Northpark Health And Rehabilitation Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 2020 North 95th Avenue, Phoenix, Arizona 85037
- CMS Provider Number
- 035299
- Inspections on file
- 13
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Northpark Health And Rehabilitation Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia and severe cognitive impairment was care planned for elopement risk and wandering with multiple interventions, yet the MDS documented no wandering behavior and the wandering/elopement risk evaluation was inconsistently documented, with an entry struck out and the assessment not signed and locked until after the resident was later found outside the facility at night and sent to the hospital. Staff interviews showed differing views of the resident’s wandering risk, with an LPN reporting the resident was anxious and wanted to go home but not considered at risk, and a CNA reporting no observed wandering, while the DON confirmed that the original elopement evaluation entry was incorrect and that the assessment was actually completed after the incident, resulting in a medical record that did not accurately reflect the resident’s status and care as required by facility policy.
A resident with hypertension, chronic kidney disease, diabetes, atrial fibrillation on anticoagulant therapy, and diuretic therapy was given multiple oral medications that were not ordered, including aspirin, carvedilol, lisinopril, and nifedipine, instead of the prescribed furosemide, spironolactone, calcitriol, and guaifenesin. An LPN entered the wrong room, used the wrong MAR, did not verify the resident’s identity, and administered the other resident’s medications. After the error, the resident’s BP readings dropped to hypotensive levels over several hours, and the resident reported that the nurse had not asked her name and that the incorrect medications took days to clear from her system. Documentation and staff interviews confirmed that these medications were not ordered for the resident and that facility policy required verification of the right resident and right medication before administration.
Surveyors found that medications were stored past their expiration dates in two medication storage rooms, including Geri-Dryl (diphenhydramine) and melatonin. The ACNO confirmed the medications were expired and stated that staff who stock the rooms are expected to check for expiration dates. The CNO reported that both central supply and nursing leadership are responsible for inventorying storage rooms, ensuring medications are checked for expiration before leaving storage, and removing expired medications. Facility policy requires nursing leadership to inspect medication storage areas for expired drugs and to promptly remove and dispose of them according to policy and DEA guidelines.
A resident with severe cognitive impairment and multiple medical conditions was not accompanied to an orthopedic appointment, where the provider instructed the facility's driver to take the resident to the ER for a potential intracranial bleed. This instruction was not followed or communicated to the necessary parties. The resident later fell at the facility, resulting in a hematoma, and was eventually sent to the hospital where multiple fractures and a subdural hematoma were diagnosed. The facility's internal investigation revealed communication failures and a lack of adherence to physician orders.
The facility failed to provide prescribed low air loss mattresses for two residents, despite physician orders and care plans indicating their necessity for preventing pressure ulcers. Staff inaccurately documented that the mattresses were in place and functional, leading to a significant deficiency in care.
The facility failed to ensure that physician orders for low air loss mattresses were correctly transcribed and implemented for two residents. Despite documentation indicating compliance, observations and staff interviews revealed that the residents were using regular mattresses instead, contrary to the physician's orders.
The facility failed to ensure their Infection Preventionist (IP) had completed the required specialized training in Infection Prevention and Control before assuming the role. The IP, an LPN, had not completed the CMS and CDC developed training course until several months after starting the role. Additionally, there was no documentation of a dedicated person with specialized training performing the IP duties in the interim period.
A resident with a MRSA abscess infection of the spine did not receive the prescribed Teflaro medication during their stay. Instead, the resident was given Vancomycin, which was not an option for treatment. Staff interviews and record reviews revealed procedural gaps and lack of proper notification to the provider and pharmacy.
A resident with multiple diagnoses, including a MRSA abscess infection, did not receive prescribed doses of Teflaro due to a failure in the facility's process for handling IV antibiotics. Staff interviews revealed that IV antibiotics are not automatically linked to the facility's PCC system and require manual approval, which was not done in this case.
A resident with multiple serious diagnoses did not receive a prescribed intravenous antibiotic during their stay. Staff failed to notify the physician or pharmacy about the unavailability of the medication, contrary to facility policy.
