Palm Valley Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Goodyear, Arizona.
- Location
- 13575 West Mcdowell Road, Goodyear, Arizona 85395
- CMS Provider Number
- 035255
- Inspections on file
- 33
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Palm Valley Post Acute during CMS and state inspections, most recent first.
A nurse left an EHR open and visible on a medication cart computer while administering medications to a resident, resulting in the resident’s medical information being exposed on the unattended screen. Upon return, the RN confirmed the EHR was still visible. Other staff, including a CNA, an LPN, and the DON, acknowledged that unsecured computer screens can allow unauthorized viewing of HIPAA-protected information and that screens can and should be locked. Facility policy prohibits unauthorized access or disclosure of resident information and requires compliance with privacy laws.
A resident with a history of traumatic brain injury, opioid use, schizophrenia, and severe cognitive impairment remained in the facility after an initially exempt stay without a new PASRR Level I or any Level II being completed when the stay converted from skilled to LTC. Despite documented schizophrenia with hallucinations and delusions and ongoing antipsychotic use, no updated PASRR documentation was found in the record at the time of the status change, contrary to facility policy requiring evaluation of applicants for serious mental disorder and/or intellectual disability.
Surveyors found that the dumpster area was not maintained in a sanitary condition, with accumulated refuse, including a clear bag of trash containing clinical-type waste, miscellaneous trash, yard waste, and a dead bird around and behind the dumpsters. The Maintenance Director reported that daily inspections and shared maintenance responsibility were expected but acknowledged the area did not meet expectations and posed an infection control risk. The Housekeeping Supervisor noted the potential for contamination and germ spread from refuse outside the dumpsters, and the Administrator stated that the protocol required closed lids and a refuse-free area, recognizing that the observed conditions could attract pests, cause foul odors, reduce a homelike environment, and create an infection control issue.
A resident with multiple comorbidities and a neurogenic bladder requiring an indwelling Foley catheter was observed twice with the catheter drainage bag placed under the bed on the floor, with tubing lying on the floor, despite a care plan and physician orders for proper catheter management. Staff, including a CNA, an RN, and the DON, all described facility practices and expectations that catheter bags be hung below bladder level, covered with a privacy/dignity bag, and never placed on the floor. Facility catheter care and infection prevention policies, as well as CDC CAUTI prevention guidance, also specified that collection bags should not rest on the floor, but these standards were not followed for this resident.
The facility was found to have a medication error rate of 30.77%, significantly above the acceptable threshold, due to failures such as administering an incorrect dose of Vitamin D3 to a resident and delayed administration of multiple scheduled medications to another resident. Staff interviews and policy review confirmed that medications were not given as ordered or within the required timeframe.
Surveyors found that single-dose Omeprazole packets were stored in a medication cart without visible expiration dates or original packaging, and expired blood culture collection kits were present in a medication storage room. Staff were unable to verify expiration dates or ensure proper labeling, contrary to facility policy.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during their review.
A resident with severe cognitive impairment was physically abused by another resident with a history of aggression, resulting in skin discoloration. Staff intervened to separate the individuals and reported the incident, but the event showed a failure to fully protect residents from abuse as required by facility policy.
A resident reported a missing wallet to staff, and the social services director attempted to submit a misappropriation complaint to the state agency. However, the required email verification step was not completed, and no follow-up was made to confirm the report was received, resulting in the incident not being documented by the state agency as required.
A resident with severe cognitive impairment and a history of falls experienced multiple falls despite care plan interventions, ultimately sustaining a significant injury that required surgical intervention. Staff and documentation confirmed that supervision and fall prevention measures were not adequate to prevent further injury.
The facility failed to notify physicians and resident representatives about missed or rescheduled dialysis treatments for three residents, did not consistently complete required pre- and post-dialysis assessments for a resident receiving outpatient dialysis, and maintained a dialysis policy lacking essential procedures and documentation requirements. These deficiencies were confirmed through record reviews, staff interviews, and policy examination.
A resident with dementia and a history of wandering was physically pushed by another cognitively impaired resident with a pattern of aggression, resulting in a fall and injury. The incident was witnessed by an LPN and substantiated through facility investigation, highlighting a failure to protect a resident from physical abuse.
A facility failed to thoroughly investigate a resident-to-resident altercation where one resident struck another in the face. Despite a staff member witnessing the incident and a skin assessment showing redness, the investigation did not include interviews with other residents present, leading to an incomplete and inaccurate conclusion.
A resident with severe cognitive impairment was physically abused by another resident with mild cognitive impairment and a history of aggression. The incident occurred in the dayroom during dinner tray distribution, resulting in a minor injury to the victim. Staff intervened quickly, but the facility failed to prevent the altercation, highlighting a deficiency in ensuring resident safety.
A resident with dementia was allegedly struck by another resident with a history of behavioral symptoms, resulting in a deficiency. The incident occurred in the day room, where staff reported an altercation involving yelling and physical contact. Despite the facility's investigation, the deficiency highlights a failure to protect the resident from abuse, as confirmed by staff interviews and documentation of redness on the resident's face.
A resident with Unspecified Dementia, Bipolar disorder, and Anxiety Disorder reported being inappropriately touched by another resident with toxic encephalopathy, major depressive disorder, and adjustment disorder in the dayroom after an activity. The resident who reported the incident pushed the other resident away and informed staff. The resident who admitted to the inappropriate behavior had a history of similar actions towards female staff, leading to interventions such as being placed on cares in pairs.
The facility failed to develop comprehensive care plans for two residents, one with a left-hand contracture and another on psychotropic medications. The first resident lacked a care plan or orders for their contracture, while the second resident's care plan did not include non-pharmacological interventions before medication. Observations and staff interviews confirmed these deficiencies, indicating a failure to adhere to the facility's care planning policy.
The facility failed to provide necessary assistance for transfers and grooming hygiene for two residents. One resident, with severe cognitive impairment, was not assisted in participating in group activities due to miscommunication among staff about their ability to be transferred. Another resident, requiring extensive assistance, was observed with long and jagged nails, indicating a lack of proper grooming care. Staff interviews revealed inconsistencies in care practices and documentation.
The facility failed to provide appropriate activities for three residents, impacting their mental and social well-being. A resident with quadriplegia was not assisted to participate in activities as per their care plan. Another resident, who is legally blind, was inaccurately documented as attending activities they did not participate in. A third resident, dependent on a vent/trach, was also incorrectly documented as attending group activities, with no evidence of one-on-one activities being provided.
The facility failed to implement non-pharmacological interventions for two residents prescribed psychotropic medications. One resident with Alzheimer's and depression was given multiple medications without documented non-pharmacological approaches. Another resident with bipolar disorder received psychotropic medications without prior non-pharmacological interventions, despite no documented physical aggression. Facility policies emphasize non-pharmacological interventions, but these were not followed, leading to potential duplicate therapy.
