Heritage Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Globe, Arizona.
- Location
- 1300 South Street, Globe, Arizona 85501
- CMS Provider Number
- 035141
- Inspections on file
- 17
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Heritage Health Care Center during CMS and state inspections, most recent first.
A resident with a right heel wound, osteomyelitis, and a history of substance use received PRN Hydrocodone-Acetaminophen and Acetaminophen outside the provider-ordered pain-level parameters. Orders specified Hydrocodone-Acetaminophen only for pain levels 4–10 and Acetaminophen for pain levels 1–3, but MAR review showed both medications were repeatedly administered when documented pain scores were 0, 1, or higher than the ordered range. Facility staff, including an LPN and the DON, acknowledged that medications are required to be administered according to provider orders and that there was no documentation authorizing these out-of-parameter doses.
A resident with multiple chronic conditions and intact cognition repeatedly alleged neglect, racial mistreatment, and mental abuse by staff, including not receiving medications as expected and feeling demeaned by an LPN. These concerns were reported by CNAs and an LPN up the chain of command to the DON, ADON, and Administrator, and the DON acknowledged being aware of at least one allegation and discussing it with others. However, the facility did not document these discussions, did not report several oral allegations of abuse and neglect to the state agency as required, and leadership determined the concerns did not meet their understanding of abuse or neglect despite facility policies mandating immediate reporting of all alleged violations to appropriate authorities.
The facility failed to maintain accurate, consistent, and accessible advance directives and code status orders for multiple residents. One resident had a POLST indicating DNR and selective treatment while an active order listed full code, and the required orange prehospital medical care directive could not be found in the EHR or nursing station binder. Another resident with extensive comorbidities had an Advance Directive Statement Form refusing CPR and defibrillation and specifying other treatment preferences, but the care plan initially lacked any advance directive focus and a later POLST ordered CPR and documented that no advance directive existed. Staff interviews revealed that nurses and CNAs relied on electronic charts and code status books that did not always match, and some staff stated they would proceed with full code when documentation conflicted or was missing, even if this went against resident wishes. Leadership acknowledged that facility policy and state law required correctly completed POLST forms and orange prehospital medical care directives for DNR/DNI status, and that these documents were not consistently completed, updated, or available as required.
Two residents with diabetes on sliding scale insulin orders experienced multiple episodes of blood glucose readings at or above the ordered notification threshold, but staff did not contact the provider as required and did not document any such notifications. For one resident with diabetes, chronic kidney disease, and long-term insulin use, the care plan omitted the specific sliding scale and notification parameters, and MAR reviews over several months showed repeated elevated readings without provider notification. For another resident with diabetes and acute kidney failure, physician orders clearly directed staff to call the medical director for blood sugars of 351 mg/dL or higher, yet MARs and progress notes showed very high readings on multiple occasions with no evidence of provider contact. Staff interviews, including with an LPN and the DON, confirmed that these elevated values were out of ordered parameters and that the provider was not notified, contrary to facility policy and recognized diabetes management guidance.
The facility failed to ensure PASARR screenings were accurate, complete, and updated for two residents with mental health and substance use-related conditions. One resident with diabetes, CKD, malnutrition, and documented substance use disorder and anxiety had a hospital-submitted PASRR Level I that omitted anxiety and substance use, and the facility did not generate its own Level I despite internal care plans and MDS data later reflecting an anxiety diagnosis and antianxiety medication orders. Another resident with an active bipolar disorder diagnosis and antipsychotic use had a PASARR form that omitted the bipolar diagnosis and antipsychotic therapy and was only partially completed, even though the MDS and physician orders documented bipolar disorder, hallucinations, and recent antipsychotic use. Staff interviews revealed that the SSD was new to the PASARR system, had not initiated additional PASARR screenings, and acknowledged that a Level II should have been requested for the resident with bipolar disorder, while the DON confirmed staff were previously unaware of requirements to update Level I when a stay would exceed 30 days and that the facility policy did not address this requirement.
