Rehab At Scottsdale Village Square
Inspection history, citations, penalties and survey trends for this long-term care facility in Scottsdale, Arizona.
- Location
- 2620 North 68th Street, Scottsdale, Arizona 85257
- CMS Provider Number
- 035217
- Inspections on file
- 44
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Rehab At Scottsdale Village Square during CMS and state inspections, most recent first.
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.
A resident admitted with a primary diagnosis of Schizoaffective Disorder and an active diagnosis of Schizophrenia had a PASRR Level 1 that identified serious mental illness and indicated the need for a Level 2 referral, but the facility did not submit this referral to the state authority. The Social Service Director reported that she completed only the Level 1 and did not send the Level 2 to AHCCCS, despite her usual practice to do so for residents with Schizophrenia. The resident had intact cognition, was receiving antianxiety and antipsychotic medications, and had a behavioral care plan addressing verbal and physical aggression and exit-seeking behaviors, while the DON confirmed the resident was on a secured unit and followed by a psychiatric provider but lacked a Level 2 PASRR determination.
Multiple residents with dementia, psychotic disorders, and severe cognitive impairment engaged in repeated resident‑to‑resident physical abuse, including punching, kicking, grabbing, and hitting, often triggered by intrusive wandering, perceived theft, unwanted touching, or attempts to take belongings such as blankets or food. Several aggressors had documented histories of delusions, sexually inappropriate behavior, prior altercations, or intolerance of others in their personal space, but these risks were not consistently reflected as physical aggression in care plans, and staff often intervened only after altercations had begun. Staff interviews described frequent resident‑to‑resident incidents, acknowledged that hitting constitutes abuse, and indicated reliance on post‑incident monitoring rather than clearly defined, proactive measures to prevent contact and escalation, despite a facility policy guaranteeing residents freedom from physical abuse.
The facility failed to individualize comprehensive care plans for multiple residents involved in resident-to-resident altercations, instead applying the same generic psychosocial focus and interventions to all parties regardless of whether they were victims or aggressors. Residents with dementia, psychotic disorders, PTSD, parkinsonism, and other psychiatric conditions had documented histories of wandering into others’ rooms, delusional accusations about stolen money, taking others’ food or belongings, prior physical aggression, and rapid behavioral escalation, yet these specific triggers and behaviors were not reflected in their active care plans. Staff, including LPNs and CNAs, described knowing resident-specific behaviors and effective de-escalation strategies, but reported limited or no access to update care plans, while the MDS nurse acknowledged using vague, standardized interventions and relying on separate Risk Management records for incident details. This disconnect between staff knowledge and the written care plans resulted in care plans that did not meet the policy requirement for comprehensive, person-centered planning based on individualized data and known behavioral patterns.
The facility failed to adequately track, trend, and analyze resident-to-resident abuse incidents within its QAA/QAPI process. QAA meeting minutes showed missing and inconsistent data on reportable incidents and unit trends, and the DON’s clinical review did not specifically address resident-to-resident abuse. The only documented action plan was a general, non-measurable strategy focused on staff education and keeping residents at arm’s length, with no evidence of resolved plans or measurable progress. Interviews with the DON and Administrator confirmed that altercations were tracked mainly as reportable events by location, without deeper analysis of triggers or patterns, despite policies requiring QAPI review and performance improvement initiatives for abuse-related events.
The facility failed to update behavioral health care plans to reflect individualized triggers and documented behaviors for two residents with severe cognitive impairment and psychiatric conditions. One resident, known by staff to have delusions about others stealing his money and to escalate quickly, accused another resident of theft and punched him in the eye, yet his care plan and IDT behavior review did not specifically address this recurrent trigger. Another resident had multiple documented episodes of taking other residents’ food and becoming difficult to redirect, but his behavioral treatment plan and care plan focused on sexual inappropriateness, elopement, and isolation without including his history of taking food or belongings. These omissions occurred despite a facility dementia protocol requiring the IDT to identify and document residents’ conditions, behaviors, and needed supports and to review changes as they arise.
A resident with schizophrenia, quadriplegia, and moderately impaired cognition became very upset in a common area, used an electric wheelchair aggressively, and kicked a CNA who intervened. The CNA responded by grabbing the resident’s leg, transferring the resident from the wheelchair to a recliner, and yelling loudly at the resident. Facility records showed no head-to-toe or skin assessment of the resident after this staff–resident altercation, and progress notes did not document risk related to the incident. Despite facility policies requiring protection from abuse, assessment, documentation, and prompt reporting of suspected staff-to-resident abuse to the State Agency, the DON and administrator determined the event was not abuse and did not report it.
A resident with quadriplegia, schizophrenia, depression, and moderately impaired cognition became physically and verbally aggressive, attempting to run into staff and others with an electric wheelchair. A CNA intervened, was kicked by the resident, then placed the resident in a recliner while yelling loudly, behavior later deemed inappropriate in a behavioral setting. No head-to-toe or skin assessment was documented after the altercation, and there was no evidence that this staff-to-resident abuse allegation was reported to the State Agency within required timeframes, despite facility policy and leadership statements that such allegations must be reported promptly.
The facility failed to submit a required 5‑day abuse investigation report to the State Survey Agency after an incident in which a resident with depression, schizophrenia, quadriplegia, and moderately impaired cognition became physically and verbally aggressive, attempted to run into staff and others with an electric wheelchair, kicked a CNA, and was then transferred to a recliner while the CNA yelled loudly. Although the event was documented on an internal suspected abuse investigation form and facility leadership described a process that includes immediate investigation and submission of a detailed report within 5 working days, surveyors found no evidence in the clinical record or facility files that the mandated 5‑day investigation report was completed or sent, and the administrator confirmed that no such report existed.
The facility failed to protect three severely cognitively impaired residents from physical abuse by another resident and by a family member. In one incident, two residents with dementia and psychiatric diagnoses were in the dining room when one, who was standing, repeatedly hit another who was in a wheelchair, resulting in a forehead injury and knuckle hematomas. Staff and documentation confirmed the altercation, and prior care plans had already identified behavior issues and the need to protect others’ rights and safety. In a separate incident, a resident with dementia, Parkinsonism, and a history of falls was verbally and physically abused by her husband, who became frustrated when assisting with medications and was reported by staff to have kicked her when she refused medication. Staff interviews and the DON’s statements confirmed that the husband’s actions, including kicking the resident, were physical abuse, despite a facility policy stating residents have the right to be free from abuse.
Multiple incidents occurred where residents with cognitive impairments engaged in physical altercations, including hitting, slapping, pushing, and punching, resulting in injuries such as abrasions, hematomas, and fractures. These events were witnessed by staff and documented in clinical records, with care plans in place for behavioral risks but insufficient to prevent abuse. Facility policies defined these actions as abuse, and staff interviews confirmed the incidents did not meet expectations for resident safety.
Multiple residents with cognitive impairment were involved in physical altercations with other residents, resulting in injuries and hospitalizations. Staff often became aware of the incidents only after they had begun, despite care plans indicating behavioral risks. The DON and staff confirmed that these events met the definition of abuse and did not meet expectations for resident safety.
The facility failed to prevent resident-to-resident physical abuse involving two separate pairs of cognitively impaired residents. In one case, a resident with dementia and known behavioral disturbance struck another resident after the second resident grabbed her wheelchair, and the second resident struck back. In another case, a wheelchair-using resident with neurological and psychiatric conditions was slapped on the back of the head, pushed from his wheelchair, and fell, sustaining a large traumatic head wound, after his roommate reacted to contact from the wheelchair. Multiple CNAs, an LPN, and an RN acknowledged that such physical altercations between residents constitute abuse and described expectations to separate and report involved residents, yet these incidents still occurred despite care plans and policies stating residents’ rights to be free from abuse.
The facility failed to prevent resident-to-resident abuse when two cognitively impaired residents with Bipolar Disorder, dementia, and known behavioral issues engaged in a physical and verbal altercation in a common area. One resident, seated in a recliner, refused to move when another resident demanded the chair, leading the standing resident to grab the seated resident’s arms, after which the seated resident pushed back and both began hitting each other and pulling hair. One resident sustained scratches and a 3 cm laceration near the eye. Staff, including a CNA, another CNA, and a nurse, intervened to separate them. Interviews with a CNA, an LPN, the DON, and the administrator confirmed prior incidents between the same two residents, staff awareness of their sudden mood changes, and existing abuse-prevention training and policies stating residents’ rights to be free from abuse, yet the altercation still occurred.
Two residents with severe cognitive impairment engaged in a physical altercation in the dayroom, resulting in both sustaining skin tears and contusions, while a CNA present was unable to separate them alone and was injured in the process. The incident occurred with only one CNA supervising twelve residents, and staff interviews and video footage confirmed the escalation and injuries.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
Multiple residents with cognitive and behavioral issues engaged in physical altercations, including hitting, biting, and kicking, resulting in injuries and distress. Staff were often unable to prevent or promptly intervene in these incidents, despite care plans identifying behavioral risks. Documentation and interviews confirmed these events were considered abuse, and the facility failed to ensure residents' rights to be free from physical abuse.
Two residents with psychiatric and behavioral diagnoses were involved in a physical altercation, resulting in one resident sustaining minor injury and property damage. Staff intervened, and the incident was recognized as abuse by facility leadership. However, the facility failed to provide required investigation documentation and did not fully adhere to its abuse prevention and reporting policies.
Two residents were involved in a physical altercation during a medication pass, resulting in one resident sustaining minor injury. Staff had difficulty separating the residents, and the incident was not reported or investigated within the facility's required timeframe for suspected abuse.
The facility did not ensure accurate documentation in the medical records for multiple residents regarding abuse incidents, resident assessments, and missing property. For example, a resident receiving dialysis did not have required pre- and post-treatment assessments documented, and several residents involved in altercations or reporting missing items had no related entries in their clinical records, despite facility policies requiring such documentation.
Surveyors found that the facility failed to maintain consistent advance directive documentation for two residents. In both cases, signed pre-hospital and/or VA advance directive forms indicated DNR status and refusal of CPR, while the face sheets, care plans, progress notes, and physician orders documented full code status. Staff, including an MDS coordinator, an LPN, and the DON, reported that advance directives are initiated on admission, reviewed quarterly, and should be updated in both physical and electronic records using a specific form, but acknowledged that discrepancies remained in these residents’ charts, creating a risk that their end-of-life wishes would not be honored.
Surveyors identified that the facility failed to remove multiple expired medications from two medication rooms, including nasal spray, stimulant laxatives, vitamin E, and influenza vaccine, which remained stored despite a policy requiring prompt removal of expired drugs. In a separate incident, a resident with multiple chronic conditions and moderate cognitive impairment was found sleeping with a cup of medications left on the bedside table after an LPN believed the doses had been taken; the resident had not been assessed or approved for self-administration as required by facility policy.
A resident with severe cognitive impairment physically and verbally abused another resident after a dispute over food. Staff intervened to separate the residents, and no injuries were reported. The incident was classified as both verbal and physical abuse according to facility policy, which states residents have the right to be free from abuse.
Multiple residents with cognitive and behavioral impairments engaged in physical and sexual abuse of peers, including incidents of unwanted touching, hitting, and altercations resulting in injuries. Despite care plans and staff awareness of behavioral risks, interventions were not effectively implemented, leading to repeated episodes of abuse and neglect among residents.
A resident with severe cognitive impairment and a history of behavioral disturbances was not consistently provided with adequate supervision, resulting in multiple altercations with other residents. Despite care plans and behavior assessments indicating the need for interventions such as 1:1 monitoring and frequent observation, these measures were not always implemented, leading to preventable incidents of physical aggression.
A resident with severe cognitive impairment and a history of behavioral disturbances physically struck another cognitively impaired resident in a common area, resulting in visible injury. The incident was witnessed by an LPN, who intervened to stop further harm. Despite existing care plans and behavioral interventions, the facility did not prevent the altercation, leading to a deficiency related to resident protection from abuse.
Two residents with cognitive impairments were involved in a physical altercation, resulting in one sustaining a skin tear to the hand. The incident was reported by the injured resident to an LPN, who observed the injury and questioned both parties. Conflicting and delusional accounts were given, and the facility's investigation was unsubstantiated due to lack of witnesses, despite documentation of prior aggressive behavior by one resident.
The facility failed to prevent resident-to-resident abuse, involving incidents where a resident with dementia hit another, causing injury, and another resident with severe cognitive impairment struck a fellow resident. Despite known behavioral issues, the facility did not effectively implement monitoring and supervision protocols, leading to these altercations.
Two residents with dementia eloped from a facility due to inadequate supervision and door functionality issues. One resident, identified as an elopement risk, left undetected and was found by police. Another resident, initially assessed as not at risk, also eloped and was returned by police. Staff reported concerns about door locks and insufficient staffing levels, contributing to the incidents.
A long-term care facility failed to administer medications within the required timeframe to six residents, leading to potential risks of unmanaged symptoms and adverse effects. Observations showed that medications scheduled for 8:00 a.m. were administered late, with some residents receiving their medications over two hours past the scheduled time. Interviews with staff revealed a lack of adherence to the policy of administering medications within one hour of the prescribed time.
A resident with severe cognitive impairment and a history of aggressive behavior hit another resident in the face during an incident in the dayroom. Despite being on one-to-one supervision, the aggressive resident managed to make contact, leading to an altercation. Staff intervened by separating the residents, and an assessment showed no apparent injury to the affected resident.
A resident with schizophrenia and dementia, identified as an elopement risk, successfully left the facility due to a malfunctioning exit door. Despite interventions like Wanderguard checks and door alarm maintenance, the resident eloped and was found outside before being redirected back. Staff interviews revealed previous maintenance issues with the door, highlighting a lapse in supervision and security measures.
A facility failed to provide adequate supervision, resulting in an altercation between two residents. One resident with PTSD was injured after being hit and kicked by another resident with anxiety disorder. Despite staff intervention, the aggressive resident was not easily redirectable, leading to emergency services being called. The facility's reliance on surveillance cameras and staff monitoring was insufficient, as the lack of cameras in certain units and inadequate staff presence contributed to the incident.
A resident in an LTC facility was administered multiple psychotropic medications without being informed of the risks and benefits, as required by facility policy. The facility relied on outdated consents from a sister facility, failing to obtain new consents upon the resident's admission. Staff interviews confirmed the oversight, highlighting a deficiency in compliance with informed consent policies.
