Sandridge Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Mesa, Arizona.
- Location
- 255 West Brown Road, Mesa, Arizona 85201
- CMS Provider Number
- 035196
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Sandridge Post Acute during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition alleged that a CNA told him to "shut the f**k up." The nurse manager and Administrator responded promptly, but the allegation was never documented in the resident’s medical record or in the facility’s risk management system, despite facility policy and a Charting and Documentation policy requiring that all incidents and events involving residents be recorded. The Administrator and DON both confirmed that no entry was made in risk management or in psychosocial/progress notes for this incident, resulting in an incomplete and inaccurate clinical record.
The facility did not follow its own policies for investigating and documenting allegations of abuse, neglect, and misappropriation involving several residents. Required 5-day investigation reports were missing or incomplete, interviews with staff and residents were not documented, and clinical records were not updated with relevant incident details. In some cases, families were not notified as required, and there was inconsistent documentation regarding the causes of injuries and incidents.
The facility did not conduct or document thorough investigations into allegations of abuse and misappropriation for two residents, including missing property and a fall resulting in injury. Required interviews and documentation were not completed, and investigation records were unavailable when requested, contrary to facility policy.
Surveyors found that medication carts containing resident medications, controlled substances, and diabetic supplies were left unattended and unlocked in multiple units. Staff interviews confirmed that this practice was not in line with facility policy, which requires all medication storage areas to be locked when not in use.
Staff left medication carts unattended with laptops displaying resident records on two separate units. Both LPNs involved acknowledged that this was not in line with facility policy and could result in unauthorized exposure of resident information. The DON and LPN Manager confirmed that such actions violate HIPAA and residents' rights to privacy, as outlined in facility policy.
A resident with severe cognitive impairment and behavioral issues, including substance use and hallucinations, physically struck another resident in the head with a metal brace following a verbal altercation. Staff initially separated the residents after the verbal exchange but did not report the incident or remove the aggressor immediately, allowing the situation to escalate to physical abuse.
A resident with a history of dementia, agitation, and poor impulse control repeatedly engaged in physical and sexual abuse toward several cognitively impaired peers, including inappropriate touching, aggression, and attempts to bring female residents into his room. Staff and housekeepers observed and reported these behaviors, but there was inconsistent escalation to the DON or Abuse Coordinator, incomplete documentation, and a lack of effective interventions, resulting in continued harm to multiple residents.
A resident with dementia and behavioral disturbances repeatedly engaged in sexually inappropriate and aggressive behaviors toward several female peers, including touching and attempting to lead them to his room. Multiple staff members observed and reported these incidents to their supervisors, but the events were not escalated to the DON or Abuse Coordinator, and no report was made to the State Agency as required by policy. The facility failed to follow its abuse reporting procedures, resulting in unaddressed allegations of abuse and ongoing risk to cognitively impaired residents.
The facility did not report multiple allegations of sexual abuse and inappropriate behaviors involving several cognitively impaired residents to the State Agency as required. Staff observed and documented incidents such as inappropriate touching and sexualized behaviors, but these were not consistently escalated to the DON or Abuse Coordinator, resulting in a failure to follow the facility's abuse reporting policy.
A facility failed to thoroughly investigate and document multiple incidents of alleged sexual and physical abuse involving several cognitively impaired residents. Staff observed inappropriate behaviors, including touching and attempts to isolate female residents, but did not consistently report these incidents to supervisory staff or follow facility policy for abuse investigations. As a result, required notifications and investigations were not completed, and the facility lacked evidence of appropriate response to all alleged violations.
A facility failed to implement its abuse policy by not promptly reporting and investigating an abuse allegation involving a resident with dementia and major depressive disorder under hospice care. A hospice CNA reported the resident's claim of being raped and visible bruises to a nurse and social worker, but the facility delayed notifying the appropriate authorities. The operation manager received the allegation from APS and reported it to the State Agency later that day. Interviews revealed a lack of awareness and delayed action among staff, indicating a breakdown in communication and reporting. The facility's policy requires immediate reporting to several entities, but law enforcement and the ombudsman were notified late, constituting a failure to adhere to the policy.
A resident under hospice care with severe cognitive impairment alleged rape, but the LTC facility delayed reporting the abuse to the State Agency. Despite the facility's policy requiring immediate reporting, the incident was only reported after APS intervention. Staff interviews revealed a lack of awareness and communication about the abuse allegation, leading to a delayed response and potential risk to the resident's safety.
