Life Care Center Of Tucson
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 6211 North La Cholla Boulevard, Tucson, Arizona 85741
- CMS Provider Number
- 035140
- Inspections on file
- 23
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Life Care Center Of Tucson during CMS and state inspections, most recent first.
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.
Two residents with dementia and severe cognitive impairment, one already care planned for risk of behavioral changes and physical aggression, were seated in a hallway with other residents when an altercation occurred. One resident was heard yelling and striking the other across the chest with a stuffed animal, and the other resident responded by kicking the aggressor in the leg. An ADON heard screaming, directly observed the physical contact between the residents, and later stated she considered the incident to be abuse. Skin assessments showed no injuries, but the event demonstrated that the facility did not effectively protect a resident’s right to be free from abuse by another resident, despite an abuse‑prevention policy requiring identification, assessment, and care planning for residents with verbally or physically aggressive behaviors.
A resident with moderate cognitive impairment and multiple medical conditions was not initially identified as an elopement risk, despite wandering behaviors. After reassessment, the resident was placed on 15-minute checks and listed in the Elopement book, but inconsistencies in risk assessment and care plan updates occurred. The resident was able to exit the facility unsupervised through the front door, with no Wander Guards or security cameras in place, and staff acknowledged that adequate protection was not provided.
A resident with chronic pain was prescribed Dilaudid, but an LPN repeatedly logged out doses on the narcotic count sheet without documenting administration on the MAR. This discrepancy led to the resident experiencing pain and raised concerns about possible medication diversion, as confirmed by staff interviews and facility policy review.
A power outage led to a malfunctioning generator and cooling system, causing uncomfortably high temperatures in a LTC facility. Several residents, including those with chronic conditions, reported discomfort due to the heat. Staff interviews revealed a lack of systematic temperature monitoring and inadequate emergency protocols, contributing to the prolonged discomfort.
The facility failed to maintain safe food storage temperatures in the walk-in refrigerator, with temperatures recorded above the critical limit of 40F. Despite policy requirements, actual temperatures were higher than recorded, posing a risk for food-borne illnesses. Staff interviews revealed the refrigerator was used for storing various food items, and maintenance errors contributed to the issue.
The facility experienced a complete power outage due to a failure in the temporary generator, which had been in use since 2020. This outage affected medical equipment, elevators, and refrigeration units, and required manual intervention to restore power. Residents on oxygen concentrators were switched to O2 tanks, and staff faced challenges due to non-functional elevators and a lack of standard procedures for power outages. The deficiency was confirmed during an exit conference.
The facility failed to maintain a safe and comfortable environment, with observations revealing safety hazards such as peeling paint, sharp handrails, and protruding nails. Staff interviews indicated a lack of proactive maintenance and communication, with issues often going unreported. The Administrator stressed the importance of a safe environment, but the facility's work order report showed no records of the identified issues, highlighting a gap in maintenance practices.
The facility failed to maintain an effective training program, resulting in incomplete or missing documentation for required annual training in areas such as abuse, resident rights, infection control, dementia care, and emergency preparedness for several staff members, including RNs, LPNs, CNAs, the DON, and the Administrator. Interviews confirmed the training program was not effectively managed, despite having a policy in place.
A resident with multiple health issues, including anxiety and malnutrition, did not consistently receive scheduled bathing assistance, as documented in the facility's records from April to July 2024. The Director of Nursing acknowledged that the facility's documentation did not clearly indicate whether bathing tasks were completed, and staff were not consistently reporting or documenting refusals. This failure could lead to poor hygiene and skin infections.
The facility failed to provide accurate Advanced Beneficiary Notices (ABNs) to two residents when Medicare services ended. One resident received a form with conflicting options selected, while another's form had no options selected, leading to ambiguity about their service continuation choices. Staff interviews confirmed the errors, with the Social Services Director taking responsibility.
A resident admitted with multiple health conditions was not weighed upon admission as required by facility policy, leading to a deficiency in monitoring their condition. The weight recorded was taken from hospital transfer records instead of being measured by facility staff. The facility policy mandates weighing residents within 24 hours of admission and regularly thereafter, which was not followed, potentially affecting the resident's health.
The facility did not ensure the daily staff posting was current and accurate, as required by policy. On a specific day, the posting displayed outdated information, including an incorrect census and missing actual hours worked by staff. The DON acknowledged the issue, noting that the staffing coordinator prepares postings, and the weekend receptionist is responsible for updating them.
The facility failed to ensure that the Administrator was free of TB before starting work. Despite being hired in early 2024, the Administrator did not provide a TB test result until July, contrary to facility policy requiring a negative TB test before employment. The Administrator, who walks the facility floors and may contact residents, was only tested after the deficiency was identified.
