Oasis Pavilion Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Casa Grande, Arizona.
- Location
- 161 West Rodeo Road Suite 1, Casa Grande, Arizona 85122
- CMS Provider Number
- 035276
- Inspections on file
- 20
- Latest survey
- April 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Oasis Pavilion Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions had an abuse allegation reported by an outside complainant, who informed the Social Services Director that someone was allegedly trying to suffocate the resident with a pillow and that the resident was being forced to drink an unknown green substance. Although facility policy and staff statements indicated that any abuse allegation must be reported to the SA, APS, Ombudsman, and the Administrator within required time frames and investigated through interviews and documentation review, the Social Services Director did not notify any agencies or the Administrator and did not initiate an investigation, relying instead on the absence of abuse documentation in the medical record. The DON, an LPN, and the Administrator all reported that they were unaware of any allegation or investigation for this resident, and review of the written policy confirmed that the facility failed to follow its own procedures for reporting and investigating the abuse allegation.
A cognitively intact resident with multiple medical conditions allegedly experienced abuse involving someone placing a pillow over the face with a sour substance. A complainant reported this allegation by phone to the Social Services Director, who, contrary to facility policy and staff expectations, did not notify the SA, APS, Ombudsman, or the Administrator because she did not believe abuse had occurred based on the medical record. Other staff, including a CNA, an LPN, the DON, and the Administrator, reported that their understanding of policy was that all abuse allegations must be reported within specified time frames, but they were not informed of this allegation, and no self-report was made to state agencies.
A cognitively intact resident with multiple medical conditions was the subject of an abuse allegation reported by a complainant, who stated someone was trying to smother the resident with a pillow and that the resident was being forced to drink an unknown green substance. The Social Services Director, who along with the DON is designated to receive and investigate abuse complaints, acknowledged receiving the complainant’s call but did not initiate an investigation because there was no documentation of abuse in the medical record and instead assured the complainant that no abuse had occurred. The DON, Administrator, and an LPN all reported they were unaware of any abuse allegation or investigation for this resident. Review of the State Agency database confirmed there was no facility self-report or 5-day investigation report, despite facility policy requiring prompt reporting and investigation of all suspected abuse incidents.
A resident with an indwelling catheter had urinary outputs documented in the medical record for days when the resident was not present in the facility, following a hospital transfer. Staff interviews revealed confusion about documentation procedures during resident absences, and the DON confirmed that such documentation should not have occurred, as facility policy requires accurate daily output records.
A resident with multiple complex medical conditions experienced a significant change in condition, including altered mental status, tachycardia, hypotension, and oxygen desaturation. Staff failed to document updated vital signs, the type and timing of hospital transfer, and physician instructions, resulting in incomplete assessment, monitoring, and emergency response. Facility policy for emergency transfers was not followed, and the clinical record lacked necessary progress notes and documentation.
A resident with multiple health conditions developed a stage III sacral pressure ulcer that required specific wound care as ordered by a physician. The wound care orders, including the use of hydrogel and calcium alginate dressings, were not entered into the MAR or TAR, resulting in the treatment not being provided or documented. The LPN responsible for wound care acknowledged the omission, and the DON confirmed that treatments must be entered and documented according to facility policy.
A resident with multiple complex diagnoses experienced a change of condition, but staff failed to document the event, physician notification, physician instructions, and the details of the hospital transfer in the clinical record. Interviews revealed missing or unclear documentation regarding vital signs, the type and timing of the transfer, and the physician's involvement, despite facility policy requiring such records.
A resident with a history of falls and multiple diagnoses was inaccurately assessed as low risk for falls upon admission to an LTC facility. Despite hospital records and care plans indicating a fall risk, the fall risk assessment conducted by an LPN did not reflect this due to a misunderstanding of the assessment criteria. Interviews with staff, including a CNA, RN, and DON, highlighted discrepancies in the assessment process, leading to potential risks in resident care.
The facility failed to protect a resident with severe cognitive impairment from abuse by her newly admitted roommate, resulting in a fall and a new fracture of the resident's left femur. Staff interviews revealed gaps in the screening process for residents with behavioral issues.
