Sandstone Of Tucson Rehab Centre
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 2900 East Milber Street, Tucson, Arizona 85714
- CMS Provider Number
- 035099
- Inspections on file
- 35
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Sandstone Of Tucson Rehab Centre during CMS and state inspections, most recent first.
Two residents with significant cognitive and behavioral issues were involved in separate resident-to-resident altercations in which the facility failed to protect them from abuse. In one case, a severely cognitively impaired resident with depression and dementia was found on the floor with facial injuries and head hematomas after her roommate, who had dementia, intrusive behaviors, poor boundaries, delusional thoughts, and poor impulse control, admitted to striking her multiple times in the face and pulling her hair following a verbal dispute. In the other case, a cognitively intact but highly anxious and behaviorally complex resident in a bariatric wheelchair yelled at another resident with schizoaffective disorder, dementia, and a documented history of verbal and physical aggression, who then reacted by cursing and extending a leg that made contact with the first resident’s forearm. Despite existing care plans and behavior tracking orders identifying both aggressor residents as having potential for physical aggression and disruptive interpersonal behavior, the facility’s actions and care planning did not prevent these altercations, and in the second incident there was no evidence that the care plan was reviewed or revised after the event.
A resident with severe cognitive impairment and multiple medical conditions had a missing wallet, bank card, and cash, and the resident’s son reported unexplained recurring financial charges. The son informed Social Services of these concerns, and Social Services contacted the Business Office and discussed the issue with the interdisciplinary team, while the son planned to cancel the card. Although APS was eventually contacted and the facility assisted with canceling the card, there was no documentation in progress notes or grievance logs of the initial allegation, and no evidence that the state agency or the Administrator were notified when the concern was first reported, contrary to facility policy requiring immediate reporting of suspected misappropriation to the Administrator and appropriate state agencies.
A dependent, quadriplegic resident with intact cognition and high fall risk, who required two‑person assistance for bed mobility, fell from the bed during a brief change when CNAs attempted to roll the resident while positioned too close to the bed’s edge. The resident slipped off the side of the bed, landing on the floor and sustaining minor abrasions and knee pain. Staff interviews and documentation showed that the resident had not been adequately moved toward the opposite side of the bed before rolling, contrary to the facility’s own procedures for safely turning dependent residents, leading to a preventable fall during in‑bed care.
Two cognitively intact residents sharing a room, one with spinal and depressive conditions and the other with cerebral palsy, scoliosis, and documented behavioral disturbances including physical aggression and poor impulse control, became involved in a physical altercation after a disagreement about television volume. One resident reported being strangled and grabbed around the neck and shoulder, resulting in a skin tear on the forearm and neck redness, while the other resident reported being punched and had a minor raised area on the cheek. The aggressive resident’s care plan already identified behavioral risks and listed interventions such as 15-minute checks and noise reduction, yet the incident still occurred in the shared room. Staff interviews reflected that a CNA heard the report of choking and saw arm scratches, the DON initially characterized the event as a behavioral outburst rather than abuse before later acknowledging it could be abuse, and the Administrator described the event as a very aggressive attack on the resident’s neck and categorized it as abuse, consistent with the facility’s abuse policy and subsequent verification of resident-to-resident abuse.
A cognitively impaired resident with dementia and behavioral symptoms was started on PRN Hydroxyzine for anxiety following a psych evaluation, and the MAR showed four doses were administered. Multiple LPNs and the DON confirmed that facility protocol and policy require a signed consent from the resident or responsible party before administering psychotropic medications and that staff must verify this consent in the system. Record review and staff interviews established that no signed consent for Hydroxyzine existed in the chart or medical records at the time the doses were given, resulting in administration of a psychotropic medication without the required informed consent.
A cognitively impaired resident with dementia and behavioral symptoms was allegedly abused during a night shift, but the LPN who witnessed the incident did not report it to the administrator before going home, later citing shock and misunderstanding of the reporting timeframe. The allegation was reported to the administrator the following afternoon, rather than immediately, despite regular abuse training and a facility policy requiring immediate reporting of suspected abuse to the administrator or designee and prompt notification of the State Agency.