A facility failed to complete a level 2 PASRR for a resident with mental illness, including schizoaffective and bipolar disorders, upon admission. The resident's care plan involved psychotropic and other medications, but the necessary referral for specialized services was not made. Interviews with staff revealed the oversight, and the facility lacked a physical copy of the level 2 PASRR, failing to follow up with ALTCS.
A resident with dementia and depressive disorder wandered away from a facility due to inadequate supervision and care planning. Despite documented wandering behaviors, the resident's care plan did not address these issues, and an elopement risk evaluation inaccurately indicated no risk. The resident exited through an unalarmed window and was later found by police with minor injuries. Staff interviews revealed awareness of the resident's desire to leave and the ease of opening the window.
The facility failed to protect residents from abuse, with incidents involving inappropriate touching and physical aggression. A resident with a history of sexually inappropriate behavior was not adequately monitored, leading to an incident with another resident. Additionally, two residents with severe cognitive impairments were involved in altercations due to insufficient staffing and inadequate interventions. The facility's leadership did not report incidents appropriately, citing cognitive status as a reason for inaction.
The facility failed to report abuse allegations involving three residents to the State Agency, APS, and law enforcement. A resident with Alzheimer's was inappropriately touched by another resident with a history of sexual inappropriateness, and another resident was found naked and touching a sleeping female resident. These incidents were not reported, and staff were unclear on what constituted a reportable event, leading to a deficiency in handling resident safety and abuse prevention.
The facility failed to thoroughly investigate allegations of abuse involving residents. In one case, a CNA found a resident cornered and inappropriately touched by another resident, but no comprehensive investigation was conducted. Another incident involved a resident found naked in another's room, with no evidence of a thorough investigation. The facility's policy outlines specific steps for investigations, but these were not followed, leading to a deficiency in ensuring resident safety and rights.
The facility failed to provide sufficient staffing, resulting in inadequate supervision and incidents of inappropriate behavior between residents. A resident with Alzheimer's was inappropriately touched by another resident with a history of behavioral disturbances. Staffing levels were below the facility's assessed needs, with staff expressing concerns about their ability to monitor and care for residents effectively. The director of nursing and administrator acknowledged staffing challenges but did not document daily assessments of residents' needs.
A resident with severe cognitive impairment attacked another resident after being told to "shut up" in the day room. The altercation was broken up by a nurse, but the aggressive resident then threatened the nurse. The facility's investigation confirmed the incident, highlighting a failure to prevent the altercation despite existing care plans and protocols.
The facility failed to consistently enforce PPE use during a COVID-19 outbreak, with staff and visitors observed not wearing masks despite clear signage and protocols. The concierge admitted to forgetting to wear a mask, and the DON and Administrator removed their masks during a conference. Shared spaces with another company complicated enforcement, and the Infection Preventionist noted challenges in ensuring compliance among non-facility staff.
The facility failed to protect residents from abuse and assess their capacity to consent to relationships. A resident reported sexual abuse by a CNA, which was not reported or addressed by management. Another resident was injured due to rough handling by the same CNA, and the incident was not properly investigated. Additionally, the facility did not assess the ability of two residents with severe cognitive impairments to consent to a sexual relationship, leading to deficiencies in care.
The facility failed to report allegations of abuse and inappropriate incidents involving residents with cognitive impairments. A resident reported sexual abuse by a CNA, but the incident was not reported to authorities. Another resident was found with bruises, allegedly from rough handling by a CNA, yet it was not reported. Two residents with severe cognitive impairments were involved in an incident of physical touching, but it was not reported, and no documentation of consent assessment was found.
The facility failed to investigate abuse allegations involving a resident with cognitive impairments who reported sexual abuse by a CNA. Another resident with severe cognitive impairment was found with bruises and scratches, allegedly due to rough handling by a CNA, but the incident was not reported or investigated. Additionally, two residents with severe cognitive impairments were found engaging in sexual acts without proper consent assessment or investigation.
A resident with severe cognitive impairment sustained a leg injury, but the LTC facility failed to notify the family, contrary to its policy. Staff interviews revealed confusion about notification requirements, and the DON confirmed no documentation of family notification was found.
A facility failed to prevent abuse between two residents with cognitive impairments, resulting in two physical altercations. The first incident involved a slap, with no immediate care plan updates or separation of residents. A second incident led to a superficial injury, prompting a psychological evaluation and relocation of the aggressive resident. Care plans were updated later to address behavioral triggers.
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.
Failure to Submit Required PASRR Level 2 Referral for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a PASRR Level 2 referral was submitted to the state-designated authority for a resident admitted with a primary diagnosis of Schizoaffective Disorder. The resident’s PASRR Level 1, completed on 2/26/2026, documented that the resident had a serious mental illness, specifically Schizophrenia, and indicated that a Level 2 referral for mental illness was necessary. Despite this, the facility did not have a Level 2 PASRR on file for the resident, as confirmed by the Administrator. The Social Service Director reported that her usual process is to complete a Level 1 PASRR for new admissions and submit a Level 2 referral to AHCCCS when a resident has a diagnosis such as Schizophrenia, but in this case she completed only the Level 1 and did not submit the Level 2 referral. The resident’s clinical record showed an intact cognition with a BIMS score of 15 and an active diagnosis of Schizophrenia, with routine use of antianxiety and antipsychotic medications. A Behavioral Care Plan effective 3/11/2026 documented that the resident exhibited verbal and physical aggression, including posturing, threats, and exit-seeking behaviors, and outlined staff interventions to manage these behaviors. The Social Service Director stated that the purpose of a Level 2 referral is to determine if the resident is appropriate for the facility and environment to meet the resident’s needs, and acknowledged that the referral for this resident was not submitted. The DON confirmed that the resident was admitted with Schizoaffective Disorder as the main diagnosis, was on a secured unit, and was followed by the facility’s psychiatric provider, and also stated she was informed that no Level 2 PASRR referral had been submitted to AHCCCS.
Failure to Prevent Repeated Resident‑to‑Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident physical abuse, despite known behavioral histories and documented patterns of aggression, delusions, and boundary violations. Multiple residents with dementia, psychotic disorders, mood disorders, and severe cognitive impairment were involved in separate altercations in which one resident physically struck, grabbed, or otherwise assaulted another. In several cases, residents had documented histories of intrusive wandering, delusions, sexually inappropriate behavior, or prior physical altercations, yet these behaviors were not consistently reflected in care plans as physical aggression risks, and preemptive interventions to prevent contact or escalation were not clearly implemented. Staff and leadership interviews repeatedly described the facility as a “behavioral facility” with unpredictable behaviors and acknowledged frequent resident‑to‑resident altercations. In one incident, a resident with dementia, severe cognitive impairment, and a history of entering other residents’ rooms reported being punched in the nose by another resident who had a personality disorder, anxiety, and a documented pattern of making false accusations, going into other residents’ rooms, and breaking their belongings. Another incident involved a resident with severe cognitive impairment and Alzheimer’s disease who was found with a purple/blue bruise under the eye after reporting that his roommate, a resident with parkinsonism, psychotic disorder, and severe cognitive impairment, punched him while accusing him of stealing millions of dollars. The facility’s investigation initially concluded that this event did not happen and later characterized it as an accident, despite an IDT note documenting that the punch occurred. In a separate case, a resident with severe cognitive impairment and bipolar and depressive disorders had his wrist grabbed and squeezed hard by another resident with dementia and severe cognitive impairment, who was described as trying to be helpful by pulling him away from automatic doors. Additional altercations included a resident with severe cognitive impairment and a history of physical aggression toward staff and others being kicked multiple times in the thigh by another resident with schizoaffective disorder, dementia with agitation, and a prior documented assault on another resident and threats toward a nurse. Staff interviews indicated that this resident became verbally and physically aggressive when frustrated, such as when needs for cigarettes, beverages, or television viewing were not met, and that another resident’s wandering likely triggered the kicking incident. Another event involved a resident with vascular dementia, anxiety disorder, violent behavior, and prior involvement in a physical altercation punching a cognitively impaired resident in the stomach after the latter attempted to help push his wheelchair, despite the aggressor’s known intolerance of being touched. In yet another case, a resident with Alzheimer’s disease, dementia with agitation, and a history of taking others’ food and becoming combative during redirection admitted to hitting his moderately cognitively impaired roommate in the head to take his blanket because he was cold. Across these events, the facility’s own abuse policy stated that residents have the right to be free from abuse, including physical abuse, yet residents repeatedly experienced physical contact and assaults from other residents.
Failure to Individualize Care Plans for Resident-to-Resident Abuse and Aggression
Penalty
Summary
The deficiency involves the facility’s failure to develop and update individualized, comprehensive care plans with measurable objectives and timetables to address resident-to-resident abuse and aggression. Surveyors found that for all sampled residents involved in altercations, the facility used the same generic psychosocial well-being care plan focus and identical interventions, regardless of whether a resident was a victim or perpetrator. These standard interventions typically included 72-hour observation, consultations with pastoral care, social services, and psychiatric services, monitoring and documenting responses, and removing residents to a calm, safe environment when conflict arose. The facility’s own policy required comprehensive, person-centered care plans based on data gathering and careful consideration of problem areas and causes, but this was not reflected in practice. Multiple resident pairs were involved in documented altercations where individualized triggers and behavior patterns were not incorporated into active care plans. One resident with dementia and severe cognitive impairment, who wandered and entered other residents’ rooms, reported being punched in the nose by another resident with a history of going into others’ rooms and breaking personal items; staff knew that one resident preferred to be left alone and that the other frequently entered rooms, but these behaviors and staff interventions were not reflected in the care plans. In another case, a resident with severe cognitive impairment and parkinsonism was bruised under the eye after his roommate, who had psychotic disorder and severe cognitive impairment, accused him of stealing millions of dollars and punched him; staff described frequent delusions about stolen money and rapid escalation, yet the care plans did not document these specific triggers or staff strategies. Similarly, a resident with severe cognitive impairment and PTSD had his wrist grabbed and squeezed by another resident with dementia who was described as trying to be helpful by pulling him away from automatic doors, but the individualized behaviors and triggers for both residents were not integrated into their care plans. Additional incidents showed a pattern of unaddressed history of physical aggression and specific behavioral triggers. One resident with schizoaffective disorder and dementia had a prior documented assault on another resident and threats toward a nurse, but his active care plan did not reflect a history of physical aggression; later, he was observed kicking another resident multiple times, and both residents received identical, non-individualized psychosocial care plan focuses. Another resident with PTSD and cognitive impairment had prior documented physical aggression in resident-to-resident altercations, yet his care plan lacked any concern for physical aggression until after he was punched in the stomach by another resident with vascular dementia and a history of arguing and swinging at others; the aggressor’s behavioral care plan listed only anxiety and screaming/agitation as current behaviors despite a recent altercation. In a separate case, a resident reported being hit in the head by his roommate, who admitted striking him to take his blanket; this roommate had multiple prior behavior notes for taking other residents’ food and becoming combative during redirection, but his behavioral treatment plan did not reflect this history and instead focused on sexually inappropriate and isolative behaviors. Staff interviews confirmed that knowledge of resident behaviors and effective interventions was not consistently translated into the care plans. An LPN stated that all behaviors should be documented in the care plan but reported that nursing staff did not have access or did not know how to access and update care plans, indicating reliance on the MDS nurse for updates. A CNA reported that she documented incidents in the charting system and informed the nurse but did not have access to care plans. The MDS nurse acknowledged that all residents involved in resident-to-resident altercations were given the same vague, general interventions and that more detailed information about incidents was kept in Risk Management, to which not all staff had access. Corporate nursing staff stated that care plans were expected to be customized and that anyone in the building could update them, but this expectation was not reflected in practice, resulting in care plans that did not capture individualized triggers, histories of aggression, or specific staff interventions known to be effective.
Failure to Analyze and Trend Resident-to-Resident Abuse Incidents in QAA/QAPI
Penalty
Summary
The deficiency involves the facility’s failure to track, trend, and analyze resident-to-resident abuse incidents and to implement a measurable, data-driven prevention plan through its Quality Assessment and Assurance (QAA) process. Review of QAA meeting minutes for a December meeting covering November showed that the number of reportable incidents for November was left blank, despite trends indicating multiple incidents across specific units. The Director of Nursing’s clinical systems review did not specifically address resident-to-resident abuse, and the documented action plan remained a general approach focused on education about behaviors, memory care, and keeping residents at arm’s length, without measurable elements. The section for resolved action plans was left blank, and there was no documentation of measurable progress on preventing resident-to-resident abuse. Further review of QAA minutes for a February meeting covering December and January showed inconsistencies between the total number of reportable incidents and the number of incidents listed by unit, and again reflected the same non-specific action plan without measurable outcomes. Interviews with the DON and the Administrator confirmed that resident-to-resident altercations were only tracked as reportable events and primarily by location, with no deeper trend analysis such as triggers, patterns, or other causative factors. The Administrator acknowledged that trend tracking for resident-to-resident abuse did not go far enough, and the DON stated that the facility did not know what triggered residents, relying on psych services after altercations. These practices did not align with facility policies requiring QAPI review and analysis of all abuse-related occurrences and integration of confirmed abuse findings into performance improvement initiatives.