The facility failed to accurately document activities for two residents, one legally blind and the other bed-bound, leading to concerns about their care. Interviews revealed that staff might have marked activities as completed without them occurring. The activities director and assistant acknowledged discrepancies in the documentation.
The facility failed to ensure proper infection control practices, with staff observed leaving dirty dishes in public areas and not adhering to PPE protocols for residents with C-Diff. CNAs were seen handling contaminated items without proper hygiene, and PPE was not removed before exiting rooms, contrary to facility policy. These actions risked spreading infections, as confirmed by the Infection Preventionist and DON.
The facility failed to provide a homelike dining environment, as observed during lunch services. Meal trays were delivered late with dome lids left on, and residents ate off trays with disposable cups. Some residents were in reclining chairs or motorized wheelchairs, unable to fit under tables, while the TV was on in the dining area.
A facility failed to thoroughly investigate an alleged sexual abuse incident involving two residents with dementia. One resident allegedly touched another inappropriately in the dining room, but the facility's report stated the allegation was not substantiated. The investigation lacked interviews with other residents and did not document corrective actions to prevent further abuse. The DON could not provide details due to a lack of documentation and a change in facility ownership.
A resident with schizophrenia and TBI was not submitted for a Level II PASARR despite exhibiting significant behavioral issues and being on multiple psychotropic medications. The facility's failure to follow its policy for PASARR evaluations resulted in the lack of identification and provision of specialized services for the resident.
The facility failed to ensure a cognitively intact resident participated in their care plan development and did not document a care plan revision for a resident with dementia who requested a door lock. Despite policies requiring resident involvement, there was no evidence of participation or documentation of care plan meetings for these residents.
A facility failed to document non-pharmacological pain management for a resident with chronic pain and other conditions. Despite orders to try alternate measures before administering pain medication, the MAR showed no evidence of such interventions for February 2024. Staff interviews revealed inconsistencies in documentation practices, with CNAs not documenting interventions and LPNs unaware of the lack of documentation. The DON acknowledged the expectation to document these interventions, highlighting a potential risk related to documentation failure.
A resident was discharged without a complete discharge summary, missing essential information about their stay and care needs. The resident, who was cognitively intact, had diagnoses including acute kidney failure and spinal stenosis. The facility's policy requires a comprehensive discharge summary, but it was not completed, and a care conference was not held due to the discharge.
A resident with a left femur fracture and other conditions did not receive physician-ordered side rails for bed mobility, as the facility failed to install them. Despite a bedrail assessment and physician order, no work order was placed for the installation. Interviews revealed confusion between physical therapy, maintenance, and nursing staff regarding responsibility for the installation, resulting in the deficiency.
A resident with a left hand contracture and hemiplegia was not provided with appropriate care and services to prevent further decline in range of motion. Despite being cognitively intact, the resident's care plan lacked specific interventions for the contracture. Observations showed no splint or towel was used on the affected hand, and interviews with staff confirmed the absence of orders or occupational therapy evaluations. The facility's policy on maintaining range of motion was not followed, leading to a deficiency in care.
A resident was found with a medicated ointment at her bedside, which was not authorized for self-administration. The facility's policy requires such items to be stored securely, but staff interviews revealed that the ointment was not the brand used by the facility and should have been stored on the wound cart. The DON confirmed that no assessment for self-administration was completed for the resident.
A resident with end-stage renal disease was not provided care in accordance with physician-ordered fluid restrictions, leading to multiple days of excessive fluid intake. Staff interviews confirmed the importance of adhering to these restrictions to prevent complications, but noted lapses in practice and documentation.
A resident with multiple medical conditions experienced a delay in receiving assistance with ADLs, including dressing and oral hygiene, before a scheduled appointment. The CNA was unable to assist the resident in a timely manner due to being occupied with other residents, resulting in a forty-four-minute delay. The facility's policy requires timely assistance, but the response time exceeded expectations.
The facility did not update the daily staff posting as required, with the last update observed being several days old. The DON acknowledged the requirement for daily updates but was unsure of the responsible party on weekends. Facility policy mandates daily posting of staffing numbers, hours, census, and date.
An LPN left a medication cart unlocked and unattended while transferring medications, contrary to facility policy requiring carts to be locked when out of sight. The DON confirmed the policy, emphasizing the need to prevent unauthorized access.
The facility was found deficient in food storage and sanitation practices. Observations revealed undated opened food items, expired food available for use, and incomplete refrigerator logs. Additionally, staff failed to follow infection control policies, with improper beard/mustache coverings and unclean vents. These issues could lead to foodborne illnesses.
A facility failed to ensure a safe environment by installing a keypad lock on a resident's room in a secured memory care unit without proper documentation or staff awareness. The lock, requested by the resident, lacked a physician order, care plan, or safety assessment. Staff were unaware of the lock's existence or the access code, and there was no policy or training provided. Concerns were raised about potential risks if the lock failed, and the facility could not provide a policy for resident door locks.
A facility failed to maintain a resident's privacy and confidentiality when an agency nurse accidentally sent a photo of the resident's genital area to the family instead of the physician. The incident occurred after the resident was treated for a UTI and candidiasis. Staff interviews revealed gaps in HIPAA training, with some staff unaware of protocols regarding photographs. The facility's policy and admission agreement emphasized the importance of protecting resident privacy.
The facility failed to protect residents from abuse, resulting in incidents of sexual and physical abuse. A resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate behavior. Despite previous interventions, the facility did not implement new measures to address ongoing issues. Additionally, a resident with schizophrenia was physically abused by two different residents with histories of aggression. The facility's response was inadequate, leading to repeated incidents of abuse.
The facility failed to provide written notification of transfer or discharge to the resident's representative for two residents, leading to a deficiency in communication. A resident with Huntington's Disease was transferred to the hospital twice without written notification to their representative. Another resident with rhabdomyolysis and ESRD was transferred due to influenza and pneumonia, but the facility did not notify the Ombudsman. The facility's policy did not specify whether notifications should be verbal or written, contributing to the deficiency.