Instances of resident-to-resident abuse were reported, highlighting deficiencies in protecting residents from harm. One incident involved a resident throwing a remote control, causing a bruise on another resident's leg. Despite interventions for the resident's impulsive behavior, the altercation occurred. Another case involved a resident being bruised by a motorized wheelchair operated by a resident with a history of impulsive behavior. The facility's documentation and witness statements indicated a lack of effective interventions to prevent these confrontations, despite existing care plans.
The facility failed to ensure the right to personal privacy for two residents. Staff entered rooms without knocking or waiting for a response, and did not introduce themselves, despite facility policy requiring these actions.
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. An RN left an uncapped syringe, a pill cup, and an open EHR displaying resident information unattended. In another instance, the RN walked away from an unlocked EHR revealing residents' names. The ADON confirmed that nurses are expected to lock medication carts and EHR screens when stepping away.
The facility failed to update the care plan for a resident with anxiety disorder, major depressive disorder, and multiple sclerosis after an incident where the resident was mean to her roommate and used a motorized scooter to bump into the roommate. Staff interviews confirmed that the care plan should have been updated to address the resident's behavior and prevent further incidents.
A facility failed to ensure proper catheter care for a resident, leading to the catheter bag dragging on the floor and inconsistent care practices among staff. This put the resident at risk for urinary catheter complications and infections.
The facility failed to keep two of the four medication carts locked and under direct supervision, leaving an uncapped syringe and a pill cup filled with pills unattended. Additionally, two unlocked medication carts with accessible over-the-counter medications were found in an unlit alcove, posing a risk of unauthorized access by residents.
The facility failed to implement proper infection control practices during insulin administration. An LPN did not wipe the needle insertion site with an alcohol swab before administration. The ADON confirmed that nurses are expected to clean the insulin container and injection area with an alcohol swab, as per facility policy.
Failure to Report and Investigate Abuse Allegation as Required by Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, and misappropriation policy when an allegation of abuse/neglect was reported for one cognitively intact resident. The resident had been admitted with diagnoses including cerebral infarction, anemia, and malignant neoplasm of the bronchus or lung, and had a BIMS score of 14, indicating intact cognition, with documented verbal and other behaviors. A complaint was filed with the State Agency (SA) alleging that someone was trying to kill the resident by putting a pillow over his face with something sour on it. Review of the SA database showed that, although this external complaint was received, there were no corresponding self-reports from the facility regarding this allegation. The complainant reported contacting the facility’s Social Services Director on a specific date to notify her of the abuse allegation and concerns that the resident was being forced to drink “green stuff” and to ask about abuse in the building. The Social Services Director, who along with the DON is responsible for receiving abuse/neglect complaints and initiating reporting and investigations, acknowledged receiving this call. She stated she is required by policy to notify the SA, APS, Ombudsman, and the Administrator within required time frames and to initiate an investigation, including staff and resident interviews and suspension of involved staff if indicated. However, she did not notify any external agencies or the Administrator and did not initiate an investigation because she did not believe abuse had occurred, citing the absence of documentation in the progress notes or medical record. The DON, LPN, and Administrator each described the facility’s policy and regulatory requirement to report all abuse allegations to the SA within two hours and complete an investigation with findings reported within five days. They all stated that any allegation should be brought to the DON, Social Services Director, or Administrator and that an investigation and required notifications would then occur. Each of these staff members reported that no allegation regarding this resident had been brought to their attention prior to the surveyor interviews, and the LPN was unaware of any investigation related to the resident. Review of the written policy confirmed that any incident or suspected incident of abuse or unexplained injury must be promptly reported to designated facility leaders and appropriate agencies, and that all allegations must be investigated with interviews and written summaries. Despite these requirements, the allegation reported by the complainant to the Social Services Director was not reported or investigated in accordance with the facility’s policy.
