Prescott Village Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Prescott, Arizona.
- Location
- 1030 Scott Drive, Prescott, Arizona 86301
- CMS Provider Number
- 035158
- Inspections on file
- 19
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Prescott Village Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to obtain and document informed consent for psychotropic and opioid medications for three residents. Two cognitively intact residents received opioids and psychotropics, including tramadol, oxycodone, trazodone, and Dilaudid, without signed, medication-specific consents, and the opioid consent forms used did not list the drug names. Another resident with severe cognitive impairment was given multiple psychotropic medications, including alprazolam, paroxetine, mirtazapine, and risperidone, but consent was only documented for some of these drugs. Staff reported that they assume an order in the EHR means consent has been obtained and do not routinely verify consents before administering these medications, despite a policy requiring informed consent prior to administration.
The facility failed to ensure PRN pain medications were administered within physician-ordered pain scale parameters for three cognitively intact residents with multiple comorbidities, including diabetes, dementia, joint replacement aftercare, encephalopathy, respiratory failure, and acute kidney failure. MAR reviews showed acetaminophen, tramadol, and oxycodone were repeatedly given for pain ratings outside the ordered ranges over several months. During interviews, an LPN, the ADON, and the interim DON each confirmed that medications had been administered outside the prescribed parameters and described associated risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. The facility’s Medication Administration policy lacked specific language on following physician-ordered pain parameters, despite requiring review of the MAR and three checks against the physician’s order, pharmacy label, and MAR.
The facility failed to ensure that a licensed pharmacist completed and documented required monthly medication regimen reviews for several residents with complex conditions and multiple medications, including psychotropics, opioids, anticonvulsants, antibiotics, diuretics, and hypoglycemics. Record review showed multiple consecutive months without documented pharmacist reviews for four residents, with only occasional single-month reviews noted and no recommendations recorded. The ADON reported that medication reviews are done on admission and that monthly pharmacist packets are reviewed by him and the provider, but he confirmed that pharmacy review records for numerous months could not be located and acknowledged this was not acceptable. The interim DON stated the pharmacist visits monthly but believed reviews were only required quarterly, despite the facility’s policy specifying that each resident’s medication regimen must be reviewed at least monthly and documented in the medical record.
Surveyors found that dietary staff did not consistently follow sanitation and food storage standards. A cook was observed preparing vegetables without a required beard net, despite facility policy and staff statements that hairnets and beard guards must be worn upon entering the kitchen to prevent hair from contaminating food. Inspectors also found expired food items, including pickled beets and processed Swiss cheese, stored in the refrigerator past their labeled use-by dates. Dietary staff, including the Director of Nutritional Services, confirmed they are responsible for labeling and checking food twice weekly and that food must be discarded by the use-by date to prevent foodborne illness, acknowledging that the observed practices did not meet facility expectations.
The facility failed to ensure that direct care staffing information submitted to CMS via PBJ was complete and accurate, as PBJ reports showed repeated excessively low weekend staffing and a one-star staffing rating while the facility’s own assessment documented higher daily nurse and CNA coverage. When surveyors requested detailed staffing submission data, the administrator could not promptly provide it, and a PBJ validation report showed that Total Employee Link Records were not submitted. Multiple residents reported long delays in call light response and assistance, including waits of 30–90 minutes, and one resident noted a nurse working six consecutive days due to open shifts. A CNA described working with only one other CNA in the building when others called off, and an LVN reported frequent staffing issues and difficulty finding replacements amid high turnover. The administrator stated that staffing was planned to meet state minimums, relied on a vendor to transmit timeclock data to CMS, did not personally review PBJ submissions, and was unaware of staffing triggers or low staffing star ratings, despite a policy requiring accurate daily submission of all direct care staffing, including agency and contract staff.
A resident with significant neurological, renal, and mental health diagnoses, and severely impaired decision-making at discharge, was sent home with a family member without a documented physician order authorizing discharge and without discharge goals or objectives in the care plan. An undated discharge planning form cited insurance as the reason for discharge and noted there would be no caregiver or home services in place. Review of the EHR showed no discharge order in the physician order tab, and a verbal discharge order with home health services was only entered months later at the direction of leadership. The ADON, Interim DON, and an LPN all acknowledged that a physician order is required for discharge and that such orders should appear in the EHR, while facility policy specifies that transfers and discharges occur only upon a physician’s order with supporting clinical documentation.
A resident with multiple chronic conditions and intact cognition signed a Prehospital Medical Care Directive refusing all resuscitation measures, and a practitioner note documented the resident as DNR. However, the EHR landing page listed the resident as full code, there was no DNR physician order, and the care plan identified the resident as full code with CPR to be initiated. On the unit, the Advanced Directives Book contained the resident’s DNR form, but the cover sheet still labeled the resident as full code. An RN, the interim DON, and a CNA all confirmed reliance on these records for code status and acknowledged that the documentation was inconsistent, contrary to facility policies requiring accurate, complete physician orders and honoring advance directives.
A resident with documented generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, and use of aripiprazole for behavior management was admitted with a hospital PASRR that showed no serious mental illness or mental illness. Despite multiple layers of review by admissions, social services, MDS, and corporate auditing, staff did not identify or correct the inaccurate Level I PASRR on admission, even though the facility’s policy requires a complete Level I PASRR screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
A resident with generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and a BIMS score indicating cognitive intactness, remained in the facility for more than 30 days while receiving aripiprazole for PTSD and bipolar disorder. The only PASARR in the record was the hospital preadmission PASARR, which was null for serious mental illness and mental illness, and no new Level I PASARR was completed within 40 days as required by facility policy. Staff interviews showed that the social services clerk did not handle PASARRs, the regional LMSW reported the facility had only recently obtained information to submit PASARRs and that incorrect hospital PASARRs should be corrected, the MDS nurse relied on social services for PASARR review and did not check for Level II PASARRs, and the admissions coordinator stated that PASARRs are reviewed before admission by intake and a corporate auditor, yet no updated PASARR was present for this resident.
A resident with multiple serious medical conditions, intact cognition, and documented ADL deficits requiring assistance with personal hygiene was observed with yellow, brittle toenails extending several centimeters beyond the toes and a jagged fingernail, despite being unable to perform self-care. The EHR, shower sheets, and skin checks contained no documentation that nail issues had been identified or that nail care had been provided, and there was no evidence of podiatry involvement. A CNA and an LVN described that CNA staff are responsible for routine nail care and documentation, with podiatry used for certain residents, while the RN confirmed that excessively long nails should have been identified during weekly skin checks. Review of records and staff interviews showed that required nail care and documentation, as outlined in facility policy, were not carried out for this resident.
A resident with moderate cognitive impairment and multiple medical conditions was found with various treatment items and medications left on an overbed table at the bedside, including Medihoney wound treatment, skin protectant, a wound cleanser, and a bottle of mineral oil labeled as a lubricant laxative. Nursing staff acknowledged that medications and treatment supplies should not be left at the bedside and were unclear about which items qualified as medications. The DON confirmed that medications, including mineral oil, are not to be stored at the bedside without a completed self-administration assessment and proper documentation, and facility policies required secure storage of medications and prohibited bedside storage without documented interdisciplinary assessment, which was not present for this resident.
A resident with severe cognitive impairment and multiple comorbidities, including acute kidney failure and a UTI, had an indwelling Foley catheter with orders for enhanced barrier precautions and routine catheter care. During ambulation with assistance from a PTA, the resident’s catheter drainage bag was observed hanging below the wheelchair and dragging on the floor, and this continued as the resident walked with the wheelchair behind. A RN, the interim DON, and a CNA all stated that catheter bags are expected to be secured, covered, and never allowed to touch the floor due to infection control concerns. The facility’s catheter care policy also specifies that the collection bag must not touch the floor at any time, but this requirement was not followed in this incident.
A deficiency was cited when a resident's care plan did not address all assessed needs and failed to include measurable timetables and specific actions, as observed in the care planning documentation.
A resident with severe cognitive impairment and a history of wandering eloped from the facility despite having a wanderguard in place, as the front door alarm was not functioning. Staff were unaware of the resident's departure until notified by an outside party, and interviews confirmed that required monitoring procedures were not effectively carried out.
A resident with a history of fractures and mobility deficits was injured during a hoyer lift transfer when two CNAs, including an agency staff member unfamiliar with the resident, used the wrong type and size of sling and failed to remove a leg strap securing the resident to the wheelchair. The improper transfer caused acute pain and resulted in a right distal femur fracture, as confirmed by x-ray and hospital evaluation. Staff did not follow established procedures for safe transfers or ensure the correct equipment was used.
A resident with multiple health issues suffered a leg injury during a hoyer lift transfer when her leg remained strapped to the wheelchair, causing significant pain. Although CNAs notified the nurse and pain medication was given, there was no timely assessment, incident report, or notification to the physician or family as required by policy. The resident's pain worsened, and only the next day was the physician notified and x-rays ordered, which later revealed a femur fracture. Required documentation and notifications were delayed, contrary to facility policy.
A resident experienced an injury during a hoyer lift transfer, but the facility failed to document the incident, assessments, and notifications in a timely and complete manner, resulting in incomplete medical records. Additionally, the facility did not provide requested therapy documentation for another resident within the expected timeframe, and staff qualification records for a contracted CNA were not readily available, causing delays during the survey process.
The facility failed to ensure that dishes and utensils were cleaned under sanitary conditions, with inconsistent dishwasher temperature readings and improper documentation by the senior cook. The Administrator confirmed the issue and the expectation for proper logging of temperatures.