Failure to Secure Electronic Health Record Screen and Protect Resident Privacy
Penalty
Summary
The facility failed to maintain confidentiality of a resident’s electronic health record (EHR) when a nurse left the record open and visible on a medication cart computer. During a medication pass observation, RN Staff #169 gathered medications for Resident #159 and then turned and walked into the resident’s room. When the nurse returned to the medication cart, surveyors observed that Resident #159’s EHR remained open and in view on the screen. Staff #169 confirmed that the visible record belonged to Resident #159 and acknowledged that anybody could see it. Multiple staff interviews confirmed awareness that leaving computer screens unsecured poses a risk to resident privacy and could constitute a HIPAA violation. The social services director stated that leaving a computer screen unsecured would be a risk for a HIPAA violation. A CNA reported that charting on certain screens may be visible to residents, noted there is a way to lock the screen, and stated that leaving the screen open is a HIPAA violation. An LPN stated that if staff need to leave their computer, they must secure it because anyone could access resident information. The DON confirmed that documentation is done in the EHR and that leaving a computer screen unsecured could allow someone to see HIPAA information. The facility’s Resident Rights policy prohibits unauthorized release, access, or disclosure of resident information and requires that all access or disclosure comply with current privacy laws.
Failure to Complete Required PASRR for Resident With Schizophrenia and Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a required Preadmission Screening and Resident Review (PASRR) was properly completed for one resident with serious mental illness and cognitive impairment. The resident was admitted with diagnoses including a personal history of traumatic brain injury, opioid use, unspecified schizophrenia, and cognitive communication deficit. An MDS dated July 23, 2025 documented a BIMS score of 7, indicating severe cognitive impairment, and the care plan included an antipsychotic medication focus related to schizophrenia with hallucinations and delusions. A PASRR Level I completed on July 18, 2025 indicated an exemption or categorical determination (such as convalescent care, respite, terminal/severe illness, or primary dementia diagnosis), but the resident remained in the facility beyond the exempt stay. When the resident’s status changed from skilled nursing to long-term care, there was no evidence in the record of a new PASRR Level I or any PASRR Level II being completed or present in the documents section. SSD staff reported that a PASRR Level I should be done if a resident remains longer than 30 days and that diagnoses such as schizophrenia with related medications would typically lead to a Level II, but acknowledged that the resident was not submitted for another Level I when transitioning to long-term care. The facility’s own PASRR policy states that all applicants to a Medicaid-certified nursing facility must be evaluated for serious mental disorder and/or intellectual disability, be placed in the most appropriate setting, and receive needed services, but this process was not followed for this resident when they remained in the facility for long-term care.
Improper Maintenance and Sanitation of Dumpster Area
Penalty
Summary
Surveyors identified a deficiency related to improper disposal of garbage and refuse in the facility’s designated dumpster area. During a kitchen inspection with the Dietary Director, surveyors observed an accumulation of refuse around and behind the trash dumpsters, including a clear bag of trash, miscellaneous trash, yard waste, and a dead bird. The Dietary Director stated that the clear bag of trash contained “medical stuff, swabs, tissue,” and that it looked clinical. Review of the facility’s undated “Refuse and Trash” policy indicated that waste should be disposed of immediately after use, with general waste going into standard trash bins. In subsequent interviews, the Maintenance Director reported that the protocol for maintaining the dumpster area was to inspect it every day, that maintenance staff shared responsibility for the area’s cleanliness, and that someone was designated every morning, but acknowledged that the dumpster area’s condition did not meet his expectations and presented an infection control risk. The Housekeeping Supervisor stated that refuse outside the dumpster area posed a potential risk of contamination and spread of germs if the trash contained something contagious and someone touched it. The Administrator stated that the protocol for the dumpster area was that lids should be closed and the area should be free from rubbish or refuse, that the maintenance team was responsible for its cleanliness, and that the area should look better and be clean. The Administrator also stated that refuse outside the dumpster could bring pests, foul odors, create a less than homelike environment, and present an infection control issue.
Improper Foley Catheter Bag Placement on Floor
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper urinary catheter bag placement for one resident. The resident had multiple medical conditions, including sequelae of cerebral infarction, chronic respiratory failure, acute pulmonary edema, type 2 diabetes mellitus, immunodeficiency, and a neurogenic bladder requiring an indwelling catheter. The resident’s care plan included interventions for indwelling catheter care, such as positioning the catheter bag and tubing below the level of the bladder and away from the entrance door, and using a privacy cover on the Foley bag. The admission MDS showed the resident was severely cognitively impaired. Physician orders directed indwelling catheter care. Despite these orders and care plan interventions, observations on the survey date showed the catheter drainage bag placed under the bed on the floor, with the catheter tubing touching the full surface of the floor, covered by a blue privacy bag. During interviews, a CNA stated that catheter care involved using appropriate PPE, changing urine drainage bags, cleaning the genitourinary area, and recording urine output, and acknowledged that the catheter should never be on the floor because it could pose a risk of infection. An RN reported that catheter care was performed every shift by CNAs or nurses and stated that the catheter should not touch the floor, and that the tubing should hang to the side of the bed covered with a dignity bag. The DON explained that CNAs were responsible for cleaning and emptying the Foley catheter, placing a privacy bag on the catheter, and ensuring it was hung up so it did not touch the floor, and stated that catheters should not be left on the floor. Facility policies on catheter care and the infection prevention and control program, as well as CDC guidance, specified that the collection bag should be kept below the level of the bladder and not rest on the floor. The observed placement of the catheter bag and tubing on the floor for this resident was inconsistent with the care plan, staff statements, facility policy, and CDC standards.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosing and Delayed Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by eight medication administration errors out of twenty-six observed opportunities, resulting in a 30.77% error rate. For one resident with diagnoses including hydronephrosis, type two diabetes mellitus, and immunodeficiency, a registered nurse administered only one tablet of Cholecalciferol (Vitamin D3) 1000 IU, despite a provider order specifying five tablets (totaling 5000 IU) to be given once daily. This discrepancy was confirmed upon review of the provider order and by the Director of Nursing, who stated that the expectation was to administer the full ordered dose. Another resident, with diagnoses including type two diabetes mellitus with ketoacidosis, reduced mobility, and a need for personal care assistance, did not receive their scheduled 08:00AM medications on time. The registered nurse responsible for medication administration acknowledged that the medications were overdue, as indicated by the red status in the electronic health record, and attributed the delay to a high patient load. The facility's policy and staff interviews confirmed that medications should be administered within one hour of the scheduled time and in accordance with prescriber orders, which was not followed in these instances.