A resident under hospice care in a facility alleged she was raped, with visible bruising observed by a CNA. Despite the facility's policy requiring immediate reporting of abuse allegations, there was a delay in notifying law enforcement and a lack of timely investigation, leading to a deficiency. The resident, with severe cognitive impairment, was able to articulate the allegations during an interview.
A resident with multiple chronic conditions and a history of leg fractures was injured during a Hoyer lift transfer when only one trained staff member and an untrained dietary director were present. The resident fell when a strap became unhooked, highlighting a breach in the facility's safety protocols requiring two trained staff members for such transfers.
A resident with dementia and other conditions eloped from a facility due to inadequate supervision and lack of a care plan despite being identified as an elopement risk. The resident expressed a desire to leave, but this was not documented, and door alarms were not functioning properly. The resident was found two days later in a hospital, and the facility's investigation could not determine how the elopement occurred.
A resident's code status was inaccurately documented in the facility's records, leading to a potential risk of not receiving care aligned with their advance directive. Despite having a full-code status in their advanced directive, the electronic health record indicated a DNR order. Staff interviews revealed confusion and lack of awareness about the resident's true code status.
A cognitively intact resident with multiple diagnoses was involved in an altercation with a staff member, where the resident hit the staff member with a broom, leading to the staff member retaliating by hitting the resident. The incident was witnessed by other staff, who intervened. Despite training on abuse prevention, the staff member's actions violated the resident's right to be free from abuse.
A resident with chronic respiratory conditions was found with an oxygen cylinder stored directly on the floor in their room, contrary to facility policy requiring cylinders to be in carriers. Multiple staff members acknowledged the risk of explosion from improper storage, yet the cylinder remained on the floor until removed during an observation.
The facility did not ensure the safety of a resident with quadriplegia, bipolar disorder, anxiety disorder, and PTSD, who was involved in physical altercations with another resident diagnosed with osteomyelitis of vertebra, depression, hypertension, and psychoactive substance abuse in remission. Incidents included the resident ramming a motorized wheelchair into the other resident, leading to physical confrontations. Witnesses reported multiple altercations, indicating insufficient safety measures to prevent resident abuse.
A resident with schizoaffective disorder, alcohol abuse, and opioid abuse, assessed with a high elopement risk score of 18, managed to leave the facility multiple times. Staff noted the resident's pacing and expressed desire to leave, but inconsistent monitoring and documentation of room checks allowed the resident to escape through open windows. Despite securing windows with sliding locks after the initial incident, the resident was able to remove a window and leave again, highlighting gaps in supervision and environmental safety measures.
Failure to Document Verbal Abuse Allegation in Resident Medical Record and Risk Management System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record and risk management documentation for a resident who alleged verbal abuse by a CNA. The resident, who had multiple diagnoses including atherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction, dysphagia, paraplegia, hypertension, hyperlipidemia, a history of recurrent pneumonia and falls, and gastrostomy status, was cognitively intact with a BIMS score of 13/15. On a specified date, the resident reported that a CNA told him to "shut the f**k up." The nurse manager responded to the scene, ensured the resident was safe, and immediately reported the allegation to the Administrator, who then went to the resident’s room. Despite these actions, the allegation of verbal abuse was not entered into the resident’s medical record and was not documented in the facility’s risk management system, contrary to facility policy and the Charting and Documentation policy, which required that any events, incidents, or accidents involving a resident be recorded in the medical record. The Administrator acknowledged that all incidents were required to be entered into the risk management system and that this did not occur for this resident. The DON confirmed that incidents, including verbal abuse, should have been documented in risk management and somewhere in the resident’s clinical chart, such as psychosocial progress notes, but no such documentation was found for this incident.