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 Prevent Resident-to-Resident Physical Abuse in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident. One resident with dementia and severe cognitive impairment, who had no documented history of verbal or physical behaviors toward others, was care planned for impaired cognitive ability with interventions such as cueing, orienting, and supervision as needed. Another resident, also with dementia and severe cognitive impairment, had a care plan identifying risk for behavioral changes related to dementia and a separate care plan identifying risk for physical aggression during ADL care and showers, including monitoring for behaviors in the dining area and for touching/striking other residents or staff. On the date of the incident, both residents were seated in a hallway surrounded by other residents when an altercation occurred. An event progress note documented that one resident was heard yelling at another, while the other resident was also yelling and hitting the first resident across the chest with a stuffed animal. The note further documented that the first resident then kicked the second resident in the leg. A similar event note for the second resident described the same sequence of events from that resident’s perspective. Skin assessments completed for both residents on the same day showed intact skin with no redness or bruising. The Assistant DON reported hearing screaming outside her office and then witnessing one resident hitting the other across the chest with a stuffed animal and the other resident kicking back. She stated that she was the only staff member to witness the incident and that she would consider the incident to be abuse. The facility’s 5‑day investigation report verified the allegation based on the evidence collected and noted that both residents were unable to recall the incident. The facility’s abuse‑prevention policy stated that procedures include identification, assessment, and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict, including verbally and physically aggressive behaviors. Despite this, the altercation occurred between the two residents, constituting a failure to protect one resident’s right to be free from abuse by another resident.
Failure to Prevent Elopement Due to Inadequate Assessment and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for a resident with multiple medical conditions, including moderate cognitive impairment. Upon admission, the resident was not initially assessed as being at risk for elopement, despite having a BIMS score of 4 and exhibiting wandering behavior. The resident was later identified as at risk for elopement after a reassessment, and interventions such as inclusion in the Elopement book and 15-minute checks were implemented. However, there was inconsistency in the risk assessments and care plan updates, as a subsequent assessment overrode the high-risk status without proper reflection in the care plan. The resident was able to exit the facility through the front door after 4 PM, reportedly with the assistance of the receptionist, despite being on 15-minute checks and listed in the Elopement book. At the time, two facility entrances were locked after 4 PM, while the others required a security code, but there were no Wander Guards or security cameras in place. Staff interviews revealed that monitoring relied primarily on 15-minute checks and staff awareness, with no electronic monitoring devices used for residents at risk of elopement. The facility's policy required the environment to remain as free of accident hazards as possible and for residents to receive adequate supervision and assistive devices to prevent accidents. Despite these policies, the resident was able to leave the facility unsupervised, and staff acknowledged that adequate protection was not provided after the resident's elopement risk was identified.
Failure to Administer and Document Pain Medication per Physician Orders
Penalty
Summary
A resident with dementia, cervical spine fusion, and a right humerus fracture was admitted to the facility and placed on pain medication therapy for chronic pain syndrome. The care plan required administration of analgesic medications as ordered by the physician and monitoring for side effects and effectiveness. A physician's order specified Dilaudid (Hydro-morphine HCI) 2 mg oral tablets, with 0.5 mg to be given every 4 hours as needed for pain. Review of the narcotic count sheet showed that an LPN logged out doses on multiple occasions, but the Medication Administration Record (MAR) did not reflect administration of the medication on several dates when the narcotic count sheet indicated it had been dispensed. Further review revealed that the resident complained of pain, and the nurse on duty was unable to administer pain medication due to discrepancies in the narcotic count sheet and medication cart key handoff times. Staff interviews indicated that the LPN may have either failed to document administration on the MAR or possibly diverted the medication, as it was not reasonable for documentation to occur on the narcotic count sheet but not on the MAR multiple times in a short period. Facility policy required medications to be administered and documented per physician orders, and defined misappropriation to include missing or diverted prescription medications.
Failure to Maintain Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain adequate and comfortable temperature levels for 14 residents, resulting in an environment that was not homelike or comfortable. On the morning of July 15, 2024, surveyors noted a significant temperature difference upon entering the facility, which felt uncomfortably warm. Interviews with staff revealed that a power outage the previous evening had caused the generator to malfunction, preventing the cooling system from activating. This led to elevated temperatures in residents' rooms, with some rooms registering temperatures as high as 87.1 degrees Fahrenheit. Several residents, including those with conditions such as dementia, chronic obstructive pulmonary disease, and heart failure, reported discomfort due to the heat. Observations confirmed that air conditioning units in many rooms were either not functioning or blowing only room temperature air. Residents expressed their discomfort, with some stating they were unable to sleep well due to the heat. Staff interviews indicated that there was no systematic approach to monitoring room temperatures or relocating residents to cooler areas during the outage. The maintenance staff acknowledged the issues with the generator and cooling system, noting that the chiller took several hours to cool the facility. Despite weekly tests on the generator, there was no alarm system to alert staff of malfunctions. The facility lacked a clear protocol for managing such situations, and staff were not adequately trained in emergency procedures, such as evacuating non-ambulatory residents from the second floor. The absence of a documented plan for addressing temperature control during power outages contributed to the prolonged discomfort experienced by the residents.