Inaccurate and Incomplete Elopement Risk Documentation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident assessed and care planned for elopement risk and wandering. The resident was admitted with dementia, encephalopathy, hypertension, and osteoarthritis, and had a BIMS score of 03, indicating severe cognitive impairment. The admission MDS assessment documented that the resident had not exhibited wandering behavior, even though a care plan dated the following day identified a focused care area for elopement risk/wandering related to decreased cognition and decreased safety awareness, with multiple interventions such as redirection, diversional activities, structured activities, toileting, walking, and reorientation strategies. An evaluation summary entry dated the same day initially indicated that a wandering/elopement risk evaluation had been completed, but this note was later struck out. A wandering/elopement risk evaluation dated that same day was not signed and locked until several weeks later, after an incident in which the resident was found outside the facility at night by another resident’s family member, lying on her stomach and complaining of back pain, unable to move or roll over, and subsequently sent to the hospital. The evaluation summary and recommendations section included instructions to keep the door closed on the resident’s unit and to have the receptionist close the front doors when off duty so only staff could unlock them. Staff interviews revealed inconsistent understanding of the resident’s wandering risk: an LPN stated the resident was not considered at risk for wandering before the incident, though the resident had been anxious and expressed a desire to go home, and a CNA reported not observing wandering behavior. The DON confirmed that the struck-out wandering/elopement risk evaluation was incorrect because the resident was not considered an elopement risk at that time and that the elopement assessment was actually completed after the incident, contrary to the documentation. This conflicted with facility policy requiring the medical record to accurately represent the resident’s experiences and condition, including changes, plan of care goals, and interventions.
Wrong-Resident Medication Administration Leading to Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received only medications ordered by the provider, resulting in administration of multiple medications that were not prescribed. The resident had diagnoses including hypertension, chronic kidney disease, type 2 diabetes, atrial fibrillation with anticoagulant therapy, and diuretic therapy for fluid overload. The care plan included avoiding aspirin due to anticoagulant therapy and administering diuretics as ordered. Provider orders and the MAR for the relevant period showed active orders for furosemide, spironolactone, calcitriol, and guaifenesin, and no active orders for aspirin 325 mg, carvedilol 6.25 mg, lisinopril 40 mg, or nifedipine ER 90 mg. On the date of the incident, an LPN entered the resident’s room with medications that were intended for another resident. The LPN later stated that she had used the wrong MAR and entered the wrong room, and that she realized the error only after the resident questioned an enoxaparin injection following administration of the oral medications. The incident note documented that the LPN administered aspirin 325 mg, carvedilol 6.25 mg, lisinopril 40 mg, and nifedipine ER 90 mg instead of the resident’s ordered furosemide 80 mg, spironolactone 25 mg, calcitriol 0.25 mcg, and guaifenesin 600 mg. Interviews with nursing staff confirmed that these medications were not ordered for the resident and that the resident did have orders for the diuretic and other listed medications that were not given at that time. Following the administration of the wrong medications, the resident experienced low blood pressure readings documented in the blood pressure summary, with systolic readings dropping below 100 mmHg and diastolic readings in the 30s and 40s over the subsequent hours. Staff interviews described that the resident’s blood pressure dropped significantly after the error, that the resident was monitored for hypotension, and that the provider was notified. The resident reported that the nurse did not ask for her name, told her the medications were for high blood pressure, and that she knew something was wrong when the nurse attempted to give an enoxaparin injection, which she did not receive as part of her usual regimen. The resident stated that the wrong medications took about two to three days to clear from her system and that staff had difficulty keeping her blood pressure in a normal range during that time. Additional documentation from a clinical consultant pharmacist outlined potential adverse reactions associated with carvedilol, lisinopril, nifedipine, and aspirin, including hypotension and bleeding, and indicated that the hypotensive medications would be eliminated from the resident’s system in two to three days. An internal investigation report recorded that the resident had a history of acute chronic diastolic heart failure, hypertension, and high risk for hypotension, and that on the date of the incident the LPN administered medications intended for another resident. The investigation noted that the resident’s creatinine rose to 2.9 with an eGFR of 15. Facility policy on medication administration required staff to follow the rights of medication administration, including right medication and right resident, but interviews and the resident’s account showed that the nurse did not verify the resident’s identity according to policy before administering the medications.
