Resolve Harmony Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 2211 East Southern Avenue, Phoenix, Arizona 85040
- CMS Provider Number
- 035205
- Inspections on file
- 26
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Resolve Harmony Center, Llc during CMS and state inspections, most recent first.
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.
PASARR screenings were missing, incomplete, outdated, or not submitted for multiple residents with psychiatric diagnoses and related behaviors. Records showed absent or blank level I forms, outdated PASARRs from other facilities, and incomplete level II documentation for residents with schizoaffective disorder, schizophrenia, bipolar disorder, depression, anxiety, hallucinations, and psychotropic medication use. The SSW/DON interview confirmed that several screenings were not updated after stays exceeded 30 days and that some were not submitted for review.
Unsafe Smoking Supervision and Storage: A resident with schizoaffective disorder, anxiety, and multiple sclerosis was assessed as unable to smoke safely without assistance, yet staff observed the resident smoking with tremors, dropping ashes and a cigarette, and without a smoking protector. The record and staff interviews showed inconsistent practices about whether smoking materials could be kept on a resident’s person, while the resident had already received a smoking violation for having a lighter or matches.
Failure to Follow Smoking Policy for Multiple Residents: The facility did not consistently implement its smoking policy for multiple residents who smoked. A resident with COPD and nicotine dependence kept a lighter under her wheelchair cushion, another resident with serious mental health diagnoses kept cigarettes, lighters, matches, and e-vapes on her person and in her room, and a third resident with a history of TIA/CVA kept cigarettes and a lighter in her room and on her person despite a signed policy requiring secure storage. Staff interviews showed conflicting understanding of whether smoking materials could be kept by residents.
A resident with testicular dysfunction had a physician order for Testosterone Cypionate 200 mg IM every 14 days, but facility records showed the injection was given once and then not again until more than two weeks later, with no documentation that the scheduled intermediate dose was administered or that the provider was notified of the missed dose. Nursing staff and leadership acknowledged that the testosterone injection due on a specific date was not given and that required notifications and documentation were not completed, despite facility expectations and pharmacy services policy. The resident reported opting to resume injections at a urology clinic due to concerns about inconsistent administration by facility staff.
Delayed MDS Transmission: A resident admitted with chronic respiratory failure, atrial fibrillation, and bipolar disorder had an admission MDS completed by the RNAC, but it was not transmitted and accepted within the required timeframe. The MDS Coordinator said the delay was related to facility issues, including a prior MDS coordinator leaving, use of a third-party transmission service, and an incorrect CCN that had to be corrected before submission.
A resident with a history of alcohol dependence and SUD was prescribed Oxycodone HCl 10 mg PRN for pain levels 5-10, but the MAR showed the opioid was administered several times when pain scores were below the ordered range. The ADON and IDON confirmed the medication was given outside provider-ordered parameters, with no supporting documentation or provider authorization found, and the resident’s care plan and opioid consent identified opioid therapy risks and directions to give medications as ordered.
Unsecured Medication Cart Left Unattended: An LPN was observed preparing medications at a med cart on the South Wing, then walking into a resident room while the cart was left unattended, facing the hallway, and unlocked. The LPN confirmed the cart was unsecured when she returned, and the interim CNO/DON stated med carts should be locked whenever not in use or when a nurse is not in front of them. The facility policy required drugs and biologicals to be stored in locked compartments, including med carts.
The facility failed to prevent abuse when two residents with moderate cognitive impairment and complex medical/psychiatric histories engaged in a physical altercation on an outdoor patio during a nursing shift change. One resident, who used a wheelchair and had multiple serious medical conditions, verbally confronted another resident known to have a care plan for verbal/physical aggression and intrusive behaviors with behavior charting orders in place. The second resident admitted to instigating the fight and holding the first resident down until other residents intervened and called for help. When LPN staff arrived, the residents had already been separated, and assessment revealed multiple bruises, scrapes, and knots on the injured resident’s hands, knee, and leg. A cognitively intact resident witness corroborated that the aggressive resident stood up, grabbed the other resident, and fought until interrupted, and the Administrator later confirmed that this unwanted physical contact met the facility’s definition of physical abuse under its abuse-prevention policy.