Failure to Report Alleged Resident Abuse to Required Agencies
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #1 to all required state agencies. Resident #1 had diagnoses including unspecified cerebral infarction, unspecified anemia, and malignant neoplasm of an unspecified part of the bronchus or lungs, and a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitive intactness. A complaint was filed with the State Agency (SA) alleging that someone was trying to kill Resident #1 by putting a pillow over his face with something sour on it. The complainant reported that she had notified the facility’s Social Services Director (Staff #35) by phone of this allegation. Review of the SA database showed no self-report from the facility regarding this allegation. Staff interviews revealed that CNAs and LPNs understood that allegations of abuse should be reported to supervisory staff such as the Social Services Director or DON, and that those leaders were responsible for notifying the Administrator, SA, Adult Protective Services (APS), Ombudsman, and police. Staff #35 acknowledged receiving the complainant’s call about possible abuse of Resident #1 but stated she did not notify SA, APS, Ombudsman, or the Administrator because she did not believe abuse had occurred, citing a lack of documentation in the progress notes or medical record. The DON and Administrator both stated they had not been informed of any abuse allegation regarding Resident #1 prior to the survey interviews. Facility policy required that any incident or suspected incident of abuse be promptly reported to appropriate agencies and facility leadership, and that all allegations of abuse be reported immediately to a direct supervisor or Social Services Director/DON/designee, including reporting to state agencies and the police, which did not occur in this case.
Failure to Investigate Reported Abuse Allegation
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving Resident #1. Resident #1 had diagnoses including unspecified cerebral infarction, unspecified anemia, and malignant neoplasm of an unspecified part of the bronchus or lungs, and a recent MDS showed a BIMS score of 14, indicating cognitive intactness, with documented verbal and other behaviors. A complaint was filed with the State Agency alleging that someone was trying to kill Resident #1 by putting a pillow over his face with something sour on it. The complainant reported that she had notified the facility’s Social Services Director (Staff #35) by phone of an abuse allegation involving Resident #1. Review of the State Agency database showed no self-report from the facility and no 5-day facility investigation report related to this allegation. Staff interviews and policy review showed that the Social Services Director and DON (Staff #68) were responsible for receiving and investigating abuse allegations, including interviewing staff and residents and suspending involved staff when indicated. Staff #35 acknowledged being contacted by the complainant about concerns that Resident #1 was being forced to drink “green stuff” and about possible abuse, but stated she told the complainant no abuse had taken place and did not initiate an investigation because there was nothing in the progress notes or medical record indicating abuse. The DON stated she was not informed of any abuse allegation regarding Resident #1 and that, had she been notified, an investigation would have been conducted and reported within 5 days per policy. The LPN (Staff #128) and the Administrator (Staff #37) both stated they were unaware of any abuse investigation for Resident #1, and the Administrator reported that no one had brought an abuse allegation regarding Resident #1 to his attention until the survey. Facility policy required that any incident or suspected incident of abuse be promptly reported to designated leadership and that all such incidents be investigated with interviews and written summaries, which did not occur in this case.
Inaccurate Documentation of Urinary Output for Absent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one resident regarding urinary output. The resident, who had multiple diagnoses including muscle weakness, mobility issues, and both acute and chronic respiratory failure, was admitted with an indwelling catheter and an order for routine catheter care. Despite being transferred to the hospital and not present in the facility, the resident's Treatment Administration Record (TAR) showed documented catheter outputs for days when the resident was not in the facility. Interviews with staff revealed uncertainty about documentation procedures when a resident is out of the facility. The LPN was unsure if outputs should be recorded during a resident's absence, while the CNA stated that output documentation is only done when the resident is present. The DON confirmed that documentation of outputs should not occur when a resident is not in the facility and verified that incorrect entries were made in the resident's record. Facility policy requires maintaining an accurate record of daily output, which was not followed in this instance.