Failure to Update Behavioral Care Plans for Individualized Triggers and Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to update and individualize behavioral health care plans to reflect known triggers and behaviors for two residents with severe cognitive impairment and significant psychiatric diagnoses. For one resident with parkinsonism, major depressive disorder, psychotic disorder, and anxiety disorder, the care plan initiated in November 2025 identified behaviors such as putting himself on the floor, hiding, refusing care, and making statements that no one was offering him anything. Interventions included medication administration, positive interaction, explaining why behavior was inappropriate, protecting others’ rights and safety, diverting attention, and removing the resident from situations. A Behavior IDT Review in February 2026 added general approaches for agitation, anxiety, or restlessness, such as calm approaches, guiding to a quiet safe space, and offering calming activities. Despite these documented approaches, the resident had a known pattern of delusional accusations about others stealing his “four million dollars,” as described by staff interviews, and this behavior was associated with rapid escalation when he became agitated. An IDT note from February 13, 2026 documented that this resident accused another resident of stealing millions of dollars and punched that resident in the eye. Staff interviews confirmed that the resident frequently accused others of stealing his money and that this was a recurrent behavior, but the care plan and behavioral interventions were not updated to specifically address this individualized trigger or the associated risk of resident-to-resident altercations. For the second resident, admitted with Alzheimer’s disease, dementia with agitation, personality change, major depressive disorder, and anxiety disorder, multiple behavior notes from July and November 2024 documented repeated incidents of taking other residents’ food and becoming combative or difficult to redirect. However, the behavioral treatment plan dated December 19, 2025 focused on sexually inappropriate and isolative behaviors, with known triggers of female staff assisting with care, and listed past behaviors such as elopement and exposing himself, without indicating a history of taking other residents’ food. A care plan focus initiated in December 2025 similarly addressed sexual inappropriateness, delusions, elopement risk, and self-isolation, with interventions such as cares in pairs and following the behavior plan, but did not include the documented pattern of taking other residents’ food or belongings. Staff interviews indicated that this resident would try to take items he wanted and that staff attempted redirection, yet these behaviors and triggers were not incorporated into the current care plan, contrary to the facility’s dementia clinical protocol requiring the IDT to identify and document the resident’s condition and needed supports and to review changes as they arise.
Failure to Protect Resident From Staff Abuse and to Report Alleged Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to follow required abuse identification and reporting processes after a staff–resident altercation. Resident #6 had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, with a care plan indicating risk for unmet emotional, intellectual, physical, and social needs related to schizophrenia and directing staff to converse with the resident while providing care. A quarterly MDS showed moderately impaired cognition with a BIMS score of 10. On the date of the incident, behavior charting documented that the resident became very upset and physically and verbally aggressive with staff, but the clinical record contained no evidence of a skin assessment after the altercation between staff and the resident. According to the facility’s suspected abuse investigation report and staff interviews, Resident #6, in an electric wheelchair, was in the common/day room and became upset with an LPN while the LPN was at the medication cart. The resident ran into or knocked over the medication cart, spilling its contents, and used the electric wheelchair in a manner described as a weapon, moving around the day room and heading toward other residents. A CNA intervened by getting in front of the wheelchair; the resident then kicked the CNA, and the CNA responded by physically grabbing the resident’s leg, transferring the resident from the electric wheelchair to a recliner, and yelling loudly at the resident. The resident then moved himself to the floor and attempted to crawl back toward the wheelchair. The facility’s documentation and interviews confirm that the CNA’s loud, angry verbal response occurred during this altercation. The DON and administrator both described abuse as including physical, verbal, emotional, and financial harm and stated that the facility’s process for staff-to-resident abuse includes separating the parties, performing a head-to-toe assessment of the resident, and reporting suspected abuse to the State Agency within two hours, followed by an investigation. However, the progress notes from August 6, 2025, to February 3, 2026, did not document risk related to this incident, and there was no documentation of a head-to-toe or skin assessment of Resident #6 after the altercation. The DON and administrator each stated they did not consider the incident to be abuse because they believed the CNA’s actions were not intentional and were aimed at protecting other residents, and therefore the incident was not reported to the State Agency, contrary to the facility’s abuse identification and investigation policy and resident rights policy that require protection from abuse and appropriate assessment and documentation when staff are implicated in potential abuse situations.
Failure to Timely Report Alleged Staff-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse involving one resident to the State Agency (SA) as required by regulation and facility policy. The resident had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, and a recent MDS showed a BIMS score of 10, indicating moderately impaired cognition. On the date of the incident, behavior charting documented that the resident became very upset and physically and verbally aggressive with staff. According to the facility’s suspected abuse investigation report, the resident was attempting to run into staff and other residents with an electric wheelchair in a common area, and a CNA intervened by getting in front of the wheelchair. The resident then kicked the CNA, and the CNA placed the resident into a recliner while yelling loudly. The investigation concluded that the CNA’s loud complaining voice was not appropriate in a behavior setting. However, there was no evidence in the clinical record of a head-to-toe or skin assessment after this altercation. Record review and staff interviews revealed no documentation that this allegation of staff-to-resident abuse was reported to the SA within the required timeframe, and the facility was unable to provide any documentation of reporting when requested by surveyors. The DON and the administrator both described abuse as including physical, verbal, emotional, and financial harm and stated that the facility’s process is to separate the parties, assess the resident for injury, and notify the SA within 2 hours for staff-to-resident incidents. Both the DON and the administrator acknowledged that the incident between the CNA and the resident was not reported to the SA, explaining that they did not consider the CNA’s actions to be intentional abuse. Review of the facility’s policy on identification and investigation of abuse, neglect, misappropriation, and injuries of unknown origin showed that any alleged abuse, including physical or verbal, must be reported to the SA immediately, but not later than 2 hours after the allegation is made, and all other reportable allegations must be reported within 24 hours, which did not occur in this case.
Failure to Submit Required 5‑Day Abuse Investigation Report
Penalty
Summary
The deficiency involves the facility’s failure to submit an abuse investigation report to the State Survey Agency within 5 working days for an allegation involving one resident. The resident had diagnoses including depression, schizophrenia, quadriplegia, and hypertension, and a recent MDS showed a BIMS score of 10, indicating moderately impaired cognition. A behavior charting assessment documented that the resident became very upset and physically and verbally aggressive with staff. On the date of the incident, documentation in a suspected abuse investigation report indicated that the resident attempted to run into staff and other residents with an electric wheelchair in a common area, a CNA positioned themself in front of the wheelchair, the resident kicked the CNA, and the CNA then placed the resident into a recliner while yelling loudly. The investigation concluded that the CNA’s loud complaining and raised voice were not appropriate in a behavioral setting. Surveyors requested the facility’s 5‑day investigation report for this abuse allegation, but the facility was unable to provide it. Review of the clinical record showed no evidence that the incident investigation report was submitted to the State Agency within 5 working days. Interviews with the DON and the administrator confirmed that facility policy and practice require immediate initiation of an abuse investigation, separation of the resident and staff, notification to the State Agency within 2 hours, and submission of a detailed investigation report within 5 working days. The administrator specifically stated that the facility did not have any 5‑day investigation report for the abuse allegation between the CNA and the resident. Review of the facility’s written policy on identification and investigation of abuse, neglect, misappropriation, and injuries of unknown origin confirmed that investigations must be completed within five working days, with limited exceptions, underscoring that the required 5‑day report was not completed or submitted in this case.
Failure to Protect Cognitively Impaired Residents From Physical Abuse by Resident and Visitor
Penalty
Summary
The deficiency involves the facility’s failure to protect three cognitively impaired residents from physical abuse by another resident and by a family member. For the first incident, two male residents with severe cognitive impairment and multiple psychiatric diagnoses, including dementia, depression, anxiety, and mood disorders, were involved in a resident‑to‑resident altercation in the dining room. One resident, seated in a wheelchair, was observed by an LPN and the activities assistant being repeatedly hit with full force by another resident who was standing over him. Staff ran to separate the residents. Initial skin assessment documented no injury to the resident in the wheelchair, but a later change in condition evaluation identified an injury described as a knot on the left side of his forehead. The resident who initiated the hitting was found to have discoloration and hematomas on the knuckles of his right hand. The facility’s own care plans and assessments documented that both residents had severe cognitive impairment, with BIMS scores of 7 and 5, and that one resident had a known behavior problem related to taking things and flushing them down the toilet. The care plan for that resident included interventions such as anticipating and meeting needs, intervening as necessary to protect the rights and safety of others, diverting attention, and removing the resident from situations as needed. Following the altercation, a new care plan focus was added for psychosocial well‑being problems related to resident‑to‑resident altercations, with interventions such as 72‑hour observation and removing residents to a calm, safe environment when conflict arises. Staff interviews confirmed that several staff members witnessed the altercation, that the resident who hit the other stated someone was trying to get into his backside, and that the other resident denied doing anything. Both residents later denied or could not consistently report the altercation when interviewed by surveyors. The second incident involved a visitor‑to‑resident altercation between a severely cognitively impaired resident with dementia, Parkinsonism, hypertension, postconcussional syndrome, and a history of falls, and her husband. A CNA reported to a nurse that he heard the husband and the resident arguing loudly in another language and that the husband physically abused the resident in the day room. Another CNA later reported that her coworker had told her she witnessed the husband kicking the resident very hard when the resident refused to take medication, and that the resident was crying afterward and unable to express herself because she spoke Korean. Additional staff interviews corroborated that the husband became frustrated when assisting the resident with medications, eating, and ADLs, had yelled at and physically touched her in those situations, and that he had kicked her when she spat out medication. The DON acknowledged that the husband’s actions, including kicking the resident, constituted physical abuse. A care plan focus for psychosocial well‑being related to dementia and the husband’s behavior documented that he became frustrated and had yelled and physically touched the resident when trying to help her, and that the resident did better when he was present, with interventions including supervised visits in public places only and removing residents to a calm, safe environment when conflict arises. Across both incidents, staff interviews showed that personnel were generally aware of different types of abuse and the expectation to separate involved parties and report incidents to the nurse, DON, or administrator. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention stated that residents have the right to be free from abuse, including physical abuse. Despite this, the survey findings concluded that the facility failed to protect the rights of three residents to be free from physical abuse by other residents and family members, based on the resident‑to‑resident altercation in the dining room and the visitor‑to‑resident altercation involving the resident’s husband physically abusing her.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of multiple residents to be free from abuse by other residents, as evidenced by several documented incidents of resident-to-resident altercations resulting in physical harm and psychosocial distress. In one case, a resident with moderate cognitive impairment and a history of dementia was struck in the face with a door by another resident, resulting in an abrasion. The incident was witnessed by a staff member, who observed a verbal argument escalating to physical aggression. The perpetrator, who also had dementia and behavioral disturbances, was placed on increased supervision following the event. Another incident involved a resident with severe cognitive impairment who sustained a hematoma around the left eye after being slapped multiple times by another resident during an altercation in the dayroom. The aggressor, also severely cognitively impaired, had a care plan indicating a risk for verbal aggression. The altercation occurred while an LPN was present in the room but had their back turned at the time. Documentation indicated that the victim exhibited non-verbal signs of pain and distress following the incident. Additional altercations included a resident being pushed to the ground by another, resulting in a fracture, and a separate event where a resident was punched in the stomach after taking another resident's food. There was also an incident where two residents began arguing and physically hitting each other at the dinner table, requiring staff intervention. In each case, the facility's own policies defined such actions as abuse, and interviews with staff confirmed that these events met the definition of abuse and did not meet facility expectations. The report details that care plans for the involved residents included interventions for behavioral risks, but these measures were insufficient to prevent the abusive incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of several residents to be free from abuse by other residents, as evidenced by multiple incidents of resident-to-resident altercations. In one case, a resident with severe cognitive impairment and a history of Alzheimer's disease was struck in the abdomen and upper body on two consecutive days by another resident with moderate to severe cognitive impairment. Both incidents occurred in the dayroom, with staff intervention occurring only after the altercations had already taken place. Documentation showed that the residents were separated and assessed, but the altercations were witnessed by staff only after the events had begun, and there was a lack of proactive supervision or intervention to prevent recurrence, despite care plans indicating risk for such behaviors. Another incident involved a resident with severe cognitive impairment and behavioral disturbances who was struck on the arm by another resident with dementia and agitation. The altercation occurred in the dayroom and was only noticed by staff after a commotion was heard. Both residents were separated and assessed, but neither could recall the incident shortly after it occurred. The care plans for both residents included interventions for behavioral risks, but the altercation still occurred without immediate staff prevention. A further incident involved a resident with moderate cognitive impairment and multiple comorbidities who was pushed to the floor by another resident with severe cognitive impairment, resulting in a fractured hip. The altercation followed a verbal exchange in the dayroom and was witnessed by staff, but intervention was not immediate enough to prevent injury. The resident who was pushed required hospitalization for the injury. Interviews with staff and the DON confirmed that these incidents met the definition of abuse and did not meet the facility's expectations for resident safety and supervision.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from resident‑to‑resident physical abuse, despite known cognitive impairments and behavioral risks. One incident involved a resident with dementia and behavioral disturbance who had a care plan intervention to be kept away from close proximity to a particular resident. On the day of the incident, this resident was self‑transferring in a wheelchair in the day room when another resident attempted to grab the wheelchair handle. The first resident turned and struck the other resident with a closed fist, and the second resident then struck back with a closed fist. Staff separated the residents and documented that the first resident had been highly agitated and disoriented for several days and did not like anyone touching her or her belongings, yet this behavior and the need for separation from the other resident had not prevented the altercation. Another incident involved two roommates, both with dementia and other neurological or psychiatric diagnoses, including Alzheimer’s disease, Parkinsonism, traumatic brain injury, epilepsy, and major depressive disorder. One resident, described as verbally aggressive with a short fuse and able to ambulate independently, was identified as the aggressor. According to documentation and staff interviews, the wheelchair‑using roommate either ran into or backed his wheelchair into the other resident, after which the aggressor slapped him on the back of the head, pushed him out of his wheelchair, and caused him to fall to the floor and hit the back of his head. A large reddened, swollen bump (“goose egg”) and a traumatic wound measuring 10 cm by 10 cm were noted on the top/back of the victim’s head. Staff and the administrator characterized this contact as physical abuse between residents. Staff interviews showed that multiple CNAs, an LPN, and an RN understood that residents hitting, pushing, or otherwise physically assaulting each other constitutes abuse and that such incidents require immediate separation of residents and reporting to supervisory staff and administration. Staff described that residents in the behavioral dementia unit could become overstimulated and that physical altercations, such as hitting or pushing, were recognized as abuse. Despite this knowledge and existing policies stating that residents have the right to be free from abuse and to be treated with respect, kindness, and dignity, the facility did not prevent the altercations between the involved residents. The facility’s own investigation and staff accounts confirmed that resident‑to‑resident physical contact occurred in both incidents, resulting in at least one resident sustaining a significant head injury, demonstrating a failure to protect these residents from abuse by other residents.