The facility failed to provide timely written transfer/discharge notices to three residents, including one with severe cognitive impairment and another who was cognitively intact. The facility's practice of verbal notification in emergencies contradicted its policy, leading to potential unsafe discharges.
The facility failed to assess and administer pain medications according to accepted standards for two residents. One resident with severe cognitive impairment and another who is cognitively intact had inconsistencies in their pain medication administration, with some medications not being administered and others given without a specified pain scale. Interviews revealed a discrepancy in understanding pain scale requirements for PRN medications.
The facility failed to ensure that a pharmacy medication recommendation for a resident on anticonvulsant therapy was reviewed and implemented. The resident's valproic acid levels were not monitored as recommended, and interviews revealed a lack of clear responsibility for following up on pharmacy recommendations.
The facility failed to ensure that a resident's clinical record included the required information for transfer/discharge. A resident with severe cognitive impairment and multiple diagnoses was discharged to a medical center due to shortness of breath, but no discharge summary was found in the clinical record. The DON acknowledged the absence, and the Administrator was unsure of the discharge policy.
The facility failed to revise care plans for two residents following falls, resulting in delayed or missing interventions. Staff interviews confirmed that the expected protocol for falls was not followed, and the Administrator acknowledged the delay in updating care plans.
Failure to Obtain and Document Informed Consent for Psychotropic and Opioid Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic and opioid medications for multiple residents, despite a policy requiring such consent before administration. For one cognitively intact resident with dementia, diabetes, dysphagia, and acute kidney failure, the MDS showed use of antidepressant and opioid medications. Physician orders included PRN tramadol and oxycodone for pain and PRN trazodone for insomnia. Review of the electronic health record did not show signed consents for tramadol, oxycodone, or trazodone. An opioid consent form in the record had an effective date but did not identify the specific opioid medications. Medication administration records showed that tramadol and oxycodone were administered numerous times over several months without documented, medication-specific informed consent. Another resident with severe cognitive impairment, Alzheimer’s disease, dementia, dysphagia, and a cognitive communication deficit was receiving multiple psychotropic medications, including alprazolam, paroxetine, mirtazapine (Remeron), and risperidone. The facility produced signed consent forms for paroxetine, mirtazapine, and risperidone, but there was no documented consent for alprazolam, despite an active order for chronic anxiety. The orders for these medications had been in place and updated over an extended period, indicating ongoing use without complete corresponding consents for all psychotropic agents. A third cognitively intact resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and knee pain had an order for scheduled oral Dilaudid three times daily for pain. The EHR did not contain a signed consent specific to Dilaudid. An opioid consent form in the record had an effective date but did not list the name of the opioid medication. Staff interviews confirmed that nurses rely on the presence of orders in the EHR as an indication that consents have been obtained and do not routinely verify consent before administering psychotropic or opioid medications. The ADON and regional nurse acknowledged that consents are required, that forms in use did not include medication names, and that an opioid consent form had been created in-house without a field for the specific drug name, contributing to the lack of medication-specific informed consent documentation.
Failure to Administer PRN Pain Medications Within Ordered Pain Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PRN pain medications were administered within the physician-ordered pain scale parameters for three residents. For one resident with type 2 diabetes, dysphagia, dementia, acute kidney failure, and a cognitive communication deficit, the MDS showed she was cognitively intact and receiving antidepressant and opioid medications. Pharmacy review in December 2025 specifically requested that nursing staff be reminded that pain medications must be given within parameters. Despite this, review of the MARs showed acetaminophen and tramadol were repeatedly administered outside the ordered pain scale ranges across multiple months, including June, November, December, January, and February. Another cognitively intact resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure had an order for acetaminophen 325 mg, two tablets every six hours PRN for generalized or breakthrough pain rated 1–4. The February MAR showed acetaminophen was administered outside of these parameters on three separate dates. This resident’s care plan, initiated in September 2025, identified a need for pain management related to right hip pain and included an intervention to administer analgesia per physician’s orders, yet the MAR documentation demonstrated that the ordered parameters were not consistently followed. A third cognitively intact resident with encephalopathy, acute and chronic respiratory failure, and acute kidney failure had an order for oxycodone 10 mg every four hours PRN for pain rated 6–10. The February MAR showed oxycodone was administered once when the resident rated pain as 3, which was outside the ordered parameters. During interviews, an LPN, the ADON, and the interim DON each reviewed the MARs and acknowledged that acetaminophen, tramadol, and oxycodone had been administered outside the prescribed pain parameters, and they described risks such as overdose, unnecessary sedation, over-sedation, lethargy, respiratory distress, constipation, and residents not being able to get ahead of their pain. Review of the facility’s undated Medication Administration policy showed it did not contain language about administering medications according to physician-established pain parameters, although it did reference reviewing the MAR for special considerations and conducting three checks against the physician’s order, pharmacy label, and MAR.
Failure to Ensure Monthly Pharmacist Medication Regimen Reviews for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly medication regimen reviews (MRRs) for multiple residents, as required by facility policy. The facility’s written Drug Regimen Review policy, revised in January 2025, states that the pharmacist will review each resident’s medication regimen at least monthly to detect irregularities and clinically significant risks, and will document in the resident’s medical record that the review has been completed. Surveyors’ review of pharmacy review documents, closed records, and staff interviews showed that these monthly reviews were missing for several residents over multiple months. For one resident with aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure, who was cognitively intact and receiving antidepressant, opioid, and anticonvulsant medications, there were no documented pharmacy reviews for October and November 2025, and January and February 2026; only a December 2025 review was present with no recommendations. Another resident with Alzheimer’s disease, dysphagia, dementia, and cognitive communication deficit, who had severe cognitive impairment and was receiving antipsychotic, antianxiety, antidepressant, antibiotic, diuretic, and hypoglycemic medications, had no documented pharmacy reviews for September, October, and November 2025, and January and February 2026, with only a December 2025 review available showing no recommendations. A third resident with traumatic ischemia of muscle, opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and left knee pain, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for August, September, October, and November 2025, and January and February 2026. A fourth resident with type 2 diabetes, dysphagia, unspecified dementia, acute kidney failure, and cognitive communication deficit, who was cognitively intact and receiving antidepressant and opioid medications, had no documented pharmacy reviews for September, October, November, and December 2025, and January and February 2026. During interviews, the ADON stated that medication reviews are conducted upon admission with the facility provider and that the facility receives a monthly packet from the pharmacist, which he and the provider review, sometimes with pharmacist suggestions that may or may not be accepted, and then sent to medical records. However, he confirmed that he could not locate the pharmacy review records for the missing months for the identified residents and acknowledged that not having monthly pharmacy reviews was not acceptable. The interim DON reported that the pharmacist is in the facility monthly but believed pharmacy reviews only needed to be conducted quarterly, which conflicted with the facility’s written policy requiring at least monthly reviews and documentation in the medical record.
Improper Hair Restraint Use and Storage of Expired Food in Dietary Services
Penalty
Summary
Surveyors identified deficiencies in the facility’s food service operations related to improper use of hair restraints and failure to discard expired food items. During an initial kitchen observation, a cook was seen preparing vegetables at the food preparation counter without a beard net, despite having a beard. Multiple staff interviews, including with another cook and the Director of Nutritional Services, confirmed that facility policy requires hairnets and beard guards to be worn upon entering the kitchen to prevent hair from falling into food or onto plates. The facility’s written Kitchen Sanitation policy, last revised January 1, 2025, also states that all kitchen staff must wear hairnets and beard guards when needed. Surveyors also observed expired food items stored in the kitchen refrigerator. A container of pickled beets with a use-by date of February 27, 2026 was found on the third shelf of the refrigerator during the initial observation. On a subsequent observation, a gallon-sized ziplock bag containing several partial blocks of pasteurized processed white Swiss cheese was found with a received date of February 23, 2026 and a use-by date of March 3, 2026, but it had not been discarded. Staff interviews revealed that cooks and the Director of Nutritional Services are responsible for checking food dates twice weekly and labeling food with received and use-by dates, and that food is not to be served past the use-by date. When shown the expired cheese, a cook acknowledged it should have been discarded and stated that expired food could cause residents to get sick. Another cook and the Director of Nutritional Services similarly stated that food not discarded by the discard date could cause a potential outbreak and foodborne illness, and both acknowledged that the observed situations did not meet expectations or policy requirements.
Inaccurate PBJ Staffing Data Submission and Reported Delays in Resident Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure that direct care staffing information submitted to CMS through the Payroll-Based Journal (PBJ) system was complete and accurate, based on verifiable and auditable data. PBJ reports showed the facility consistently triggered for excessively low weekend staffing for three quarters and received a one-star staffing rating for two fiscal quarters. The facility assessment documented a licensed capacity of 58 residents with a current census of 50 and indicated daily nursing staffing of three nurses on day shift and two on night shift, with an RN present at least 8 consecutive hours per day and three CNAs on night shift and four on day shift. However, when surveyors requested detailed staffing submission data, the administrator stated that timeclock data went to a vendor (Xchieve) which then submitted to CMS, and that the information was located out of state and not immediately available. Review of the PBJ submitter final file validation report obtained from the facility showed that the Total Employee Link Records portion failed to be submitted. Resident and staff interviews and facility documentation further demonstrated discrepancies and concerns related to staffing. Multiple alert and oriented residents reported long waits for assistance, including call lights taking 30–60 minutes or up to 1.5 hours to be answered, and one resident reporting that a nurse worked six days in a row due to open shifts. Another resident reported the facility felt understaffed with CNAs, especially on day shift. A CNA reported having to work with only one other CNA in the building when others called off, and an LVN stated that staffing was an issue when staff called out and that finding replacements was difficult, with significant staff turnover in the prior six months. The administrator stated that staffing expectations were to meet state minimums, that direct care staff included CNAs, LPNs, RNs, and therapy, and that all staff clocked in and out with data sent to the vendor, but the administrator did not review PBJ data after submission, was unaware of staffing triggers or low staffing star ratings, and could not state the nursing turnover rate. The facility’s staffing policy required submission of daily direct care staffing information, including agency and contract staff, to the CMS PBJ system and directed staffing inquiries to the administrator or designee, but the incomplete PBJ submission and lack of administrative oversight led to inaccurate staffing information being reported.