Failure to Assess, Monitor, and Document Emergency Response for Resident with Change in Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed, monitored, and provided with an appropriate emergency response during a change in condition. The resident, who had multiple complex diagnoses including altered mental status, COPD, brain neoplasm, diabetes, hemiplegia, and slurred speech, was admitted with orders for oxygen therapy and regular monitoring of oxygen saturation. On the day of the incident, the last recorded oxygen saturation was 93% in the morning, but there was no documentation of further vital signs or oxygen levels in the afternoon when the resident's condition changed. Despite the resident exhibiting altered mental status, tachycardia, hypotension, and oxygen desaturation into the 80s, there was a lack of clear documentation regarding the assessment of the resident's condition, the timing and type of transfer to the hospital, and whether the transfer was emergent or non-emergent. Interviews with nursing staff and the DON revealed confusion and inconsistent accounts about who ordered the transfer, the resident's status at the time, and the communication with the medical provider. The hospital transfer form did not specify the time of transfer, the type of transfer, or provide updated vital signs at the time of transfer. Facility policy required that in the event of an emergency transfer, staff should call 911 if clinical criteria are met, document the resident's condition, and notify the attending physician. However, the clinical record lacked progress notes detailing the change in condition, updated vitals, and physician instructions. The deficiency was identified due to these omissions in assessment, monitoring, documentation, and emergency response for the resident experiencing a significant change in condition.
Failure to Provide Physician-Ordered Wound Care for Pressure Ulcer
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, malnutrition, dementia, and chronic kidney disease, was admitted and identified as being at risk for skin breakdown. Upon admission, the resident had a stage I pressure ulcer on the sacrum/coccyx and a stage II closed blister on the left foot. The care plan included interventions such as incontinence care, regular repositioning, and wound care as ordered by the physician. Orders were in place for wound cleansing, use of a low airloss mattress, application of barrier cream, and specific wound treatments for the left heel and buttocks. On December 24, a physician upgraded the sacral wound from stage I to stage III, noting the presence of eschar and necrotic tissue, and provided new wound care orders, including cleansing with wound cleanser, application of hydrogel ointment, and use of calcium alginate dressings. However, these new orders were not entered into the order summary, Medication Administration Record (MAR), or Treatment Administration Record (TAR). As a result, there was no documentation that the prescribed wound care was provided. The wound nurse acknowledged that the order for hydragel calcium alginate was not entered, and therefore, the treatment was not documented or performed as required. Interviews with the wound nurse and the Director of Nursing confirmed that the omission of the physician's wound care orders led to the failure to provide the necessary treatment. The facility's policy and the wound nurse's job description require that all physician orders be entered and carried out, and that treatments be documented. The lack of order entry and documentation resulted in the resident not receiving wound care in accordance with professional standards of practice.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to properly document a resident's change of condition, the notification of the physician, the physician's instructions, and the details of the hospital transfer in the clinical record. The resident in question had multiple significant diagnoses, including altered mental status, COPD, malignant neoplasm of the brain, type II diabetes, hemiplegia, and slurred speech, and was noted to have moderate cognitive impairment. On the day of the incident, the resident's oxygen saturation was last recorded in the morning, but there was no documentation of vital signs or oxygen levels at the time of the change of condition in the afternoon, when the resident was transferred to the hospital. Staff interviews revealed confusion and lack of clarity regarding the events leading up to the transfer. The DON acknowledged that there was no documentation of the resident's change of condition, vitals, or whether the physician had been notified or had ordered the transfer as emergent or non-emergent. The hospital transfer form did not specify the time or type of transfer, and staff were unable to confirm these details during interviews. The nurse practitioner later entered a late note indicating the resident was exhibiting altered mental status, tachycardia, hypotension, and oxygen desaturation, and that the resident was sent out via 911 for a higher level of care, but this was not contemporaneously documented. Facility policy requires prompt notification and documentation of changes in a resident's condition, including physician notification and recording of relevant information in the medical record. However, in this case, the required documentation was incomplete or missing, including the resident's condition at the time of transfer, the physician's instructions, and the specifics of the hospital transfer. This failure to document key aspects of the resident's care and transfer process constitutes the deficiency identified in the report.