Surveyors found that kitchen staff failed to follow facility food safety policies requiring proper labeling and dating of stored food items. During a walkthrough of refrigerators, freezers, and dry storage, multiple items—including grapes, pepperoni, vegan burger patties, cod fish patties, potatoes, bananas, and tortilla chips—were observed without required received dates, open dates, or use-by dates. In interviews, the Food Services Director and Dietary Manager confirmed that policy mandates all stored and opened foods be labeled with these dates and, when repackaged, placed in sealed, labeled containers, but the observed practices did not meet these standards.
Two residents with dementia engaged in a physical altercation over a personal item, resulting in one slapping the other and a subsequent shove. Staff intervened and separated the residents, but documentation showed that not all required notifications were made. Despite existing care plans and staff training on abuse prevention, the incident was recognized as abuse and highlighted a failure to fully protect residents from such events.
A resident with cognitive impairment, mobility limitations, and a history of falls was not provided with adequate supervision or timely staff response, leading to two falls. The resident reported long wait times for assistance, resulting in attempts to transfer independently. Staff interviews revealed inconsistent awareness and implementation of fall prevention interventions, contributing to repeated falls and injuries.
Two residents with severe cognitive impairment were physically abused by another resident with a history of agitation and psychotic disorder. In separate incidents, the aggressive resident struck one resident in a common area and slapped another in their shared room, resulting in emotional distress and minor injury. Both events were witnessed by staff and documented, revealing a failure to prevent resident-to-resident abuse despite existing care plans and interventions.
Pain Medications Administered Outside Ordered Parameters for PRN Use
Penalty
Summary
Surveyors identified a deficiency in medication administration in which a resident’s drug regimen was not kept free from unnecessary drugs, specifically pain medications given outside provider-ordered parameters. The cognitively intact resident had diagnoses including Type 2 Diabetes Mellitus without complications, a right heel pressure ulcer, and acute osteomyelitis of the right ankle and foot, and had a care plan addressing pain related to a right heel wound as well as risk for negative health outcomes related to continued substance use while in the facility. Provider orders included PRN Hydrocodone-Acetaminophen 5-325 mg every four hours as needed for pain intensity 4–10, to be held if the resident was drowsy, and PRN Acetaminophen 325 mg, two tablets every six hours as needed for pain intensity 1–3, not to exceed 3 grams in 24 hours. The facility’s Administration of Medications policy required staff to note the resident’s history and any parameters around drug administration and identified opioids as high-alert medications. Record review showed multiple instances in which nursing staff administered these medications outside the ordered pain-level parameters. The January Medication Administration Record (MAR) showed Hydrocodone-Acetaminophen was given once for a documented pain level of 1, and the February MAR showed it was given for pain levels of 0 and 1, despite the order specifying use only for pain levels 4–10. The January MAR also showed Acetaminophen was administered on several dates when the recorded pain levels were 6, 7, 5, 4, or 0, outside the ordered 1–3 pain range, and similar out-of-parameter administrations occurred in February for pain levels 4 and 5. Interviews with an LPN and the DON confirmed that medications are to be given according to provider orders, that these administrations occurred outside the ordered parameters, and that there was no documentation in the record authorizing administration outside the provider’s orders for the identified dates.