Failure to Investigate and Document Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to implement its own policies and procedures requiring thorough investigations of abuse, neglect, and misappropriation allegations for four residents. In multiple cases, the facility did not complete or retain required 5-day investigation reports, did not document interviews with staff or residents, and failed to update clinical records with relevant information about incidents. For example, one resident experienced an unwitnessed fall resulting in a hematoma, but the facility could not provide the mandated 5-day investigation report, and the resident's family reported not being notified of the incident on the day it occurred. Attempts to contact staff involved at the time were unsuccessful, and documentation was incomplete. Another resident reported rough treatment by a CNA, resulting in a bruise, but the facility's 5-day report was incomplete and lacked staff or resident interview accounts. There was also no documentation of disciplinary action taken against the staff member involved. Interviews with current staff revealed inconsistent practices regarding documentation and investigation, with some staff unaware of the incidents or unable to recall details. The facility's policies required interviews with witnesses, residents, and staff, as well as immediate family notification, but these steps were not consistently followed or documented. Additional deficiencies included a failure to investigate a resident's report of a missing wallet, which involved potential misappropriation of funds. The facility did not document interviews or complete a 5-day investigation report, and the administrator confirmed that such incidents are reportable and should be investigated with written records. In another case, a resident sustained a hip fracture after a fall, with conflicting documentation about whether a resident-to-resident altercation occurred. The incident report did not address the altercation as a probable cause, and required documentation and interviews were missing. Facility policies clearly outlined the steps for investigating and documenting such incidents, but these were not adhered to in the cases reviewed.
Failure to Conduct Thorough Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of abuse and misappropriation of property for two residents. For one resident with multiple psychiatric and medical diagnoses, documentation showed that the resident reported a missing wallet containing important identification cards following a hospital stay. Although the resident did not suspect theft or want police involvement, there was no evidence that the facility conducted or documented interviews with staff, the resident, or other potential witnesses. Additionally, when requested, the facility was unable to provide a five-day investigation report or related grievance logs, and the administrator confirmed that such documentation was not available. For another resident with dementia and a history of falls, the facility reported a witnessed fall that resulted in a hip fracture. The clinical record indicated a change in the resident's condition prior to the fall, and a physician's note later stated the injury was due to a resident-to-resident altercation. However, there was no documentation in the clinical record to support the occurrence of an altercation, and required interviews with staff and residents were not completed. Attempts to interview staff were unsuccessful due to lack of recollection or staff no longer being employed. Facility policies required comprehensive investigations of all incidents, including interviews with witnesses, staff, and residents, as well as detailed documentation of the circumstances and follow-up. In both cases, the facility did not follow its own policies and procedures for investigating and documenting incidents of potential abuse, misappropriation, or altercations, resulting in incomplete investigations and insufficient records.
Medication Carts Left Unattended and Unlocked
Penalty
Summary
Surveyors observed that three medication carts were left unattended and unlocked in multiple units of the facility. On several occasions, medication carts containing resident medications, over-the-counter drugs, diabetic supplies, lancets, narcotic medications, medicated patches, and alcohol pads were accessible while nursing staff were not present or were inside resident rooms. These observations were confirmed by staff interviews, where nurses acknowledged that leaving carts unlocked and unattended was not consistent with facility policy or their usual practice. The fill-in Director of Nursing and LPN Manager also confirmed that medication carts should not be left unlocked when unattended. A review of the facility's policy on Medication Labeling and Storage, revised in December 2025, indicated that all compartments containing medications and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible. Despite this policy, surveyors were able to access medication carts without restriction, and staff confirmed the presence of controlled substances and diabetic supplies in these carts at the time of the observations.
Failure to Maintain Confidentiality of Resident Records
Penalty
Summary
Staff failed to maintain the confidentiality of resident-identifiable information by leaving laptops with open resident records unattended on medication carts in two separate units. On two occasions, surveyors observed medication carts left unattended with laptops displaying resident records while the assigned nurses were inside resident rooms. Both nurses acknowledged during interviews that leaving the laptops open and unattended was not consistent with their process or facility policy, and recognized that this practice could result in unauthorized exposure of resident information. The fill-in Director of Nursing and LPN Manager confirmed that staff are expected to ensure computer screens are not left open and unattended, as this would violate HIPAA and residents' rights to privacy. Facility policy reviewed by surveyors stated that unauthorized release, access, or disclosure of resident information is prohibited, and all such actions must comply with current privacy laws. No specific resident medical history or condition was mentioned in relation to the deficiency.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident. One resident, with a history of major depressive disorder, PTSD, bipolar disorder, and severe cognitive impairment, exhibited behavioral problems including hallucinations, delusions, and a history of substance use. This resident left the facility unsupervised, returned after several hours, and reported using methamphetamine. The resident continued to display nonsensical speech, delusions, and hallucinations upon return. On the morning following the resident's return, a verbal altercation occurred between this resident and another resident with mild cognitive impairment and a history of schizoaffective disorder. The altercation escalated when the first resident swung a metal ankle foot orthosis (AFO) brace at the other resident, striking him in the head. Staff initially separated the residents after the verbal exchange but did not report the incident immediately. The situation escalated again, resulting in physical contact before staff intervened and removed the aggressor from the area. Facility documentation and staff interviews confirmed that the incident was not promptly reported after the initial verbal altercation, and the resident who committed the abuse was not immediately removed from the situation. The facility's policy states that residents have the right to be free from abuse, including physical and verbal abuse, and that staff are responsible for protecting residents from abuse by others. The failure to intervene effectively and promptly report the incident led to a resident being physically abused by another resident.