Multiple incidents occurred in which residents engaged in physical altercations in unsupervised common areas, including the patio and smoking area. These altercations involved the use of wheelchairs as weapons, physical blows, and objects such as coffee mugs, resulting in injuries and emotional distress. Staff interviews and facility policy confirmed that such resident-to-resident interactions are considered abuse, and the lack of supervision contributed to the escalation of these events.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with a history of falls and cognitive impairment experienced multiple falls, including one resulting in a lumbar fracture. Despite these incidents, the fall care plan was not updated to include new interventions, as confirmed by the DON and ADON. Facility policy requiring timely care plan updates after significant events was not followed.
Two residents did not receive care that met professional standards when staff failed to promptly transfer a resident with severe back pain after a fall and did not consistently update or communicate fall risk assessments for another high-risk resident. Staff interviews revealed that CNAs and nurses were not reliably informed about residents' fall risk status or preventive measures, and there was no formal fall management program in place. Facility policies requiring timely assessment, communication, and individualized interventions were not followed.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two cognitively intact residents with behavioral histories were involved in a physical altercation on the patio, resulting in one resident losing a tooth after being struck by another. The incident was documented, and both police and APS were notified. Facility policies prohibiting abuse were reviewed, and the administrator confirmed the injury and refusal of treatment.
Multiple residents were involved in physical altercations, including hitting and biting, after ongoing verbal disputes and behavioral issues were not effectively managed. Staff and witnesses reported escalating tensions and aggressive behaviors prior to the incidents, but interventions were insufficient to prevent injuries, resulting in minor wounds and the involvement of law enforcement.
A resident with respiratory issues was neglected when the facility failed to administer and monitor oxygen therapy as ordered. Despite experiencing symptoms of distress and having an oxygen saturation below 90%, the resident did not receive oxygen until reaching the hospital. The LPN could not find an oxygen concentrator and did not inform the DON, leading to a delay in care. The facility's policy requires daily monitoring of oxygen levels, which was not documented, resulting in a deficiency.
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.
PASARR screenings were missing, outdated, or not submitted for multiple residents with mental health diagnoses
Penalty
Summary
The facility failed to ensure PASARR screenings were updated appropriately and accurately submitted, when applicable, for six sampled residents. The deficient practice involved residents with diagnoses and care plans reflecting serious mental health conditions, including schizoaffective disorder, schizophrenia, bipolar disorder, major depressive disorder, anxiety disorder, auditory hallucinations, and behavioral disturbances. Review of clinical records, MDS assessments, care plans, physician notes, and PASARR documents showed that required PASARR documentation was missing, incomplete, outdated, or not submitted for the residents reviewed. For one resident, the record contained a PASARR level 1 and level 2 dated after admission, but there was no PASARR document on admission and no updated PASARR after the stay exceeded 30 days. The Social Service Director stated she completed the level 2 and attempted to submit it, but said she was waiting for the guardian's signature even though the form reflected verbal consent from the guardian. For another resident, the only PASARR in the record was a level 1 from another facility completed for a 30-day convalescent stay, and it was not updated after the resident remained in the facility longer than 30 days. The form sections for mental illness, symptoms, psychiatric treatment history, psychotropic medications, ID/DD, referral determination, and consent were left blank. Additional residents also lacked proper PASARR processing. One resident had diagnoses including schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder, but no completed level 1 PASARR was found in the record; the Social Service Director stated PASARRs could not be submitted because the facility did not yet have an AHCCCS identification number. Another resident had diagnoses including schizoaffective disorder, depression, and anxiety disorder, and the record contained no PASARR on admission; the Social Service Director stated the PASARR was completed later but was not submitted because she had been told not to send paper PASARR documents. For two other residents, the records contained PASARRs from other facilities that were not updated after admission or after the stay exceeded 30 days, despite diagnoses and care plans showing psychotropic medication use, hallucinations, depression, anxiety, and behavioral concerns. The Social Service Director acknowledged that residents staying beyond 30 days should have updated PASARRs and that level 2 PASARRs should have been submitted for residents with diagnoses such as schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder.