Expired and Unlabeled Medications Found in Medication Storage Areas
Penalty
Summary
Surveyors observed that several single-dose blister packets of Omeprazole were stored in a medication cart without their original box, and the individual packets did not display an expiration date. The LVN assigned to the cart confirmed that the expiration date could not be located on the packets and that the original box, which may have contained the expiration date, was not retained. The LVN was unable to verify the expiration dates or how long the medications had been stored in this manner. Additionally, in a medication storage room, a pile of blood culture collection kits was found on a shelf, and inspection revealed that at least one kit was expired. Nursing staff were unsure about the meaning of the date on the kit until the Executive Director confirmed it was expired. The expired kits were present in the medication room, contrary to facility policy, which requires medications and biologicals to be stored in their original packaging and for expired items to be removed.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and multiple psychiatric and medical diagnoses was physically abused by another resident who was moderately cognitively impaired and had a history of behavioral problems, including verbal and physical aggression. The incident occurred in a hallway where the aggressor began punching the victim, resulting in skin discoloration to the victim's arms and upper body. Staff intervened to separate the residents, and the incident was reported to facility leadership and law enforcement. Review of the care plan for the resident with behavioral issues showed interventions were in place to protect others, such as removing the resident from situations and monitoring behaviors, but the altercation still occurred. Staff interviews confirmed that immediate action was taken to separate the residents and report the incident, but the event demonstrated a failure to fully protect residents from abuse as required by facility policy and resident rights.
Failure to Report Misappropriation Allegation to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of misappropriation of a resident's property was appropriately reported to the state agency as required. A resident reported a missing wallet to a certified nursing assistant, and later to the social services director. The social services director attempted to submit the complaint through the state agency's reporting portal and received an email requiring verification to complete the submission. However, the staff member did not verify the email address and did not follow up with the state agency to confirm receipt of the report. As a result, the incident was not documented as received by the state agency. Facility documentation indicated that the incident was reported, but review of the state agency's intake system showed no record of the submission. Interviews with staff confirmed that the required verification step was not completed and no further action was taken to ensure the report was received. The facility's policy requires immediate reporting of abuse, neglect, exploitation, or misappropriation, but this process was not followed in this case.
Failure to Prevent Falls and Injury in Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including Parkinson's disease, dementia, and a prior TIA, was identified as high risk for falls and had multiple documented falls after admission. The care plan included several interventions such as floor mats, use of a front wheeled walker, and staff intervention when ambulating without assistive devices. Despite these interventions and ongoing care plan revisions, the resident continued to experience falls, including one that resulted in a significant injury requiring surgical intervention. On one occasion, the resident sustained a skin tear and was found rolling on the floor while a CNA was attempting to assist him back onto his floor mat. Subsequently, the resident was sent to the emergency department for evaluation of a right hip deformity and returned to the facility with multiple bruises and surgical staples following an open reduction internal fixation of a right hip fracture. Staff interviews confirmed the process for responding to falls, but the documentation and interviews indicated that the implemented interventions were not sufficient to prevent further falls and injury for this resident.
Deficient Dialysis Care: Incomplete Assessments, Poor Communication, and Inadequate Policy
Penalty
Summary
The facility failed to ensure proper notification of physicians and resident representatives regarding missed and rescheduled dialysis treatments for three residents. In several instances, residents who were scheduled for dialysis either missed their treatments or had them rescheduled, but there was no documentation that the physician or the resident's representative was informed of these changes. For example, one resident missed dialysis on two separate occasions due to a holiday and staff shortage, but there was no evidence in the clinical record that the provider or representative was notified or that a physician order was obtained to reschedule the treatment. Similar lapses were observed for two other residents, where missed or rescheduled dialysis sessions were not properly communicated or documented as required by facility policy. Additionally, the facility did not consistently complete pre- and post-dialysis assessments for a resident who received outpatient dialysis. The clinical record review revealed that on multiple occasions, the required assessments were either missing or incomplete, despite the resident having received dialysis on those dates. Interviews with nursing staff confirmed that these assessments were expected to be completed and documented in the electronic medical record each time a resident underwent dialysis. However, discrepancies were found between the medication administration record, progress notes, and the actual assessments, with some information missing or not entered in the correct section of the clinical record. The facility's policy on dialysis care was also found to be lacking in several key areas. The policy did not include detailed procedures for the initiation, administration, and discontinuation of dialysis treatments, nor did it specify documentation requirements, communication protocols between the nursing home and dialysis provider, or comprehensive care planning responsibilities. Other omissions included the management of dialysis emergencies, monitoring and documentation of nutrition and hydration needs, and the care and assessment of dialysis access sites. Interviews with facility leadership confirmed that the existing policy was the only one in place and that infection control input had not been incorporated into the policy revision process.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, depression, and a history of falls was not protected from physical abuse by another resident with dementia and behavioral issues. The first resident was known to be resistive to care, exhibited wandering and intrusive behaviors, and was unable to complete a BIMS interview. The second resident also had significant cognitive impairment, agitation, and a history of physical aggression. On the date of the incident, the second resident physically pushed the first resident, causing a fall and resulting in physical injury, as observed by an LPN and documented in the clinical record. Staff interviews revealed that the second resident had a pattern of aggressive behavior, and the first resident was known to wander and interact with others' belongings. The facility's policy required the administrator to determine protective actions upon any abuse allegation, but the incident still occurred, resulting in substantiated physical abuse. The event was witnessed by staff, and the facility's investigation confirmed the occurrence of physical aggression leading to injury.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged resident-to-resident abuse incident involving two residents. Resident #77, who has a diagnosis of dementia and other health conditions, was reported to have struck Resident #88, who also suffers from dementia and other cognitive impairments, in the face during an altercation in the dayroom. The initial investigation report noted that there was insufficient evidence to confirm physical contact, despite a staff member witnessing the incident and a skin assessment revealing redness on Resident #88's face. The investigation was incomplete as it did not include interviews with other residents who were present during the incident, as required by the facility's policy on abuse investigations. Staff interviews revealed that the incident occurred in a crowded dayroom, and a staff member observed Resident #77 making a fist and striking Resident #88. However, the investigation report failed to document these observations adequately and did not include interviews with other potential witnesses. The Director of Nursing and the facility administrator acknowledged the oversight in the investigation process, noting that previous investigations had been accepted without additional resident interviews. The facility's policy mandates that all witnesses to an incident be interviewed, but this was not adhered to in this case, leading to an incomplete investigation and an inaccurate conclusion regarding the incident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #2, who has severe cognitive impairment due to unspecified dementia, was involved in an incident with Resident #12, who has mild cognitive impairment and a history of verbal and physical aggression. On the day of the incident, staff were distributing dinner trays in the dayroom when Resident #12, upset by Resident #2's screaming, left his table and hit Resident #2 in the eye before staff could intervene. The altercation resulted in a small open area on Resident #2's lower brow. Staff interviews revealed that the incident was quickly addressed by separating the residents and notifying the necessary personnel, including the Administrator, DON, police, and family members. The facility's policy and procedures, as well as the State Operations Manual, emphasize the importance of monitoring and intervening in situations that could lead to abuse. Despite regular abuse training, the staff's inability to prevent the altercation indicates a failure to ensure a safe environment for all residents.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #1, who was admitted with encephalopathy, Alzheimer's disease, and dementia, was involved in an incident where they were allegedly struck by Resident #2. Resident #1's care plan indicated a risk for psychosocial behaviors and behavioral symptoms due to dementia, but no physical aggression was noted prior to the incident. On July 12, 2024, a skin wound note documented redness on Resident #1's face, and subsequent charting noted no signs of pain or bruising, although the resident continued to scream at times. Resident #2, who was admitted with end-stage renal disease, Alzheimer's disease, and dementia, had a history of verbal and behavioral symptoms that posed a risk to themselves and others. Their care plan included interventions for managing these behaviors, such as medication administration and monitoring for side effects. On the day of the incident, staff reported an altercation between Resident #2 and Resident #1, with Resident #2 allegedly striking Resident #1 in the face. Interviews with staff confirmed the altercation, and it was noted that Resident #1's face was slightly red after the incident. The facility's policy on resident rights, which guarantees freedom from abuse, was not upheld in this case. Despite the facility's investigation and documentation of the incident, the deficiency occurred due to the failure to prevent the altercation and protect Resident #1 from abuse by Resident #2. The facility's documentation and staff interviews highlighted the lack of direct observation of the incident, but physical contact was confirmed by staff, indicating a breach in resident safety and care protocols.