Inaccurate Fall Risk Assessment in Resident's Health Record
Penalty
Summary
The facility failed to ensure that the electronic health record for a resident was complete and accurately documented, which could result in incomplete and/or inaccurate clinical records and potentially impact resident care. The resident was admitted with multiple diagnoses, including malignant neoplasm of the kidney, secondary malignant neoplasm of the brain, and a history of repeated falls. Despite this, the fall risk assessment conducted upon admission incorrectly indicated that the resident was at low risk for falls, with a score of '0'. This was inconsistent with the resident's documented history of falls in the hospital records, MDS, and care plan. Interviews with staff revealed discrepancies in the understanding and execution of the fall risk assessment process. A CNA mentioned that fall risk information is shared during shift changes and documented in the electronic health record. An RN stated that the fall risk assessment should include a review of the resident's fall history, interviews with the resident or family, and a review of hospital documentation. However, the LPN who conducted the assessment admitted to considering only the resident's fall history within the facility, not prior to admission, leading to the inaccurate assessment. The Director of Nursing acknowledged that the fall risk assessment should have identified the resident as a fall risk, as it should capture both current and historical information. The facility's policy on falls and fall risk management emphasizes the importance of identifying interventions based on previous evaluations and data to prevent falls. The failure to accurately assess the resident's fall risk could lead to staff confusion and inadequate precautions being put in place, as noted by the MDS nurse and the Director of Nursing.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to ensure the right of one resident to be free from abuse by another resident. Resident #2, who has severe cognitive impairment and uses a walker for mobility, was admitted with a history of hypertension, strokes, and falls. On April 5, 2024, a nurse responded to calls for help and found Resident #2 on the floor, reporting that her roommate, Resident #1, had pulled her off the bed and pushed her to the floor. An x-ray taken the following day revealed a new fracture of Resident #2's left femur. Interviews with Resident #2 confirmed the incident, and the resident reported soreness and pain in the left hip area where the fracture was identified. Resident #1, admitted for palliative care with severe cognitive impairment, had no documented history of behavioral issues prior to the incident. The facility's investigative report noted that Resident #1 had been admitted only an hour before the incident occurred. Interviews with staff revealed that the facility typically does not admit residents with dementia and behavioral issues due to inadequate training. The Director of Nursing (DON) confirmed that the screening process for prospective residents is conducted by the Admissions Coordinator and herself, and that Resident #1's case manager had reported no behavioral issues. Despite this, the incident occurred, resulting in physical harm to Resident #2.
Resident-to-Resident Abuse Due to Impulsive Behaviors
Penalty
Summary
The report details instances where residents in the facility were subjected to abuse by other residents, leading to deficiencies in protecting residents from harm. In the case of resident #1 and resident #149, resident #149 threw a remote control at resident #1, resulting in a large bruise on her leg. Resident #149 exhibited impulsive behavior and outburst behaviors, leading to the altercation. Despite interventions in place for resident #149's behavioral symptoms, the incident still occurred, indicating a failure to adequately prevent resident-to-resident abuse. Similarly, resident #63 reported that resident #15 had bumped into her with a motorized wheelchair, causing a bruise on her knee. Resident #15 had a history of impulsive behavior, and the incident with resident #63 was not an isolated event, as similar behaviors had been displayed with previous roommates. The facility's failure to address resident #15's tendency to intimidate roommates or use the wheelchair to harm others contributed to the deficiency in protecting resident #63 from abuse. The facility's investigation reports, witness statements, and documentation highlighted the confrontations between the residents, indicating a lack of effective interventions to prevent resident-to-resident abuse. Despite the residents' cognitive statuses and care plans being in place, the incidents occurred, underscoring the need for improved monitoring, supervision, and intervention strategies to ensure the safety and well-being of all residents in the facility.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure the right to personal privacy for two residents. Resident #6, who was admitted with diagnoses including unspecified injury of the head and generalized muscle weakness, reported that staff were either not knocking or not waiting for a reply before entering her room. An observation confirmed that a CNA entered Resident #6's room without knocking or waiting for a response, and did not introduce herself. The CNA admitted to not following the correct process of knocking and waiting for permission to enter the room. Similarly, Resident #79, who was admitted with cardiorespiratory conditions and coronary artery disease, reported that staff entered her room without knocking or waiting for her response. An observation confirmed that a CNA knocked once and entered Resident #79's room without waiting for a response. The CNA acknowledged that she did not wait for the resident's response before entering. The assistant Director of Nursing stated that staff are expected to knock, wait for a response, and introduce themselves before entering a resident's room. The facility's policy on Residents Rights emphasizes the right to personal privacy and respectful treatment.