Failure to Obtain and Document Physician Order Prior to Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document a physician’s order prior to discharging a resident. The resident was admitted with hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side, dysphagia, acute kidney failure, and major depressive disorder. On admission, staff assessed the resident’s cognitive skills for daily decision making as moderately impaired, and at discharge they were assessed as severely impaired. Progress notes documented that the resident was discharged home with a family member, but the physician’s orders did not contain an order authorizing discharge, and the resident’s care plan did not include discharge goals or objectives. A Discharge Planning Review form, which was undated, indicated the resident was discharged home due to insurance, noted that the resident would not have a caregiver after discharge, and that no home services were in place. Surveyor review of the EHR did not show a discharge order in the physician’s order list or order tab. A physician’s order for discharge with home health services, dated as a verbal order on the day of discharge, was not entered into the EHR until months later, with a printed date corresponding to the survey. The ADON stated that residents who discharge require a discharge summary, physician’s orders indicating the resident is able to discharge, and a recapitulation of the stay, and acknowledged being asked by the Interim DON to enter the discharge order on the survey date, while being unsure whether the physician had actually given an order at the time of discharge. The Interim DON reported that a physician’s order was received the day of discharge but confirmed it was only entered into the EHR on the survey date. An LPN stated that everything related to a resident, including discharge, requires a physician’s order and that the order tab is the only place in the system where such orders can be found, and confirmed that the discharge order for this resident was created the day before his interview. The facility’s Transfer and Discharge policy, last revised in June 2020, states that residents are transferred or discharged upon a physician’s order and that the clinical record must contain physician documentation supporting the necessity of the transfer or discharge.
Inconsistent Documentation of DNR Status and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent documentation of a resident’s code status and advance directives across the medical record and unit reference materials. A cognitively intact resident, as evidenced by a BIMS score of 14 on the admission MDS, had multiple serious diagnoses including hypertension, osteomyelitis, anemia, MRSA infection, rheumatoid arthritis, chronic kidney disease, type 2 diabetes with neuropathy, muscle wasting, muscle weakness, and gait abnormalities. The resident signed a Prehospital Medical Care Directive indicating refusal of all resuscitation measures in the event of cardiac or respiratory arrest, including chest compressions, intubation, artificial ventilation, defibrillation, ACLS drugs, and related emergency procedures. Despite this signed directive, the electronic health record (EHR) landing page listed the resident as a full code, and there was no corresponding DNR physician order in the orders section. A practitioner progress note documented the resident’s code status as DNR on the same date as the directive, but this was not translated into an active order. The care plan further reflected a full-code CPR focus, with a goal that CPR be initiated and followed, and interventions referencing ensuring proper documents were signed and counseling the resident and family, thereby conflicting with the signed DNR directive and practitioner note. On the unit, the Advanced Directives Book contained the resident’s orange DNR form, but the cover sheet listing resident names identified the resident as a full code, creating additional inconsistency. During interviews, an RN stated she would rely on the Advanced Directives Book to determine code status during an emergency and confirmed the discrepancy between the book’s cover sheet and the DNR form, as well as the EHR landing page showing full code. The interim DON confirmed that the EHR landing page pulls from physician orders, acknowledged there was no DNR order and no care plan reflecting DNR status, and stated that documentation needs to match so everyone is on the same page. A CNA also stated that advanced directives are documented in the EHR and in a binder for DNR residents and emphasized that all documentation must be accurate so staff know how to act. Facility policies on Advanced Directives and Physician Orders required honoring residents’ directives and ensuring orders are complete and accurate, but these expectations were not met for this resident.
Failure to Ensure Accurate Level I PASRR for Resident With Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure a complete and accurate Level I PASRR assessment on admission for one resident. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15 indicating intact cognition. The resident’s care plan documented use of the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. However, the PASRR received from the hospital indicated “null” for serious mental illness and mental illness, meaning no psychiatric diagnoses were identified at the hospital level, despite the resident’s documented psychiatric conditions. During interviews, the social services clerk reported working on discharge planning from the beginning of admission but stated she did not handle PASRRs. A regional LMSW explained that the facility had recently obtained the ability to submit PASRRs electronically and stated that incorrect hospital PASRR data should be corrected immediately, acknowledging that the resident’s psychiatric diagnoses should have been identified and reviewed to determine if a Level II PASRR was needed. The MDS nurse stated he was told social services reviewed PASRRs and therefore did not check whether residents had a Level II, and that he had never seen a Level II from the hospital. The admissions coordinator reported that PASRRs are reviewed prior to accepting a resident by herself, central intake, and a corporate auditor, and that the Level I PASRR is usually the last document sent before admission. Despite this, the inaccurate Level I PASRR for this resident was not corrected on admission, contrary to the facility’s PASRR policy requiring Level I screening for all first-time applicants before admission or on the first day Medicaid reimbursement is requested.
Failure to Complete Required Level I PASARR for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a new Level I PASARR was completed within the required timeframe for a resident who remained in the facility for more than 30 days. The resident was admitted with diagnoses including generalized anxiety disorder, bipolar disorder, major depressive disorder, PTSD, muscle weakness, morbid obesity, and bariatric surgery status, and had a BIMS score of 15, indicating cognitive intactness. The care plan documented that the resident was receiving the psychotropic medication aripiprazole for PTSD and bipolar disorder, initiated and revised in late January 2026. The only PASRR available in the record was the preadmission PASRR from the hospital, which was null for serious mental illness and mental illness, and there was no evidence of a second Level I PASARR being completed after the resident had been in the facility for more than 30 days. Interviews with staff revealed gaps in responsibility and process for PASARR completion and review. The social services clerk reported working on discharge planning from admission and stated she did not handle PASARRs, while the regional LMSW explained that the facility had only recently received information to be able to submit PASARRs and that incorrect hospital PASRR data should be corrected immediately; however, no corrected PASRR was found for this resident. The MDS nurse stated he was told that social services reviewed PASARRs, that he did not check for Level II PASARRs, and that he had never seen a Level II from the hospital, acknowledging that an inaccurate Level I on admission could affect needed services. The admissions coordinator reported that PASARRs are reviewed prior to accepting a resident by herself and the central intake team, and that a corporate auditor reviews the PASARR and admission information. The facility’s PASRR policy stated that if a facility stay is longer than 30 days, a Level I screening must be performed within 40 days of admission, which was not done for this resident.
Failure to Provide and Document Necessary Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic nail care and assistance with activities of daily living for a resident who was unable to perform this care independently. The resident was admitted with multiple significant diagnoses, including sequelae of cerebral infarction, systolic heart failure, anemia, acute kidney failure, acute respiratory failure with hypoxia, osteoporosis, major muscle wasting and atrophy, muscle weakness, dysphagia, gait and mobility abnormalities, cognitive communication deficit, need for assistance with personal care, and neuromuscular bladder dysfunction. A 5-day MDS showed the resident was cognitively intact with a BIMS score of 14, had no psychosis or behaviors, but had upper extremity impairment on both sides and lower extremity impairment on one side. The care plan documented significant ADL deficits and indicated the resident required caregiver assistance with personal hygiene/oral care and extensive assistance for repositioning and turning in bed. Despite these documented needs, the EHR contained no evidence that the resident’s finger or toenail issues had been identified, nor that the nails had been trimmed or cleaned. During an observation, the resident was seen in bed with left toenails that were yellowish, brittle, and extending a few centimeters above the tip of the toes, while the right foot had an orthopedic boot and a wound dressing was present on the left foot. In a subsequent observation, the resident’s left thumb nail was jagged, and the right hand had contractures, with no indication that the toenails had been trimmed since the prior day. The resident reported that her toenails had not been cut for several months. Interviews with staff revealed inconsistencies between facility expectations and actual practice and documentation. A CNA stated that nail care is performed during showers and documented on shower sheets, and that CNA staff trim nails that are jagged or extend more than 1/4 inch, with podiatry involved for some diabetic residents’ toenails. An LVN stated that CNA staff provide fingernail care for non-diabetic residents and that nail care documentation should be in the EHR, with podiatry responsible for toenail care. Upon direct observation of the resident, both the LVN and the assigned RN acknowledged that the resident’s fingernails and toenails were excessively long and should have been clipped, and the RN stated that such issues should be identified during weekly skin checks and had not been identified by either CNA staff or nursing. Review of shower sheets and skin checks showed no documentation of excessively long nails, podiatry involvement, or nail care, despite a facility policy requiring CNA staff to trim and document nail care unless specific conditions such as diabetes, circulatory impairment, or problematic nails were present.