Resident-to-Resident Sexual Abuse Incident
Penalty
Summary
The facility failed to protect resident #4002 from sexual abuse by another resident, #4805. Resident #4002, diagnosed with Unspecified Dementia, Bipolar disorder, and Anxiety Disorder, reported being inappropriately touched by resident #4805 in the dayroom after an activity. Resident #4002 pushed resident #4805 away and reported the incident to staff. Resident #4805, diagnosed with toxic encephalopathy, major depressive disorder, and adjustment disorder, admitted to touching resident #4002's buttock but denied pulling her pants down. Staff interviews revealed that resident #4805 had a history of inappropriate behavior towards female staff, leading to interventions such as being placed on cares in pairs.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a left-hand contracture. The resident, who was admitted with multiple diagnoses including a contracture of the left hand, did not have a care plan or physician orders addressing this condition. Despite being cognitively intact, as indicated by a BIMS score of 13, the resident did not receive an Occupational Therapy Evaluation to address the contracture. Observations over several days confirmed the absence of any splint or towel on the resident's left hand, and interviews with staff revealed a lack of orders to address the contracture. Another deficiency was identified in the care plan for a resident with a history of atherosclerotic heart disease, dementia, and bipolar disorder, who was prescribed multiple psychotropic medications. The care plan included goals to prevent drug-related complications but did not mention any non-pharmacological interventions before administering these medications. The MAR lacked documentation of any non-pharmacological interventions attempted before medication administration over a four-month period. Interviews with the unit nurse manager and the DON confirmed that non-pharmacological interventions were expected but not performed, as indicated in the resident's medical record. The facility's policy on comprehensive person-centered care plans, revised in December 2016, requires the development and implementation of care plans that include measurable objectives and timetables to meet residents' needs. However, the deficiencies observed in the care plans for the two residents indicate a failure to adhere to this policy, potentially resulting in suboptimal care and services for the residents involved.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to provide necessary assistance for transfers and grooming hygiene for two residents, leading to deficiencies in care. Resident #80, who has severe cognitive impairment and is dependent on staff for all transfers, was not assisted in participating in group activities as outlined in their care plan. Despite having a geriatric chair available, the resident was observed lying in bed with the TV on for several consecutive days, and staff interviews revealed a lack of coordination and communication regarding the resident's ability to be transferred out of bed. The Director of Activities noted that the resident should be participating in group activities, but the CNAs were not getting the resident up due to misinformation about the resident's stability and availability of a wheelchair. Interviews with CNAs and LPNs revealed conflicting information about the resident's ability to be transferred, with some staff believing it was unsafe due to the resident's condition. The Director of Nursing acknowledged the need for the resident to participate in activities but noted that the geriatric chair was shared among multiple residents, which may have contributed to the lack of participation. Regarding resident #406, the facility failed to maintain proper grooming hygiene, specifically nail care. The resident, who has cognitive impairment and requires extensive assistance with activities of daily living, was observed with long and jagged nails over several days. Despite the facility's policy for weekly nail care, there was no documentation of nail care being performed or refused. Staff interviews indicated that nail care was typically done on Sundays, but there was no evidence of this being completed for the resident, posing a risk of injury due to the resident's hand contracture.
Failure to Provide Appropriate Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs of three residents, impacting their mental and social well-being. Resident #80, who is non-verbal and quadriplegic, was observed lying in bed with the TV on for several days, despite care plan interventions that included being out of bed for activities. The Director of Activities acknowledged that the resident had not attended group activities as documented, and there was a lack of coordination between the activities staff and CNAs to ensure the resident was up and participating in activities. Resident #58, who is legally blind and has intact cognition, was documented as attending various activities, but interviews revealed that the resident had not engaged in these activities. The Activities Director and an assistant admitted that activities staff might be documenting attendance inaccurately, and the resident expressed that she did not participate due to her blindness and inability to walk. This discrepancy highlights a failure in accurately assessing and documenting the resident's participation in activities. Resident #108, who is bed-bound and dependent on a vent/trach, was also documented as attending group activities, but interviews with staff revealed that the resident had not participated in these activities. The Activities Assistant confirmed that the resident did not attend group activities due to their medical condition, and there was no evidence of one-on-one activities being provided. This indicates a lack of appropriate activity planning and documentation for residents with significant physical limitations.
Failure to Implement Non-Pharmacological Interventions for Psychotropic Medication Use
Penalty
Summary
The facility failed to implement non-pharmacological interventions for two residents, leading to a deficiency in care. Resident #61, diagnosed with Alzheimer's Disease, unspecified dementia, depression, and unspecified psychosis, was prescribed multiple psychotropic medications, including Fluoxetine, Lorazepam, and Seroquel, without any documented non-pharmacological interventions. The resident's medication administration record and active orders lacked any indication of attempts to use non-pharmacological approaches, which is a requirement before administering psychotropic medications. Resident #115, with diagnoses including atherosclerotic heart disease, dementia, and bipolar disorder, was also found to have been administered psychotropic medications such as Quetiapine Fumarate, Haloperidol, and Depakote without prior non-pharmacological interventions. Despite the care plan's requirement to monitor for physical aggression, there was no documentation of such behavior from November 2023 to February 2024. Interviews with staff revealed that non-pharmacological interventions were not attempted before administering these medications, and there was no differentiation in targeted behaviors for the medications, which could lead to duplicate therapy. The facility's policies on tapering medications and administering psychotropic medications emphasize the importance of non-pharmacological interventions and gradual dose reduction. However, these policies were not adhered to, as evidenced by the lack of documented non-pharmacological interventions for the residents involved. The Director of Nursing and Unit Nurse Manager acknowledged the absence of these interventions and the potential issue of duplicate therapy due to the same targeted behavior for multiple medications.