Unsafe Smoking Supervision and Storage
Penalty
Summary
The facility failed to ensure that one sampled resident was free from accidents and hazards related to safe smoking. Resident #37 had diagnoses including schizoaffective disorder, bipolar type; mood disorder due to a known physiological condition; generalized anxiety disorder; multiple sclerosis; and other muscle spasm. A safe smoking assessment documented that the resident was not able to smoke a cigarette or use a smoking device with safe technique, including lighting matches or a lighter, holding the cigarette or device while smoking, disposing of ashes appropriately, or extinguishing and disposing of the cigarette before it became dangerously short. The care plan identified the resident as a smoker who required supervision during smoking. The resident’s smoking policy form stated that smoking materials were to be stored in a secure area and that having cigarettes or combustible material on the resident’s person was a direct violation of the policy. A smoking violation document showed the resident received a verbal education offense for having a lighter or matches, and the materials were confiscated with a room search completed. During an observation, the resident was seen smoking in the designated supervised smoking area while staff noted tremors, ashes dropping onto the resident, and no smoking protector in place. Staff stated the resident had dropped ashes and a cigarette on her person and had dropped a cigarette on the ground. Interviews with staff showed inconsistent understanding of the smoking process and storage of smoking materials. Some staff stated residents could keep smoking materials on their person if they were unsupervised, while others stated residents were not allowed to keep cigarettes, lighters, matches, or electronic vapes on their person and that smoking materials were stored by staff. The interim DON stated the policy did not state where unsupervised residents could keep smoking materials, and that both supervised and unsupervised residents were not allowed to keep smoking materials on their person. The facility policy titled Resident Smoking stated that residents who smoke are assessed to determine whether supervision is required and that smoking materials for residents requiring supervision are maintained by nursing staff.
Failure to Follow Smoking Policy for Multiple Residents
Penalty
Summary
The facility failed to implement its smoking policy for three residents who were identified as smokers. Resident #12 had diagnoses including type 2 diabetes mellitus, nicotine dependence, COPD, depression, anxiety, and seizures, and had a BIMS score of 15. Although a safe smoking assessment and smoking evaluation were documented, the resident stated that she kept cigarettes and an orange lighter under the cushion of her wheelchair in her room, and an observation confirmed the lighter was stored there. The resident also stated that she smoked in the designated smoking area and that the Activity Director purchased and supplied cigarettes and lighters for residents. Resident #26 was admitted with diagnoses including paraplegia, major depressive disorder, anxiety disorder, bipolar disorder, and schizoaffective disorder, and had a BIMS score of 15. The record showed a progress note identifying her as a smoker and orienting her to the smoking areas, but there was no evidence of a smoking assessment or signed smoking policy in the record at that time. During interviews and observation, Resident #26 stated that she kept cigarettes, lighters, matches, and electronic vapes on her person and in her room, and she showed six electronic vapes, a box of cigarettes, and a lighter. The interim DON observed the items and confiscated them during the interview. Resident #41 had diagnoses including a history of TIA and cerebral infarction without residual deficits, major depressive disorder, and polyneuropathy, and had a BIMS score of 15. The record included a smoking assessment and a signed smoking policy stating that smoking materials were to be stored in a secure area and not kept on the resident’s person. However, interviews and observation showed that Resident #41 kept smoking materials on her person and in her room, including two boxes of cigarettes and a lighter. Staff interviews showed conflicting understanding of the smoking policy, with some staff stating residents were not allowed to keep smoking materials in their rooms or on their persons, while others stated unsupervised smokers could keep them on their person.
Failure to Administer Ordered Testosterone Injections as Scheduled
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered testosterone therapy as prescribed for Resident #2 and to document appropriate follow-up when a dose was missed. Resident #2, who had testicular dysfunction and was cognitively intact with a BIMS score of 15, was re-admitted with an order for Testosterone Cypionate 200 mg IM every 14 days in the afternoon for supplementation. The January Medication Administration Record showed the resident received the injection on January 15, 2026, but there was no documentation that the scheduled dose on January 29, 2026, was given. A nursing note documented that the next testosterone injection was administered on February 8, 2026, which exceeded the 14-day interval specified in the order, and the clinical record did not contain documentation supporting administration outside the ordered schedule. Interviews with staff confirmed that the ordered testosterone injection was not administered on January 29, 2026, and that there was no documentation that the provider was notified of the missed dose. The RN stated that testosterone therapy is important for maintaining the resident’s mood and overall well-being and that if a medication is not available, staff should notify the provider and pharmacy, document the notifications, and inform the resident. The ADON and Interim DON both stated that facility expectations are for staff to follow physician orders as written and to promptly notify the provider when medications are unavailable or cannot be administered as ordered, which did not occur in this case. The resident reported changing back to receiving injections at the urology clinic due to concerns that the facility had not reliably administered the injections as scheduled.