Medications and Treatments Improperly Left at Bedside
Penalty
Summary
Surveyors identified a deficiency related to improper storage of medications and treatments at the bedside for Resident #46. The resident was admitted with diagnoses including left hand contracture, dysphagia, major depressive disorder, and muscle weakness, and had a BIMS score of 10 indicating moderate cognitive impairment. The care plan contained no documentation authorizing medications at the bedside. During an observation in the resident’s room, surveyors noted an overbed table covered with a disposable bed pad holding multiple items, including a clear resealable bag with gauze, an abdominal pad package, bandages, an opened 200-count package of 4x4 gauze sponges, three individually wrapped oral swabs, a silver wound dressing package, a small black tube with a white cap, an opened skin protectant packet, a spray bottle of Skintegrity wound cleanser, and a nearly full 16-ounce bottle of mineral oil labeled as a lubricant laxative. In interviews, an RN identified the black tube as Medihoney used for wound treatment and acknowledged that it, along with the skin protectant, should not be kept at the bedside, and was unsure whether the wound cleanser could remain in the room or if mineral oil was considered a medication. A CNA stated that no medications or treatment supplies are allowed to be left at the bedside. The regional interim DON confirmed that medications are not to be left at the bedside unless a self-administration assessment is completed, the physician is contacted, and the appropriate form is completed and signed, and further clarified that medications are anything administered to residents, including mineral oil. The DON was only aware of the wound cleanser being at the bedside and not the mineral oil, Medihoney, or skin protectant. Facility policies on Medication Storage, Medication Administration, and Self-Administration of Medications all required secure storage of medications, prohibited leaving medications at the bedside, and required documentation of interdisciplinary assessment and determination regarding bedside storage in the medical record and care plan, which had not been done for this resident.
Failure to Maintain Catheter Bag Off the Floor During Resident Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control standards for the management of an indwelling urinary catheter for Resident #27. The resident was re-admitted with multiple diagnoses including chronic kidney disease, acute kidney failure, urinary tract infection, infection and inflammatory reaction due to other urinary catheter, obstructive and reflux uropathy, and pneumonia, and had a BIMS score of 7 indicating severe cognitive impairment. Physician orders documented enhanced barrier precautions due to a Foley catheter, catheter care every shift and as needed, and weekly changes of the catheter securement device. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, away from the entrance room door, to check tubing for kinks, and to keep the drainage bag off the floor. On the survey date, the resident was observed in the hallway seated in a wheelchair and being assisted with ambulation by a PTA, with the catheter bag hanging below the wheelchair and dragging on the floor. The PTA then assisted the resident to stand and walk with the wheelchair behind, while the catheter bag continued to trail on the floor. A RN, when the issue was pointed out, stated that the bag should never touch the floor under any circumstances due to infection control concerns and adjusted the bag once the resident was seated in the dining area. The PTA acknowledged that the bag had been touching the floor and stated it should not have been. The interim DON and a CNA both stated that catheter bags are expected to be secured, hanging from the bed or wheelchair, covered with a privacy cover, properly anchored, and never allowed to touch the floor, citing infection control concerns and risk of rupture or the bag popping open. The facility’s catheter care policy, last reviewed in January 2025, specified that the collection bag must not touch the floor at any time, which was not followed in this instance.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was found that the care plan did not comprehensively cover the resident's assessed needs or include clear, measurable objectives and interventions.
Failure to Prevent Resident Elopement Due to Inoperative Door Alarm
Penalty
Summary
A resident with a history of dementia, disorientation, and a recent fracture was admitted to the facility and assessed as a moderate elopement risk upon admission. The resident's cognitive status declined over time, as indicated by a drop in the BIMS score from 10 to 3, reflecting severe cognitive impairment. Physician orders were in place for a wanderguard device due to the risk of elopement, and staff were instructed to monitor the device's function. Despite these measures, the resident was last seen at the nurses station and was later found at a nearby emergency room, having left the facility without staff knowledge. Staff interviews confirmed that the wanderguard was in place at the time of the incident, but the front door alarm was not functioning, allowing the resident to exit undetected. Staff reported that residents at risk for elopement are typically monitored with wanderguards and that door alarms are expected to alert staff if such residents approach exits. However, on the day of the incident, the malfunctioning front door alarm failed to activate, and the resident was able to leave the premises. The deficiency was further evidenced by staff statements acknowledging the resident's increased elopement risk following improved mobility and the lack of immediate staff awareness of the resident's departure. Facility policy required reinforcement of procedures for residents at risk of elopement, but these procedures were not effectively implemented in this case.
Failure to Ensure Safe Hoyer Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide safe assistance to a resident during a mechanical hoyer lift transfer, resulting in an injury. The resident, who had a history of multiple fractures, an open wound on the right foot, epilepsy, and a disorder of bone density and structure, required a mechanical lift for all transfers due to an activity of daily living self-care deficit. On the day of the incident, two CNAs attempted to transfer the resident from her wheelchair to her bed using a hoyer lift. The resident's leg was still strapped to the wheelchair during the lift, and the wrong type and size of sling was used. The resident immediately complained of pain, and the transfer was halted, but the resident sustained a fracture to the right distal femur as confirmed by subsequent x-rays and hospital evaluation. Multiple staff interviews and witness statements revealed that the CNAs involved were not familiar with the resident's specific needs and did not ensure the correct sling was used or that all straps were removed prior to the transfer. One CNA was an agency staff member unfamiliar with the resident, and the other was not experienced with the resident's care. The resident's usual sling was missing, and the staff used a different type of sling, which was not appropriate for the resident's condition. The improper placement of the sling and failure to unstrap the resident's leg from the wheelchair leg rest led to the resident experiencing acute pain and ultimately a femur fracture. Facility documentation and policy review indicated that staff did not follow established procedures for assessing the resident's needs, choosing the correct sling, and ensuring all safety measures were in place before performing the transfer. The incident was not immediately recognized as a significant injury, and there was a delay in notifying the physician and obtaining diagnostic imaging. The lack of adherence to safe transfer protocols and insufficient staff familiarity with the resident's care requirements directly contributed to the accident and resulting injury.
Failure to Timely Assess, Document, and Notify After Resident Injury
Penalty
Summary
A resident with multiple medical conditions, including an open wound, pelvic fractures, and a history of bone disorders, experienced an incident during a hoyer lift transfer. During the transfer, the resident's leg remained strapped to the wheelchair, resulting in immediate pain and distress. Although the CNAs involved notified the nurse within five minutes and Tylenol was administered, there was no documented assessment, incident report, or notification to the physician or the resident's family on the day of the incident. The resident's pain escalated throughout the day, requiring stronger pain medication, but still no communication with the provider was documented at that time. The following day, the resident continued to experience significant pain, prompting further assessment and eventual notification of the physician, who ordered x-rays. The x-rays, completed the next day, revealed a distal femur fracture, and the resident was subsequently sent to the emergency room for further evaluation and treatment. Documentation showed that the required change of condition evaluation was not completed until several days after the incident, and the incident report was also delayed. Interviews with staff confirmed that the incident was not reported or documented according to facility policy on the day it occurred. Facility policies required immediate assessment, documentation, and notification to the physician and family following incidents resulting in injury or significant change in condition. However, the clinical record review, staff interviews, and policy review revealed that these steps were not followed. The lack of timely assessment, documentation, and notification could have resulted in delayed care and lack of awareness by the physician and family regarding the resident's condition.
Incomplete Medical Records and Delayed Documentation Provision
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced an incident during a hoyer lift transfer. The resident, who had multiple medical conditions including an open wound, pelvic fractures, hypothyroidism, epilepsy, and bone disorders, was involved in a transfer incident where the hoyer lift sling was not properly used, resulting in acute pain and a subsequent diagnosis of a distal femur fracture. Despite the incident occurring, there was no documentation in the clinical record on the day of the event, including progress notes, incident reports, or assessments. Notification to the physician and the resident's family was also not documented on the day of the incident. Documentation of the change in condition and related assessments were completed days later, and staff interviews confirmed that required documentation and reporting protocols were not followed at the time of the incident. Additionally, the facility did not provide requested documentation for another resident in a timely manner during the survey process. When therapy documentation was requested, there was a significant delay in providing the records, exceeding the expected two-hour turnaround time. The delay persisted despite multiple reminders to facility leadership, and the required documents were only provided the following day. There were also delays and missing documentation related to staff qualifications and training for a contracted CNA, with competency checklists and orientation records not readily available and only submitted after further requests. Facility policy requires prompt and thorough documentation of incidents, changes in condition, and communication with physicians and families. The failure to document the incident, assessments, and notifications as required, as well as the delay in providing requested records, resulted in incomplete and inaccurate medical records and hindered the survey process. These deficiencies were confirmed through record reviews, staff interviews, and policy review.
Failure to Maintain Sanitary Conditions in Dishwashing
Penalty
Summary
The facility failed to ensure that dishes and utensils were cleaned under sanitary conditions, which could result in residents becoming ill. During an initial walk-through of the kitchen, it was observed that the temperature gauge on the dishwasher had not been working since December 31, 2023. The senior cook, who was responsible for the kitchen, stated that he had been using an external thermometer to manually check the dishwasher temperature. However, the temperature readings during the wash cycle varied significantly, with readings of 118 degrees, 140 degrees, and 203 degrees, none of which consistently met the required temperature for sanitization. Additionally, the senior cook admitted to not properly documenting the temperature readings on the dishwasher temperature log from January 1, 2024, to January 22, 2024, and falsely indicated that he had checked the temperature for all three meals each day, even on days he was not present at work, as confirmed by his time card records. The facility's policy and the dishwasher instruction manual both require specific temperature ranges for the wash and rinse cycles to ensure proper sanitization, which were not consistently met or documented. An interview with the Administrator revealed that the facility was aware of the issue and was expecting a new dishwasher to be installed. The Administrator also confirmed that the expectation was for the dishwasher temperature log to be initialed by the staff who checked the temperature each meal. The failure to maintain and document proper dishwasher temperatures as per the facility's policy and the dishwasher's instruction manual could lead to unsanitary conditions and potential illness among residents. The facility's policy requires the wash cycle to be between 150 to 165 degrees Fahrenheit and the rinse cycle to be between 150 to 180 degrees Fahrenheit, which were not consistently achieved or recorded during the observed period.