Inaccurate Documentation of Resident Activities
Penalty
Summary
The facility failed to accurately document activities in the clinical records for two residents, which could result in them not receiving appropriate care and services. Resident #58, who is legally blind and has multiple health conditions, was documented as attending various group activities despite her statements that she did not participate due to her blindness and inability to walk. Interviews with the activities director and assistant revealed that staff might have been marking activities as completed without them actually occurring. Resident #108, who has chronic respiratory failure, quadriplegia, and mild cognitive impairment, was also inaccurately documented as attending group activities. Observations showed the resident was bed-bound and non-verbal, making it difficult for him to leave his room. The activities assistant confirmed that the resident did not attend group activities and that staff were documenting attendance inaccurately. The activities director and assistant both acknowledged discrepancies in the documentation of activities for these residents. The activities director admitted uncertainty about how the documentation was completed, and the assistant confirmed that resident #108 had never attended group activities, despite records indicating otherwise. This inaccurate documentation raises concerns about the facility's adherence to professional standards in maintaining accurate medical records.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control practices, as evidenced by multiple observations of staff not adhering to established protocols. On several occasions, dirty dishes were left in public areas, such as the dining room and handrails, which staff acknowledged could lead to the spread of infection. Certified nursing assistants (CNAs) were observed handling potentially contaminated items without following proper hygiene practices, such as washing hands or disposing of personal protective equipment (PPE) correctly. These actions were contrary to the facility's policy, which mandates that dirty dishes be taken directly to the kitchen to prevent contamination. Additionally, there were lapses in following contact precautions for residents diagnosed with Clostridium Difficile (C-Diff). Staff were observed not wearing or improperly using PPE when entering and exiting rooms of residents on contact precautions. For instance, a CNA was seen exiting a room with a surgical mask below her nose and goggles on her head, failing to remove them before leaving the room, which is against the facility's policy. The facility's policy requires that all PPE be removed and hands washed with soap and water before exiting a room to prevent the spread of infection. The facility's infection control policies, including those for handling C-Diff, were not consistently followed, as evidenced by staff not washing hands with soap and water after contact with residents or contaminated items. The Infection Preventionist and Director of Nursing confirmed that these practices were not in line with the facility's expectations and posed a risk of spreading infections. The facility's policies emphasize the importance of maintaining a safe, sanitary environment and adhering to transmission-based precautions, which were not upheld in these instances.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike dining environment for its residents, as observed during multiple lunch services. On February 25, 2024, meal trays were delivered late to residents, with dome lids left covering the plates, both in residents' rooms and in the dining area of the 200 wing. The television was on in the corner of the dining area while staff distributed coffee. On February 28, 2024, lunch trays were delivered to the dining area first, with domes still on the food, and then to residents in their rooms. Some residents were in reclining chairs or motorized wheelchairs, unable to fit under the tables. On February 29, 2024, trays were delivered to different wings at staggered times, with the 200 wing receiving trays last. Trays with domes were scattered on tables, and lemonade was served in disposable cups, with residents eating off trays.
Failure to Investigate Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving two residents. Resident #79, who has unspecified dementia, a history of traumatic brain injury, and epilepsy, was allegedly touched inappropriately by Resident #252, who has dementia with behavioral disturbance and major depressive disorder. The incident occurred in the dining room, where Resident #252 placed his hand on Resident #79's leg. A CNA intervened and separated the residents, but the facility's report stated that the allegation was not substantiated. The investigation did not include interviews with other residents, and no corrective actions were documented to prevent further abuse. The Director of Nursing (DON) was unable to provide specific details about the incident due to a lack of documentation and not being employed at the facility at the time. The facility's policy on abuse requires thorough investigation and documentation of all incidents, including interviews with witnesses, staff, and residents. However, the report lacked comprehensive interviews and documentation, failing to meet the facility's policy requirements. The DON mentioned that the facility had no incident reports for the residents involved due to a change in ownership.
Failure to Conduct Level II PASARR for Resident with Schizophrenia and TBI
Penalty
Summary
The facility failed to submit a Level II Pre-Admission Screening and Resident Review (PASARR) for a resident diagnosed with schizophrenia and traumatic brain injury (TBI). The resident was admitted and readmitted to the facility with these diagnoses, and the quarterly Minimum Data Set (MDS) assessment indicated significant behavioral issues, including physical and verbal aggression, wandering, and rejection of care. Despite these indicators, the facility did not complete the necessary Level II PASARR, which is required when a Level I PASARR identifies potential mental disorders or intellectual disabilities. The resident exhibited numerous behavioral issues, such as urinating on the floor, flipping the mattress, verbal outbursts, and physical aggression towards other residents. These behaviors were documented in various behavioral and nurse's notes. The resident was on multiple psychotropic medications, including antipsychotics, antianxiety, and antidepressants, and had a care plan that included interventions for managing physical aggression and agitation. However, the facility's failure to conduct a Level II PASARR meant that specialized services that could have been identified and provided were not considered. An interview with the Social Services Director revealed that the facility's process for handling PASARR was not followed correctly in this case. The director acknowledged that the resident should have been submitted for a Level II PASARR and was not appropriate for the facility. The facility's policy requires that any resident identified with a possible mental disorder, intellectual disability, or related disorder be referred for a Level II evaluation, but this step was not taken for the resident in question.
Deficiencies in Resident Care Plan Participation and Documentation
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact, participated in the development of their care plan. The resident was admitted with diagnoses including hyperlipidemia, type 2 diabetes mellitus, and essential hypertension. Despite being cognitively intact, as indicated by a BIMS score of 13, the resident reported never being invited to a care plan meeting and was unaware of the services and care they were supposed to receive. The facility's records showed that care conferences were held on multiple occasions, but there was no documentation indicating that the resident was invited or participated in these meetings. Another deficiency was identified regarding a resident with moderate cognitive impairment, as indicated by a BIMS score of 9, who was admitted to a secured memory care unit with a diagnosis of unspecified dementia and Parkinson's. The resident requested a battery-powered keypad lock on their room door, but there was no documentation in the care plan or progress notes regarding this request. The care plan lacked measurable objectives or timeframes related to the resident's ability to use the lock, and there was no assessment of the resident's competency or safety concerning the lock. Interviews with facility staff revealed that care plan meetings were conducted quarterly, and residents or their representatives were notified via mail. However, there was an expectation that any facility-initiated care plan meetings would be documented in progress notes, which was not done in these cases. The facility's policies required that residents be informed and participate in their care plans, but these requirements were not met for the residents involved.