Failure to Protect Residents from Sexual and Physical Abuse by a Peer
Penalty
Summary
The facility failed to protect six residents from sexual and physical abuse by another resident, resulting in multiple incidents of inappropriate touching, physical aggression, and sexualized behaviors. The resident responsible for the abuse had a history of dementia, agitation, schizophrenia, and poor impulse control, with documented behavioral issues including aggression toward other residents and staff, as well as repeated sexualized behaviors toward female peers. Despite these ongoing behaviors, interventions such as 1:1 supervision were not consistently implemented, and staff responses were often limited to redirection, which proved ineffective in preventing further incidents. Several incidents were documented in clinical records and staff interviews, including the resident physically assaulting another resident over a chair, resulting in a hairline rib fracture, and multiple episodes of inappropriate sexual contact, such as touching, kissing, and attempting to bring female residents into his room. Staff and housekeepers observed these behaviors and reported them to supervisors, but there was a lack of consistent escalation to the Director of Nursing or Abuse Coordinator. In some cases, staff did not recognize the need to report incidents as abuse, and documentation of these events was incomplete or missing from resident records. The facility's failure to ensure timely and appropriate reporting, documentation, and intervention allowed the abusive behaviors to continue, exposing vulnerable residents with severe cognitive impairments to further harm. Interviews revealed that staff were aware of the resident's unpredictable aggression and sexualized behaviors, but did not consistently implement or escalate protective measures. The facility's policies required immediate reporting and intervention for abuse, but these procedures were not followed, resulting in ongoing risk and actual harm to multiple residents.
Failure to Report and Investigate Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse policy by not reporting multiple allegations of sexual abuse and inappropriate behaviors involving several residents to the State Agency. The report details repeated incidents where one resident, with a history of dementia, agitation, and behavioral disturbances, engaged in sexually inappropriate and aggressive behaviors towards female peers, including touching, kissing, rubbing, and attempting to lead them to his room. These behaviors were observed and documented by various staff members, including CNAs, LPNs, and housekeeping staff, and were sometimes witnessed by other residents' family members. Despite these observations, there was a lack of consistent documentation in the residents' records and no evidence that these incidents were reported as required by facility policy. Interviews with staff revealed a breakdown in communication and reporting procedures. Several staff members, including CNAs and housekeeping, reported incidents to their immediate supervisors or unit managers, but these reports were not escalated to the Director of Nursing (DON) or the Abuse Coordinator as required. The Abuse Coordinator stated he did not file a report with the state agency because he was not fully informed of the details, and the unit manager indicated she did not feel the incidents warranted further reporting since no one was visibly hurt or in distress. This resulted in the DON and Abuse Coordinator being unaware of the full extent of the resident's behaviors and the ongoing risk to other residents. The facility's policy clearly states that all allegations of abuse, neglect, or exploitation must be reported immediately to the appropriate authorities, including the state agency, within two hours. However, the report demonstrates that this policy was not followed, as multiple incidents involving inappropriate sexual contact and aggression were not reported or investigated according to protocol. The lack of timely and appropriate reporting could result in continued resident-to-resident abuse and a failure to protect vulnerable residents with severe cognitive impairments and behavioral issues.