Failure to Provide Written Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely written notification of transfer or discharge to three residents, as required by policy and regulations. Resident #3, who was cognitively intact with a BIMS score of 13, was transferred to the hospital due to a fall resulting in a pelvic fracture. Although the resident's emergency contact was notified via telephone, there was no documentation of a written notice provided to the resident regarding the transfer. The facility's Administrator confirmed that the facility does not provide written statements for hospital transfers, which is against the facility's policy and regulatory requirements. Similarly, Resident #37, who had severe cognitive impairment with a BIMS score of 7, was transferred to the hospital due to shortness of breath. The clinical record lacked evidence of a written notice of transfer/discharge being provided to the resident or their representative. Interviews with the Director of Nursing and the Administrator revealed that the facility's practice was to notify the resident's representative verbally in case of an emergency transfer, but no written notice was provided, which contradicts the facility's policy. This failure to provide written notification could result in residents having an unsafe discharge.
Failure to Properly Assess and Administer Pain Medications
Penalty
Summary
The facility failed to assess and administer pain medications according to accepted standards of clinical practice for two residents. Resident #16, who has severe cognitive impairment, was prescribed Acetaminophen 325 mg to be given 650 mg by mouth every 4 hours as needed for pain, not to exceed 3,000 mg per day. The Medication Administration Record (MAR) showed that the medication was administered on two occasions in January 2024 with a pain scale of 5. However, the orders did not include a pain scale, which is necessary to determine the appropriateness of the medication for the level of pain experienced by the resident. Resident #30, who is cognitively intact, had multiple pain medication orders, including Acetaminophen, Ibuprofen, and Oxycodone-Acetaminophen. The MAR for December 2023 and January 2024 revealed inconsistencies in the administration of these medications, with some medications not being administered at all and others being administered without a specified pain scale. Interviews with the Clinical Care Coordinator and the Director of Nursing highlighted a discrepancy in the facility's understanding and implementation of pain scale requirements for PRN pain medications. The facility's policy on the administration of PRN medications states that they should be administered consistent with the prescriber's parameters and registered nurse's procedures, but this was not followed in these cases.
Failure to Implement Pharmacy Medication Recommendation
Penalty
Summary
The facility failed to ensure that a pharmacy medication recommendation was reviewed and implemented for a resident diagnosed with Major Depressive Disorder and epilepsy. The resident was on anticonvulsant medication therapy with Divalproex Sodium, and a pharmacy consultation report recommended monitoring valproic acid trough concentration. However, the clinical record did not show that the valproic acid levels were drawn as recommended. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) revealed that there was no clear responsibility for following up on pharmacy recommendations, and the resident's Depakote level was missed during leadership transitions. The DON acknowledged that pharmacy reviews should be completed timely and expected that pharmacy reviews be presented to the Medical Director or the resident's Primary Care Provider the next business day. The facility's policy on physician/practitioner orders emphasized the importance of processing and transcribing orders immediately upon receipt. Despite this policy, the facility failed to ensure that the pharmacy's recommendation for monitoring valproic acid levels was followed, resulting in a deficiency in the resident's care.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure that a resident's clinical record included the required information for transfer/discharge. Resident #37, who had severe cognitive impairment and multiple diagnoses including COPD, endocarditis, and supraventricular tachycardia, was discharged to Yavapai Regional Medical Center due to shortness of breath. However, a review of the clinical record revealed no evidence of a discharge summary. The Director of Nursing acknowledged the absence of the discharge summary and stated it should have been completed in a timely manner. The facility Administrator was unsure of the resident discharge policy and needed to check it to determine when a discharge summary should be provided.
Failure to Revise Care Plans Following Falls
Penalty
Summary
The facility failed to ensure that care plans were revised for two residents following falls. Resident #15, who was admitted with hemiplegia and epilepsy, experienced a fall on 7/4/23. Despite this incident, no new interventions were documented in the clinical record until 8/21/23. Similarly, Resident #21, admitted with vascular dementia and generalized anxiety disorder, fell on 9/27/22 and sustained a head injury resulting in a subdural hematoma. However, no care plan for falls was documented until 11/20/22, and no immediate interventions were put in place following the fall on 9/27/22. Interviews with staff revealed that the expected protocol for falls, including immediate assessment, notification of relevant parties, and updating the care plan with new interventions, was not followed. The Registered Nurse and Licensed Practical Nurse both confirmed that interventions were either delayed or missing entirely. The Administrator also acknowledged that interventions should have been implemented sooner and that the care plans were not updated promptly to reflect the residents' needs following their falls.
Latest citations in Arizona
Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
Two residents with known behavioral issues and cognitive/neurologic conditions were involved in a patio altercation where one resident struck another on the head after a verbal interaction and dispute over a book. Care plans for both residents already identified behavioral disturbances, including verbal and physical aggression, and outlined interventions such as providing a calm environment, diverting attention, and intervening to protect others. Despite these plans and prior documented episodes of verbal aggression and a previous physical altercation involving one of the residents, staff‑witness accounts and later review of video footage confirmed that one resident approached and hit another on the head, causing the victim to report pain and fear, demonstrating a failure to protect residents from physical abuse.
A resident with multiple comorbidities, intact cognition, and a care plan requiring two-person assistance for toileting repeatedly requested help for a brief change using the call light and by wheeling to the nurses’ station. A CNA, who had documented training on professional language and abuse prevention, allegedly failed to respond to the call light, refused to assist because a second staff member was not available, and used profanity toward the resident in the context of the resident’s complaints about delayed care, causing the resident to cry and feel unsafe. Another staff member reported seeing the CNA on her phone while call lights were on, hearing the profane statement directed at the resident, and later comforting the resident, while additional staff confirmed the resident’s report that the CNA was rude and blamed her for not receiving care. The facility’s abuse policy defined mental and verbal abuse to include profane, insulting, or degrading language and depriving a resident of care, which aligned with the described interaction.
A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with hemiplegia, psychiatric diagnoses, and dependence on staff for ADLs required assistance with toileting hygiene and bathing per the care plan and MDS, which documented bilateral extremity impairment and wheelchair use. CNA task logs for bowel/bladder and toilet use contained multiple blank shifts, leaving it unclear whether toileting and hygiene care was provided or refused, despite the EHR having specific codes for refusals and unavailability. Behavior and NP notes described the resident’s verbal aggression, sexually inappropriate comments, resistance to care, shower refusals, and repeated complaints that peri care was inadequate, while a nurse documented finding the peri area clean after one such complaint. A CNA and an LPN both stated that blank entries likely reflected a failure to chart and that all ADL care should be documented, consistent with facility policies requiring provision and documentation of ADL services. Surveyors concluded that the facility failed to ensure and document necessary ADL care, specifically toileting hygiene, for this resident.
A resident with spinal conditions, a history of lumbar compression fracture, and documented ADL self-care deficits was care planned and Kardexed for two-person maximum assist transfers for bathing and wheelchair transfers. Despite this, a CNA transferred the resident alone multiple times between a recliner, wheelchair, and shower chair using only a gait belt, during which the resident reported the CNA was rough, fast, and caused pain. An LPN received the resident’s complaint that the CNA was not caring and was the only staff present, while another CNA and a regional clinical specialist confirmed that the Kardex required two-person assist and that the CNA had performed the transfers without assistance, in violation of the plan of care and facility expectations.
Two residents with known behavioral issues, one with severe cognitive impairment and one cognitively intact, were involved in a resident-to-resident physical altercation. A resident with a history of behavioral problems, including prior physical altercations, entered another resident’s room and allegedly punched him multiple times in the face and twisted his arm, resulting in a black eye, skin tears, bruising, and minor cuts. Staff later observed the injured resident approaching the nurses’ station with these injuries, and leadership confirmed via camera review that the aggressor had entered the victim’s room and that a physical altercation occurred, despite an existing abuse policy intended to protect residents from abuse.
The facility failed to prevent resident-to-resident verbal and physical abuse involving two separate pairs of residents with known psychiatric and behavioral issues. In one case, a cognitively intact resident with a history of agitation and verbal aggression insulted another cognitively intact resident with schizoaffective disorder and intermittent explosive disorder during dinner; after repeated verbal exchanges, the second resident stood up, shoved the table, and punched the first resident in the eye, resulting in an orbital fracture and retrobulbar hemorrhage. In another case, a resident with schizophrenia, bipolar disorder, and documented verbal aggression argued over a soda with a peer who had borderline personality disorder and a care plan for bullying and physical aggression; the argument escalated from name-calling to one resident standing and swinging at the other, with the alleged victim later reporting facial and chin pain despite no visible injury on assessment. In both incidents, residents with identified behavior risks and existing behavior plans engaged in escalating verbal conflicts in common areas that were not effectively de-escalated before they became physical or attempted physical assaults.