Failure to Prevent Resident-to-Resident Physical Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse during a resident-to-resident altercation involving two cognitively impaired residents with behavioral health diagnoses. One resident had Bipolar Disorder, Alzheimer’s Disease, Anxiety, and severe cognitive impairment (BIMS score of 03), and had documented prior verbal and physical altercations with other residents. On the day of the incident, progress notes and a change in condition evaluation documented that this resident became upset by another resident’s actions, which escalated into a physical altercation. The care plan for this resident had been revised to identify risk for psychosocial well-being problems related to resident-to-resident altercations. The second resident involved had Bipolar Disorder, Anxiety, Depressive Disorder, and severe cognitive impairment (BIMS score of 05), with a care plan focus indicating potential for verbal aggression, yelling, or cursing at others related to dementia. Progress notes documented that this resident was identified as the aggressor in a physical and verbal altercation with another resident and sustained scratches and a 3 cm laceration to the outer right eye. Staff interviews described that this resident’s mood could switch instantly and that there had been prior incidents between these two residents, including a dispute over a recliner and an episode where one resident threw water on the other. During the altercation described by a CNA, one resident was sitting in a recliner in the day room when the other resident, who believed the recliner should be vacated, told him to get up. When the seated resident refused, the standing resident grabbed both of his arms, leading the seated resident to become upset, stand up, and push the other resident. Both residents then began hitting each other, with one pulling the other’s hair, before CNAs and a nurse intervened to separate them. Interviews with staff, including a CNA, an LPN, the DON, and the administrator, confirmed that staff had received abuse and neglect training and that the facility had a policy stating residents have the right to be free from abuse and neglect. Despite this, the facility did not prevent the resident-to-resident physical abuse between these two residents, who had known behavioral issues and a history of prior incidents with each other.
Failure to Prevent Resident-to-Resident Physical Abuse in Dayroom
Penalty
Summary
The facility failed to protect residents' rights to be free from physical abuse, as evidenced by an altercation between two residents with severe cognitive impairment. One resident with dementia, bipolar disorder, and other comorbidities became agitated over a seating arrangement with another resident diagnosed with Alzheimer's disease, Parkinson's disease, and bipolar disorder. The situation escalated into a verbal and physical altercation in the dayroom, where only one CNA was present with twelve residents at the time. The altercation involved pushing, kicking, and grabbing, resulting in both residents sustaining skin tears and contusions on their right hands. Staff interviews and video footage confirmed that the altercation lasted approximately one minute before additional staff arrived to intervene. The CNA present attempted to separate the residents but was not strong enough to do so alone and sustained scratches in the process. The incident was witnessed by other staff who arrived after the altercation had escalated, and both residents were noted to be upset and verbally aggressive following the event. The care plans for both residents were updated to reflect the psychosocial risk related to resident-to-resident altercations after the incident. A review of facility policies revealed that residents have the right to be free from abuse, including abuse by other residents, and that the facility is committed to preventing such incidents. Despite these policies, the staffing level in the dayroom at the time of the incident was insufficient to prevent or promptly intervene in the altercation, resulting in physical harm to both residents and injury to a staff member.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents of resident-to-resident altercations resulting in physical harm or distress. Several residents with cognitive impairments, behavioral disturbances, or psychiatric diagnoses were involved in physical altercations, including punching, hitting, biting, kicking, and other aggressive behaviors. In many cases, care plans identified behavioral risks and interventions, such as redirection or increased supervision, but these measures were not effective in preventing the altercations. Staff were often present or nearby during these incidents but were unable to intervene in time to prevent physical contact or injury. Specific incidents included residents with severe cognitive impairment or behavioral issues engaging in physical fights, such as punching each other in the face, smacking, or dragging another resident by the arm. In some cases, residents sustained visible injuries, such as bruises, bites, or skin discoloration, and required assessment and treatment. Documentation revealed that staff sometimes struggled to separate residents during altercations, and in several instances, altercations lasted for several minutes before staff could intervene. Some residents had a documented history of prior altercations with the same peers, and staff were aware of these patterns. The facility's documentation and interviews with staff and the administrator confirmed that these incidents were considered abuse and required reporting. However, the recurrence of such events, the inability to prevent or promptly stop physical altercations, and the lack of effective interventions to protect residents' rights to be free from abuse constituted a failure to ensure resident safety. The facility was also unable to provide investigation documents for some incidents beyond a 12-month period, indicating gaps in record-keeping related to abuse investigations.
Failure to Adhere to Abuse Prevention Policy After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to adhere to its abuse prevention policy following an incident of resident-to-resident abuse involving two residents. One resident, with a history of schizoaffective disorder, bipolar disorder, Asperger's syndrome, and behavioral problems including physical aggression, physically grabbed another resident's arm and attempted to drag him to the floor. Staff intervened with difficulty, and the aggressor attempted to throw a chair but was stopped. The resident expressed indifference when told not to abuse others. The victim, who also had multiple psychiatric and medical diagnoses, was found with slight discoloration on his arm and a ripped shirt sleeve after the altercation. Documentation indicated that the incident was recognized as abuse by the administrator and abuse coordinator. Despite the facility's policies requiring immediate reporting and investigation of abuse allegations, the investigation documentation could not be provided for review beyond 12 months. The facility's policies, revised in 2021 and 2022, clearly state the requirement for immediate reporting and investigation of abuse, as well as the right of residents to be free from abuse, neglect, and exploitation. However, the lack of available investigation records and the events described indicate that the facility did not fully implement or adhere to these policies in response to the incident.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an incident involving abuse between two residents. One resident, with a history of schizoaffective disorder, bipolar disorder, and behavioral problems including physical aggression and peer altercations, became physically aggressive during a medication pass. The resident yelled at a nurse, pointed a finger close to the nurse's face, and then charged at another resident, grabbing his arm and attempting to drag him to the floor. Staff had difficulty separating the two residents, and the aggressive resident attempted to throw a chair before being stopped by staff. The incident resulted in the second resident sustaining slight discoloration to his left arm and a ripped shirt sleeve. Despite the severity of the altercation, the facility did not initiate an investigation or notify all required parties until the following day, outside of the facility's policy requirement to report suspected abuse immediately, defined as within two hours. Clinical records and interviews confirmed the delay in reporting. The facility was unable to provide investigation documents beyond 12 months, and policy review confirmed the expectation for immediate reporting and investigation of abuse allegations.
Failure to Accurately Document Abuse Incidents and Resident Assessments
Penalty
Summary
The facility failed to ensure accurate and complete documentation in the medical records for six residents in relation to abuse incidents, resident assessments, and the safeguarding of resident-identifiable information. For one resident with end-stage renal disease and multiple comorbidities, there was no evidence that staff completed required assessments before or after dialysis treatments, despite care plan interventions and policy requirements. Interviews with nursing staff and the DON revealed that while some monitoring was claimed to occur, there was no documentation in the medical record to support that assessments, including fistula site checks, were performed as required. Several residents involved in physical altercations did not have any documentation in their medical records regarding these incidents, even though the facility had reported the events to the state agency. The DON confirmed the absence of documentation for these altercations in the clinical records of the affected residents. Additionally, for a resident who reported a missing ring and alleged misappropriation of property, there was no documentation of the incident or the allegation in the clinical record, nor was the missing item recorded on the resident's inventory sheet. Policy reviews indicated that the facility's procedures required documentation of all services, incidents, and changes in resident condition in the medical record, as well as specific protocols for documenting abuse, neglect, and misappropriation allegations. Despite these policies, the facility did not maintain complete and accurate records for the identified residents, as confirmed by staff interviews and record reviews.
Inconsistent Advance Directive Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that advance directives were accurately completed and consistently maintained in the clinical records of two residents. For one resident with multiple diagnoses including hypertension, hyperlipidemia, epilepsy, schizoaffective disorder, intracranial injury with loss of consciousness, and major depressive disorder, a physician’s order documented full code status. However, a pre-hospital medical care directive signed by the resident indicated that the resident did not want CPR and was DNR. Despite this, the face sheet and care plan both listed the resident as full code, while the care plan goal stated that the resident’s end-of-life wishes would be honored. For a second resident with extensive medical conditions including kyphosis, hypertension, Type 2 DM with neuropathy, spinal stenosis, atherosclerotic heart disease, vascular dementia, mood disturbance, GERD, hyperlipidemia, anxiety disorder, COPD, dysphagia, and major depressive disorder, both a VA Advance Directive and a pre-hospital medical care directive signed by the resident documented DNR status and refusal of CPR. In contrast, the face sheet, care plan, progress notes, and a physician’s order all identified this resident as full code. Staff interviews confirmed that advance directives are initiated on admission and reviewed quarterly, that staff are expected to check both physical and electronic charts for code status, and that a specific form is required to document changes with updates to the EHR by medical records. The DON confirmed that discrepancies existed in both residents’ records and acknowledged that this could result in residents’ end-of-life wishes not being honored, contrary to facility policy on advance directives.
Expired Medications in Storage and Unsecured Bedside Medications
Penalty
Summary
Surveyors found that the facility failed to store and manage medications according to professional standards and facility policy. During an observation of the central medication room, multiple expired medications were identified, including unopened boxes of Alfrin Allergy Sinus nasal spray with an expiration date of January 2025, Bisacodyl stimulant laxative with an expiration date of June 2025, and Vitamin E 180 mg (400 IU) with an expiration date of April 2025. In a separate medication room (Vistas South), twenty boxes of Flucelvax Trival 2024–2025 syringes were found in the medication refrigerator, all expired as of June 17, 2025. These medications remained in storage despite the facility’s written policy requiring that all expired, discontinued, or deteriorated medications be promptly removed from storage and handled per pharmacy instructions. Surveyors also identified a failure to ensure medications were not left at a resident’s bedside without an assessment and authorization for self-administration. One resident with alcohol dependence, major depressive disorder, anxiety disorder, GERD, COPD, type 2 diabetes, and hyperlipidemia had a BIMS score of 12, indicating moderate cognitive impairment, and was documented as alert and oriented times two. During observation, this resident was found sleeping with a small cup of medications (aripiprazole, hydroxyzine, and cholecalciferol) left on the bedside table. The LPN who administered the medications stated she believed the resident had taken them but concluded the resident must have pocketed them and later spit them out after she left. The clinical record contained no evidence that the resident had been assessed and determined able to self-administer medications, despite the facility’s policy that residents may self-administer only if the physician and interdisciplinary team determine they have the decision-making capacity to do so safely.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident with moderate cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, ate another resident's cookie during lunch. The second resident, who had severe cognitive impairment and a history of neurocognitive disorder with Lewy bodies, Parkinson's disease, and traumatic brain injury, responded by swinging at and hitting the first resident on the left ear. Staff intervened to separate the residents, and no physical injuries or pain were reported by the resident who was struck. Staff interviews confirmed that the incident involved both verbal and physical abuse, as the aggressor yelled, swore, and made unwanted physical contact. Facility policy defines abuse as the willful infliction of injury resulting in physical harm, pain, or mental anguish, and states that residents have the right to be free from abuse by anyone, including other residents. The incident was observed by staff, and the facility's policies regarding abuse prevention and resident rights were reviewed as part of the investigation.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical and sexual abuse, as well as neglect, as evidenced by several documented resident-to-resident altercations. In one incident, a resident with moderate cognitive impairment and a history of sexually inappropriate behavior was observed pushing a female resident with severe cognitive impairment against a wall and fondling her breasts in a common area. Staff and other residents reported that the female resident appeared frightened and expressed fear of the male resident, who had previously exhibited similar behaviors. Despite care plan interventions to prevent unsupervised contact, the incident occurred, and both residents were interviewed regarding the event. In other cases, residents with behavioral and cognitive impairments engaged in physical altercations resulting in injuries. For example, one resident struck another in the face multiple times in a dayroom altercation, with both residents having documented histories of aggression and care plans indicating the need for close monitoring and separation. Another incident involved a resident hitting a peer in the head over a dispute about a television remote, with witnesses and staff confirming the aggressive behavior. Additional altercations included a resident attacking a roommate, resulting in bleeding and emergency medical intervention, and another resident causing facial injuries to a peer who wandered into his room. The report details that in each of these cases, the facility's interventions, such as care plans for behavioral management and monitoring, were either insufficient or not effectively implemented to prevent abuse. Staff interviews confirmed awareness of the residents' behavioral risks and the definitions of abuse, but the incidents still occurred, indicating lapses in supervision and protection. Facility policies reviewed defined abuse broadly, including physical, sexual, and verbal abuse, and emphasized the right of residents to be free from such harm, yet the documented events demonstrate that these standards were not upheld in practice.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to a resident with severe cognitive impairment and a history of behavioral disturbances, including physical aggression. The resident, diagnosed with dementia, anxiety disorder, and major depressive disorder, had multiple care plans indicating a risk for psychosocial distress and physical aggression, with interventions such as one-on-one care and frequent observation. Despite these interventions, the resident was involved in several resident-to-resident altercations, as documented in the facility's incident log and progress notes. One incident involved the resident physically striking another resident in the dayroom after a dispute over seating. Clinical documentation and behavior charting assessments revealed ongoing agitation, aggression, and poor boundaries, with interventions such as redirection and, at times, 1:1 monitoring. However, the implementation of 1:1 monitoring was inconsistent, as not all assessments indicated this level of supervision. Staff interviews confirmed that one-on-one care was only consistently provided after repeated incidents of aggression. The facility's policy required measures to minimize the possibility of abuse and address problematic resident behavior, but the failure to provide consistent supervision led to preventable altercations.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with severe cognitive impairment from being physically abused by another resident, also with severe cognitive impairment. The incident took place in a dayroom where one resident, who had a history of agitation, aggression, and behavioral disturbances, told the other to move and then struck him in the right eye. The altercation was witnessed by an LPN, who intervened to separate the residents. The assaulted resident was found to have discoloration around the right eye, and during an interview, stated he was punched by someone he did not know for no reason. Prior to the incident, the resident who initiated the altercation had documented episodes of agitation, aggression, and other behavioral issues, with interventions such as emotional support and redirection being used. The care plan for this resident identified a risk for psychological and emotional distress following altercations, but the interventions in place did not prevent the physical abuse from occurring. Facility policies reviewed emphasized the right of residents to be free from abuse and the responsibility of staff to minimize the possibility of abuse, but these measures were not sufficient to prevent the incident.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a skin tear injury. One resident, with a history of dementia, major depressive disorder, and traumatic brain injury, was identified as having potential for physical and verbal aggression. This resident was involved in an altercation with his roommate, who had moderate cognitive impairment and multiple psychiatric and medical diagnoses. The incident occurred when the aggressive resident struck his roommate on the left hand, causing a skin tear, as the latter was attempting to leave their shared room. Clinical documentation and staff interviews confirmed that the altercation resulted in a physical injury. The injured resident reported the incident to an LPN, who observed the wound and questioned both residents. Both provided conflicting accounts, with the aggressive resident referencing delusional beliefs and claiming the other resident had provoked him. The LPN and administrator both noted that the explanations given by the residents were inconsistent and, at times, nonsensical, but it was clear that a physical altercation had taken place, resulting in injury. The facility's investigation into the incident was ultimately unsubstantiated due to the lack of witnesses and conflicting statements from those involved. However, documentation revealed that the aggressive resident had a prior history of altercations and of taking belongings from others. Facility policies reviewed during the investigation emphasized the right of residents to be free from abuse and the facility's commitment to preventing such incidents, but the event demonstrated a failure to ensure this protection.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident #44, who has a history of psychological emotional distress, was involved in an altercation with Resident #33. Resident #33, diagnosed with dementia and known for wandering and aggressive behavior, allegedly hit Resident #44, causing him to fall and sustain injuries. Despite interventions in place, such as monitoring and one-to-one supervision, these measures were not effectively implemented, leading to the incident. Another incident involved Resident #70, who has severe cognitive impairment and a history of aggressive behavior, hitting Resident #180 in the back of the head. This incident was witnessed by a CNA, who intervened to separate the residents. Both residents have a history of behavioral issues, and the facility's failure to provide adequate supervision and documentation of checks contributed to the occurrence of this altercation. The facility's policies on abuse prevention were not adequately followed, as evidenced by the lack of consistent monitoring and documentation of residents with known behavioral issues. Staff interviews revealed inconsistencies in the understanding and implementation of abuse prevention protocols, contributing to the facility's failure to ensure a safe environment for all residents.