Failure to Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to ensure that allegations of sexual abuse involving five residents were reported to the State Agency as required. Multiple incidents were documented in clinical records and staff interviews, including inappropriate touching, sexualized behaviors, and physical aggression by one resident towards several female residents, all of whom had varying degrees of cognitive impairment. Staff observed and documented these behaviors, such as a resident rubbing another's legs, attempting to take female residents to his room, and grabbing buttocks, but these incidents were not consistently reported to the appropriate authorities. Interviews with staff revealed a lack of clarity and consistency in reporting procedures. Some staff members, including CNAs and housekeepers, witnessed or were informed of inappropriate behaviors and reported them to their immediate supervisors or unit managers. However, these reports were not always escalated to the Director of Nursing or the Abuse Coordinator, as required by facility policy. In several cases, staff made subjective decisions about whether incidents were reportable, often based on whether physical harm was observed, rather than following the policy to report all allegations of abuse immediately. Facility documentation and policy review confirmed that the policy required immediate reporting of all abuse allegations to local, state, and federal agencies, as well as internal leadership. Despite this, the Abuse Coordinator and DON were not informed of several incidents, and no reports were filed with the State Agency for the sexual abuse allegations involving the five residents. The deficiency was further evidenced by interviews with the DON and Abuse Coordinator, who were unaware of the full extent of the incidents until informed by surveyors.
Failure to Investigate and Report Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to provide evidence that alleged violations involving sexual abuse among five residents were thoroughly investigated. Multiple clinical record reviews, staff interviews, and policy reviews revealed that incidents of inappropriate sexual and physical behaviors by one resident towards several female residents were either not documented, not reported to appropriate supervisory staff, or not investigated according to facility policy. Staff interviews indicated that several incidents, such as inappropriate touching, attempts to take female residents to the perpetrator's room, and physical aggression, were observed by various staff members, including CNAs, housekeepers, and LPNs. However, these incidents were not consistently reported to the Director of Nursing (DON) or the Abuse Coordinator, and in some cases, staff made unilateral decisions not to escalate the reports, believing the incidents did not warrant further action if no physical harm was observed. Clinical documentation showed repeated behavioral issues, including sexualized behaviors and aggression, by a resident with moderate cognitive impairment and a history of psychiatric diagnoses. Despite multiple behavioral notes and staff observations of inappropriate contact with other residents—many of whom had severe cognitive impairment and were unable to protect themselves—there was a lack of thorough investigation or documentation of these incidents in the affected residents' records. Interviews with staff revealed a lack of clarity and consistency in reporting procedures, with some staff assuming others had reported incidents or believing that redirection was sufficient if no injury occurred. The DON and Abuse Coordinator were not made aware of several incidents, and the facility's policy requiring immediate reporting and investigation of abuse allegations was not followed. Additionally, the review of facility records and interviews highlighted that the required notifications to state agencies and thorough investigations were not completed for several incidents. The facility's own policy mandates immediate reporting of all abuse allegations to supervisory staff and external agencies, but this was not adhered to. The lack of documentation and investigation could result in further incidents not being addressed, and the facility did not have evidence that it responded appropriately to all alleged violations as required.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy by not reporting and investigating an allegation of abuse involving a resident to the State Agency. The resident, who was admitted to the facility with diagnoses of senile degeneration of the brain, unspecified dementia, and major depressive disorder, was under hospice care. During an interview, a hospice CNA reported that the resident had expressed being raped and had visible bruises, which were communicated to a nurse and a social worker. However, the facility did not report the allegation to the appropriate authorities immediately as required by their policy. The facility's operation manager received an allegation of abuse from adult protective services and submitted a report to the State Agency later that day. Interviews with various staff members, including a CNA, LPN, RN, and the social service director, revealed a lack of awareness or delayed action regarding the abuse allegation. The social service director and other staff members were not aware of the allegation until informed by APS, indicating a breakdown in communication and reporting within the facility. The facility's policy requires immediate reporting of abuse allegations to several entities, including the state licensing agency, ombudsman, resident's representative, APS, law enforcement, and the resident's attending physician. Despite this, the facility did not notify law enforcement until later in the day, and the ombudsman and case manager were informed the following day. This delay in reporting and investigating the abuse allegation constitutes a failure to adhere to the facility's abuse policy, potentially resulting in further incidents of abuse.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Agency in a timely manner. The resident, who was admitted to the facility with diagnoses including senile degeneration of the brain, unspecified dementia, and major depressive disorder, was under hospice care. On January 6, a hospice CNA observed bruising on the resident and heard the resident claim she had been raped. The CNA reported these observations to a hospice nurse and a social worker, but the facility did not report the allegation to the State Agency until January 13, after being contacted by Adult Protective Services (APS). Interviews with facility staff revealed a lack of awareness and communication regarding the abuse allegation. A licensed practical nurse and a social service director both stated they were unaware of any abuse allegations until APS intervened. The Director of Nursing (DON) confirmed that the facility has a policy requiring abuse allegations to be reported within two hours, but this protocol was not followed. The DON only reported the incident to the Department of Health after being informed by APS, and there was confusion among staff about who was responsible for notifying law enforcement and other required parties. The facility's policy on reporting abuse, neglect, and exploitation was not adhered to, as the report to the State Agency was delayed, and there was uncertainty about whether law enforcement had been notified. The resident's account of the alleged abuse was detailed and consistent, yet the facility's response was inadequate and delayed, potentially compromising the resident's safety and well-being.