Failure to Report Resident’s Abuse and Neglect Allegations to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse and neglect reporting policies and to timely report allegations of neglect to the state agency for one resident. The resident had multiple medical diagnoses, including type 2 diabetes mellitus, depression, urinary retention, benign prostatic hyperplasia, muscle spasm, and morbid obesity due to excess calories. A care plan initiated in February 2024 identified a risk for change in mood or behavior related to medical conditions, with interventions including medications as ordered. A quarterly MDS assessment documented intact cognition with a BIMS score of 15/15 and noted that the resident experienced depressed mood and behavioral symptoms in the days preceding the assessment. The resident’s care plan for risk of change in mood and behavior was revised in February 2025 to note that the resident made untrue statements about receiving medications on time. On a date in February 2026, a behavior progress note documented that the resident told a medication technician he was being neglected and wanted to speak to a nurse immediately. The note indicated the allegation was reported to the DON, who spoke with the resident and instructed staff to provide care with two staff present in the room; however, there was no evidence that this allegation was reported to the state agency. The care plan was later revised to include interventions for two-person care and medication pass. Another behavior progress note in February 2026 recorded that the resident complained of not receiving nighttime medications and accused staff of abusing and neglecting him, and the nurse documented that the ADON was notified and that medications were being administered per physician orders. A separate note the same day indicated that care in pairs was continuing. During interviews, the resident stated that an LPN had inflicted mental abuse on him through prior interactions that made him feel less than a man, and that he experienced increased anxiety and anxiety attacks when aware that this LPN would be on shift. He also reported feeling abused and neglected due to his race and said he had informed the DON but felt nothing was done. CNAs reported that the resident had shared allegations of abuse and neglect with them and that they relayed these concerns to nurses, who responded that they were already aware and would handle the matter; the CNAs were unsure what actions were taken. An LPN stated that allegations of abuse and neglect, including verbal and physical abuse and withholding care, must be reported to the state agency within two hours and that she had reported the resident’s allegations about water restrictions and medications to the ADON, DON, and Administrator, but she was not informed of any subsequent facility actions. The DON stated that all allegations of abuse and neglect, including verbal abuse, were to be reported to the abuse coordinator, and acknowledged that a prior allegation of neglect documented in a June 2024 progress note had not been reported to her, and therefore was not reported to the state agency as required by policy and regulation. Regarding the February 13, 2026 progress note, the DON confirmed that the allegation of neglect had been reported to her but that she did not document any discussion with the resident. The DON, ADON, and Social Services confirmed that a conversation about the allegations occurred but was not documented and that they determined the allegation did not meet their understanding of abuse or neglect and did not require further action, including reporting to the state agency, contrary to facility policy and regulatory requirements. Social Services noted the resident had increased depression and anxiety and did not connect these behaviors with the abuse and neglect allegations. The facility’s policies on abuse identification and on reporting and response required staff to report suspected abuse, neglect, or exploitation to leadership and mandated that all alleged violations, whether oral or written, be reported to the facility and appropriate officials within prescribed timeframes, which did not occur in this case. An LPN identified as the alleged perpetrator stated that whether she would report an allegation depended on who made it and the rapport she had with the resident, indicating she would decide what to report based on that relationship. She also stated she could not recall the resident disclosing allegations of abuse or neglect to her or against her and denied that any such allegations would be true based on her character. She did not describe specific actions or behaviors that would constitute abuse or neglect. Overall, the documented allegations by the resident, the staff interviews, and the policy review show that multiple allegations of abuse and neglect were not reported to the state agency and were not handled in accordance with the facility’s written abuse and neglect reporting policies and regulatory requirements.
Failure to Maintain Accurate and Accessible Advance Directives and Code Status Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure that valid, consistent, and readily accessible advance directives and medical orders were in place and accurately reflected for multiple residents, resulting in conflicting code status information and missing documentation. For one resident with diagnoses including malignant neoplasm of the prostate, acute kidney failure, hypothyroidism, glaucoma, benign prostatic hyperplasia, and muscle weakness, a POLST form documented a choice of no CPR and selective treatment to avoid intensive care and resuscitation efforts. Despite this, an active order in the clinical record listed the resident as full code, and staff were unable to locate the required prehospital medical care directive (orange advance directive form) in either the electronic health record or the nursing station binder at the time of review. The DON later acknowledged that staff were expected to follow the most recent POLST indicating DNR, but this conflicted with the active full code order and the absence of the required orange directive form. Another resident, with a complex medical history including traumatic brain injury, hypertension, GERD, tremor, long-term anticoagulant and insulin use, schizoaffective disorder, Guillain-Barré syndrome, generalized anxiety disorder, bipolar disorder, dementia with behavioral disturbance, neoplasm, protein-calorie malnutrition, dyspnea, and