Inadequate Supervision Leads to Resident Elopements
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of two residents, leading to a deficiency in ensuring a safe environment. Resident #13, who was admitted with diagnoses including dementia with agitation and epilepsy, was identified as an elopement risk due to a history of elopements and wandering behavior. Despite this, the resident managed to leave the facility undetected on January 5, 2025. The resident was last seen walking in the hallway, and shortly after, staff realized he was missing. The facility was searched, and the police were called. The resident was found and returned to the facility later that morning. Observations revealed that the door to the Kiva unit could be reopened without re-entering a keycode, which was identified as a potential concern for elopement. Resident #22, admitted with dementia and severe cognitive impairment, was also able to elope from the facility. Although initially assessed as not at risk for elopement, the resident's care plan indicated disorientation and impaired safety awareness. On January 8, 2025, the resident was last seen in the courtyard and was later found missing. A search was conducted, and the police were notified. The resident was eventually found by a passerby and returned to the facility by the police. Interviews with staff revealed that the resident may have followed someone out of the facility, as the unit required a physical key for entry and exit. Interviews with staff and maintenance personnel highlighted issues with door functionality and staffing levels. Staff reported that doors did not always lock properly, and maintenance records showed frequent work orders for door repairs. Additionally, staff expressed concerns about inadequate staffing levels, which may have contributed to the inability to monitor residents effectively. The facility's policy on wandering and elopements was reviewed, indicating a commitment to identifying at-risk residents and preventing harm, but the incidents demonstrated a failure to implement effective measures to prevent elopement.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to administer medications within the required timeframe to six residents, which could result in symptoms not being managed effectively and/or adverse effects. Observations revealed that medications scheduled for 8:00 a.m. were administered late to several residents. For instance, Resident #66, who has severe cognitive impairment and multiple diagnoses including Parkinson's disease, received their 8:00 a.m. medications at 9:36 a.m. Similarly, Resident #55, with severe cognitive impairment and conditions such as hypertension and Parkinson's disease, received their medications at approximately 10:07 a.m. Resident #12, with mild cognitive impairment and a history of major depression and transient ischemic attack, was observed receiving their 8:00 a.m. medications at 10:36 a.m. This included a medication that needed to be administered before meals, which was given after breakfast. Resident #2, who is cognitively intact and has a history of venous thrombosis and type II diabetes, received their medications at 10:45 a.m. Additionally, staff was observed administering medications to Resident #15 at 10:55 a.m. Resident #25, with severe cognitive impairment and multiple diagnoses including congestive heart failure and COPD, received their 8:00 a.m. medications at 11:21 a.m. The RN initially withheld blood pressure medication due to a low reading taken at 7:15 a.m., but upon rechecking, the blood pressure was within normal limits. Interviews with staff revealed that medications are supposed to be administered within one hour of the scheduled time, but this was not adhered to, leading to delays in medication administration.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to prevent an incident of resident-to-resident abuse involving two residents with severe cognitive impairments. Resident #26, who has a history of aggressive behaviors and severe cognitive impairment, was involved in an altercation with Resident #32. On the day of the incident, Resident #26 was agitated and aggressive, and despite being on a one-to-one supervision, managed to hit Resident #32 in the face. The incident occurred in the dayroom during medication administration, and staff intervened by separating the residents and redirecting them. Resident #32, who also has severe cognitive impairment and a history of physical aggression, was unable to recount the incident but indicated discomfort by placing a nurse's hand over his eye/head area. An assessment showed no apparent injury. Interviews with staff revealed that Resident #26 was known for being fast and aggressive, and the CNA responsible for her supervision did not see Resident #32 approaching. The facility's policy emphasizes the residents' right to be free from abuse, yet the incident highlights a failure in ensuring this protection.
Resident Elopement Due to Door Malfunction
Penalty
Summary
The facility failed to prevent the elopement of a resident identified as an elopement risk due to their medical conditions, including schizophrenia and vascular dementia. The resident, who had a history of attempting to leave the unit by trying different codes on the keypad and setting off alarms, successfully eloped from the facility. The care plan for the resident included interventions such as conducting Wanderguard safety checks and ensuring door alarms were functioning properly. However, on the day of the incident, the exit door malfunctioned, allowing the resident to leave the facility undetected until they were found outside and redirected back. Interviews with staff revealed that the door where the resident exited had previously required electrical wiring replacement, but there was no documentation to confirm when this maintenance occurred. The facility's policy required staff to ensure doors were secured and to account for residents at the beginning of each shift. Despite these measures, the resident was able to elope, indicating a failure in the facility's supervision and maintenance of safety measures. The incident highlights the need for consistent monitoring and maintenance of security systems to prevent such occurrences.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent abuse between two residents, leading to an altercation. Resident #3, who has a history of PTSD and anxiety, was involved in a physical altercation with Resident #4, who has anxiety disorder and other medical conditions. The incident occurred in the dayroom where Resident #3 was found with a bloody thumb after being yelled at by Resident #4. Later, Resident #3 reported being hit and kicked by Resident #4 in his room, resulting in an abrasion on his thumb. Resident #4, who was observed yelling and attempting to approach Resident #3, was described as aggressive and not easily redirectable. Despite staff intervention, Resident #4 continued to exhibit aggressive behavior, leading to the involvement of emergency services. Staff interviews revealed that the altercation was not an isolated incident, as similar conflicts had occurred previously. The staff's response included separating the residents and conducting frequent checks, but the supervision was insufficient to prevent the altercation. The facility's policy on abuse prevention emphasizes protecting residents from abuse by others, including fellow residents. However, the supervision and monitoring practices, as described by the Director of Nursing, were inadequate in this case. The facility relied on surveillance cameras and staff monitoring, but the lack of cameras in certain units and insufficient staff presence contributed to the failure to prevent the altercation between the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of psychotropic medications prior to administration. This deficiency was identified through a review of clinical records, staff interviews, and facility policy. The resident in question was admitted with several diagnoses, including cerebrovascular accident, aphasia, non-Alzheimer's dementia, and hemiplegia. The care plan indicated the use of psychotropic medications for conditions such as schizoaffective disorder and bipolar disorder with hallucinations. However, the facility did not provide evidence that the resident or their representative was informed about the psychotropic medications' risks and benefits. The resident's clinical records showed multiple psychotropic medications being administered over several months, including Rexulti, hydroxyzine, sertraline, and trazodone. Despite the administration of these medications, the facility did not have updated consents for the medications after the resident's admission. The Director of Nursing (DON) revealed that the consents on file were dated before the resident's admission and were transferred from a sister facility. The facility's policy requires that residents and/or their representatives be informed and participate in care planning and treatment, which was not adhered to in this case. Interviews with staff, including an LPN and the DON, confirmed that the facility relied on consents from a sister facility without obtaining new consents upon the resident's admission. The facility's policy on psychotropic medication use emphasizes the right of residents and/or their representatives to decline treatment, highlighting the importance of informed consent. The lack of updated consents and failure to inform the resident or their representative of the medication risks and benefits constitutes a deficiency in the facility's compliance with resident rights and informed consent policies.
Failure to Complete Level 2 PASRR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The resident had a Pre-Admission Screening and Resident Review (PASRR) level one completed at an outside hospital, but the referral determination section was left blank. Upon admission to the facility, the resident had diagnoses including schizoaffective disorder, anxiety disorder, type 2 diabetes mellitus, and bipolar disorder. Despite these diagnoses, a level 2 PASRR referral was not completed, which is necessary for residents with such mental health conditions. The resident's care plan included the use of psychotropic, anti-anxiety, and antidepressant medications, with interventions to monitor for side effects and effectiveness. The resident's medication administration record showed various medications administered for conditions like depression, bipolar disorder, and schizophrenia. Despite these interventions, the facility did not complete the required level 2 PASRR referral, which could have ensured the resident received necessary specialized services. Interviews with facility staff, including the social service director and the administrator, revealed that the level 2 PASRR referral was overlooked. The social service director acknowledged the need for a level 2 PASRR due to the resident's mental health diagnoses. The administrator and DON confirmed that the hospital completed the initial PASRR, but the facility did not have a physical copy of the level 2 PASRR and had not followed up adequately with the Arizona Long Term Care System (ALTCS) to ensure its completion.
Resident Elopement Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with amyotrophic lateral sclerosis, dementia with psychosis, and depressive disorder, leading to the resident wandering away and becoming lost in the community. Despite exhibiting wandering and elopement behaviors on multiple occasions, the resident's elopement risk evaluation indicated no risk for elopement, and the care plan did not address these behaviors. The resident's behavior monitoring and intervention notes consistently documented wandering and elopement behaviors, yet no interventions were implemented to address these issues. On September 9, 2024, the resident was found missing from their room, having exited through a window that lacked an alarm. The resident was later located by police officers a block from the facility, having sustained minor injuries from a fall while attempting to enter a moving vehicle. Interviews with staff revealed that the resident had expressed a desire to leave the facility and had been restless and pacing prior to the incident. Staff also noted that the window in the resident's room was easy to open, contributing to the resident's ability to leave the facility undetected. The facility's policy on wandering and elopements, revised in March 2019, stated that residents at risk for unsafe wandering should have care plans with strategies and interventions to maintain safety. However, the director of nursing acknowledged that the resident was not care planned for wandering behaviors, and the facility relied on an initial assessment that inaccurately indicated no risk for elopement. This oversight in care planning and risk assessment contributed to the resident's ability to wander away from the facility, resulting in the incident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, specifically sexual abuse, by other residents. Resident #40, who had severe cognitive impairment and a history of wandering, was inappropriately touched by another resident, #49, who had a history of sexually inappropriate behavior. Despite previous incidents, there was no evidence of new interventions to address resident #49's behavior, and the incident was not reported to the state agency or police. The facility's Director of Nursing (DON) and Administrator were aware of the incident but did not take appropriate action, citing the cognitive status of resident #40 as a reason for not considering it abuse. Additionally, the facility failed to protect residents #25 and #5 from abuse by resident #6. Resident #25, with severe cognitive impairment and a history of aggressive behavior, was involved in an altercation with resident #6, who also had severe cognitive impairment and a history of physical aggression. The facility's staff, including CNAs and LPNs, reported difficulties in managing these behaviors due to insufficient staffing, which hindered their ability to monitor and redirect residents effectively. The facility's policies on abuse and neglect were not adequately implemented, as evidenced by the lack of timely reporting and intervention in these incidents. Interviews with staff revealed a lack of awareness and training on handling such situations, and the facility's leadership did not prioritize the safety and protection of residents. The facility's assessment claimed it could provide the necessary supervision and care, but the incidents demonstrated a failure to meet these standards.