Multiple residents with dementia and other psychiatric conditions physically abused other residents in common areas and on an outside ramp when staff supervision was inadequate. In one case, a resident with schizoaffective disorder and a known history of verbal and physical aggression, already agitated over smoking restrictions and having threatened and struck staff, was allowed to remain in a common area and struck another resident on the shoulder. In another incident, a resident with dementia and documented combative behavior picked up a folded tray table and hit a non-verbal resident who was seated nearby, while scheduled CNAs and an LPN later reported they did not witness the event and trainees described the assault. In a third event, a resident with violent behavior blocked a narrow ramp and pushed another resident’s wheelchair backward using his hands and feet, causing the wheelchair to flip and the resident to fall and hit his head, with the incident observed and reported by housekeeping rather than direct care staff. These events reflect failures to provide continuous observation and to prevent resident-to-resident physical abuse despite known behavioral risks.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a notice of discharge to the State Ombudsman for one resident. Resident #59 was admitted with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension, and the hospital discharge summary showed the resident was transferred to the facility for therapy services. The discharge planning and discharge progress notes dated 2/15/2026 documented that the resident arrived with family, and the family expressed concern that the assigned room did not have adequate space for the resident's belongings. The same documentation showed the family elected to take the resident home against medical advice, and the electronic medical record, including the AMA Release Form dated 2/15/2026, showed the resident was discharged home with the responsible party. During record review, the Administrator was asked to provide documentation of discharge notices sent to the Ombudsman for the prior 6 months. The Administrator documented that the Ombudsman did not require the facility to send discharge notices directly to her, while also acknowledging that discharge notices had not been sent and that the facility would send notices for discharged residents moving forward. The Ombudsman stated she had periodically received discharge notices in the past but had not received discharge notices from the facility after 12/4/2026, and confirmed the facility is required to provide discharge notices per regulation.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. One resident had multiple diagnoses including cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment, with a BIMS score indicating severe cognitive impairment. This resident had care plans addressing impaired cognitive function and behavioral disturbances, including verbal and physical abuse, with interventions such as providing a calm environment, diverting attention, and intervening as necessary to protect the rights and safety of others. Despite these identified needs and planned interventions, this resident was involved in a resident‑to‑resident altercation on the patio in which another resident struck him on the head after a verbal interaction. The second resident involved had diagnoses including metabolic encephalopathy and pain, and a care plan for behavioral disturbances such as refusal of care, refusal of medication, and verbal and physical abuse. This care plan also included interventions to document behaviors, reinforce why inappropriate behavior is unacceptable, and intervene as necessary to protect the rights and safety of others, including removing the resident from situations as needed. Prior to the incident on the patio, this resident had a documented history of involvement in a physical altercation with another resident, where he was described as the non‑aggressor, and had ongoing behavioral charting for verbal aggression and argumentative behavior. Behavior notes documented episodes of verbal aggression, cursing at staff, and yelling related to environmental changes. On the date of the incident leading to the deficiency, an internal incident report documented that the second resident slapped the first resident on the back of the head on the patio after a verbal confrontation. Witness accounts varied: the activities assistant reported hearing a loud slapping sound and seeing the second resident standing, then intervening, while another resident witness stated she saw the second resident hit the first resident on the head with a book because of a dispute over ownership of the book, and that there had been no argument beforehand. The DON reported that camera footage showed the two residents conversing about three feet apart on the smoking patio, then the second resident wheeled up to the first resident and hit him on the head, which the DON characterized as physical abuse. The administrator also acknowledged that video footage showed the second resident tapping the first resident’s head. The first resident later indicated he was in pain afterward and felt scared. These events occurred despite existing behavior care plans and interventions intended to prevent such incidents, resulting in a failure to ensure residents were free from physical abuse by another resident.
Verbal Abuse and Failure to Respond to Resident’s Request for Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by a CNA. The resident, who had type 2 diabetes mellitus with foot ulcers, absence of the left foot, morbid obesity, and a mood disorder, was care planned for ADL self-care deficits and required maximum assistance for toileting and two-person dependent assistance with transfers. A quarterly MDS showed the resident had a BIMS score of 14, indicating intact cognition, and required substantial assistance for toilet transfers. On the morning in question, an event note documented that the resident was wheeling herself in her wheelchair in the hallway to the nurses’ station to request assistance with a brief change when a CNA seated at the nurses’ station heard her, turned around, and made an inappropriate comment, after which the resident began crying. The facility’s investigation materials described differing accounts of the interaction but consistently referenced the use of profanity by the CNA in the context of the resident’s request for care. The resident reported that she had not received care that morning, had urinated on herself, and had activated her call light, but the CNA would not answer it. The resident stated that when she told the CNA she was going to notify someone about the lack of assistance, the CNA became angry, stood up, and told her, “it’s your fucking fault,” which made her cry and feel unsafe. A staff member (Staff #118) provided a written statement and interview indicating that around 5:15 a.m. he observed multiple call lights on, including the resident’s, and saw the CNA sitting at the nurses’ station on her phone. He stated that the resident came out of her room begging for help with a brief change, that the CNA refused because she did not have a second person to assist, and that at one point the CNA told the resident, “it was [the] resident’s fucking fault,” after which the resident went back to her room crying. The CNA involved had documented training on professional language and on abuse, neglect, exploitation, resident rights, respect in the workplace, and prevention of abuse, including mental and verbal abuse. Her written statement acknowledged that the resident’s call light had been on since about 4:00 a.m. and that the resident later came out of her room angry about the wait; she claimed she agreed with the resident and went downstairs to get another CNA, and admitted she may have used the term “fuck” but denied directing it at the resident. Another CNA (Staff #24) stated that the resident was on “cares in pairs” because she accused staff of not helping her, that the resident used her call light frequently and wanted care immediately, and that delays could occur due to the need for two staff, though communication about delays could ease the situation. A staff member (Staff #38) reported that the resident later said she had a rough morning because she needed help and the CNA was rude and blamed her for not getting care due to the “cares in pairs.” The facility’s abuse policy defined mental and verbal abuse as conduct, including the use of profanity, that can cause humiliation, intimidation, fear, shame, agitation, or degradation, and included mocking, insulting, ridiculing, and threatening residents, including depriving a resident of care, as examples of mental and verbal abuse. The facility’s documentation also showed that the CNA had signed an education acknowledgment form stating she was trained to use professional language and that profanity was prohibited at work. The investigation report and staff interviews consistently placed the resident in a position of repeatedly requesting assistance for incontinence care, with her call light on and her coming into the hallway to seek help, while the CNA did not provide the requested care and used or was alleged to have used profanity in response to the resident’s complaints. The DON acknowledged receiving a report that the CNA was not helping the resident and had sworn at her, and stated that verbal abuse of residents can affect a resident’s psychological well-being. The combination of the resident’s report, corroborating staff statements, and the facility’s own policy definitions formed the basis for the finding that the resident was not kept free from verbal abuse.
Failure to Follow Physician-Ordered Cut-Up Diet Leads to Fatal Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered diet specifying that a resident’s food be cut into bite-sized pieces, and to ensure that this requirement was consistently communicated and implemented by nursing and dietary staff. Resident #9 had multiple diagnoses including heart failure, chronic atrial fibrillation, chronic kidney disease, and moderate vascular dementia with anxiety. A physician order dated December 23, 2024, prescribed a regular diet with regular texture, thin liquids, and explicitly directed that food be cut into bite-sized pieces with large protein portions. The facility’s nutrition care plan initiated on December 30, 2024, referenced the regular diet with large protein portions but did not include the requirement to cut food into bite-sized pieces. The cognition and ADL care plans addressed cognitive impairment and self-care deficits but did not incorporate the ordered cut-up diet or any specific swallowing precautions, despite the resident’s cognitive impairment and upper extremity limitations documented on the MDS. The dietary management and electronic systems in use contained the cut-up order, but this information was not reliably translated into practice. The Menu Wizard tray card history, as reviewed by the senior menu specialist, showed a diet order of regular, regular, thin liquids with notes to cut food into bite-sized pieces and provide large protein portions, and this instruction had been in place since December 23, 2024. The dietary manager stated that dietary staff are responsible for cutting food and that bite-sized pieces would include items like burritos, with food expected to arrive on the unit already cut. However, he also indicated he could not retrieve prior diet slips after discharge and relied on nursing to relay changes. The DON asserted that the “cut into bite-sized pieces” language was a preference rather than part of the actual diet order and stated that only the basic diet components (regular texture, thin liquids) transfer to the kitchen, while additional information such as cutting food does not cross over. In contrast, the prescribing physician confirmed that he ordered regular food, thin liquids, cut into bite-sized pieces, and large protein portions as a single diet order and expected the entire order, including cutting food into bite-sized pieces, to be followed. On the day of the choking event, breakfast trays were delivered to Resident #9’s room, and the resident was served an egg burrito, oatmeal, and cranberry juice. CNA staff reported that the burrito was cut in half but not further cut into bite-sized pieces, and CNA #6 stated she did not know the resident’s diet, did not recall reviewing the meal ticket, and believed his meals did not need to be cut up. She also stated she was unaware of any special instructions to cut the resident’s food into bite-sized pieces and that she typically relied on dietary and nursing to communicate such needs. Multiple CNAs and the charge nurse indicated they were not aware of any formal special diet instructions beyond a regular diet, although the charge nurse acknowledged knowing the family’s preference for cut-up food and finger foods and that dietary did not always cut up his meals, requiring nursing to do so. The resident’s family member reported repeated concerns to the dietary manager, charge nurse, DON, and CNAs about the resident’s food not being cut up, and stated that both she and a hired companion frequently found his meals