A cognitively intact resident with multiple behavioral health and neurological diagnoses, including Huntington’s disease and anxiety disorder, repeatedly requested a replacement cellphone after her previous phone broke, but the facility did not facilitate obtaining one despite the resident having sufficient personal funds and being her own responsible party. The business office manager acknowledged the resident’s request and available trust fund balance but delayed action while waiting for the resident’s sister, who was minimally involved, to decide, citing prior excessive food spending via cellphone. The social service director reported that the resident’s cellphone had been removed for several months due to concerns about a hot charger and weight gain from food orders, limiting her to using facility phones at the nurses’ station or unit. This inaction conflicted with the resident’s care plans, which emphasized phone-based communication to support mood and psychosocial well-being, and with facility policy guaranteeing residents the right to keep personal possessions and have reasonable access to a telephone for private conversation.
A cognitively impaired resident with dementia, aphasia, and hemiplegia, living on a secured unit and care planned as at risk for psychosocial and cognitive problems, was punched twice in the nose in a hallway by another resident with dementia, schizophrenia, psychosis, and a documented history of physical aggression toward staff and other residents. The victim sustained a nasal abrasion, pain, and subsequent bruising around one eye, while the aggressor later stated he acted because he believed the other resident had touched his girlfriend’s hand, although she was not present. Prior episodes in which the aggressive resident hit another resident and struck a CNA’s hand and threw a bedside commode were documented in nursing notes but were not incorporated into care plans with specific preventive interventions at the time. Facility policies required assessment, care planning, monitoring, and implementation of interventions for residents with aggressive behaviors and for resident-to-resident altercation risk, but these measures were not effectively implemented for the aggressive resident, leading to the verified abuse incident.
A cognitively intact resident with depression and COPD befriended a younger, cognitively intact resident with a history of poor impulse control. The older resident gave the younger resident a debit card and cash to hold, after which the younger resident used the funds without permission for online purchases, clothing, and virtual slot game coins. The victim later reported that money was being stolen and became upset, anxious, and withdrawn after realizing the financial exploitation. Staff interviews confirmed that the victim’s funds were used without consent and that boxes of purchases were observed in the alleged perpetrator’s room. Although staff described the situation as financial abuse and exploitation, the facility’s incident follow-up report omitted the residents’ names, no self-report for the relevant period was found, and the administrator could not locate a complete reportable event or investigation record, demonstrating a failure to protect the resident’s property and to properly document the substantiated misappropriation.
The facility failed to maintain documentation showing that an allegation of financial misappropriation between two cognitively intact residents was thoroughly investigated. One resident with depression, COPD, anemia, and weakness reported that a younger resident, whom she had befriended, used her debit card and cash without permission, leading to distress, increased anxiety, and a desire to leave the facility. Staff interviews confirmed that the situation was viewed as financial abuse or exploitation and that outside agencies and police were contacted, but the incident follow-up report omitted the residents’ identities and lacked staff or resident interview statements. When surveyors requested the self-report and investigation records for the period in question, the administrator could not locate any reportable event or complete investigative documentation, resulting in a deficiency for failure to maintain records of a thorough investigation.
A resident was readmitted with multiple conditions including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit, and was assessed on admission as a high fall risk using the Morse Fall Scale. Despite this, the facility did not develop a required baseline care plan within 48 hours to address the resident’s immediate needs, and the comprehensive care plan was not initiated until later. Nursing notes documented unsteady gait, poor balance, and the resident’s attempts to ambulate independently, followed by multiple falls and subsequent neuro checks. An RN later confirmed that no baseline care plan existed in the EMR, and the DON acknowledged that the fall care plan did not reflect the high fall risk identified in the assessment and was not updated after the falls, contrary to facility policy and CMS requirements for baseline care planning.