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and correct alleged violations of abuse for a resident, leading to a deficiency that could result in psychosocial harm and further abuse. The resident, who was admitted to the facility with diagnoses of senile degeneration of the brain, unspecified dementia, and major depressive disorder, was under hospice care. During an interview, a CNA reported that the resident had repeatedly stated she was raped and wanted to press charges. The CNA observed bruising on the resident's body, which she reported to a nurse and a social worker, but was told there was no sheet available to document the skin assessment. The nurse, upon being informed of the allegations, conducted a head-to-toe assessment and found bruising on the resident's wrists. Despite the resident's severe cognitive impairment, she was able to articulate allegations of rape during an interview with surveyors. The facility's operation manager reported receiving an allegation of abuse from adult protective services and submitted a facility report. However, the social service director claimed to have no knowledge of the allegations until informed by APS, indicating a lack of communication and timely reporting within the facility. The facility's policy requires immediate reporting of abuse allegations to various authorities, including law enforcement, within two hours. However, there was a delay in notifying law enforcement, as the LPN/unit manager only contacted them later in the evening. The facility's failure to adhere to its policy and promptly investigate and report the allegations of abuse contributed to the deficiency identified by the surveyors.
Improper Use of Hoyer Lift Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the proper protocol for using a Hoyer lift, resulting in a major injury to a resident. The resident, who had multiple chronic conditions including COPD, heart failure, and a history of leg fractures, required extensive assistance for mobility and was at risk for falls. Despite the care plan indicating the need for two staff members during transfers, the resident was transferred using a Hoyer lift with only one trained staff member and a dietary director who was not trained in Hoyer lift operations. During the transfer, the resident fell when one of the straps of the Hoyer lift became unhooked, causing the resident to slide out of the sling and onto the floor. The incident report and interviews revealed that the dietary director was acting as a spotter from the hallway and did not enter the room, contrary to the facility's policy that required two caregivers to be present during such transfers. The CNA involved in the transfer admitted uncertainty about whether the sling was properly secured, and the dietary director acknowledged a lack of training in Hoyer lift operations. The facility's policies and the Hoyer lift manual both emphasized the necessity of having two trained staff members present during transfers to ensure safety. However, the facility allowed untrained staff to act as spotters, which contributed to the incident. The Director of Nursing and other staff interviews confirmed that the dietary director was not trained in Hoyer lift operations, and the facility's policy did not explicitly require the second person to be trained, leading to a breach in safety protocols and resulting in the resident's injury.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia, diastolic congestive heart failure, adjustment disorder, and anxiety disorders. The resident was identified as being at risk for elopement, with assessments indicating a high risk score and verbal expressions of a desire to leave the facility. Despite these indicators, there was no evidence of a care plan or interventions implemented to address the resident's elopement risk until after the incident occurred. On the evening of the incident, the resident was reported missing by a CNA during routine checks. The resident had been expressing a desire to leave the facility for the past week, but this was not documented in the clinical records. The facility initiated an elopement procedure, but the resident was not found until two days later when a hospital case manager informed the facility that the resident was in the emergency department. The facility's investigation could not determine how the resident eloped, as there were no cameras in the secure unit, and the door alarms were not functioning properly. Interviews with staff revealed that the resident had been moved to a locked unit due to wandering behavior and a decrease in BIMS score. However, the door to the smoking area was found to be unlocked and the alarm did not sound, which may have facilitated the resident's elopement. The facility's policy required risk assessments and care plans for residents at risk of elopement, but these were not adequately implemented for the resident in question.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status for a resident was accurate and consistent in the medical record, which could result in the resident not receiving care consistent with their signed advance directive. The resident, who was cognitively intact, had a documented advanced directive indicating they were to be resuscitated and hospitalized. However, discrepancies were found in the electronic health record, where a DNR order was noted, conflicting with the resident's full-code status as per the advanced directive. This inconsistency was not updated in the physician's order until a later date. Interviews with staff revealed a lack of awareness and understanding of the resident's true code status. A CNA and an RN both believed the resident was a DNR based on the profile page in the electronic health record, which did not match the advanced directive. The DON acknowledged the mismatch and stated that the code status should always align with the most current advanced directive form. The facility's policy required that advanced directives be communicated to direct care staff and physicians, but this was not effectively implemented, leading to the deficiency.
