating her roommate. Despite these reports, the facility did not report the allegations of verbal abuse to the state agency within the required timeframe. The facility's Executive Director and Director of Nursing were informed of the allegations but did not consider the incidents as reportable verbal abuse. The facility's abuse policy defines abuse as the willful infliction of injury or intimidation causing mental anguish, including verbal abuse. The facility had prior complaints involving the same CNA for verbal abuse, which were also not reported as required. This failure to report alleged abuse constitutes a deficiency in the facility's compliance with regulatory requirements.
Verbal Abuse by Staff Member in LTC Facility
Penalty
Summary
The facility failed to protect three residents from verbal abuse by a staff member, identified as staff #42. Resident #456, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture and anxiety disorder, filed a grievance on May 22, 2024, reporting that staff #42 refused to assist him, stating, 'I am 55 and I am not picking you up.' This resident had a BIMS score of 15, indicating no cognitive impairment, and was dependent on staff for care. Resident #457, admitted with acute cystitis and anxiety disorder, reported an incident on July 16, 2024, where staff #42 was rude and upset about having to replace bed sheets after urine spilled. The resident had a BIMS score of 13, also indicating no cognitive impairment, and was dependent on staff for care. Staff #42 was subsequently not assigned to this resident again. Resident #458, with a diagnosis of a wedge compression fracture and other conditions, filed a grievance on July 30, 2024, stating that staff #42 was rude when asked for assistance with hygiene due to the resident's physical limitations. The resident had a BIMS score of 14, indicating no cognitive impairment, and required assistance due to a TLSO brace and orthostatic hypotension. The facility's abuse policy defines abuse as actions causing mental anguish, which was corroborated by interviews with other staff members who confirmed the verbal abuse by staff #42.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy for abuse prevention and reporting, as evidenced by incidents involving three residents and a staff member, CNA #42. Resident #456, who had no cognitive impairment, filed a grievance after CNA #42 refused to assist him, citing her age as a reason for not providing care. This incident was not reported or investigated according to the facility's policy. Resident #457, also cognitively intact, reported an incident where CNA #42 was rude and upset about having to change bed sheets. Although CNA #42 was not assigned to this resident again, the incident was not reported or investigated as required by the facility's abuse policy. The care plan for this resident indicated dependency on staff for care, highlighting the importance of staff support. Resident #458, who required assistance due to a TLSO brace and orthostatic hypotension, reported verbal abuse from CNA #42. The resident felt uncomfortable with the staff member's comments, yet the incident was not reported or investigated. Interviews with other staff members confirmed that the comments made by CNA #42 constituted verbal abuse, but the Director of Nursing did not consider it reportable unless the resident explicitly stated discomfort. The facility's documentation revealed a lack of thorough investigation and reporting of these incidents, contrary to their stated policy.
Failure to Report Alleged Abuse by Staff
Penalty
Summary
The facility failed to report alleged violations of abuse involving three residents, which could lead to further abuse. Resident #456, who had no cognitive impairment, filed a grievance against a CNA, staff #42, for being unqualified and refusing to assist him. Resident #457, also cognitively intact, reported an incident where staff #42 was rude and upset about changing bed sheets. Resident #458, who required assistance due to a back injury and orthostatic hypotension, reported that staff #42 made a racially insensitive and inappropriate comment when asked for help with toileting. Interviews with staff members revealed differing opinions on whether the incidents constituted abuse. Staff #43 and staff #40 considered the comments made by staff #42 as verbal abuse, while the DON, staff #28, viewed it as poor communication and customer service, stating it was only abuse if the resident felt uncomfortable. Despite the grievances and staff opinions, the incidents were not reported to the appropriate authorities as required by the facility's policy. The facility's policy mandates that any suspected or witnessed abuse be reported to the Executive Director and other relevant entities, including Adult Protective Services and the State Survey Agency. The policy also requires an immediate investigation and suspension of the alleged perpetrator pending results. However, the facility did not adhere to these procedures, as the incidents involving staff #42 were not reported, and the required investigation and notifications were not conducted.