Improper Food Storage Temperatures in Walk-In Refrigerator
Penalty
Summary
The facility failed to ensure that multiple food items were stored at safe temperatures in accordance with professional standards, potentially placing residents at risk for food-borne illnesses. During observations of the kitchen's walk-in refrigerator, temperatures were consistently recorded above the critical limit of 40 degrees Fahrenheit, with readings of 45F, 42F, and 50F on different occasions. Despite the facility's policy requiring temperatures to be under 40F, the temperature logs inaccurately recorded temperatures within the acceptable range, suggesting a discrepancy between actual and recorded temperatures. Interviews with kitchen staff and the Registered Dietician revealed that the walk-in refrigerator was used to store various food items, including dairy, meat, and leftovers, all of which require safe storage temperatures to prevent bacterial growth. The Maintenance Director admitted that the refrigerator was mistakenly set to 40F during maintenance, and the external thermometer was broken, leading to incorrect temperature readings. The Executive Director acknowledged the issue and stated that corrective measures were being implemented. The facility's policy emphasized the importance of maintaining food storage temperatures to prevent foodborne illnesses, highlighting the deficiency in adhering to these standards.
Emergency Power System Failure
Penalty
Summary
The facility failed to ensure that its emergency and standby power systems were functioning properly, which led to a complete power outage on July 14, 2024. The facility had been relying on a rental generator since March 2, 2020, and during the power failure, the temporary generator did not activate, leaving the facility without power. This outage affected critical systems, including medical equipment, elevators, and refrigeration units. Staff interviews revealed that the maintenance director was notified of the outage and arrived at the facility to find it in darkness, with staff panicking. It took approximately one hour to troubleshoot and manually start the generator, but the chillers remained inactive due to high voltage requirements. Additionally, the circular pumps were bypassed, and alarms were turned off, which contributed to the delay in addressing the issue. The power outage had significant implications for resident care, as those on oxygen concentrators had to be switched to O2 tanks. The lack of power also raised concerns about resident safety, as the elevators were non-functional, preventing the movement of residents if necessary. Staff interviews indicated a lack of standard procedures for handling power outages, and no mock disaster drills had been conducted. The absence of red plugs in resident rooms further complicated the situation, as extension cords had to be used. The deficiency was confirmed during the exit conference on July 18, 2024, highlighting the facility's prolonged reliance on a temporary generator without a permanent solution in place.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for residents, as observed during a walk-through on July 14, 2024. Several safety hazards were identified, including missing doorway frames with peeling paint, rough and sharp handrails, and doorframes with gouges. Additionally, a nail was found sticking out at the nurse's station, and screws were protruding from a handrail by the stairway. These conditions posed potential risks for injury to residents and staff. Interviews with staff revealed a lack of proactive maintenance and communication regarding the facility's condition. A Registered Nurse noted that maintenance had not sought input from staff or residents about necessary repairs, and the overall appearance of the facility was accepted as it was. The Maintenance Director acknowledged that while priority work orders related to resident safety were addressed promptly, other issues like painting took longer to resolve. The Director also mentioned that maintenance walk-throughs were conducted weekly, but issues not reported by staff or residents might go unnoticed. The Administrator emphasized the importance of maintaining a clean and safe environment to ensure residents' quality of life. However, a review of the facility's work order report showed no records of the identified issues, indicating a gap in the reporting and addressing of maintenance needs. The facility's policies on preventive maintenance and resident rights highlighted the requirement for a safe and homelike environment, which was not upheld in this instance.
Deficient Staff Training Program
Penalty
Summary
The facility failed to implement and maintain an effective training program for its staff, as evidenced by the lack of completion of required annual training in key areas such as abuse, resident rights, infection control, dementia care, and emergency preparedness. Employee records revealed that several staff members, including registered nurses, licensed practical nurses, certified nursing assistants, the Director of Nursing, the Maintenance Director, and the Administrator, had incomplete or missing documentation for these mandatory trainings. For instance, some staff members had not completed emergency preparedness training, while others lacked documentation for abuse or infection control training. Interviews with facility staff, including the human resources accounting clerk and the Director of Nursing, confirmed that the training program was not effectively managed. The human resources accounting clerk indicated that training notifications were typically sent via email from the corporate office, and all staff were required to complete the training annually based on their hire date. However, the Director of Nursing acknowledged that not all staff had completed the necessary training, despite having a policy in place that outlined the annual training requirements. The facility's policy on yearly required training did not include dementia care, further contributing to the deficiency.