Resident Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure that a resident was free from staff abuse, as evidenced by an incident involving a cognitively intact resident with a BIMS score of 15. The resident, who had diagnoses including chronic obstructive pulmonary disease, hypertension, paraplegia, muscle weakness, and idiopathic neuropathy, was involved in an altercation with a staff member. On the day of the incident, the resident was observed hitting a staff member with a broom, which led to the staff member, identified as staff #121, retaliating by hitting the resident. This incident was witnessed by other staff members, who intervened to separate the resident and the staff member. The facility's investigative report confirmed that staff #121 was terminated following the incident. Interviews with various staff members revealed that they were aware of the facility's policies on abuse and had received training on the subject. Despite this, staff #121 was observed willfully hitting the resident, which constitutes a violation of the resident's right to be free from abuse. The facility's policy on abuse prevention, as well as the resident's rights policy, clearly state that residents should be protected from abuse by facility staff or others.
Improper Storage of Oxygen Cylinder in Resident's Room
Penalty
Summary
The facility failed to ensure the safe storage of oxygen cylinders for a resident diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. The resident was observed with an oxygen cylinder placed directly on the floor in their room, without a carrier or stabilizing support mechanism. This was noted during multiple observations on the same day, indicating a lack of adherence to safety protocols regarding the storage of oxygen cylinders. Interviews with various staff members, including a licensed practical nurse, a certified nursing assistant, a registered nurse, and the director of nursing, confirmed that the facility's policy requires oxygen cylinders to be stored in carriers and not directly on the floor. The staff acknowledged the potential risks associated with improper storage, such as the cylinder tipping over and potentially exploding. Despite this understanding, the oxygen cylinder remained improperly stored until it was eventually removed by a staff member after being pointed out during an observation.
Resident Safety and Abuse Prevention Deficiency
Penalty
Summary
The facility failed to ensure that resident #14 was free from abuse by resident #21, leading to a deficiency in protecting residents from abuse. Resident #14, admitted with quadriplegia, bipolar disorder, anxiety disorder, and post-traumatic disorder, was involved in altercations with resident #21, resulting in physical harm. Resident #21, admitted with osteomyelitis of vertebra, depression, hypertension, and psychoactive substance abuse in remission, was also engaged in altercations with resident #14, indicating a lack of safety measures in place to prevent such incidents. Additionally, resident #40 witnessed resident #14 ramming his motorized wheelchair into resident #21, leading to a physical altercation between the two residents. Resident #6 reported an incident where resident #14 ran over resident #21 with his wheelchair, escalating into a physical confrontation.
Elopement Risk Management and Monitoring Deficiency
Penalty
Summary
The facility failed to prevent elopement of Resident #1, who was admitted with diagnoses including schizoaffective disorder, alcohol abuse, and opioid abuse. Despite a high elopement risk assessment score of 18, the resident was able to leave the facility on multiple occasions. Staff observations noted the resident pacing the unit, expressing a desire to leave, and ultimately escaping through open windows. Interviews with staff members revealed a lack of consistent monitoring and documentation of room checks, with instances where the resident was missing for days before being located at his mother's house. The facility's policy emphasizes resident safety supervision and the prevention of accidents as a priority, targeting interventions to reduce individual risks related to environmental hazards. Despite efforts to secure windows with sliding locks after the initial elopement incident, Resident #1 was still able to remove a window and leave the facility again.
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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