A resident with multiple comorbidities, impaired mobility, and severely impaired cognition was assessed as high risk for falls on admission and had an initial care plan addressing fall risk and ADL deficits. Nursing notes later documented unsteady gait, poor balance, refusal to follow instructions, and three separate fall incidents, including unwitnessed falls with injuries, with neuro checks and immediate post-fall assessments completed each time. Despite these events and the documented high fall risk, the comprehensive care plan was not reviewed or revised after the falls, and the DON acknowledged that the fall care plan did not reflect the high fall risk identified in the assessment, in contrast to the facility’s fall prevention policy and interdisciplinary care planning expectations.
A cognitively intact resident with Huntington’s disease and significant behavioral issues participated in a group activity using toy guns and foam darts, where residents were not positioned as the activity director required to prevent darts from striking others, and the sole activity aide left the room briefly, leaving all participants unsupervised. Another cognitively intact resident with a history of suicidal ideation, substance use, homelessness, and extensive incarceration was assessed as low risk for wandering/elopement using a tool that did not address psychosocial or substance‑use factors, and later left the premises by car during an unsupervised smoking break after requesting a dressing change be delayed until after smoking. Subsequent observation showed multiple residents smoking outside without staff present while the receptionist remained inside, despite facility policies requiring adequate supervision, elopement risk assessment, and activity programming coordinated with comprehensive assessments.
A resident with intact cognition and a documented history of altercations, including a care plan intervention to be removed from the environment when verbally escalating, approached a cognitively impaired, wandering resident in a hallway, verbally challenged her, and scratched her arm, causing multiple superficial skin tears and pain. Documentation and interviews showed that staff recognized the event as physical abuse and that it occurred despite an existing abuse policy requiring an environment free from abuse.
A resident with severe cognitive impairment and psychiatric diagnoses was subjected to verbal and physical abuse by a roommate with a known history of aggression and behavioral disturbances. Despite staff awareness of both residents' behavioral histories and concerns about room compatibility, the two were assigned as roommates, leading to an incident where one resident verbally threatened and physically struck the other. Staff intervened during the altercation, but the facility failed to prevent the abuse, resulting in a violation of the resident's right to safety.
Two residents with severe cognitive impairment and histories of aggressive behavior physically assaulted peers in separate incidents. In one case, a resident struck another on the head, causing bleeding, while in another, a resident hit a peer on the nose following a wheelchair collision. Staff interviews and documentation confirmed that both incidents involved residents with known behavioral risks who were able to harm others before being separated by staff.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Surveyors found that staff were not consistently trained or monitored, and there was a lack of regular review or updating of procedures to protect residents.
Two residents with cognitive and behavioral impairments were involved in an altercation where one threatened to harm the other, requiring CNA intervention. Although the incident was documented by an LPN and later verified, it was not reported to state agencies or investigated immediately as required by facility policy. Staff interviews confirmed the delay in reporting and lack of prompt action.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Multiple residents experienced abuse and neglect due to lapses in supervision and failure to implement care plans. Incidents included a resident with cognitive impairment physically assaulting another resident and a CNA after being removed from 1:1 supervision, a resident with dementia entering another's room and striking her, and a resident with Parkinson's disease sustaining a burn from hot coffee due to inadequate supervision and lack of appropriate adaptive equipment. Staff interviews confirmed that interventions were not consistently followed, leading to these events.
A resident with behavioral symptoms and a history of resistance to care reported verbal abuse and neglect by a CNA, but the allegation was not reported to the State Survey Agency within the required timeframe. Staff interviews revealed confusion about reporting responsibilities, and internal records confirmed that the incident was not reported as required by facility policy.
The facility failed to monitor and document behaviors before administering medications to two residents, risking over-medication. One resident with severe cognitive impairment was prescribed Paroxetine and Risperidone, while another was on Escitalopram and Olanzapine. Staff interviews confirmed that behavior tracking was not conducted as required by facility policy.
A resident with severe cognitive impairment and high fall risk experienced an unwitnessed fall, resulting in a head abrasion. The facility failed to conduct and document the required neurochecks as per policy, with only one check recorded. Staff interviews confirmed the importance of neurochecks for identifying potential issues like brain bleeds, highlighting a lapse in following professional standards of practice.