Failure to Assist Resident with Bathing
Penalty
Summary
The facility failed to ensure that a resident received assistance with bathing, which could result in poor hygiene and skin infections. The resident, who was admitted with diagnoses including anxiety, depression, malnutrition, and a history of venous thrombosis, had a care plan indicating a need for assistance with bathing due to weakness and decreased mobility. Despite being scheduled for baths twice a week, the resident's shower/bathing task sheets from April to July 2024 showed multiple instances where bathing did not occur, and refusals were not consistently documented. Interviews with the Director of Nursing revealed that the facility's skin care alert form was being used to document various tasks, but it did not specify whether a shower, hair washing, or nail care was completed. The DON acknowledged that staff were not identifying which specific task was being done and emphasized the expectation that CNAs should report refusals to the nurse, who should then document the refusal and have the resident sign it. The facility's policy stated that residents would receive assistance as needed for ADLs, and any changes in ability should be reported to the nurse.
Inaccurate Completion of Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide accurate and complete Advanced Beneficiary Notices (ABNs) to two residents when their Medicare services were terminated. Resident #222, who was admitted with multiple diagnoses including severe cognitive impairment, received an ABN that incorrectly had both option 1 and option 3 selected, which are conflicting choices. This error in the form could lead to confusion about the resident's decision regarding the continuation of services and their financial liability. Resident #223, who was cognitively intact, received an ABN form where no options were selected, leaving ambiguity about the resident's choice to continue or discontinue services. Interviews with staff revealed that the Social Services Director acknowledged the errors in completing the ABNs and took responsibility for the inaccuracies. The administrator confirmed that the ABNs were not completed accurately, which could impact reimbursement and resident rights.
Failure to Conduct Initial and Ongoing Weights for Resident
Penalty
Summary
The facility failed to ensure that initial and ongoing weights were conducted for a resident, leading to a deficiency in monitoring the resident's condition. The resident, who was admitted with diagnoses including anoxic brain damage, Parkinson's disease, and chronic respiratory disease, was not weighed upon admission as required by the facility's policy. Instead, the weight recorded in the clinical record was taken from the hospital transfer records. This oversight was confirmed during an interview with a Registered Dietician, who stated that the resident should have been weighed monthly to assess and monitor weight loss, fluctuations, and fluid shifts. The Director of Nursing confirmed that the facility policy mandates all residents be weighed within 24 hours of admission, weekly for the first four weeks, and then monthly. The failure to weigh the resident as per policy could result in significant weight changes going unrecognized, potentially affecting the resident's health. The facility's policy and procedures emphasize the importance of accurate weight measurement for various clinical assessments and interventions, highlighting the deficiency in adhering to these standards.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting included the correct and up-to-date information as required by their policy. On July 14, 2024, the daily staff posting was observed to be outdated, displaying information from July 12, 2024, with a census of 60, while the actual census on July 14, 2024, was 58. Additionally, the posting did not include the actual hours worked by staff, which is a requirement according to the facility's policy. The Director of Nursing (DON) acknowledged the outdated posting and indicated that the Central Supply Director/staffing coordinator is responsible for preparing the postings, with the weekend receptionist tasked with updating them. The facility's policy, revised on December 13, 2023, mandates that nurse staffing information be posted daily in a prominent location, accessible to residents and visitors, and must include the facility name, current date, resident census, and total number of staff and actual hours worked per shift. The policy also requires that any staff absences due to callouts or illness be reflected in the posting. The failure to update the staff posting as per the policy resulted in incorrect information being displayed, which was not in compliance with the facility's procedures.
Failure to Ensure TB Testing for Administrator
Penalty
Summary
The facility failed to ensure that a staff member, specifically the Administrator, was free of tuberculosis (TB) prior to commencing work. The Administrator was hired on January 8, 2024, but did not provide a current TB test result before starting her duties. This oversight was confirmed during an interview with the accounting clerk/human resources personnel, who acknowledged that the Executive Director is supposed to have a TB test before working in the building to prevent the risk of TB spreading. Further interviews revealed that the Administrator herself admitted to not having a TB test prior to working at the facility, although she was tested on July 16, 2024, with results pending. The Director of Nursing confirmed that all new hires are required to show a negative TB test result before working. Despite not interacting directly with residents, the Administrator walks the floors and can come into contact with residents, increasing the risk of TB exposure. The facility's policy, revised in June 2024, mandates TB testing in accordance with CDC guidelines, which was not adhered to in this case.
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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