Failure to Report Abuse and Inappropriate Behavior
Penalty
Summary
The facility failed to report allegations of abuse involving three residents to the State Agency, Adult Protective Services, and local law enforcement. Resident #40, who has Alzheimer's disease and dementia, was inappropriately touched by another resident, #49, who has vascular dementia and a history of sexual inappropriateness. Despite documentation of the incident, it was not reported to the appropriate authorities. The Director of Nursing (DON) and the Administrator were unaware of the incident initially, and the DON later stated that the behavior was not considered abuse due to the cognitive status of Resident #40. Resident #25, diagnosed with vascular dementia and severe cognitive impairment, was involved in incidents where he was found naked in another resident's room and touching a sleeping female resident. These incidents were not reported to the State Agency, APS, or law enforcement. The DON acknowledged a disconnect in staff reporting and mentioned ongoing training to address the issue. The facility's policy requires all reports of abuse, neglect, or exploitation to be reported to local, state, and federal agencies, but this was not followed. The facility's staff, including the DON and Administrator, were not consistently notified of reportable events, leading to a failure in reporting. Interviews with staff revealed confusion about what constitutes a reportable event, with some staff believing that behaviors considered baseline did not need to be reported. The facility's assessment indicated they could provide the necessary supervision and care, but the incidents suggest otherwise. The lack of reporting and proper documentation of these incidents highlights a significant deficiency in the facility's handling of resident safety and abuse prevention.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse involving residents. In one instance, a certified nurse assistant (CNA) found a resident cornered outside with another resident who touched her inappropriately. Although the CNA intervened and initiated 15-minute checks, there was no evidence of a comprehensive investigation, including interviews with other residents, staff, or witnesses, nor was there documentation of reporting the incident to appropriate agencies or conclusions drawn from the investigation. Another incident involved a resident found naked in another resident's room and touching a sleeping female's thighs. Despite the severity of the situation, there was no evidence of a thorough investigation, including observations, interviews, or reporting to appropriate agencies. The Director of Nursing (DON) acknowledged a disconnect with staff regarding the reporting of such incidents and noted that training was being conducted to address this issue. The facility's policy on abuse, neglect, exploitation, and misappropriation outlines specific steps for conducting investigations, including reviewing documentation, interviewing involved parties, and documenting the investigation thoroughly. However, these procedures were not followed in the reported incidents, leading to a deficiency in ensuring the safety and rights of the residents involved.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure sufficient staffing to provide adequate supervision for residents, leading to incidents involving inappropriate behavior between residents. Resident #40, diagnosed with Alzheimer's disease and dementia, was found in a situation where another resident, #49, touched her inappropriately. This incident was documented on August 28, 2024, and resulted in the initiation of 15-minute checks and notification of the power of attorney, director of nursing, and physician. Resident #49, with a history of vascular dementia and behavioral disturbances, had previous incidents of inappropriate behavior, including an event on August 8, 2024, where he was reported to have fondled Resident #40. The facility's staffing schedule revealed a shortage of CNAs, with only 12 CNAs on the day and night shifts, and 16 on the evening shift, despite the facility's assessment indicating a need for 56 CNAs daily. Interviews with staff, including CNAs and LPNs, highlighted concerns about insufficient staffing levels, which hindered their ability to monitor residents effectively and provide timely care. Staff reported difficulties in preventing falls, providing activities of daily living, and monitoring residents' behaviors due to the reduced staff-to-resident ratio. The director of nursing and the administrator acknowledged the staffing challenges but indicated that staffing decisions were based on daily assessments of residents' behaviors and needs, which were not documented. The staffing coordinator admitted to not reviewing clinical records to determine staffing needs and relied on staff reports. The administrator expressed a belief that the facility provided adequate supervision, despite acknowledging the responsibility to protect residents. The lack of sufficient staff was linked to increased risks of neglect, falls, and vulnerability to inappropriate acts among residents.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #650, who was cognitively intact with a BIMS score of 13, was involved in an altercation with Resident #625, who had severe cognitive impairment with a BIMS score of 4. The incident occurred in the day room when Resident #650 told Resident #625 to "shut up," which led to Resident #625 becoming angry and physically attacking Resident #650. The altercation was broken up by a nurse, and Resident #625 then turned his aggression towards the nurse, threatening and spitting. Resident #650 had been transferred to the facility following an altercation and had a care plan indicating a risk for psychosocial emotional distress related to resident-to-resident altercations. Despite this, the facility did not prevent the altercation from occurring. Resident #625 had a history of verbal aggression and psychotic thinking, as noted in his care plan, and had been reported as irritable and short-tempered prior to the incident. However, no physical aggression had been observed before the altercation with Resident #650. The facility's investigation confirmed the altercation and noted that Resident #625 was triggered by Resident #650's comment. Witness statements corroborated the sequence of events, and the facility's policy on abuse prevention was not effectively implemented to prevent the incident. Interviews with staff indicated that the protocol for handling such altercations involved separating the residents and reporting the incident, but the deficiency lay in the failure to prevent the altercation from occurring in the first place.
Inconsistent PPE Use During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control standards, particularly in the use of Personal Protective Equipment (PPE), during a COVID-19 outbreak. Observations revealed that staff, including the concierge at the front desk, were not consistently wearing masks despite the presence of signs indicating a COVID-19 outbreak and the requirement for all staff to wear CDC-recommended PPE, including N95 masks. The concierge admitted to forgetting to wear a mask and was not accustomed to wearing one anymore. Additionally, individuals in the reception area and hallway were observed not wearing masks, and the Director of Nursing (DON) and Administrator removed their masks during a conference. Interviews with staff, including CNAs and the Infection Preventionist (IP), highlighted inconsistencies in the implementation of infection control protocols. Staff were aware of the outbreak and the requirement to wear masks upon entering the facility, yet there was confusion about the enforcement of these protocols, particularly in shared spaces with another company operating in the same building. The IP noted that the receptionist, who was not their employee, was expected to wear a mask and educate visitors, but enforcement was challenging. The DON acknowledged the importance of following protocols to prevent the spread of infection but noted that it was up to guests to comply with PPE requirements. The facility's infection control policy, dated October 2018, aimed to maintain a safe and sanitary environment to prevent disease transmission. However, the report indicates a lack of consistent adherence to these policies, particularly in the shared entry areas and among staff not directly employed by the facility. The report does not mention any corrective actions or follow-up measures taken to address these deficiencies.
Failure to Protect Residents from Abuse and Assess Consent Capacity
Penalty
Summary
The facility failed to protect the rights of residents to be free from abuse, resulting in a condition of Immediate Jeopardy and Substandard Quality of Care. Resident #23, who had a history of schizoaffective disorder, bipolar type, dementia, and anxiety disorder, reported allegations of sexual abuse by a certified nurse assistant (CNA). Despite the resident's moderate cognitive impairment and history of behavioral issues, the allegations were not reported to the State Agency or addressed by management. Interviews revealed that the resident had made multiple allegations of inappropriate touching by the CNA, which were not taken seriously by the facility's staff, including the Director of Nursing (DON), who failed to report the incident. Resident #3, diagnosed with generalized anxiety disorder, major depressive disorder, and Parkinson's disease, was found with bruises and scratches allegedly caused by rough handling by the same CNA. The incident was reported by other CNAs, but management did not take appropriate action. The DON did not consider the event reportable, attributing the injuries to the resident's agitation and history of swinging arms. The facility's failure to investigate and report the incident properly contributed to the deficiency. Additionally, the facility did not assess the ability of residents #45 and #9 to consent to a sexual relationship, despite incidents of inappropriate behavior between them. Both residents had severe cognitive impairments, and the facility lacked documentation of any assessment regarding their capacity to consent. The DON acknowledged the incident but failed to document or report it appropriately. The facility's policies on abuse prevention and reporting were not followed, leading to the identified deficiencies.
Failure to Report Allegations of Abuse and Inappropriate Incidents
Penalty
Summary
The facility failed to report allegations of abuse to the State Agency, Adult Protective Services, and local law enforcement for three residents. Resident #23, who had moderate cognitive impairment, reported allegations of sexual abuse by a certified nurse assistant (CNA). Despite the resident's claims and the involvement of multiple staff members who were aware of the allegations, there was no evidence that the incident was reported to the appropriate authorities. Interviews with staff revealed inconsistencies in the handling of the allegations, with some staff dismissing the claims as false due to the resident's history of behavioral issues. Resident #3, who had severe cognitive impairment, was found with bruises and scratches, reportedly caused by rough handling by a CNA. Witnesses reported seeing the CNA push a table against the resident, yet the incident was not reported to the necessary agencies. The Director of Nursing (DON) did not consider the event reportable, attributing the injuries to the resident's agitation and behavior, despite staff reports suggesting otherwise. Residents #45 and #9, both with severe cognitive impairments, were involved in an incident of physical touching that was not reported. The DON stated that an assessment of the residents' ability to consent to a sexual relationship was conducted, but no documentation was found. The facility's policy requires reporting such incidents, but the DON did not report the incident to the State Agency or police, citing the need for an investigation to ensure resident safety.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving multiple residents, leading to a deficiency in ensuring resident safety. Resident #23, who has schizoaffective disorder, bipolar type, dementia, and anxiety disorder, reported allegations of sexual abuse by a CNA. Despite the resident's moderate cognitive impairment and history of false accusations, the facility did not report the allegations to local agencies or conduct a comprehensive investigation. Interviews with staff revealed inconsistencies in the handling of the allegations, and the alleged CNA continued to work in proximity to the resident without any protective measures in place. Resident #3, with severe cognitive impairment due to generalized anxiety disorder, major depressive disorder, and Parkinson's disease, was found with bruises and scratches. The incident was reportedly caused by rough handling by a CNA, but the facility did not report the incident to appropriate authorities or conduct a thorough investigation. The DON did not consider the event reportable, attributing the injuries to the resident's agitation and behavior, despite witness accounts of the CNA's actions. Additionally, an incident involving residents #45 and #9, both with severe cognitive impairments, was not properly investigated. The residents were found engaging in sexual acts, but there was no documentation of their ability to consent. The facility's policy requires thorough investigation and reporting of such incidents, but this was not adhered to, leaving the residents unprotected and the incidents unaddressed.
Failure to Notify Family of Resident Injury
Penalty
Summary
The facility failed to notify a resident's representative of an injury sustained by the resident, which is a violation of their policy. The resident, who had a history of dementia, hypertension, type 2 diabetes mellitus, and other conditions, sustained an injury to his left lower leg on March 19, 2024. Despite the facility's policy requiring notification of the resident's family in such events, there was no documentation in the electronic health record indicating that the family had been informed. Interviews with staff members revealed a lack of clarity and adherence to the notification policy, with one LPN unsure if the injury required family notification and unable to recall if such notification had occurred. The Director of Nursing confirmed that the expectation was for family notification to be documented, but upon review, no evidence of such documentation was found. The facility's policy on accidents and incidents mandates prompt investigation and documentation, including family notification, but this was not followed in the case of the resident's injury. The failure to notify the family could result in them being unaware of the resident's condition, as well as other staff being uninformed about whether the notification had occurred.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in two incidents of physical altercations. The first incident occurred when a resident with dementia, PTSD, and adjustment disorder was slapped by another resident with dementia, PTSD, and major depressive disorder. The staff conducted a skin assessment on the victim and found no injuries. Despite the incident, no changes were made to the care plans of either resident, and they continued to reside in the same unit. A second incident occurred when the same aggressive resident hit the victim again, causing a superficial scratch. This time, a psychological evaluation was ordered, and the aggressive resident was moved to another unit. However, the care plan for the aggressive resident was only updated later to include triggers for their behavior, such as loud noises or shouting. Interviews with staff revealed a lack of clarity and prompt action in updating care plans and separating the residents after the first incident.
Latest citations in Arizona
Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
Two residents with known behavioral issues and cognitive/neurologic conditions were involved in a patio altercation where one resident struck another on the head after a verbal interaction and dispute over a book. Care plans for both residents already identified behavioral disturbances, including verbal and physical aggression, and outlined interventions such as providing a calm environment, diverting attention, and intervening to protect others. Despite these plans and prior documented episodes of verbal aggression and a previous physical altercation involving one of the residents, staff‑witness accounts and later review of video footage confirmed that one resident approached and hit another on the head, causing the victim to report pain and fear, demonstrating a failure to protect residents from physical abuse.
A resident with multiple comorbidities, intact cognition, and a care plan requiring two-person assistance for toileting repeatedly requested help for a brief change using the call light and by wheeling to the nurses’ station. A CNA, who had documented training on professional language and abuse prevention, allegedly failed to respond to the call light, refused to assist because a second staff member was not available, and used profanity toward the resident in the context of the resident’s complaints about delayed care, causing the resident to cry and feel unsafe. Another staff member reported seeing the CNA on her phone while call lights were on, hearing the profane statement directed at the resident, and later comforting the resident, while additional staff confirmed the resident’s report that the CNA was rude and blamed her for not receiving care. The facility’s abuse policy defined mental and verbal abuse to include profane, insulting, or degrading language and depriving a resident of care, which aligned with the described interaction.
A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with hemiplegia, psychiatric diagnoses, and dependence on staff for ADLs required assistance with toileting hygiene and bathing per the care plan and MDS, which documented bilateral extremity impairment and wheelchair use. CNA task logs for bowel/bladder and toilet use contained multiple blank shifts, leaving it unclear whether toileting and hygiene care was provided or refused, despite the EHR having specific codes for refusals and unavailability. Behavior and NP notes described the resident’s verbal aggression, sexually inappropriate comments, resistance to care, shower refusals, and repeated complaints that peri care was inadequate, while a nurse documented finding the peri area clean after one such complaint. A CNA and an LPN both stated that blank entries likely reflected a failure to chart and that all ADL care should be documented, consistent with facility policies requiring provision and documentation of ADL services. Surveyors concluded that the facility failed to ensure and document necessary ADL care, specifically toileting hygiene, for this resident.
A resident with spinal conditions, a history of lumbar compression fracture, and documented ADL self-care deficits was care planned and Kardexed for two-person maximum assist transfers for bathing and wheelchair transfers. Despite this, a CNA transferred the resident alone multiple times between a recliner, wheelchair, and shower chair using only a gait belt, during which the resident reported the CNA was rough, fast, and caused pain. An LPN received the resident’s complaint that the CNA was not caring and was the only staff present, while another CNA and a regional clinical specialist confirmed that the Kardex required two-person assist and that the CNA had performed the transfers without assistance, in violation of the plan of care and facility expectations.
Two residents with known behavioral issues, one with severe cognitive impairment and one cognitively intact, were involved in a resident-to-resident physical altercation. A resident with a history of behavioral problems, including prior physical altercations, entered another resident’s room and allegedly punched him multiple times in the face and twisted his arm, resulting in a black eye, skin tears, bruising, and minor cuts. Staff later observed the injured resident approaching the nurses’ station with these injuries, and leadership confirmed via camera review that the aggressor had entered the victim’s room and that a physical altercation occurred, despite an existing abuse policy intended to protect residents from abuse.
The facility failed to prevent resident-to-resident verbal and physical abuse involving two separate pairs of residents with known psychiatric and behavioral issues. In one case, a cognitively intact resident with a history of agitation and verbal aggression insulted another cognitively intact resident with schizoaffective disorder and intermittent explosive disorder during dinner; after repeated verbal exchanges, the second resident stood up, shoved the table, and punched the first resident in the eye, resulting in an orbital fracture and retrobulbar hemorrhage. In another case, a resident with schizophrenia, bipolar disorder, and documented verbal aggression argued over a soda with a peer who had borderline personality disorder and a care plan for bullying and physical aggression; the argument escalated from name-calling to one resident standing and swinging at the other, with the alleged victim later reporting facial and chin pain despite no visible injury on assessment. In both incidents, residents with identified behavior risks and existing behavior plans engaged in escalating verbal conflicts in common areas that were not effectively de-escalated before they became physical or attempted physical assaults.