A facility failed to protect residents from abuse, as two cognitively impaired residents were involved in an inappropriate incident due to inadequate supervision. Despite care plans for frequent safety checks, a resident with dementia was found in another resident's room without pants, with the other resident's hand in her groin. Staff interviews revealed insufficient supervision and confusion about consent and abuse policies.
A resident with severe cognitive impairment assaulted another resident due to inadequate supervision by a CNA, who failed to maintain the required one-on-one supervision. This lapse allowed the resident to leave a shared bathroom and attack another resident, resulting in physical injury. The facility's policy mandates that residents be free from abuse, but the failure to adhere to supervision requirements led to this incident.
A resident with cognitive impairments eloped from a secured unit after being mistakenly identified as a visitor by a staff member. Despite being assessed as a low elopement risk, the resident had shown exit-seeking behavior. Staff failed to secure the exit, and the facility lacked a documented policy for security doors.
The facility failed to hold regular resident council meetings and address grievances and recommendations voiced during these meetings. Reviews of council minutes and grievance logs showed no written documentation of feedback or resolution. Interviews with residents and staff confirmed that issues raised were not followed up on, leading to residents feeling unheard and frustrated.
The facility failed to ensure that meals were provided to residents seated together at the same time, compromising their dignity. Observations revealed sporadic meal service without regard to seating arrangements, confirmed by interviews with the Food Service Director and Administrator.
A resident admitted with a fracture of the left patella was not informed of their rights due to the facility's failure to complete the non-clinical admission packet. The absence of a ward clerk led to this oversight, as confirmed by the DON and ADON.
The facility failed to protect a resident with dementia from physical abuse by another resident with a history of aggression. Despite multiple incidents and internal reports, the aggressive resident's care plan was not updated to include interventions to manage her behavior, contrary to facility policy.
The facility failed to ensure timely PASARR level II referrals for two residents with serious mental disorders, resulting in potential lapses in appropriate service provision. Despite having policies in place, the facility did not adhere to the required procedures, as evidenced by the delayed referrals and lack of documentation.
The facility failed to ensure that a resident or the resident's representative was able to participate in the care planning process. Despite being cognitively intact and wanting to provide input, the resident was not invited to care plan meetings for about a year, and there was no documentation of invitations or attendance in the medical record.
The facility failed to administer medications as ordered for three residents, resulting in incorrect medication administration. Errors included administering the wrong type of insulin, an incorrect dosage of a nicotine patch, and a chewable aspirin tablet instead of an enteric-coated capsule. These errors were identified through observations and staff interviews, indicating a failure to follow the facility's medication administration policy.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director was hired without the necessary qualifications and had not completed the required training course. Despite this, the facility's owners and Administrator allowed her to transfer from another facility. The job description clearly states that satisfactory completion of a training course and a minimum of two years of experience are required, which the current Activity Director did not meet.
A resident with cognitive intactness had several medications left at the bedside without proper self-administration assessment or approval, posing a risk of medication-induced harm. Staff confirmed that the medications should not have been at the bedside without proper approval, and the facility's policy on self-administration was not followed.
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.11%. Errors included incorrect administration of insulin, nicotine patches, and aspirin to three residents. The Director of Nursing acknowledged the issue, which violated the facility's policy.
The facility failed to ensure that expired medications and devices were not readily accessible for use. During observations, expired enteral feeding supplies and a topical medication were found in the medication storage room and a medication cart. The LPNs confirmed the expiration dates and stated that the expired items would be discarded. The DON acknowledged that expired items should be removed and discarded according to the facility's policy.
The facility failed to provide food at a palatable and appetizing temperature, as evidenced by multiple resident complaints and a test tray observation showing food temperatures below the facility's standard. The Administrator acknowledged the issue, but the current food service did not meet expectations.
The facility failed to maintain proper food safety and hygiene practices, including transporting uncovered food past COVID-19 isolation rooms and storing undated and expired food items in a filthy resident refrigerator/freezer. Staff acknowledged the deficiencies, which did not meet the facility's standards.