served uncut despite his upper extremity weakness and motor decline. Later that morning, an LPN who had just started her shift and was not familiar with the resident found him in bed with his breakfast tray in front of him, food apparently eaten, and “mushy” food around and in his mouth. The resident appeared to be sleeping, did not respond to his name, and was grunting and moaning with snoring-type respirations. The LPN manually removed food from his mouth and began suctioning, and the charge nurse arrived with a suction machine and a LifeVac device. Staff observed egg on the resident’s chest and in his mouth, and suctioning removed egg and mucus secretions. EMS was called, and the resident was transported to the hospital. Hospital emergency department documentation recorded that the resident had been eating eggs, was later found choking and unresponsive, and presented with aspiration into the airway and respiratory failure with hypoxia and hypercapnia. The resident was documented as DNR/DNI and was ultimately pronounced deceased. The survey findings attribute this event to the facility’s failure to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and implemented by staff. The report also notes that for Resident #9 there were no active orders for PT/OT/ST evaluation or treatment on the Order Summary Report despite a NP/PA progress note planning for such services, and that the SLP evaluation focused on cognition and compensatory strategies rather than swallowing, with no active speech therapy orders in the diet context. Staff interviews revealed inconsistent understanding of the resident’s diet requirements, with some staff describing cut-up food and finger foods as a preference rather than an order, and others stating they had no knowledge of any special diet instructions. The grievance logs contained no formal grievances from the family member despite her statements that she had repeatedly complained about meals not being cut up and about the resident not being taken to the dining room as he preferred. Collectively, these documented actions and inactions show that the facility did not ensure the physician-ordered diet specifying cut-up, bite-sized food was integrated into the care plan, reliably communicated to dietary and direct care staff, or consistently implemented at the bedside for Resident #9, culminating in a choking and aspiration event requiring hospitalization and resulting in death.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notices to residents and to send copies of those notices to the Office of the State Long-Term Care Ombudsman for multiple residents. Surveyors found that the facility relied on the Notice of Medicare Non-Coverage (NOMNC) as its only discharge/transfer notice and did not use any separate form that met regulatory content requirements. The NOMNC used by the facility did not include the effective date of transfer/discharge, the location to which the resident would be transferred or discharged, the name, address, and telephone number of the State Long-Term Care Ombudsman, or contact information for protection and advocacy agencies for individuals with developmental disabilities or mental disorders. Staff interviews confirmed that the Resident Relations Manager and Business Office Manager considered the NOMNC to be the facility’s discharge/transfer notice and that they did not provide ombudsman information to residents or send copies of discharge/transfer notifications to the ombudsman. For Resident #107, who had hemiplegia and hemiparesis following cerebral infarction, systolic congestive heart failure, muscle issues, and gait and mobility abnormalities, the physician documented that the resident would transfer to another SNF at the family’s request, and a subsequent note showed the resident was discharged via transport van. The discharge MDS documented an unplanned discharge to a SNF. However, review of the clinical record revealed no evidence that a discharge notification was sent to the State Long-Term Ombudsman. The facility’s Admissions, Transfers and Discharges policy referenced reporting information in accordance with facility policy and professional standards but did not include requirements for notifying the ombudsman. For Resident #8, admitted with COPD, palliative care, and paroxysmal atrial fibrillation, the care plan included goals for pre-discharge planning. A discharge order and a discharge-transfer note/summary documented discharge home with oxygen equipment, home health services, narcotic medications, and a scheduled PCP appointment, and this summary was signed by the resident’s family. The documentation given to the family did not include the ombudsman’s contact information or an explanation of appeal rights. The discharge MDS showed an unplanned discharge home with return not anticipated, and there was no evidence in the clinical record that the ombudsman was notified of the discharge. An email sent about 19 days after discharge contained only a list of residents who were discharged, deceased, or transferred, and for this resident it listed a discharge/transfer to another hospital without the reason for discharge or the same information provided to the family. For Resident #12, admitted with atherosclerotic heart disease, the discharge MDS documented an unplanned discharge to hospice at home. A discharge/transfer/LOA form indicated discharge to the community with hospice services at a private home/apartment, initiated by the resident or representative, and a discharge summary and progress note documented discharge home with belongings, medications, and paperwork. There was no physician order for discharge in the order summary report, and the clinical record did not show that a copy of the discharge notification was sent to the ombudsman. In an interview, the Resident Relations Manager stated that a copy of the notification is not sent to the ombudsman and that ombudsman information is not provided to residents. For Resident #100, admitted with COPD, an order directed transfer to the ED for shortness of breath, and a discharge summary documented respiratory distress and transport via ambulance to an acute care hospital. A social services note stated that the resident or representative was provided written notice of transfer, bed-hold notice, readmission policy, ombudsman and appeals information. However, the clinical record contained no evidence that a copy of the transfer notice was sent to the State Long-Term Care Ombudsman. For Resident #102, admitted and later readmitted with hepatic encephalopathy, influenza, and cirrhosis, clinical documentation showed an anticipated discharge to the community, an NP note indicating discharge to prior living arrangements, and an unplanned discharge home/community on the MDS. A discharge/transfer/LOA form and discharge summary documented discharge to a private home/apartment without hospice, initiated by the resident or representative, and a social services note recorded that the family picked the resident up and took him back to the reservation. There was no physician discharge order, and no indication in the record that a copy of the discharge notification was sent to the ombudsman. Interviews with the ombudsman and facility staff further described the deficient practice. The ombudsman reported that their office previously received a list of discharged/transferred residents but had not received anything for recent months and that they were sent only a list, not copies of discharge/transfer notifications. The Resident Relations Manager and Business Office Manager stated that Resident Relations is responsible for presenting the notice of proposed discharge/transfer, that the notice is presented up to 72 hours prior to discharge, and that a copy of the notification is not sent to the ombudsman. They also stated they were unsure if any policy or guidance outlined what information must be included in the notice and confirmed that the NOMNC was the only form used as a discharge/transfer notice, even though it lacked ombudsman and advocacy contact information. The acting DON reported being unfamiliar with discharge/transfer notification requirements, and the Executive Director stated that the facility used only the NOMNC, believed no paper notice was required beyond that, and understood the facility’s obligation as sending a monthly list of discharged/transferred residents to the ombudsman, not copies of the actual transfer/discharge notifications.
Failure to Ensure and Document Toileting Hygiene Assistance for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident dependent on staff for ADLs, including toileting hygiene, consistently received and had documented assistance with these needs. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side, along with schizophrenia and major depressive disorder. The care plan identified the resident as being at risk for functional self-care deficits and functional mobility limitations and specified that he required assistance with toileting hygiene and bathing/showering, including washing, rinsing, and drying, with baths/showers to be provided per his schedule and preferences. The admission MDS documented that the resident was cognitively intact, had bilateral upper and lower extremity impairment interfering with daily function, used a wheelchair, and was dependent on staff for toileting hygiene, shower/bathing, oral and personal hygiene, dressing, and footwear. Review of the December CNA task logs for bowel and bladder and toilet use showed multiple shifts left unmarked/undocumented, meaning it was unclear whether toileting and bowel/bladder care were provided or refused on those shifts. The bowel and bladder task log had blank entries on several specific dates and shifts, and the toilet use task log also contained numerous blank entries across day, evening, and night shifts. A CNA explained that CNA care is documented in the EHR using specific codes, including codes for refusal and resident unavailability, and that if a task is left blank it likely means the CNA did not chart, making it questionable whether the care was provided. The CNA stated that blank areas mean one would not know if care was provided, and that everything should be charted so that care conferences and assessments have accurate data. An LPN similarly stated that blanks on the bowel and bladder task log made her think that either someone did not chart or the resident did not have a bowel movement, and that whoever was on shift should have charted appropriately so that others could determine whether care was provided. The resident’s record also contained multiple behavior and NP notes describing ongoing verbal aggression, sexually inappropriate comments, resistance to care, and specific complaints about how peri care and showers were provided. Notes documented that the resident sometimes refused showers, stated he only needed one shower a week, and complained that staff did not clean his peri area adequately after bowel movements, including an incident where he alleged staff did not clean under his penis despite a nurse finding his peri area and brief clean and dry. Another note described the resident demonstrating that he could clean his own peri area and then verbally abusing staff. Additional documentation described the resident’s frequent agitation, oppositional behavior, verbal aggression, and disruptive behavior during care interactions, including cursing at staff, making derogatory comments, and repeatedly activating the call light. Despite these behaviors and complaints, the facility’s own policies required that residents unable to carry out ADLs independently receive appropriate support and assistance with toileting and personal hygiene, and that all services provided, refusals, and care-specific details be documented in the medical record. The combination of the resident’s dependence on staff for toileting hygiene and the numerous undocumented shifts on CNA task logs led surveyors to determine that the facility failed to ensure ADL care such as toileting hygiene was provided and properly documented for this resident. Facility staff interviews reinforced the importance of ADL care and documentation and highlighted the gap between expectations and practice. The CNA familiar with the resident described him as a two-person assist due to behaviors, using briefs rather than the toilet, being very sexual, refusing care from male staff, and demanding extra wiping and frequent changes, which led staff to implement cares-in-pairs and show him wipes after each wipe to prove cleanliness. The CNA acknowledged that blank documentation entries likely meant CNAs did not chart and that this created uncertainty about whether care was provided. The LPN stated that residents should be rounded on at least every two hours for ADL care, emphasized that ADL care is important for dignity and to prevent skin breakdown, and confirmed that uncharted tasks prevent others from concluding whether care was provided. These findings, combined with the facility’s policies requiring provision and documentation of ADL services, formed the basis for the deficiency that the facility failed to ensure ADL care, specifically toileting hygiene, was provided and documented for this resident.