Multiple residents with dementia and other psychiatric conditions physically abused other residents in common areas and on an outside ramp when staff supervision was inadequate. In one case, a resident with schizoaffective disorder and a known history of verbal and physical aggression, already agitated over smoking restrictions and having threatened and struck staff, was allowed to remain in a common area and struck another resident on the shoulder. In another incident, a resident with dementia and documented combative behavior picked up a folded tray table and hit a non-verbal resident who was seated nearby, while scheduled CNAs and an LPN later reported they did not witness the event and trainees described the assault. In a third event, a resident with violent behavior blocked a narrow ramp and pushed another resident’s wheelchair backward using his hands and feet, causing the wheelchair to flip and the resident to fall and hit his head, with the incident observed and reported by housekeeping rather than direct care staff. These events reflect failures to provide continuous observation and to prevent resident-to-resident physical abuse despite known behavioral risks.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a notice of discharge to the State Ombudsman for one resident. Resident #59 was admitted with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension, and the hospital discharge summary showed the resident was transferred to the facility for therapy services. The discharge planning and discharge progress notes dated 2/15/2026 documented that the resident arrived with family, and the family expressed concern that the assigned room did not have adequate space for the resident's belongings. The same documentation showed the family elected to take the resident home against medical advice, and the electronic medical record, including the AMA Release Form dated 2/15/2026, showed the resident was discharged home with the responsible party. During record review, the Administrator was asked to provide documentation of discharge notices sent to the Ombudsman for the prior 6 months. The Administrator documented that the Ombudsman did not require the facility to send discharge notices directly to her, while also acknowledging that discharge notices had not been sent and that the facility would send notices for discharged residents moving forward. The Ombudsman stated she had periodically received discharge notices in the past but had not received discharge notices from the facility after 12/4/2026, and confirmed the facility is required to provide discharge notices per regulation.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. One resident had multiple diagnoses including cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment, with a BIMS score indicating severe cognitive impairment. This resident had care plans addressing impaired cognitive function and behavioral disturbances, including verbal and physical abuse, with interventions such as providing a calm environment, diverting attention, and intervening as necessary to protect the rights and safety of others. Despite these identified needs and planned interventions, this resident was involved in a resident‑to‑resident altercation on the patio in which another resident struck him on the head after a verbal interaction. The second resident involved had diagnoses including metabolic encephalopathy and pain, and a care plan for behavioral disturbances such as refusal of care, refusal of medication, and verbal and physical abuse. This care plan also included interventions to document behaviors, reinforce why inappropriate behavior is unacceptable, and intervene as necessary to protect the rights and safety of others, including removing the resident from situations as needed. Prior to the incident on the patio, this resident had a documented history of involvement in a physical altercation with another resident, where he was described as the non‑aggressor, and had ongoing behavioral charting for verbal aggression and argumentative behavior. Behavior notes documented episodes of verbal aggression, cursing at staff, and yelling related to environmental changes. On the date of the incident leading to the deficiency, an internal incident report documented that the second resident slapped the first resident on the back of the head on the patio after a verbal confrontation. Witness accounts varied: the activities assistant reported hearing a loud slapping sound and seeing the second resident standing, then intervening, while another resident witness stated she saw the second resident hit the first resident on the head with a book because of a dispute over ownership of the book, and that there had been no argument beforehand. The DON reported that camera footage showed the two residents conversing about three feet apart on the smoking patio, then the second resident wheeled up to the first resident and hit him on the head, which the DON characterized as physical abuse. The administrator also acknowledged that video footage showed the second resident tapping the first resident’s head. The first resident later indicated he was in pain afterward and felt scared. These events occurred despite existing behavior care plans and interventions intended to prevent such incidents, resulting in a failure to ensure residents were free from physical abuse by another resident.
Verbal Abuse and Failure to Respond to Resident’s Request for Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by a CNA. The resident, who had type 2 diabetes mellitus with foot ulcers, absence of the left foot, morbid obesity, and a mood disorder, was care planned for ADL self-care deficits and required maximum assistance for toileting and two-person dependent assistance with transfers. A quarterly MDS showed the resident had a BIMS score of 14, indicating intact cognition, and required substantial assistance for toilet transfers. On the morning in question, an event note documented that the resident was wheeling herself in her wheelchair in the hallway to the nurses’ station to request assistance with a brief change when a CNA seated at the nurses’ station heard her, turned around, and made an inappropriate comment, after which the resident began crying. The facility’s investigation materials described differing accounts of the interaction but consistently referenced the use of profanity by the CNA in the context of the resident’s request for care. The resident reported that she had not received care that morning, had urinated on herself, and had activated her call light, but the CNA would not answer it. The resident stated that when she told the CNA she was going to notify someone about the lack of assistance, the CNA became angry, stood up, and told her, “it’s your fucking fault,” which made her cry and feel unsafe. A staff member (Staff #118) provided a written statement and interview indicating that around 5:15 a.m. he observed multiple call lights on, including the resident’s, and saw the CNA sitting at the nurses’ station on her phone. He stated that the resident came out of her room begging for help with a brief change, that the CNA refused because she did not have a second person to assist, and that at one point the CNA told the resident, “it was [the] resident’s fucking fault,” after which the resident went back to her room crying. The CNA involved had documented training on professional language and on abuse, neglect, exploitation, resident rights, respect in the workplace, and prevention of abuse, including mental and verbal abuse. Her written statement acknowledged that the resident’s call light had been on since about 4:00 a.m. and that the resident later came out of her room angry about the wait; she claimed she agreed with the resident and went downstairs to get another CNA, and admitted she may have used the term “fuck” but denied directing it at the resident. Another CNA (Staff #24) stated that the resident was on “cares in pairs” because she accused staff of not helping her, that the resident used her call light frequently and wanted care immediately, and that delays could occur due to the need for two staff, though communication about delays could ease the situation. A staff member (Staff #38) reported that the resident later said she had a rough morning because she needed help and the CNA was rude and blamed her for not getting care due to the “cares in pairs.” The facility’s abuse policy defined mental and verbal abuse as conduct, including the use of profanity, that can cause humiliation, intimidation, fear, shame, agitation, or degradation, and included mocking, insulting, ridiculing, and threatening residents, including depriving a resident of care, as examples of mental and verbal abuse. The facility’s documentation also showed that the CNA had signed an education acknowledgment form stating she was trained to use professional language and that profanity was prohibited at work. The investigation report and staff interviews consistently placed the resident in a position of repeatedly requesting assistance for incontinence care, with her call light on and her coming into the hallway to seek help, while the CNA did not provide the requested care and used or was alleged to have used profanity in response to the resident’s complaints. The DON acknowledged receiving a report that the CNA was not helping the resident and had sworn at her, and stated that verbal abuse of residents can affect a resident’s psychological well-being. The combination of the resident’s report, corroborating staff statements, and the facility’s own policy definitions formed the basis for the finding that the resident was not kept free from verbal abuse.
Failure to Follow Physician-Ordered Cut-Up Diet Leads to Fatal Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered diet specifying that a resident’s food be cut into bite-sized pieces, and to ensure that this requirement was consistently communicated and implemented by nursing and dietary staff. Resident #9 had multiple diagnoses including heart failure, chronic atrial fibrillation, chronic kidney disease, and moderate vascular dementia with anxiety. A physician order dated December 23, 2024, prescribed a regular diet with regular texture, thin liquids, and explicitly directed that food be cut into bite-sized pieces with large protein portions. The facility’s nutrition care plan initiated on December 30, 2024, referenced the regular diet with large protein portions but did not include the requirement to cut food into bite-sized pieces. The cognition and ADL care plans addressed cognitive impairment and self-care deficits but did not incorporate the ordered cut-up diet or any specific swallowing precautions, despite the resident’s cognitive impairment and upper extremity limitations documented on the MDS. The dietary management and electronic systems in use contained the cut-up order, but this information was not reliably translated into practice. The Menu Wizard tray card history, as reviewed by the senior menu specialist, showed a diet order of regular, regular, thin liquids with notes to cut food into bite-sized pieces and provide large protein portions, and this instruction had been in place since December 23, 2024. The dietary manager stated that dietary staff are responsible for cutting food and that bite-sized pieces would include items like burritos, with food expected to arrive on the unit already cut. However, he also indicated he could not retrieve prior diet slips after discharge and relied on nursing to relay changes. The DON asserted that the “cut into bite-sized pieces” language was a preference rather than part of the actual diet order and stated that only the basic diet components (regular texture, thin liquids) transfer to the kitchen, while additional information such as cutting food does not cross over. In contrast, the prescribing physician confirmed that he ordered regular food, thin liquids, cut into bite-sized pieces, and large protein portions as a single diet order and expected the entire order, including cutting food into bite-sized pieces, to be followed. On the day of the choking event, breakfast trays were delivered to Resident #9’s room, and the resident was served an egg burrito, oatmeal, and cranberry juice. CNA staff reported that the burrito was cut in half but not further cut into bite-sized pieces, and CNA #6 stated she did not know the resident’s diet, did not recall reviewing the meal ticket, and believed his meals did not need to be cut up. She also stated she was unaware of any special instructions to cut the resident’s food into bite-sized pieces and that she typically relied on dietary and nursing to communicate such needs. Multiple CNAs and the charge nurse indicated they were not aware of any formal special diet instructions beyond a regular diet, although the charge nurse acknowledged knowing the family’s preference for cut-up food and finger foods and that dietary did not always cut up his meals, requiring nursing to do so. The resident’s family member reported repeated concerns to the dietary manager, charge nurse, DON, and CNAs about the resident’s food not being cut up, and stated that both she and a hired companion frequently found his meals served uncut despite his upper extremity weakness and motor decline. Later that morning, an LPN who had just started her shift and was not familiar with the resident found him in bed with his breakfast tray in front of him, food apparently eaten, and “mushy” food around and in his mouth. The resident appeared to be sleeping, did not respond to his name, and was grunting and moaning with snoring-type respirations. The LPN manually removed food from his mouth and began suctioning, and the charge nurse arrived with a suction machine and a LifeVac device. Staff observed egg on the resident’s chest and in his mouth, and suctioning removed egg and mucus secretions. EMS was called, and the resident was transported to the hospital. Hospital emergency department documentation recorded that the resident had been eating eggs, was later found choking and unresponsive, and presented with aspiration into the airway and respiratory failure with hypoxia and hypercapnia. The resident was documented as DNR/DNI and was ultimately pronounced deceased. The survey findings attribute this event to the facility’s failure to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and implemented by staff. The report also notes that for Resident #9 there were no active orders for PT/OT/ST evaluation or treatment on the Order Summary Report despite a NP/PA progress note planning for such services, and that the SLP evaluation focused on cognition and compensatory strategies rather than swallowing, with no active speech therapy orders in the diet context. Staff interviews revealed inconsistent understanding of the resident’s diet requirements, with some staff describing cut-up food and finger foods as a preference rather than an order, and others stating they had no knowledge of any special diet instructions. The grievance logs contained no formal grievances from the family member despite her statements that she had repeatedly complained about meals not being cut up and about the resident not being taken to the dining room as he preferred. Collectively, these documented actions and inactions show that the facility did not ensure the physician-ordered diet specifying cut-up, bite-sized food was integrated into the care plan, reliably communicated to dietary and direct care staff, or consistently implemented at the bedside for Resident #9, culminating in a choking and aspiration event requiring hospitalization and resulting in death.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notices to residents and to send copies of those notices to the Office of the State Long-Term Care Ombudsman for multiple residents. Surveyors found that the facility relied on the Notice of Medicare Non-Coverage (NOMNC) as its only discharge/transfer notice and did not use any separate form that met regulatory content requirements. The NOMNC used by the facility did not include the effective date of transfer/discharge, the location to which the resident would be transferred or discharged, the name, address, and telephone number of the State Long-Term Care Ombudsman, or contact information for protection and advocacy agencies for individuals with developmental disabilities or mental disorders. Staff interviews confirmed that the Resident Relations Manager and Business Office Manager considered the NOMNC to be the facility’s discharge/transfer notice and that they did not provide ombudsman information to residents or send copies of discharge/transfer notifications to the ombudsman. For Resident #107, who had hemiplegia and hemiparesis following cerebral infarction, systolic congestive heart failure, muscle issues, and gait and mobility abnormalities, the physician documented that the resident would transfer to another SNF at the family’s request, and a subsequent note showed the resident was discharged via transport van. The discharge MDS documented an unplanned discharge to a SNF. However, review of the clinical record revealed no evidence that a discharge notification was sent to the State Long-Term Ombudsman. The facility’s Admissions, Transfers and Discharges policy referenced reporting information in accordance with facility policy and professional standards but did not include requirements for notifying the ombudsman. For Resident #8, admitted with COPD, palliative care, and paroxysmal atrial fibrillation, the care plan included goals for pre-discharge planning. A discharge order and a discharge-transfer note/summary documented discharge home with oxygen equipment, home health services, narcotic medications, and a scheduled PCP appointment, and this summary was signed by the resident’s family. The documentation given to the family did not include the ombudsman’s contact information or an explanation of appeal rights. The discharge MDS showed an unplanned discharge home with return not anticipated, and there was no evidence in the clinical record that the ombudsman was notified of the discharge. An email sent about 19 days after discharge contained only a list of residents who were discharged, deceased, or transferred, and for this resident it listed a discharge/transfer to another hospital without the reason for discharge or the same information provided to the family. For Resident #12, admitted with atherosclerotic heart disease, the discharge MDS documented an unplanned discharge to hospice at home. A discharge/transfer/LOA form indicated discharge to the community with hospice services at a private home/apartment, initiated by the resident or representative, and a discharge summary and progress note documented discharge home with belongings, medications, and paperwork. There was no physician order for discharge in the order summary report, and the clinical record did not show that a copy of the discharge notification was sent to the ombudsman. In an interview, the Resident Relations Manager stated that a copy of the notification is not sent to the ombudsman and that ombudsman information is not provided to residents. For Resident #100, admitted with COPD, an order directed transfer to the ED for shortness of breath, and a discharge summary documented respiratory distress and transport via ambulance to an acute care hospital. A social services note stated that the resident or representative was provided written notice of transfer, bed-hold notice, readmission policy, ombudsman and appeals information. However, the clinical record contained no evidence that a copy of the transfer notice was sent to the State Long-Term Care Ombudsman. For Resident #102, admitted and later readmitted with hepatic encephalopathy, influenza, and cirrhosis, clinical documentation showed an anticipated discharge to the community, an NP note indicating discharge to prior living arrangements, and an unplanned discharge home/community on the MDS. A discharge/transfer/LOA form and discharge summary documented discharge to a private home/apartment without hospice, initiated by the resident or representative, and a social services note recorded that the family picked the resident up and took him back to the reservation. There was no physician discharge order, and no indication in the record that a copy of the discharge notification was sent to the ombudsman. Interviews with the ombudsman and facility staff further described the deficient practice. The ombudsman reported that their office previously received a list of discharged/transferred residents but had not received anything for recent months and that they were sent only a list, not copies of discharge/transfer notifications. The Resident Relations Manager and Business Office Manager stated that Resident Relations is responsible for presenting the notice of proposed discharge/transfer, that the notice is presented up to 72 hours prior to discharge, and that a copy of the notification is not sent to the ombudsman. They also stated they were unsure if any policy or guidance outlined what information must be included in the notice and confirmed that the NOMNC was the only form used as a discharge/transfer notice, even though it lacked ombudsman and advocacy contact information. The acting DON reported being unfamiliar with discharge/transfer notification requirements, and the Executive Director stated that the facility used only the NOMNC, believed no paper notice was required beyond that, and understood the facility’s obligation as sending a monthly list of discharged/transferred residents to the ombudsman, not copies of the actual transfer/discharge notifications.