Failure to Protect Residents From Abuse During Resident-to-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by other residents, resulting in two separate resident-to-resident altercations involving four residents. In the first incident, one resident with severe cognitive impairment, major depressive disorder, vascular dementia, psychotic and mood disturbances, and anxiety was found on the floor next to her bed with blood on her face after staff heard yelling from a shared room. Documentation shows that another resident in the room, who also had severe cognitive impairment, dementia, major depressive disorder, anxiety, intrusive behaviors, poor boundaries, delusional thoughts, and poor impulse control, admitted to hitting her roommate in the face several times after believing she had been insulted and accused of cheating with the roommate’s husband. The injured resident was assessed with hematomas on the back of the head, a facial laceration under the nose, a bloody nose, and later imaging showed a shallow abrasion of the upper lip and mild tenderness of the left knee. Witness accounts from staff and CNAs confirmed that the aggressor resident struck the victim with a closed fist and pulled her hair, causing the victim to lose balance and fall to the floor. The resident who was the aggressor in the first incident had an existing order for behavior tracking related to intrusive behaviors and crossing other residents’ boundaries, as well as a care plan focus on behavioral disturbances including intrusive behaviors, poor boundaries, pacing, delusional thoughts, and physical aggression related to dementia and poor impulse control. Despite these identified risks, the two residents were roomed together, and there is no indication in the report that the care plan for the aggressor resident had been focused on preventing such altercations with roommates prior to the event. The victim resident’s care plan also identified problematic behaviors related to anxiety and agitation, including pulling out her hair, and interventions included not invading her personal space. Staff interviews indicated that the victim resident had paranoid thoughts about staff and residents attempting to poison her and that such paranoid behaviors were considered her baseline. The combination of both residents’ behavioral and cognitive profiles, along with their shared room arrangement, contributed to the altercation in which one resident physically assaulted the other. In the second incident, another resident with borderline personality disorder, major depressive disorder, generalized anxiety disorder, Huntington’s disease, and a history of physical and verbal aggression was involved in a hallway altercation with a resident who had schizoaffective disorder, major depressive disorder, dementia, anxiety, epileptic seizures, and a documented history of verbal and physical aggression, including kicking, hitting, pinching, scratching, spitting, biting, and using abusive language toward staff and peers. The victim resident, who had intact cognition and was known to be anxious, sensitive, and demanding, was self-propelling in a bariatric wheelchair toward the front of the hallway and yelled “get out of the way” as she approached the other resident sitting in her doorway. The other resident, who had care plan focuses on psychotropic medication use for behavior management, potential to be physically aggressive, disruptive interpersonal behavior, and instigating behaviors, reacted by loudly cursing and extending her left leg, making brief contact with the victim’s right forearm. The incident was witnessed by an LPN, and a skin check on the victim showed only small old bruises on the hands and forearms with no new discoloration, swelling, or redness. However, despite the documented behavioral history and care plan problem areas for the aggressor resident, the care plan was not reviewed or revised following this incident, and there was no evidence of updated interventions addressing the new altercation. The deficiency is further supported by staff interviews describing frequent resident-to-resident altercations on the behavioral unit and the need to separate residents when such events occur. A CNA reported that the victim in the second incident was consistently anxious and did not tolerate delays, while the aggressor was usually pleasant but had a documented history of aggressive and instigating behaviors. Another CNA and the nurse consultant corroborated the details of the first incident, including the aggressor resident’s admission to hitting her roommate and the observed injuries to the victim. The facility’s abuse and neglect policy defines abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, including hitting and punching. The verified findings of physical contact, hitting, and resulting injuries in the first incident, and the physical contact in the second incident, demonstrate that the facility did not adequately protect residents from abuse by other residents as required by its own policy and regulatory standards.