type 2 diabetes with polyneuropathy, had an order indicating DNR and no feeding tube. An Advance Directive Statement Form documented that this resident did not want CPR or defibrillation in the event of cardiac arrest, did not want a feeding tube, did want IV hydration, wanted adequate pain medication even if it risked depressing respiration, wanted transfer to the hospital if their condition became terminal or irreversible, and would accept blood transfusions but not mechanical ventilation. However, the resident’s care plan initially contained no focus or interventions related to advance directives after admission, and only later was revised to state that the resident had an advance directive for CPR, do not shock, and DNI. A POLST completed later documented “Yes, CPR, attempt resuscitation” and stated that no advance directive existed, directly conflicting with the previously completed Advance Directive Statement Form. Staff interviews further demonstrated inconsistent understanding and implementation of the facility’s advance directive process. Nursing staff reported that code status information should be available in the electronic chart and in a code status book at each nursing station, and that changes in code status should be reflected in both locations. One LPN stated that if an advance directive was incorrect, staff could go against the resident’s wishes, and a CNA reported that if forms and lists did not match the health record, they would proceed with full code until the correct status was confirmed, even though this could result in care against the resident’s wishes. The ADON and DON described a process requiring both a correctly completed POLST and a prehospital medical care directive on orange paper for DNR/DNI status, in accordance with state law and facility policy, and acknowledged that incomplete, conflicting, or inaccessible documents could lead to treatment being performed against a resident’s wishes. The facility’s own policy required review and updating of advance directives at admission, quarterly, and with changes in condition, and required social services to ensure copies were in the medical record with corresponding physician orders, but these expectations were not met for the residents reviewed. Additional findings showed that for another resident, staff could not locate any advance directive or POLST in the electronic record or nursing station binder, despite an active order indicating DNI and do not shock status. The DON confirmed that, given this active order, both a POLST and an orange prehospital medical care directive should have been completed and present in the record, but they were not. The state prehospital medical care directive requirements specified that the DNR document must be on orange paper, signed by the patient, health care provider, and a witness or notary, and displayed visibly for first responders, yet such a valid document was not consistently available for the residents in question. Overall, the facility did not follow its own policy and state requirements to ensure that advance directives and related medical orders were accurately completed, consistently documented, and readily accessible, leading to conflicting and incomplete information regarding residents’ code status and treatment preferences.
Failure to Notify Provider of Critically Elevated Blood Glucose Levels per Insulin Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders requiring provider notification for abnormal blood glucose levels for two residents with diabetes who were receiving insulin on sliding scale orders. For one resident with Type 2 Diabetes Mellitus, Stage 4 chronic kidney disease, long-term insulin use, a right heel pressure ulcer, and acute osteomyelitis of the right ankle and foot, a provider order dated October 20, 2025 directed staff to notify the provider and administer 12 units of Humalog for glucose levels of 351 mg/dL or greater. The resident’s diabetes care plan, initiated October 21, 2025, instructed staff to obtain blood sugar checks and administer medications as ordered, but did not include the specific sliding scale insulin parameters or the requirement to contact the provider when glucose exceeded 351 mg/dL. Review of the December 2025 MAR showed multiple blood glucose readings at or above 351 mg/dL on several dates, with no documentation that the provider was notified as ordered. Further review of the same resident’s records showed that in January 2026 and February 2026, blood glucose levels again reached 351 mg/dL or greater on multiple dates, triggering the order to administer 12 units of Humalog and notify the provider. However, the clinical record contained no documentation that the provider was contacted for any of these elevated readings. The admission MDS indicated the resident was cognitively intact with a BIMS score of 15 and received daily insulin therapy. Interviews with facility staff, including a CNA, the RD, an LPN, and the DON, confirmed that staff understood that elevated blood glucose levels and sliding scale orders requiring provider notification must be reported to the provider, and the DON acknowledged that the provider should have been contacted for each instance and that no documentation of such notifications could be found. For a second resident re-admitted with diagnoses including type 2 diabetes mellitus, long-term insulin use, and acute kidney failure, a physician order dated November 28, 2025, and again on December 5, 2025, specified Humalog insulin to be given subcutaneously before meals and at bedtime per a sliding scale, with instructions that for blood glucose levels of 351 mg/dL or greater, 10 units of insulin should be administered and the medical director called. Review of the December 2025 MAR showed multiple blood glucose readings above 351 mg/dL on several dates, and a February 2026 MAR entry showed a blood sugar of 449 mg/dL, with no evidence that the physician was notified on any of these occasions. Progress notes from December 2025 through January 2026 also lacked documentation of provider notification when blood sugars exceeded 351 mg/dL. Interviews with an LPN and the DON confirmed that the resident’s blood sugars were very high on the identified dates and that the provider was not notified, despite facility policy requiring orders to be followed and documentation to be consistent with professional standards and guidance indicating that persistent elevated readings above the ordered sliding scale should be communicated to the provider.