Delayed MDS Transmission
Penalty
Summary
The facility failed to transmit the admission MDS for one resident within the required regulatory timeframe after admission. The resident was admitted with diagnoses including chronic respiratory failure, atrial fibrillation, and bipolar disorder, and the admission MDS showed an ARD of October 26, 2025. The RN Assessment Coordinator signed the assessment as complete on November 3, 2025, and the resident’s BIMS score was 14, indicating cognitive intactness. Review of the CMS QIES Third-Party Service Bureau User Request form showed the facility authorized an outside entity to submit PBJ and/or assessment data, but the MDS submission option was not selected. The resident’s MDS Summary showed the assessment was not accepted until December 23, 2025. During interviews, the MDS Coordinator stated the assessment process began on October 20, 2025 and was completed on November 3, 2025, but transmission was delayed because of facility issues, including the prior MDS coordinator quitting unexpectedly, the decision to use a third-party transmission service, and an incorrect CCN that had to be corrected before successful submission.
Unnecessary Drug Administration Outside Ordered Pain Parameters
Penalty
Summary
The facility failed to ensure that one resident with a history of substance use disorder was not administered pain medication outside of provider-ordered parameters. The resident was re-admitted with diagnoses including aftercare following surgical amputation, paraplegia, cirrhosis of the liver, and alcohol dependence. The resident’s opioid consent form identified dependence and addiction as risks of opioid therapy, and care plans directed staff to administer medications as ordered and provide pain management as needed. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 15 and that he received PRN pain medication and was on opioid therapy. The resident had an order for Oxycodone HCl 10 mg every four hours as needed for pain levels between 5 and 10, but the MAR showed the medication was given outside those parameters on multiple occasions. In January 2026, Oxycodone HCl was administered at pain levels of 1 on two dates; in February 2026, it was administered at a pain level of 2; and in March 2026, it was administered at a pain level of 1. During interview, the ADON confirmed the order and stated that if medication must be given outside ordered parameters, the provider must be notified. The IDON also reviewed the record, identified the out-of-parameter administrations, stated there was no supporting documentation or provider authorization for those doses, and noted the nurses involved were no longer employed by the facility.
Unsecured Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure one medication cart was secured when left unattended. During an observation on March 10, 2026 at 09:32 a.m. on the South Wing, a staff member was seen preparing medications at the medication cart, collecting a medication cup with medications, and then walking around the cart and into a resident room next to the cart. At that time, the medication cart was left facing out into the hallway and was unattended and unlocked. An interview at 09:33 a.m. with the LPN who had been using the cart confirmed that the medication cart was unlocked when she returned from passing medications to a resident. The LPN stated that leaving a medication cart unlocked and unattended could result in unauthorized staff or residents/visitors accessing the medications. An interview on March 11, 2026 with the interim CNO/DON also confirmed that medication carts should be locked at all times when not in use or when a nurse is not in front of the cart. The facility policy titled Medication Storage, reviewed/revised October 1, 2025, stated that all drugs and biologicals will be stored in locked compartments, including medication carts.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by another resident, resulting in a physical altercation with documented injuries. One resident, identified as having severe to moderate cognitive impairment, multiple serious medical conditions, and using a manual wheelchair, was involved in an incident on the facility patio with another resident. The resident’s clinical record showed a history of rejecting care on some days and being at risk for falls due to decreased mobility and strength. On the date of the incident, nursing documentation reflected that the resident’s primary physician and nurse practitioner were notified about an event involving another resident. The other resident involved in the altercation had a history of diffuse traumatic brain injury, schizoaffective disorder, major depressive disorder, seizures, hemiplegia, and other conditions, with a BIMS score indicating moderate cognitive impairment. This resident’s care plan, initiated months before the incident, identified verbal and physical aggression, intrusive behaviors, and outbursts, and included the January altercation as part of the behavioral focus. Orders in place required behavior charting on day and evening shifts. A nursing progress note documented behavior issues for this resident around the time of the incident, noting that he was redirected to his room. On the day of the event, during a nursing shift change, staff heard residents on the patio calling for help. When LPN staff responded, the two residents had already stopped fighting and were back in their wheelchairs, with other residents present who had witnessed the altercation. One cognitively intact resident witness reported that the alleged victim verbally confronted the other resident, who then stood up from his wheelchair, grabbed the resident, and engaged in a physical fight until other residents intervened and called for help. The resident identified as the aggressor admitted that he instigated the physical altercation, held the other resident down, and continued fighting until separated. Subsequent assessment documented that the victim had a knot on his left hand, a bruise and scrape on his right hand, a scrape on his right knee, and a bruise with two knots on his left leg. The facility Administrator and Abuse Coordinator stated that unwanted physical contact met the definition of physical abuse and that this incident constituted abuse and did not meet facility expectations, despite a written policy requiring an environment free from abuse.