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s funds to all mandated entities and within required timeframes. A complaint received by the state agency on February 11, 2026, alleged that a resident was missing a wallet containing $2,000, a bank card, and identification, and that the resident’s son had identified a recurring charge of about $800 per month on the account. The complaint also stated that the facility assisted the family in canceling the bank card. Facility records showed that the incident was initially reported to facility staff on December 16, 2025, indicating a significant delay between the initial report and notification to the state agency. The resident involved was first admitted in September 2024 and re-admitted later with diagnoses including vascular dementia (mild) with psychotic disturbance, delirium due to a known physiological condition, gram‑negative sepsis, and type 2 diabetes mellitus with hyperglycemia and a foot ulcer. An admission MDS with a BIMS score of 03 indicated severe cognitive impairment. Despite the son’s report on December 16, 2025, of unexplained financial charges and concerns about missing funds, review of the resident’s progress notes and the facility’s grievance records from April 2025 to January 2026 revealed no documentation of the missing funds or misappropriation concerns at that time. A late-entry Social Services note dated February 10, 2026, documented that Social Services was notified of concerns regarding a missing wallet and bank card and that an APS intake was completed in accordance with mandatory reporting requirements. A typed Social Services Incident Timeline provided by the facility stated that on December 16, 2025, the resident’s son met with Social Services to report concerns about financial charges, that Social Services contacted the Business Office for clarification, and that the son intended to cancel the card. The report also indicated that an interdisciplinary discussion occurred and that potential financial exploitation would be reported to APS. However, there was no evidence in the clinical record that the state agency or the Administrator were notified of the December 16, 2025 allegation, despite facility policy requiring all allegations or suspicions of abuse, including financial abuse and misappropriation, to be reported immediately to the Administrator and to appropriate state agencies, with a final investigation report submitted within five working days. During interviews, the Administrator and DON acknowledged that staff are expected to report such incidents immediately and that failing to report delays the response and investigation process.
Failure to Safely Reposition Dependent Resident During In‑Bed Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a dependent, quadriplegic resident from a preventable accident during in‑bed care, specifically a fall from the bed while staff were changing the resident’s brief. The resident had diagnoses including quadriplegia, major depressive disorder, anxiety disorder, insomnia, and neuromuscular bladder dysfunction, and required assistance for all ADLs. An annual MDS showed intact cognition with a BIMS score of 15, limited range of motion in both upper and lower extremities, and dependence on staff for rolling left and right in bed. A fall scale evaluation identified the resident as high fall risk, and the care plan included an intervention for two staff to assist with bed mobility due to limited physical mobility. On the day of the incident, nursing documentation indicated that the resident was being changed and was positioned on his right side with his head and body on the edge of the bed when he slipped from that position and fell to the floor, landing face down and hitting his head. The nurse’s note recorded that the resident complained of knee pain, had small scratches on the right buttock, and an abrasion on the right knee, but no documented head or body injury. The physician/practitioner note confirmed that staff reported the resident hit his knees and head with staff present. The resident later stated in an interview that during a brief change he fell off the edge of the bed and hurt his knee and head. Two CNAs directly involved in the incident described that the resident was paralyzed, unable to move himself, and required two staff to roll him in bed. They reported that at the time of the fall the resident was too close to the edge of the bed before they began rolling him, and that as one CNA rolled and the other pulled the resident toward her, he slipped quickly off the side of the bed onto the floor. Both CNAs stated that the resident had not been moved sufficiently toward the opposite side of the bed before rolling, and that this lack of pre‑positioning contributed to the fall. Facility leadership and a unit manager described the expected safe procedure for turning a dependent resident, including using a draw sheet, coordinating movements, and first moving the resident toward the opposite side of the bed to create space for rolling, and the DON acknowledged that having the resident positioned on his side at the edge of the bed, as documented, did not meet expectations for safe procedure. These facts demonstrate that the facility did not ensure the environment and supervision were free from accident hazards during the resident’s in‑bed care, resulting in a fall from the bed.