Improper Single-Staff Transfer During Shower Contrary to Two-Person Assist Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was transferred in accordance with the care plan and transfer orders during bathing and showering. The resident had diagnoses including a wedge compression fracture of the 3rd lumbar vertebra, surgical aftercare, cauda equina syndrome, spinal stenosis, and a need for assistance with personal care. A care plan initiated on April 10, 2026 documented that the resident required assistance with bathing and showering and had an ADL self-care performance deficit. Interventions initiated on April 20, 2026 and resident task documentation revised on April 14, 2026 indicated that the resident required a two-person maximum assist for transfers to the wheelchair. Despite these documented requirements, a facility investigation dated April 22, 2026 revealed that a CNA (Staff #79) transferred the resident alone from a recliner to a wheelchair, from the wheelchair to a shower chair, and then back from the shower chair to the wheelchair and into bed, using only a gait belt and without a second staff member. The resident reported that the CNA was alone during all transfers, was very rough, and that the transfers were painful, and also stated that the CNA did not speak to him during the shower. An LPN (Staff #96) confirmed receiving a complaint from the resident that the CNA was not caring and was very fast during the shower, and that the CNA was the only staff member present. Another CNA (Staff #72) stated that the Kardex identifies the resident as a two-person assist and that she always obtains another person to help with transfers, noting that transferring the resident alone could cause pain and injury. The Regional Clinical Specialist (Staff #102) stated that CNAs are expected to follow the Kardex for transfer assistance levels and confirmed that the investigation determined the CNA had transferred the resident without assistance, contrary to policy and the plan of care.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. Resident #1 had severe cognitive impairment with a BIMS score of 05 and a care plan identifying behavioral problems, including taking others’ belongings, eating other residents’ food, inappropriate contact with other residents’ belongings and clothing, giving food to other residents without permission, refusing medication and care, and initiating a physical altercation with another resident. Despite these identified behaviors and the existence of a care plan focused on behavior problems, Resident #1 was able to enter Resident #2’s room and engage in a physical altercation. Resident #2 was cognitively intact with a BIMS score of 14 and had a care plan for behavior problems related to verbal and physical behaviors, including prior verbal altercations with other residents, use of profanity, striking another resident in the head, spitting water on staff, kicking at staff during care, cursing at staff, and refusing brief checks and changes. On the day of the incident, Resident #2 approached the nurses’ station with a hematoma to the left eye, a large skin tear to the right forearm, minor cuts to the nose, lip, and right hand, and bruising to the left hand. Resident #2 reported that Resident #1 had entered his room, punched him multiple times in the face, grabbed and twisted his arm, and then left the room. Staff interviews and facility documentation confirmed that no staff witnessed any verbal altercation between the two residents prior to the event, and that earlier in the day Resident #2 did not have any injuries. After the incident, staff observed Resident #2 with a swollen eye and face, bruising, and lacerations consistent with his report. The Administrator and DON stated that review of camera footage showed Resident #1 entering Resident #2’s room and that a physical altercation occurred, confirming that Resident #1 went into Resident #2’s room, hit him in the face, and then exited. The facility’s abuse policy stated an objective to provide a safe haven for residents through preventive measures that protect every resident’s right to freedom from abuse, but the documented resident-to-resident physical abuse occurred despite these stated objectives.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse by other residents. One incident involved a resident with borderline personality disorder, schizophrenia, major depressive disorder, generalized anxiety disorder, a history of traumatic brain injury, and chronic pain syndrome, who had intact cognition and documented patterns of agitation, aggression, yelling, cursing, and threatening others. While in the dining room during dinner, this resident verbally insulted another cognitively intact resident with schizoaffective disorder, bipolar type, intermittent explosive disorder, and personality change due to a physiological condition. Multiple accounts from staff and both residents indicate that after being told not to talk to him, the verbally aggressive resident continued speaking, and the other resident stood up, shoved the table, and struck him in the left eye with a closed fist. As a result of this altercation, the assaulted resident reported pain, nausea, and later requested psychiatric support and antidepressant therapy. Clinical documentation and hospital imaging confirmed an acute left inferior orbital wall fracture and retrobulbar hemorrhage, with visible bruising to the left eye. Prior to this event, the aggressor had known psychiatric diagnoses and was receiving multiple psychotropic and mood-stabilizing medications for mood swings, aggression, disorganized thinking, paranoia, and intermittent explosive disorder. The facility’s records show that the aggressor had behavior care plans related to behavior problems and intermittent explosive disorder, but there is no indication in the report that staff anticipated or intervened to prevent this specific escalation in the dining room before the physical strike occurred. A second incident involved two other residents with significant psychiatric and behavioral histories. One resident had schizophrenia, bipolar disorder, anxiety disorder, intellectual disabilities, and obesity, with a behavioral care plan noting verbal aggression, demanding behaviors, and instructions for staff not to provide requests when made in a rude, threatening, or aggressive manner. The other resident had borderline personality disorder, bipolar disorder, pseudobulbar affect, anxiety disorder, PTSD, and type 1 diabetes, with a behavioral treatment plan for bullying or physical aggression toward peers and interventions directing staff to intervene promptly, remind the resident of respectful behavior expectations, and separate and redirect her if needed. Despite these identified risks and care plan directives, the two residents engaged in a verbal argument over a soda at the nurses’ station, during which one resident called the other a “fat b****” and continued name-calling after being told to stop, leading the other resident to stand up and swing at her. Documentation from behavior notes, incident notes, and the facility’s investigation shows that both residents stood up from their wheelchairs and approached each other during the argument. One resident reported being slapped in the face and later complained of chin pain, while the other resident was documented as having swung her arm at the peer. A skin assessment performed shortly after did not show visible injury, redness, trauma, or swelling, and witnesses, including staff and another resident, reported seeing a swing but were unsure if physical contact occurred. The facility’s investigation ultimately concluded that it could not determine whether physical contact was made, but the event was characterized as a verbal altercation that escalated to at least an attempted physical strike. In both sets of incidents, residents with known behavioral risks and existing behavior plans engaged in escalating verbal conflicts that were not effectively de-escalated or prevented from becoming physical, resulting in at least one resident sustaining a confirmed serious injury and another reporting pain after an alleged slap. Across these events, the facility had identified behavioral risks for the involved residents and had documented care plans and behavior interventions addressing aggression, bullying, and inciting peers. However, during the actual incidents, residents engaged in escalating verbal abuse in common areas (dining room and nurses’ station) that progressed to physical aggression or attempted physical aggression. The report describes that staff were present in the vicinity and, in some cases, intervened only after the physical act occurred or as the residents were already standing and approaching each other. The survey findings conclude that the facility failed to ensure that the affected residents were free from physical or verbal abuse by other residents, as required, resulting in resident-to-resident altercations that included verbal insults, threats, and at least one confirmed physical assault causing an orbital fracture and retrobulbar hemorrhage.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Supervision in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents and to provide adequate supervision in common areas. One cognitively impaired resident with dementia and depression was struck on the right shoulder by another resident with schizoaffective disorder and a history of verbal and physical aggression. Prior to the assault, the aggressive resident had been up all night, repeatedly demanding cigarettes outside of scheduled smoking times, threatening staff, calling 911, grabbing a housekeeper’s keys and injuring her shoulder, and punching a CNA in the abdomen. Despite these escalating behaviors and the resident’s known behavioral care plan identifying verbal and physical aggression and exit-seeking, the resident remained in the common area where he randomly hit the other resident’s shoulder in passing. Staff and police were present on campus, but the aggressive resident was still able to make physical contact with the other resident before being removed. Another deficiency occurred when a resident with dementia, bipolar disorder, major depressive disorder, and anxiety, who had a behavioral care plan for combative behavior, severe agitation, cursing, striking out, and threats, struck another cognitively impaired, non-verbal resident with a tray table in a common area. The victim had dementia, diabetes, and a cognitive communication deficit, and was known to wander and exhibit other non-directed behavioral symptoms. The incident was reported as occurring while the two residents were in a common area, and multiple scheduled CNAs and an LPN assigned to that unit later stated they did not witness the event. Statements from trainees indicated they observed the aggressor pick up a folded wooden table, yell profanities, and launch it at the victim’s head while the victim remained seated and non-verbal. The DON acknowledged that no CNA was physically present in the common area at the time, that trainees were only observing, and that the nurse preparing medications did not provide full attention to supervising the residents, resulting in no staff supervision in the room when the altercation occurred. A further deficiency involved a resident with mild cognitive impairment and no documented behavioral symptoms who was pushed backwards in his wheelchair by another resident with dementia, anxiety disorder, and violent behavior. The incident occurred on a narrow, steep ramp outside the dayroom, where only one person at a time could pass. The aggressor, also in a wheelchair, blocked the ramp and told the other resident he could not come up, then pushed the resident’s shoulder with his hand and used his feet to kick the wheelchair, causing it to flip and the resident to fall to the ground and hit his head. A housekeeping/laundry staff member witnessed the event and reported that the aggressor refused to let the other resident pass and then pushed him down the ramp. The DON stated that CNAs conduct rounding outside every 15 minutes, but the report does not indicate that any direct care staff were present at the ramp when the altercation occurred, and the event was instead discovered and reported by non-nursing staff after the fall. Across these incidents, the facility’s own documentation and staff interviews show that residents with known histories of aggression, agitation, or violent behavior were able to physically assault other residents in common areas and on an outside ramp without effective, continuous supervision by assigned nursing staff. Behavioral care plans identified risks such as verbal and physical aggression, striking out, and threats, and the DON stated that when residents are in common areas there should always be a staff member observing them. However, in the described events, residents were either not directly supervised by CNAs in the common areas, or staff attention was divided, allowing aggressive residents to hit, push, or otherwise physically abuse other residents before staff intervened. These actions and inactions led to resident-to-resident altercations that constituted physical abuse under the facility’s own definitions and policies.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