Failure to Prevent Resident-to-Resident Abuse in Unsupervised Common Areas
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple resident-to-resident altercations that resulted in physical and emotional harm. In one incident, a resident with schizoaffective disorder and moderate cognitive impairment was involved in an altercation with another resident, during which both used their wheelchairs as weapons and physical blows were exchanged. The altercation began as a verbal dispute inside the building and escalated on the patio, where there was no staff supervision. Witnesses confirmed the physical nature of the altercation, and the facility's investigation determined that both residents were active participants. Staff interviews revealed that residents were allowed to access the patio and smoke without supervision, and staff typically became aware of incidents only when informed by other residents. Another incident involved two residents in the designated smoking area, where one resident was observed throwing rocks at cats. When confronted by another resident, the situation escalated to physical violence, with one resident hitting the other in the face and tearing their shirt. Security footage confirmed the sequence of events, and the injured resident exhibited physical signs of distress, including redness on the face and anxiety. Staff interviews consistently identified such resident-to-resident altercations as abuse according to facility policy, which defines abuse as the willful infliction of injury or pain. A third altercation occurred between two residents following a verbal disagreement, which escalated to both residents throwing coffee at each other, and one resident being struck in the face with a mug. Staff and resident interviews confirmed the altercation and described ongoing behavioral issues between the involved residents. Facility policy and staff statements consistently recognized these interactions as abuse. In all cases, the lack of supervision in common areas such as the patio and smoking area contributed to the occurrence and escalation of these incidents.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Update Fall Care Plan After Resident Falls
Penalty
Summary
The facility failed to update the fall care plan for a resident who had a history of falls and multiple medical conditions, including abnormal gait, generalized muscle weakness, dorsalgia, and a previous lumbar vertebra fracture. The resident experienced at least two falls during their stay, as documented in nursing progress notes. After one fall, the resident reported sliding from a chair due to a cushion, resulting in a bruise, and later complained of severe back pain, which led to an emergency room visit and diagnosis of a lumbar spine fracture. Despite these incidents, there was no documentation that the fall care plan was updated to reflect new interventions following the falls. Interviews with the DON and ADON confirmed that the care plan was not revised after each fall, and that standard interventions such as moving the resident closer to the nurse's station or providing non-skid socks were not documented as added to the care plan. The facility's policy requires the care plan to be updated within seven days of the comprehensive assessment and after significant changes, but this was not followed in the resident's case. The lack of timely updates to the care plan was acknowledged by facility leadership during the survey.