Failure to Complete and Update Accurate PASARR Screenings for Residents With Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to ensure PASARR (Preadmission Screening and Resident Review) screenings and referrals were accurate, complete, and submitted according to professional standards for two residents. For one resident with diagnoses including long-term insulin use, Type 2 diabetes, stage 4 chronic kidney disease, and malnutrition, the hospital-submitted PASRR Level I did not reflect the resident’s history of anxiety or substance use disorder. The facility did not generate its own PASRR Level I, despite internal documentation identifying substance use disorder and elopement risk, and a mood/behavior care plan that referenced risk for mood or behavior changes. The admission MDS showed moderately impaired cognition but no history of anxiety or antianxiety medication use, even though the resident later had an order for an antianxiety medication and a quarterly MDS listed an active anxiety disorder diagnosis. For the second resident, who had an active diagnosis of bipolar disorder, the care plan documented the use of antipsychotic medications related to this diagnosis. However, the PASARR form completed for this resident did not include the bipolar disorder diagnosis or any evidence of ordered antipsychotic medication, and only three of the five PASARR review pages were completed. Subsequent clinical documentation, including a physician’s order for olanzapine for bipolar disorder and behaviors such as hallucinations and repeated requests for assistance, as well as a quarterly MDS indicating bipolar disorder and recent antipsychotic use, demonstrated that the PASARR information was incomplete and inconsistent with the resident’s actual condition and treatment. Interviews with facility staff further demonstrated gaps in the PASARR process. The Activities Director stated that a correct PASARR helps staff develop appropriate interventions but acknowledged reliance on her own assessment when the PASARR is inaccurate. The Social Services Director reported being new to the PASARR portal, lacking access for a period, and not having completed additional PASARR level screenings since assuming the role, despite acknowledging that a Level II should have been submitted for the resident with bipolar disorder once it was clear the stay would exceed 30 days. The DON confirmed that social services is responsible for PASARR completion, that staff were previously unaware of requirements such as updating Level I when a stay is expected to exceed 30 days, and that the diagnoses, care plans, and PASARR information for the residents did not match. The facility’s PASARR policy also lacked language addressing the requirement to update a Level I when an individual’s stay will exceed 30 days, as specified in the state Medicaid policy manual.
Failure to Label and Date Stored Food Items per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices based on observations in the kitchen refrigerators, freezers, and dry storage areas. During an inspection of Refrigerator #1, an original package of grapes was found without any received date, opened date, or use-by date. In Freezer #1, an original package of pepperoni was labeled only with a received date of September 5, 2025, but lacked an opened date and use-by date. In the same freezer, an opened original package of vegan burger patties, received on January 7, 2026, had no open date or use-by date, and an opened original package of cod fish patties had no received date, opened date, or use-by date. In the dry storage area, an original box of potatoes, a box of bananas, and an original bag of tortilla chips were all found without any received dates, and the tortilla chips also lacked an opened date and use-by date. In interviews following these observations, the Food Services Director and the Dietary Manager & Director confirmed that facility policy requires all items stored in the refrigerator, freezer, and dry storage to be labeled with a received date, open date, and, when applicable, a use-by date, in a manner accessible to staff. They stated that opened items kept in original packaging are expected to be placed in sealable containers or packages and labeled with the required dates, and that fresh produce boxes must retain the received date and be checked daily for wholesomeness. The facility’s written “Food Safety” policy, last reviewed May 1, 2025, further documented that pre-packaged food transferred to new containers must be labeled with contents and date, that received food must be dated if not already indicated, that each item in multi-item boxes must be individually dated, and that opened packages must be resealed tightly and labeled with a use-by date when applicable. The observed lack of required labeling and dating on multiple food items demonstrated noncompliance with these established policies and professional standards for food storage.