Failure to Ensure and Document Toileting Hygiene Assistance for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident dependent on staff for ADLs, including toileting hygiene, consistently received and had documented assistance with these needs. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side, along with schizophrenia and major depressive disorder. The care plan identified the resident as being at risk for functional self-care deficits and functional mobility limitations and specified that he required assistance with toileting hygiene and bathing/showering, including washing, rinsing, and drying, with baths/showers to be provided per his schedule and preferences. The admission MDS documented that the resident was cognitively intact, had bilateral upper and lower extremity impairment interfering with daily function, used a wheelchair, and was dependent on staff for toileting hygiene, shower/bathing, oral and personal hygiene, dressing, and footwear. Review of the December CNA task logs for bowel and bladder and toilet use showed multiple shifts left unmarked/undocumented, meaning it was unclear whether toileting and bowel/bladder care were provided or refused on those shifts. The bowel and bladder task log had blank entries on several specific dates and shifts, and the toilet use task log also contained numerous blank entries across day, evening, and night shifts. A CNA explained that CNA care is documented in the EHR using specific codes, including codes for refusal and resident unavailability, and that if a task is left blank it likely means the CNA did not chart, making it questionable whether the care was provided. The CNA stated that blank areas mean one would not know if care was provided, and that everything should be charted so that care conferences and assessments have accurate data. An LPN similarly stated that blanks on the bowel and bladder task log made her think that either someone did not chart or the resident did not have a bowel movement, and that whoever was on shift should have charted appropriately so that others could determine whether care was provided. The resident’s record also contained multiple behavior and NP notes describing ongoing verbal aggression, sexually inappropriate comments, resistance to care, and specific complaints about how peri care and showers were provided. Notes documented that the resident sometimes refused showers, stated he only needed one shower a week, and complained that staff did not clean his peri area adequately after bowel movements, including an incident where he alleged staff did not clean under his penis despite a nurse finding his peri area and brief clean and dry. Another note described the resident demonstrating that he could clean his own peri area and then verbally abusing staff. Additional documentation described the resident’s frequent agitation, oppositional behavior, verbal aggression, and disruptive behavior during care interactions, including cursing at staff, making derogatory comments, and repeatedly activating the call light. Despite these behaviors and complaints, the facility’s own policies required that residents unable to carry out ADLs independently receive appropriate support and assistance with toileting and personal hygiene, and that all services provided, refusals, and care-specific details be documented in the medical record. The combination of the resident’s dependence on staff for toileting hygiene and the numerous undocumented shifts on CNA task logs led surveyors to determine that the facility failed to ensure ADL care such as toileting hygiene was provided and properly documented for this resident. Facility staff interviews reinforced the importance of ADL care and documentation and highlighted the gap between expectations and practice. The CNA familiar with the resident described him as a two-person assist due to behaviors, using briefs rather than the toilet, being very sexual, refusing care from male staff, and demanding extra wiping and frequent changes, which led staff to implement cares-in-pairs and show him wipes after each wipe to prove cleanliness. The CNA acknowledged that blank documentation entries likely meant CNAs did not chart and that this created uncertainty about whether care was provided. The LPN stated that residents should be rounded on at least every two hours for ADL care, emphasized that ADL care is important for dignity and to prevent skin breakdown, and confirmed that uncharted tasks prevent others from concluding whether care was provided. These findings, combined with the facility’s policies requiring provision and documentation of ADL services, formed the basis for the deficiency that the facility failed to ensure ADL care, specifically toileting hygiene, was provided and documented for this resident.
Improper Single-Staff Transfer During Shower Contrary to Two-Person Assist Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was transferred in accordance with the care plan and transfer orders during bathing and showering. The resident had diagnoses including a wedge compression fracture of the 3rd lumbar vertebra, surgical aftercare, cauda equina syndrome, spinal stenosis, and a need for assistance with personal care. A care plan initiated on April 10, 2026 documented that the resident required assistance with bathing and showering and had an ADL self-care performance deficit. Interventions initiated on April 20, 2026 and resident task documentation revised on April 14, 2026 indicated that the resident required a two-person maximum assist for transfers to the wheelchair. Despite these documented requirements, a facility investigation dated April 22, 2026 revealed that a CNA (Staff #79) transferred the resident alone from a recliner to a wheelchair, from the wheelchair to a shower chair, and then back from the shower chair to the wheelchair and into bed, using only a gait belt and without a second staff member. The resident reported that the CNA was alone during all transfers, was very rough, and that the transfers were painful, and also stated that the CNA did not speak to him during the shower. An LPN (Staff #96) confirmed receiving a complaint from the resident that the CNA was not caring and was very fast during the shower, and that the CNA was the only staff member present. Another CNA (Staff #72) stated that the Kardex identifies the resident as a two-person assist and that she always obtains another person to help with transfers, noting that transferring the resident alone could cause pain and injury. The Regional Clinical Specialist (Staff #102) stated that CNAs are expected to follow the Kardex for transfer assistance levels and confirmed that the investigation determined the CNA had transferred the resident without assistance, contrary to policy and the plan of care.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. Resident #1 had severe cognitive impairment with a BIMS score of 05 and a care plan identifying behavioral problems, including taking others’ belongings, eating other residents’ food, inappropriate contact with other residents’ belongings and clothing, giving food to other residents without permission, refusing medication and care, and initiating a physical altercation with another resident. Despite these identified behaviors and the existence of a care plan focused on behavior problems, Resident #1 was able to enter Resident #2’s room and engage in a physical altercation. Resident #2 was cognitively intact with a BIMS score of 14 and had a care plan for behavior problems related to verbal and physical behaviors, including prior verbal altercations with other residents, use of profanity, striking another resident in the head, spitting water on staff, kicking at staff during care, cursing at staff, and refusing brief checks and changes. On the day of the incident, Resident #2 approached the nurses’ station with a hematoma to the left eye, a large skin tear to the right forearm, minor cuts to the nose, lip, and right hand, and bruising to the left hand. Resident #2 reported that Resident #1 had entered his room, punched him multiple times in the face, grabbed and twisted his arm, and then left the room. Staff interviews and facility documentation confirmed that no staff witnessed any verbal altercation between the two residents prior to the event, and that earlier in the day Resident #2 did not have any injuries. After the incident, staff observed Resident #2 with a swollen eye and face, bruising, and lacerations consistent with his report. The Administrator and DON stated that review of camera footage showed Resident #1 entering Resident #2’s room and that a physical altercation occurred, confirming that Resident #1 went into Resident #2’s room, hit him in the face, and then exited. The facility’s abuse policy stated an objective to provide a safe haven for residents through preventive measures that protect every resident’s right to freedom from abuse, but the documented resident-to-resident physical abuse occurred despite these stated objectives.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse by other residents. One incident involved a resident with borderline personality disorder, schizophrenia, major depressive disorder, generalized anxiety disorder, a history of traumatic brain injury, and chronic pain syndrome, who had intact cognition and documented patterns of agitation, aggression, yelling, cursing, and threatening others. While in the dining room during dinner, this resident verbally insulted another cognitively intact resident with schizoaffective disorder, bipolar type, intermittent explosive disorder, and personality change due to a physiological condition. Multiple accounts from staff and both residents indicate that after being told not to talk to him, the verbally aggressive resident continued speaking, and the other resident stood up, shoved the table, and struck him in the left eye with a closed fist. As a result of this altercation, the assaulted resident reported pain, nausea, and later requested psychiatric support and antidepressant therapy. Clinical documentation and hospital imaging confirmed an acute left inferior orbital wall fracture and retrobulbar hemorrhage, with visible bruising to the left eye. Prior to this event, the aggressor had known psychiatric diagnoses and was receiving multiple psychotropic and mood-stabilizing medications for mood swings, aggression, disorganized thinking, paranoia, and intermittent explosive disorder. The facility’s records show that the aggressor had behavior care plans related to behavior problems and intermittent explosive disorder, but there is no indication in the report that staff anticipated or intervened to prevent this specific escalation in the dining room before the physical strike occurred. A second incident involved two other residents with significant psychiatric and behavioral histories. One resident had schizophrenia, bipolar disorder, anxiety disorder, intellectual disabilities, and obesity, with a behavioral care plan noting verbal aggression, demanding behaviors, and instructions for staff not to provide requests when made in a rude, threatening, or aggressive manner. The other resident had borderline personality disorder, bipolar disorder, pseudobulbar affect, anxiety disorder, PTSD, and type 1 diabetes, with a behavioral treatment plan for bullying or physical aggression toward peers and interventions directing staff to intervene promptly, remind the resident of respectful behavior expectations, and separate and redirect her if needed. Despite these identified risks and care plan directives, the two residents engaged in a verbal argument over a soda at the nurses’ station, during which one resident called the other a “fat b****” and continued name-calling after being told to stop, leading the other resident to stand up and swing at her. Documentation from behavior notes, incident notes, and the facility’s investigation shows that both residents stood up from their wheelchairs and approached each other during the argument. One resident reported being slapped in the face and later complained of chin pain, while the other resident was documented as having swung her arm at the peer. A skin assessment performed shortly after did not show visible injury, redness, trauma, or swelling, and witnesses, including staff and another resident, reported seeing a swing but were unsure if physical contact occurred. The facility’s investigation ultimately concluded that it could not determine whether physical contact was made, but the event was characterized as a verbal altercation that escalated to at least an attempted physical strike. In both sets of incidents, residents with known behavioral risks and existing behavior plans engaged in escalating verbal conflicts that were not effectively de-escalated or prevented from becoming physical, resulting in at least one resident sustaining a confirmed serious injury and another reporting pain after an alleged slap. Across these events, the facility had identified behavioral risks for the involved residents and had documented care plans and behavior interventions addressing aggression, bullying, and inciting peers. However, during the actual incidents, residents engaged in escalating verbal abuse in common areas (dining room and nurses’ station) that progressed to physical aggression or attempted physical aggression. The report describes that staff were present in the vicinity and, in some cases, intervened only after the physical act occurred or as the residents were already standing and approaching each other. The survey findings conclude that the facility failed to ensure that the affected residents were free from physical or verbal abuse by other residents, as required, resulting in resident-to-resident altercations that included verbal insults, threats, and at least one confirmed physical assault causing an orbital fracture and retrobulbar hemorrhage.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Supervision in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents and to provide adequate supervision in common areas. One cognitively impaired resident with dementia and depression was struck on the right shoulder by another resident with schizoaffective disorder and a history of verbal and physical aggression. Prior to the assault, the aggressive resident had been up all night, repeatedly demanding cigarettes outside of scheduled smoking times, threatening staff, calling 911, grabbing a housekeeper’s keys and injuring her shoulder, and punching a CNA in the abdomen. Despite these escalating behaviors and the resident’s known behavioral care plan identifying verbal and physical aggression and exit-seeking, the resident remained in the common area where he randomly hit the other resident’s shoulder in passing. Staff and police were present on campus, but the aggressive resident was still able to make physical contact with the other resident before being removed. Another deficiency occurred when a resident with dementia, bipolar disorder, major depressive disorder, and anxiety, who had a behavioral care plan for combative behavior, severe agitation, cursing, striking out, and threats, struck another cognitively impaired, non-verbal resident with a tray table in a common area. The victim had dementia, diabetes, and a cognitive communication deficit, and was known to wander and exhibit other non-directed behavioral symptoms. The incident was reported as occurring while the two residents were in a common area, and multiple scheduled CNAs and an LPN assigned to that unit later stated they did not witness the event. Statements from trainees indicated they observed the aggressor pick up a folded wooden table, yell profanities, and launch it at the victim’s head while the victim remained seated and non-verbal. The DON acknowledged that no CNA was physically present in the common area at the time, that trainees were only observing, and that the nurse preparing medications did not provide full attention to supervising the residents, resulting in no staff supervision in the room when the altercation occurred. A further deficiency involved a resident with mild cognitive impairment and no documented behavioral symptoms who was pushed backwards in his wheelchair by another resident with dementia, anxiety disorder, and violent behavior. The incident occurred on a narrow, steep ramp outside the dayroom, where only one person at a time could pass. The aggressor, also in a wheelchair, blocked the ramp and told the other resident he could not come up, then pushed the resident’s shoulder with his hand and used his feet to kick the wheelchair, causing it to flip and the resident to fall to the ground and hit his head. A housekeeping/laundry staff member witnessed the event and reported that the aggressor refused to let the other resident pass and then pushed him down the ramp. The DON stated that CNAs conduct rounding outside every 15 minutes, but the report does not indicate that any direct care staff were present at the ramp when the altercation occurred, and the event was instead discovered and reported by non-nursing staff after the fall. Across these incidents, the facility’s own documentation and staff interviews show that residents with known histories of aggression, agitation, or violent behavior were able to physically assault other residents in common areas and on an outside ramp without effective, continuous supervision by assigned nursing staff. Behavioral care plans identified risks such as verbal and physical aggression, striking out, and threats, and the DON stated that when residents are in common areas there should always be a staff member observing them. However, in the described events, residents were either not directly supervised by CNAs in the common areas, or staff attention was divided, allowing aggressive residents to hit, push, or otherwise physically abuse other residents before staff intervened. These actions and inactions led to resident-to-resident altercations that constituted physical abuse under the facility’s own definitions and policies.
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