Failure to Investigate and Report Alleged Abuse by Staff Member
Penalty
Summary
The facility failed to investigate and correct alleged violations of abuse involving three residents by a staff member, identified as staff #42. Resident #456, who had no cognitive impairment, filed a grievance stating that staff #42 was not qualified for her job and refused to assist him, citing her age as a reason. Resident #457, also cognitively intact, reported an incident where staff #42 was rude and upset about having to replace bed sheets after a urine spill. Resident #458, who required assistance due to a back injury and orthostatic hypotension, reported that staff #42 made a racially insensitive and inappropriate comment when he requested help with toileting. Interviews with staff members, including the Resident Relations Manager and the Director of Nursing (DON), revealed that these incidents were brought to the attention of the DON, but staff #42 was only written up much later, on October 1, 2024. The facility's documentation showed that the incidents were not reported or investigated at the time they occurred, contrary to the facility's policy on abuse. The policy mandates immediate reporting and investigation of suspected abuse, including notifying various entities and conducting interviews to determine if there is a trend. The facility's failure to adhere to its abuse policy was further highlighted by interviews with other staff members, who confirmed that the comments made by staff #42 constituted verbal abuse. Despite this, the DON did not consider the incidents reportable unless the residents explicitly stated they felt uncomfortable. This lack of action and failure to follow established procedures for handling abuse allegations led to the deficiency noted in the report.
Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to administer scheduled pain medication in accordance with physician orders for three residents, leading to potential inadequate pain control. Resident #14, who was admitted with conditions including COPD and chronic pain, received Oxycodone outside of the prescribed parameters on multiple occasions. The medication was administered for pain levels of 0, contrary to the physician's order for administration at pain levels 4-10. There was no evidence that the provider was notified of these deviations, nor were post-administration pain assessments documented. Resident #4, with a history of opioid dependence and other significant health issues, also received pain medication outside of the prescribed parameters. Roxicodone was administered for a pain level of 0 on numerous occasions, and the provider was not notified in most instances. The resident's orders were for administration at higher pain levels, and the lack of adherence to these orders was not documented or communicated to the provider. Resident #40, who had diagnoses including acute osteomyelitis and heart failure, was given Oxycodone for a pain level of 0, which was outside the ordered parameters. The facility's policy required pre-administration assessments and adherence to medication orders, which were not followed. The DON acknowledged the errors and attributed them to the nurse's inexperience, indicating a failure in ensuring proper medication administration training and oversight.
Deficiency in CNA CPR Certification Compliance
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) maintained valid CPR and first aid certifications, as required by their job descriptions. Personnel file reviews revealed that CNAs Staff #48, #61, and #42 did not have evidence of obtaining CPR or First Aid certifications. The job description for CNAs, revised in September 2016, listed an active CPR certification as a minimum requirement. However, a new job description, which was undated and not signed by any CNAs, indicated that CPR certification was preferred but not required. Interviews with the Director of Nursing and the Corporate HR Operations Manager revealed inconsistencies in the understanding and implementation of the CPR certification requirement. The facility's policy on emergency procedures required that the CPR team include at least one nurse, one LPN/LVN, and two CNAs, all certified in CPR/BLS. Despite this, the Director of Nursing acknowledged that no CNAs, including Staff #48 and #61, had CPR certifications. The Corporate HR Operations Manager confirmed that a new policy and job description were intended to remove the CPR requirement for CNAs, but the transition was not properly executed, as evidenced by CNAs signing the incorrect job description. This oversight could potentially result in harm to residents due to staff not being knowledgeable about providing emergency care as part of the CPR team.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, specifically a cell phone, which went missing during the night. The resident, who had intact cognition as indicated by a BIMS score of 12, reported the missing phone to the facility. The facility's investigative report noted that the phone was reported missing on the morning following the incident, and attempts to contact a registry-contracted CNA, who was suspected of involvement, were unsuccessful due to the use of a false phone number. The facility's documentation also revealed that another resident reported missing property during the same period. The facility's policy on resident rights emphasizes protection from misappropriation of property, yet the investigation into the missing phone was inconclusive. The Executive Director noted discrepancies in the report to the Arizona State Board of Nursing, suggesting that the allegation against the CNA could not be substantiated. Despite the facility's process for handling missing items, which includes searching and reporting, the missing phone was not recovered, and the investigation did not lead to a resolution.
Failure to Document and Investigate Grievance
Penalty
Summary
The facility failed to file and investigate a grievance according to its policy for a resident who was admitted with diagnoses including hypertension, shoulder pain, delirium, hallucinations, and the presence of a pacemaker. The resident's husband reported concerns to the nursing staff, resident relations, and the executive director, including issues such as water damage in the room and the resident being left inappropriately dressed. Despite these concerns being communicated verbally, the facility did not document or investigate the grievance as required by their policy. The executive director acknowledged the concerns as a quality of care issue but did not initiate a formal grievance process, citing the husband's refusal to fill out a grievance form and his insistence on discharging the resident. The resident relations manager also failed to document the grievance, and the facility's grievance log showed no record of the incident. This lack of documentation and investigation represents a failure to honor the resident's right to voice grievances without discrimination or reprisal.
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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