Failure to Document Non-Pharmacological Pain Management
Penalty
Summary
The facility failed to ensure that non-pharmacological approaches to pain management were offered and documented for a resident with chronic pain syndrome, anxiety disorder, recurrent depressive disorder, chronic migraine, and mobility issues. The resident was cognitively intact and receiving regularly scheduled and as-needed pain medications, as well as non-pharmacological interventions according to the MDS assessment. However, a review of the MAR for February 2024 showed that non-pharmaceutical interventions were not provided or documented for the entire month, despite an order requiring alternate measures to be tried before administering pain medication. Interviews with staff revealed inconsistencies in the documentation process. A CNA stated that non-pharmaceutical interventions were implemented but not documented by CNAs. An LPN confirmed that such interventions should be documented in the MAR, regardless of who provided them, but found no evidence of documentation for the resident in question. The LPN also noted that the resident often refused non-pharmaceutical interventions, which was not documented. The DON acknowledged the expectation to conduct and document these interventions as ordered by the physician, but noted that the risk might be related to the failure to document rather than the administration of medication outside the ordered frequency.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure that a discharge summary for a resident contained a recapitulation of the resident's stay, which could result in an unsafe discharge. The resident, who was cognitively intact with a BIMS score of 15 out of 15, was admitted with diagnoses including acute kidney failure, spinal stenosis, and acidosis. Upon discharge, the clinical record lacked a comprehensive discharge summary detailing the resident's physical and mental status, impairments, activities of daily living, special treatments, psychosocial status, discharge potential, dental status, activities, and rehabilitation potential. The Social Services Director indicated that the facility's process involves sending clinical information and medication orders with the resident upon discharge. However, the discharge summary, which should include essential information such as transportation details, durable medical equipment needs, and other critical data, was missing from the electronic health record. The facility's policy requires a discharge summary to be developed when a discharge is anticipated, but in this case, the summary was not completed, and a care conference meeting was not held due to the resident's discharge.
Failure to Install Physician-Ordered Bed Rails for Resident
Penalty
Summary
The facility failed to ensure that a resident had side rails installed for mobility independence as ordered by the physician. The resident, who was admitted with a fracture of the left femur, osteoarthritis, and major depressive disorder, was cognitively intact and required extensive assistance for activities of daily living, bed mobility, and transferring. A physician order was placed for two non-restraining quarter side rails to assist with bed mobility, and a bedrail assessment confirmed the need for these rails. Despite the order and assessment, the side rails were not installed, as confirmed by the maintenance director who found no work orders for the resident's room during the relevant period. Interviews with facility staff revealed a breakdown in communication and process. The physical therapist stated that maintenance was responsible for installing the rails, while the maintenance director indicated that nursing was responsible for placing the work order. The Director of Nursing acknowledged that the work order system did not show the rails were installed, and there was no documentation to confirm their installation. Facility policies required maintenance to inspect beds and related equipment and for licensed nursing personnel to ensure physician orders were recorded and implemented, but these procedures were not followed, leading to the deficiency.
Failure to Address Resident's Left Hand Contracture
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a left hand contracture, which could result in a decline in the resident's range of motion and mobility. The resident, who was admitted with a diagnosis of contracture of the muscle in the left hand and hemiplegia following a cerebral infarction, was cognitively intact with a BIMS score of 13. Despite the resident's care plan addressing various needs related to hemiplegia and contractures, it did not include specific interventions for the left hand contracture. Observations revealed that no splint or towel was used on the resident's left hand during multiple assessments. Interviews with facility staff, including an LPN and the Director of Rehabilitative Services, confirmed that there were no orders or occupational therapy evaluations to address the resident's left hand contracture. The facility's policy on Resident Mobility and Range of Motion, which aims to prevent avoidable reductions in ROM, was not adhered to, as there was no evidence of assessment or interventions for the contracture. The lack of appropriate care planning and intervention for the resident's condition constitutes a deficiency in the facility's care practices.
Failure to Secure Medicated Ointment at Resident's Bedside
Penalty
Summary
The facility failed to ensure that medications were not left unattended at the bedside for a resident, which could result in accidental medication-related injuries. Resident #96, who was cognitively intact according to a recent assessment, was observed with a tube of Chamosyn with Manuka Honey, a medicated moisture barrier, on her bedside table. There was no physician order or assessment of competency for the self-administration of medications for this resident. Staff interviews revealed that the product was not the brand used by the facility, and it was supposed to be stored in a drawer to prevent accidental ingestion by confused residents. Further observations confirmed that the medicated ointment remained in the resident's room, contrary to facility policy. Interviews with staff, including a CNA and an LPN, indicated that such products should be stored on the wound cart and not left in resident rooms. The Director of Nursing confirmed that medications should not be at the bedside and that there was no assessment for self-administration for the resident. Facility policies require that self-administration of medications be documented and approved by the care team, and unauthorized medications found at the bedside should be removed and returned to the nurse in charge.
Failure to Adhere to Fluid Restrictions for Dialysis Patient
Penalty
Summary
The facility failed to adhere to physician orders regarding fluid restrictions for a resident diagnosed with end-stage renal disease, among other conditions. The resident was on a fluid restriction of 1200 ml per day, as per the physician's orders. However, the electronic health record revealed that the resident's fluid intake exceeded this limit on multiple occasions, with recorded intakes ranging from 1380 ml to 1640 ml over several days. Observations also noted the presence of a water pitcher at the resident's bedside, which could contribute to the excess fluid intake. Interviews with staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed the importance of adhering to fluid restrictions for dialysis patients to prevent complications such as fluid overload. The staff acknowledged the failure to follow the physician's orders and noted that previous practices, such as posting fluid restrictions on the wall, were discontinued after facility renovations. The Director of Nursing also confirmed the discrepancies in fluid intake documentation and emphasized the expectation that physician orders should be followed.
Delay in Assistance with ADLs for Resident
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of a resident, resulting in a delay in assistance with activities of daily living (ADLs). The resident, who has a moderate cognitive impairment and multiple medical conditions including a left knee prosthetic joint infection and chronic pressure wounds, required assistance with dressing and oral hygiene before a scheduled appointment with a notary. Despite the resident's request for help from a Certified Nursing Assistant (CNA), assistance was delayed for forty-four minutes, causing the resident to be unprepared when the notary arrived. The delay occurred because the CNA was occupied with assisting other residents and did not seek additional help to meet the resident's needs in a timely manner. The facility's policy requires that appropriate care and services be provided for residents unable to carry out ADLs independently, but the response time for the call-light exceeded the Director of Nursing's expectation of a 15-minute response time. This deficiency highlights a failure in staffing and coordination to ensure timely assistance for residents with scheduled appointments.