Failure to Ensure Privacy and Security of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. During an observation, an uncapped syringe and a pill cup filled with an assortment of pills were left unattended on a medication cart. Additionally, the electronic health record (EHR) was left open and uncovered, displaying a resident's picture and list of medications. The registered nurse responsible for the medication cart and EHR was found in an alcove with another patient, leaving the medication and EHR screen out of her line of sight. In another instance, the same registered nurse walked away from the medication cart with an unlocked EHR that revealed a list of residents' names. The nurse was about to enter a resident's room for medication administration before being stopped to lock the EHR screen. The Assistant Director of Nursing confirmed that nurses are expected to lock the medication carts and EHR screens when stepping away. Facility policies reviewed indicated that unauthorized release, access, or disclosure of resident information is prohibited and that medication carts must be securely locked when not in the nurse's view.
Failure to Update Care Plan Following Resident Altercation
Penalty
Summary
The facility failed to ensure that the care plan for a resident was updated and revised as needed. Resident #15, who was admitted with diagnoses of anxiety disorder, major depressive disorder, and multiple sclerosis, was involved in an incident where she was reported to have been mean to her roommate, bumped into the roommate with a motorized scooter, and claimed control over the room. Despite this behavior, the care plan was not updated to address these issues or include interventions to manage the resident's behavior towards her roommates. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that the care plan should have been updated following the incident to mitigate further occurrences. The ADON acknowledged that the lack of an updated care plan could lead to repeated incidents and emphasized the importance of updating care plans to inform staff about the resident's needs. The facility's policies on care plans and abuse and neglect also support the need for timely updates and revisions to care plans based on changes in a resident's condition or behavior.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care and services related to an indwelling urinary catheter for a resident. The resident was observed with the catheter tubing exposed and the catheter bag dragging on the floor while being wheeled through the hallway. The Licensed Practical Nurse (LPN) acknowledged the incorrect placement and the associated risks of contamination and urinary tract infection (UTI). The resident also reported that catheter care was provided only once a day or when it itched, and during an interview, the catheter bag was again observed touching the floor while the resident was in bed. Further interviews with staff revealed inconsistencies in catheter care practices. A Certified Nursing Assistant (CNA) stated that catheter care was provided during each brief change and documented in the resident's electronic record. However, the CNA also acknowledged that the catheter bag should not touch the floor and should be placed below the resident's waist. The Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed that the correct placement of the catheter bag was below the patient for easy flow and that the catheter tubing should not touch the floor. They also mentioned that catheter care training was provided regularly to staff. The facility's policy on urinary catheters and incontinence, reviewed and revised in January 2024, emphasized the importance of keeping the catheter tubing and drainage bag off the floor to prevent UTIs. Despite these policies, the observations and staff interviews indicated a failure to adhere to proper catheter care protocols, putting the resident at risk for urinary catheter complications and infections.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to keep two of the four medication carts locked and under the direct supervision of authorized staff. During an observation on March 6, 2024, an uncapped syringe and a pill cup filled with an assortment of pills were left unattended on a medication cart. Additionally, two unlocked and unsupervised medication carts were found in an unlit alcove of Hall B, with over-the-counter medications easily accessible in the top drawer of both carts. These observations were made in areas where residents could potentially access the medications, posing a risk of unauthorized ingestion. In interviews conducted with staff, the LPN acknowledged that a resident could take and ingest medications that were not theirs. The ADON confirmed that nurses were expected to lock the medication carts and the facility's EHR when stepping away. The facility's policy on Medication Administration, reviewed in October 2023, mandates that nurses must ensure the medication cart is securely locked at all times when not in the nurse's view. The failure to adhere to this policy was evident in the observations made during the survey.
Failure to Implement Infection Control Practices During Insulin Administration
Penalty
Summary
The facility failed to implement proper infection control practices during insulin medication administration. During an observation, an LPN did not wipe the single-resident use needle insertion site with an alcohol swab before placing the needle for administration. In an interview, the ADON confirmed that nurses are expected to clean the top of the insulin container and the skin injection area with an alcohol swab prior to administration. The facility's policy on Medication Administration also mandates the use of proper administration techniques, including maintaining sterility.
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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