Failure to Protect Residents from Abuse During Roommate Altercation
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse, as evidenced by an altercation between two roommates. One resident, who had diagnoses including dementia and severely impaired cognition, was involved in a physical altercation with her roommate over a plastic flower. During the incident, one resident slapped the other on the face, and the other responded by shoving her roommate's shoulder. Staff intervened and separated the residents, and a skin assessment was completed with no injuries noted. Clinical documentation and staff interviews confirmed that the altercation was witnessed by staff, who heard a commotion and observed the physical exchange. The residents were separated, and notifications were made to the DON, administrator, and provider. However, the behavioral progress note indicated that the resident's representative and case manager were not notified of the incident. Both residents had care plans indicating a potential for verbal aggression related to dementia, with interventions to assess and anticipate needs, but the altercation still occurred. Staff interviews revealed that the incident was recognized as a form of abuse, with both the LPN and Medication Technician stating that physical contact such as slapping or pushing constitutes abuse. The facility's policies on abuse prevention and resident rights were reviewed, confirming the expectation to prevent all types of abuse. Despite these policies and staff training, the incident occurred, resulting in a failure to fully protect residents from abuse as required.
Failure to Provide Adequate Supervision Resulting in Resident Falls
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including moderate cognitive impairment, osteoporosis, and dementia, was not provided with adequate supervision to prevent falls. The resident had a documented history of falls, impaired mobility, and required assistance with activities of daily living (ADLs) and transfers. Despite these needs, the care plan interventions prior to the falls primarily included having the call light within reach, staff assistance for transfers and toileting, and the use of non-slip socks or shoes during mobility. However, the resident experienced two falls within a short period, one in the bathroom while attempting to transfer from the wheelchair without assistance and another after falling asleep in the wheelchair and sliding to the floor. Documentation and staff interviews revealed that the resident had reported using the call light for assistance but experienced significant delays in staff response, sometimes waiting an hour or more. The resident stated that due to these delays, he attempted to perform tasks independently, leading to falls. Staff interviews indicated inconsistent awareness of the resident's fall risk status and interventions, with one CNA unaware that the resident was a fall risk prior to the incidents and noting the absence of a yellow armband, which was supposed to indicate fall risk. The care plan and interventions were not consistently communicated or implemented among staff, and there was a lack of timely and effective supervision tailored to the resident's needs. The facility's policy required providing an environment free from accident hazards and adequate supervision to prevent avoidable accidents. Despite this, the resident's increased weakness, cognitive impairment, and history of falls were not sufficiently addressed through effective supervision or timely staff response. The lack of prompt assistance and inconsistent implementation of fall prevention interventions contributed to the resident's repeated falls and subsequent injuries, including compression fractures and increased back pain.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with severe cognitive impairment and a history of agitation and psychotic disorder initiated a verbal altercation with another cognitively impaired resident in a common area. Despite staff presence, the aggressive resident struck the other on the back of the head, an act witnessed by staff. The victim was left teary-eyed but did not sustain physical injuries. The aggressive resident had a recent reduction in antipsychotic medication, which was later increased after the incident due to a return of behavioral issues. In the second incident, the same aggressive resident was involved in a physical altercation with a different roommate, also diagnosed with severe dementia and behavioral disturbances. The altercation occurred in their shared room, where the aggressive resident slapped the roommate on the face, resulting in visible redness and emotional distress. The aggressive resident claimed provocation, but the victim denied any physical aggression. Staff responded to the incident after hearing a scream and found the victim holding her face and visibly upset. The incident was documented, and the residents were separated immediately after. Both incidents were substantiated or under investigation by the facility, with staff interviews confirming the aggressive resident's history of agitation, confrontational behavior, and recent emotional distress related to personal matters. The facility's policy prohibits all forms of abuse, including resident-to-resident abuse, but the interventions in place failed to prevent these incidents. The events were witnessed by staff, and the facility's documentation confirmed the occurrence of physical abuse between residents.
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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