Failure to Update Daily Staff Posting
Penalty
Summary
The facility failed to ensure that the daily staff posting was updated and displayed as required. On February 25, 2024, the staff posting observed was dated February 22, 2024, indicating that it had not been updated for several days. During an interview on February 29, 2024, the Director of Nursing (DON) admitted that the daily staff posting should be updated daily but was unsure who was responsible for this task on weekends. The facility's policy, revised in August 2022, mandates that direct care daily staffing numbers, including the number of nursing staff, hours worked, census, and date, be posted for every shift.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that a medication cart was secured when left unattended, which could result in residents having access to medications and potentially causing harm. On February 25, 2024, at 10:36 a.m., an LPN was observed removing multiple medications from a medication cart located near the nursing station on hall #200. The LPN took these medications to a second cart next to a room and then into the medication room, leaving the first cart unlocked and unattended. Upon exiting the medication room, the LPN acknowledged that the cart should have been locked to prevent unauthorized access. An interview with the Director of Nursing on February 29, 2024, confirmed that medication carts are required to be locked when not within the eyesight of nursing staff to prevent access by residents and staff. The facility's policy, revised in April 2019, states that medication carts must be kept closed and locked when out of sight of the medication nurse or aide. This incident highlights a breach in protocol, as the LPN did not secure the medication cart as required by the facility's policy.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a kitchen inspection. Several food items, including cheese slices, milk, cucumbers, and dessert cups, were found opened and not dated, which is against the facility's policy on food receiving and storage. Additionally, expired food items such as flour and cornstarch were readily available for resident use. The logs for the walk-in refrigerator and freezer were incomplete, with missing dates noted. These lapses in food safety practices could potentially lead to foodborne illnesses among residents. Furthermore, the kitchen staff did not adhere to the facility's infection control policies. During observations, a kitchen staff member was seen without proper beard/mustache covering, and another staff member wore a face mask incorrectly, exposing facial hair. The vents over the food tray line were also found to have a brown string-like substance hanging from them, indicating a lack of cleanliness. The facility's policies require that food and nutrition services staff wear appropriate hair restraints to prevent hair from contacting food, and that environmental surfaces be cleaned regularly to maintain a sanitary environment.
Deficient Safety Measures in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe and functional environment for residents and staff, as evidenced by the presence of a battery-powered keypad lock on the door of a resident's room in a secured memory care unit. The resident, who was admitted with unspecified dementia and other conditions, reportedly requested the lock. However, there was no physician order, progress note, safety or competency assessment, or care plan for the lock, and the staff were unaware of its existence or the code to access the room. Interviews with various staff members, including an LPN, CNA, and the Director of Nursing, revealed a lack of awareness and documentation regarding the lock. The LPN was surprised to find the lock engaged and was initially unable to open the door. The CNA knew the code to access the room, but there was no key available for the lock, and the maintenance staff did not have a schedule for lock maintenance. The Director of Nursing confirmed the absence of a care plan or evaluation for the lock. The plant and operations manager stated that the lock was installed following a work order approved by the administrator, but there was no training or in-service provided to staff regarding the lock. The activities assistant and another LPN expressed concerns about potential negative outcomes if the lock failed, such as the resident being unable to exit the room in an emergency. The facility was unable to provide a policy for resident door locks, highlighting a significant oversight in ensuring a safe environment for residents.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the personal privacy and confidentiality of medical records for a resident, leading to a deficiency. The incident involved an agency nurse who mistakenly sent a photo of the resident's genital area to the resident's family instead of the intended recipient, the physician. This occurred after the resident had been treated for a urinary tract infection and urogenital candidiasis, following a hospital visit. The error was acknowledged in the facility's initial self-report and confirmed in a subsequent 5-day report. Interviews with staff revealed gaps in training and understanding of HIPAA regulations. A Licensed Practical Nurse recalled receiving education on HIPAA but noted it did not cover the use of photographs. A Registered Nurse confirmed that staff were instructed not to discuss resident information outside the treatment team. The Director of Nursing stated that HIPAA education was provided during orientation and annually, emphasizing that resident information should only be shared with authorized individuals. The facility's policy and admission agreement both highlighted the importance of protecting resident privacy and confidentiality.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents from abuse, resulting in incidents of sexual and physical abuse. Resident #79, who had severe cognitive impairment, was subjected to sexual abuse by Resident #252, who had a history of sexually inappropriate behavior. Despite previous incidents and interventions such as a 1:1 sitter and psychiatric evaluations, Resident #252 continued to exhibit inappropriate behavior, including touching Resident #79 inappropriately. The facility did not implement new interventions to address these behaviors, and there was a lack of documentation and incident reports due to a change in facility ownership. In another incident, Resident #33, who had schizophrenia and cognitive impairments, was physically abused by Resident #354. Resident #354, who had moderate cognitive impairment and a history of aggression, hit Resident #33 with a towel after being provoked by a verbal interaction. The facility's response included separating the residents and initiating abuse reporting protocols, but the documentation suggests that the interventions were not sufficient to prevent further incidents. Additionally, Resident #33 was involved in another altercation with Resident #356, who had a history of aggressive behavior and cognitive impairments. Resident #356 physically assaulted Resident #33, punching him in the face multiple times. The facility's investigation confirmed the incident, but the report indicates that the facility's measures to manage aggressive behaviors and protect residents were inadequate, leading to repeated incidents of abuse.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to the resident's representative for two residents, leading to a deficiency in communication. Resident #81, diagnosed with Huntington's Disease and epilepsy, was transferred to the hospital on two occasions due to changes in condition, including fever, seizures, and tremors. Although verbal notifications were made to the resident's family or representative, there was no evidence of written notification as required by facility policy. Interviews with the Director of Nursing (DON) revealed that notifications were typically made verbally in emergency situations, and the facility policy did not specify whether notifications should be verbal or written. Resident #65, with diagnoses including rhabdomyolysis and end-stage renal disease, was transferred to the hospital due to influenza and pneumonia. The clinical record lacked evidence of written notification to the resident's representative regarding the transfer. Additionally, the facility failed to notify the Ombudsman of the resident's transfer, as required. Interviews with the social worker and DON confirmed that notifications for hospital transfers in November and December were not sent to the Ombudsman, and the facility's practice was to prioritize verbal notifications in emergencies. The facility's policy on changes in a resident's condition or status, revised in May 2017, required prompt notification to the resident, attending physician, and representative. However, the policy did not clarify whether notifications should be verbal or written, contributing to the deficiency. The DON emphasized that patient care was prioritized over written notifications in emergency situations, and written notifications were typically reserved for notices of Medicare non-coverage.
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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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