Expired Medications Found in Medication Storage Rooms
Penalty
Summary
Surveyors identified a failure to ensure medications were not stored past their expiration dates, as required by facility policy and professional standards. During an observation of a medication storage room conducted with the Assistant Chief Nursing Officer (ACNO), one bottle of Geri-Dryl (Diphenhydramine Hydrochloride) with an expiration date of 07/2025 was found stored beyond its expiration. In a second medication storage room observed shortly afterward, two bottles of Melatonin 3 milligrams with an expiration date of 11/2025 were also found stored past expiration. In an interview, the ACNO confirmed that the identified medications were expired and stated that the expectation was that staff responsible for stocking the medication rooms also check medications to ensure they are not expired. The ACNO stated that the risk associated with storing expired medications is that the medications are less effective. In a separate interview, the Chief Nursing Officer (CNO) stated that both central supply and nursing leadership are responsible for inventorying the medication storage rooms and disposing of expired medications, and that medications are expected to be checked for expiration before leaving the storage room. The CNO stated that the risk associated with storing expired medications is that there could be adverse reactions. Review of the facility’s “Medication Storage and Labeling” policy showed that nursing leadership is responsible for inspecting medication carts and storage rooms for expired medications and that expired medications must be promptly removed and disposed of per facility policy and DEA guidelines.
Failure to Follow Physician Orders and Ensure Timely Medical Care
Penalty
Summary
The facility failed to ensure that a resident received services according to professional standards, specifically regarding the notification to a provider, required communication, and clarifying and following a physician's order. The resident, who had severe cognitive impairment and multiple medical conditions including a chronic right humeral fracture, was not accompanied by a caregiver to an orthopedic appointment. During the appointment, the orthopedic provider instructed the facility's driver to take the resident to the emergency room for evaluation of a potential intracranial bleed, but this instruction was not followed or communicated to the necessary parties. Upon returning to the facility, the resident was not assessed for the condition that prompted the emergency room recommendation. The Charge Nurse and other staff members failed to notify the resident's physician or family about the orthopedic provider's instructions. The resident later experienced a fall at the facility, resulting in a hematoma, and was eventually sent to the hospital where multiple fractures and a subdural hematoma were diagnosed. The facility's internal investigation revealed communication failures and a lack of adherence to physician orders, leading to the termination of several staff members. The report highlights the breakdown in communication and failure to follow physician orders, which resulted in the resident not receiving timely medical evaluation and treatment. The facility's policies on physician orders and change of condition were not adhered to, contributing to the resident's subsequent injuries and delayed medical care. Interviews with staff and the resident's family further underscored the lack of communication and appropriate action following the orthopedic appointment.
Failure to Provide Prescribed Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that care and services were provided to prevent the development of pressure ulcers for two residents. Resident #26, who had multiple diagnoses including diabetes mellitus with foot ulcer and peripheral vascular disease, was admitted with an order for a low air loss mattress to prevent pressure ulcers. However, it was observed that the resident did not have the prescribed mattress, and staff confirmed that the mattress had not been provided despite the physician's order. The resident's care plan included various skin care interventions, but the lack of the low air loss mattress was a significant oversight in their care plan execution. Similarly, Resident #39, who was admitted with diagnoses including peripheral vascular disease and acute osteomyelitis, was also supposed to have a low air loss mattress as per the physician's order. Despite documentation indicating that the mattress was being checked for functionality every shift, it was observed that the resident had a regular mattress instead. Interviews with staff confirmed that the resident did not have the prescribed low air loss mattress, which was crucial for preventing pressure ulcers given the resident's condition. Both residents had care plans and physician orders that included the use of low air loss mattresses to prevent pressure ulcers. However, the facility failed to provide these mattresses, and staff inaccurately documented that the mattresses were in place and functional. This discrepancy between the documented care and the actual care provided represents a significant deficiency in the facility's ability to prevent and manage pressure ulcers in these residents.
Failure to Implement Physician Orders for Low Air Loss Mattresses
Penalty
Summary
The facility failed to ensure that physician orders for low air loss mattresses were correctly transcribed and implemented for two residents. Resident #26, who was admitted with multiple diagnoses including type 2 diabetes mellitus with foot ulcer and heart failure, had a physician's order for a low air loss mattress to be checked for functionality every shift. Despite documentation in the Treatment Administration Record (TAR) indicating compliance, an observation revealed that the resident did not have the prescribed mattress. Interviews with staff confirmed the discrepancy and highlighted the potential risk of worsening the resident's wound due to the incorrect mattress type. Similarly, Resident #39, admitted with diagnoses including Peripheral Vascular Disease and Acute Osteomyelitis of the Left Ankle and Foot, also had a physician's order for a low air loss mattress. The TAR indicated that the mattress was being checked every shift, but an observation and staff interviews revealed that the resident was using a regular mattress instead. The Chief Nursing Officer and other staff confirmed the inconsistency between the physician's order and the actual mattress provided, which could impact the resident's risk for pressure ulcers. The facility's policy on the prevention and treatment of pressure ulcers was not adhered to in these cases.