Failure to Meet Professional Standards in Fall Management and Response
Penalty
Summary
The facility failed to ensure that two residents received services that met professional standards of quality, as evidenced by documentation, staff interviews, and review of facility policies. One resident was admitted with multiple diagnoses including abnormal gait, muscle weakness, and a history of falls and fractures. After experiencing a fall, the resident complained of severe back pain and requested to be sent to the emergency room. Despite the complaint of severe pain following a fall and a history of lumbar fracture, the resident was sent to the hospital via non-emergent transportation, resulting in a significant delay. Staff interviews revealed that both the DON and ADON acknowledged that severe back pain after a fall should have prompted an emergent transfer, and the nurse involved stated that an emergency call would be appropriate if a resident had severe pain, indicating a possible fracture. The facility's policy required prompt assessment and following emergency personnel orders, which was not adhered to in this case. Another resident with diagnoses including cardiomyopathy, cerebral infarction, and hemiplegia was identified as a high fall risk upon admission and had a history of multiple falls with injuries. Despite physician orders for fall risk assessments every three months and after falls, there was no evidence of updated fall risk assessments following subsequent falls. Interviews with CNAs and LPNs revealed that direct care staff were not consistently informed of residents' fall risk status or specific preventative measures. New staff reported not receiving written or verbal information about which residents were at risk for falls, and there was no formal system in place to communicate this information. Observations confirmed that a resident's bed was kept in a high position, contrary to best practices for fall prevention, and staff were unaware of the resident's fall risk status. The DON stated that fall risk and preventative measures were supposed to be communicated verbally and through a CNA sheet, but both new and existing staff reported not receiving this information. The DON also admitted uncertainty about the existence of a formal fall management program. Facility policy required individualized interventions and regular fall risk assessments, but these were not consistently implemented or communicated to staff. The lack of updated assessments, failure to communicate fall risk status, and improper response to acute pain after a fall contributed to the facility's failure to meet professional standards of quality care for these residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent one resident from physically abusing another resident, resulting in physical harm. Resident #2, who was cognitively intact and had a history of behavioral issues including outbursts of anger and exposing himself, was involved in an altercation with Resident #4 on the facility patio. During this incident, Resident #2 knocked out Resident #4's tooth, while Resident #4 struck Resident #2 with a stick. The altercation was documented in progress notes, and both the police and Adult Protective Services were notified immediately after the event. Resident #4, also cognitively intact and with a history of behavioral problems such as making false accusations and interfering with facility protocols, lost newly cemented dental bridges as a result of the altercation. Interviews confirmed that Resident #4 had been involved in previous altercations at the facility. The facility's policies on abuse and resident rights, which prohibit physical abuse and guarantee freedom from abuse and neglect, were reviewed as part of the investigation. The administrator confirmed the loss of the tooth and noted that the resident refused treatment.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Injuries
Penalty
Summary
The facility failed to protect multiple residents from resident-to-resident abuse, resulting in several altercations that led to physical injuries. In one incident, two cognitively intact residents with significant medical histories, including hemiplegia, diabetes, and dementia, engaged in a physical altercation in their shared room. The altercation escalated from verbal disputes over environmental factors, such as a smell in the room, to physical violence, including hitting and biting. Both residents sustained minor injuries, including a bite mark and contusions, and the police were notified. Staff and witness statements confirmed that the altercation was preceded by ongoing arguments and that staff were aware of escalating tensions but were unable to prevent the physical confrontation. In another event, a resident with severe cognitive impairment and a history of aggressive behavior struck another resident multiple times in the head and face in a common area. The aggressor had a documented pattern of combative and violent behavior towards both staff and peers, with multiple nursing notes describing ongoing agitation, attempts to strike staff, and threats of violence. Despite these documented behaviors and ongoing medication adjustments, the resident was able to physically assault another resident, resulting in a contusion and a small open wound. Multiple staff and resident witnesses observed the unprovoked attack, and the aggressor continued to display aggressive behavior throughout the day. The facility's documentation and witness statements indicate that staff were aware of behavioral issues and prior verbal disputes among residents but did not implement effective interventions to prevent physical altercations. The care plans for the involved residents included goals to prevent altercations and manage behaviors, but these measures were insufficient to ensure resident safety. The facility's failure to anticipate and address escalating behaviors directly resulted in residents sustaining injuries from peer-to-peer abuse.
Failure to Administer and Monitor Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident was not neglected, as evidenced by the lack of proper oxygen administration and monitoring. The resident, who was admitted with acute respiratory disease, pneumonia due to coronavirus, wheezing, and spinal stenosis, had an order for oxygen therapy to be applied as needed for oxygen saturation below 90%. However, the care plan did not include a plan for oxygen therapy, and there was no documentation of oxygen saturation rates on a specific date when the resident experienced symptoms of distress. On the day of the incident, the resident complained of chest pain, shortness of breath, numbness, and anxiety, with an oxygen saturation of 87%. Despite the need for oxygen, the medication and treatment administration records did not show that oxygen was administered. Interviews revealed that the LPN responsible for the resident's care was unable to find an oxygen concentrator and did not inform the DON of this issue. The resident was eventually sent to the emergency room, where it was noted that oxygen was not provided until arrival at the hospital. Interviews with staff indicated that vital signs, including oxygen levels, should have been checked daily, especially given the resident's condition and medication orders. The DON acknowledged that there was no documentation of oxygen levels on multiple days and that the resident's oxygen level should have been monitored daily. The facility's policy on respiratory care and oxygen administration requires that residents receive necessary care and be transferred to the hospital if interventions do not work, highlighting a failure in following these procedures.
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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