Infection Preventionist Lacked Required Training
Penalty
Summary
The facility failed to ensure that their Infection Preventionist (IP) had completed the specialized training in Infection Prevention and Control prior to assuming the role. A review of the Licensed Practical Nurse/Infection Preventionist's (LPN, staff #300) personnel/training record revealed that staff #300 had not completed all the Center for Medicare and Medicaid (CMS) recommended specialized training topics. Specifically, he had not been awarded a certificate for the CMS and CDC developed training titled The Nursing Home Infection Preventionist Training Course. Staff #300 had been in the role since April 2023 but only completed the course in July 2023. Additionally, there was no documentation that a dedicated person with specialized training was performing the duties of the IP in the interim period, despite staff #300 being trained by the Regional Clinical (RC) staff. The facility's policy indicated that the IP should have clinical professional training and specialized training in infection prevention and control. The CMS QSO policy memo dated March 11, 2019, noted that effective November 28, 2019, the final requirement for infection control prevention and control training for nursing homes included specialized training for individuals responsible for the facility's Infection Prevention and Control Program. The memo further noted that CMS and CDC collaborated on the development of a free online training course in infection prevention and control for nursing home staff, which is approximately 19 hours and comprised of 23 modules. In order to receive the certificate of completion, learners must complete all modules and pass a post-course exam.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident was free from neglect by not providing necessary provider-prescribed medications. Resident #152, who had multiple diagnoses including a MRSA abscess infection of the spine, was admitted with a physician's order for Teflaro 600mg to be administered intravenously twice daily. However, during the resident's stay from October 7, 2022, to October 10, 2022, the medication was not administered at all. Instead, the resident received Vancomycin, which was not an option for treatment as indicated by the consulting infectious disease doctor. This lapse in medication administration was confirmed through a review of the Medication Administration Record (MAR) and physician's notes, which highlighted the necessity of Teflaro for the resident's condition and the failure of Vancomycin as a treatment option. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed procedural gaps that contributed to the deficiency. The LPN stated that new orders for IV antibiotics are called into the pharmacy by nursing, and in the event of a medication not being delivered, the provider and pharmacy should be notified. However, no such notification was documented. The DON confirmed that IV antibiotics and expensive medications require approval and that the resident did not receive any doses of Teflaro. The facility's policy on pharmacy services mandates accurate acquiring, receiving, dispensing, and administering of drugs to meet residents' needs, which was not adhered to in this case.
Failure to Administer Prescribed IV Antibiotics
Penalty
Summary
The facility failed to ensure that Resident #152 was treated according to professional standards. The resident, who was admitted with diagnoses including a MRSA abscess infection of the spine, Bacteremia, COPD, Diabetes type 2, Anxiety, and Hypertension, had a physician's order for Teflaro 600mg to be administered intravenously twice daily for a spinal abscess. However, a review of the Medication Administration Record (MAR) revealed that the resident did not receive any doses of Teflaro during their stay from October 7, 2022, to October 10, 2022. Interviews with staff indicated that the facility's process for handling IV antibiotics was flawed. The Licensed Practical Nurse (LPN) stated that IV antibiotics are not automatically linked to the facility's PCC system and require manual intervention. The Director of Nursing (DON) confirmed that IV antibiotics could be missed if not approved, especially if they are over $200. The DON also noted that the resident received doses of Vancomycin but not Teflaro. The facility policy requires staff to notify the attending physician when issues with medication administration arise, but this protocol was not followed in this case.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that medications were available as ordered for a resident with multiple serious diagnoses, including a MRSA abscess infection of the spine, Bacteremia, COPD, Diabetes type 2, Anxiety, and Hypertension. The resident was admitted with a physician's order for an intravenous antibiotic, which was not administered at any point during the resident's stay. The Medication Administration Record (MAR) confirmed that the resident did not receive any doses of the prescribed medication from admission to discharge. Interviews with staff revealed that the standard procedure for new IV antibiotic orders involves calling the pharmacy, and if a medication is not available, notifying the provider and pharmacy to obtain a stat order or adjust the medication. However, there was no evidence that the physician or pharmacy were notified about the unavailability of the medication. The Director of Nursing confirmed that the resident did not receive the medication and stated that staff should have notified her and the provider if the drug did not arrive on time. The facility's policy on Pharmacy Services mandates procedures to ensure the accurate acquiring, receiving, dispensing, and administering of drugs to meet the needs of each resident, which was not followed 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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