Failure to Protect Cognitively Intact Resident From Roommate’s Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from abuse by his roommate during a resident-to-resident altercation. One resident with a history of spinal fusion, lower back pain, and major depressive disorder reported to an RN that his roommate physically attacked him after a disagreement about the television volume. Nursing documentation and a skin assessment noted a skin tear on the resident’s left forearm and redness on the right side of his neck, attributed to physical contact/aggression with another resident. The resident later told surveyors that his roommate started strangling him after he asked him to turn down the television volume, and the surveyor observed a quarter-sized scab on his left arm that the resident stated was from the attack. The roommate involved in the altercation was also cognitively intact and had diagnoses including cellulitis of both lower limbs, cerebral palsy, scoliosis, and documented behavioral disturbances such as physical aggression, impulsivity, verbal aggression, and poor impulse control related to a mood disorder. The care plan for this resident identified these behavioral issues and included interventions such as 15-minute checks, reducing noise, dimming lights, and offering choices. Despite these identified risks and planned interventions, the altercation occurred in the shared room, where the roommate allegedly grabbed the first resident around the neck and shoulder area after a verbal disagreement about the television volume. Nursing notes documented that the aggressor resident reported being punched in the face and then reacting by grabbing the other resident’s neck and shoulder, and that he had a minimal raised area on the left cheekbone without discoloration or pain. Interviews with staff and leadership showed uncertainty and inconsistency in recognizing and characterizing the incident as abuse. A CNA reported hearing the resident state that his roommate had choked him and observed scratches on the resident’s left arm, but did not witness the event. The DON initially described the event as a behavioral incident stemming from anger and emotions, expressed uncertainty about who grabbed whom, and stated that she did not initially consider it abuse because she viewed abuse as an intentional act, later acknowledging that the situation could probably be abuse. The Administrator described the event as a very aggressive altercation in which the roommate went under the curtain, was very angry, and went after the resident’s neck with both hands, and categorized the incident as abuse toward the resident. The facility’s abuse and neglect policy defined abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, and the facility’s own 5-day report ultimately verified the allegation of resident-to-resident abuse.
Psychotropic Medication Administered Without Required Consent
Penalty
Summary
The deficiency involves the facility’s failure to obtain a signed consent from the responsible party before initiating a new psychotropic medication, Hydroxyzine, for Resident #4. The resident was admitted with dementia with associated psychotic, mood, and anxiety disturbances, a history of UTIs, and repeated falls. An admission MDS showed a BIMS score of 02, indicating cognitive impairment, and documented behaviors including physical and verbal symptoms, other behavioral symptoms interfering with care and activities, rejection of care, and wandering. On February 3, 2026, a psych evaluation note ordered Hydroxyzine 50 mg by mouth every 6 hours as needed for anxiety manifested by calling out, and the MAR showed that the resident received four doses between February 3 and February 7, 2026. Review of the clinical record did not reveal a signed consent for the Hydroxyzine 50 mg order. LPN Staff #10 stated that consents for psychotropic medications are to be obtained at admission and must be signed by the resident or responsible party prior to administration, with verbal consent allowed if the family cannot come in to sign. After reviewing the record, Staff #10 confirmed she could not locate a signed consent for Hydroxyzine, acknowledged the medication should not have been administered without consent, and reported that the family member knew the medication was being given. She further stated that the family member had agreed to the medication during a care plan meeting but ultimately decided not to sign the consent form, and she herself had not attended that meeting. The Behavioral Health Unit Manager (LPN Staff #37) and LPN Staff #86 both confirmed that there was no signed consent for Hydroxyzine in the chart, despite the medication having been administered four times. Staff #37 stated that nurses are not to administer Hydroxyzine without a signed consent and that administration without consent was not in accordance with protocol. Staff #86 reported that the resident had been on Mirtazapine, that the family did not want the resident on Seroquel, and that the family wanted non-pharmacological interventions tried first, while acknowledging that a signed consent was required before administering Hydroxyzine. The DON (Staff #22) explained that the nurse who enters or verifies a psychotropic order is responsible for obtaining consent and that nurses are expected to check the system for a signed consent before administering such medications. She confirmed that no signed consent for Hydroxyzine could be found and that the medication had been administered four times without it. The facility’s psychoactive drug use policy stated that residents and/or responsible parties will be asked to make an informed choice concerning psychoactive drug use, with risks and benefits explained.
Delayed Reporting of Alleged Abuse to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse involving Resident #4 to the State Agency within the required regulatory timeframe. Resident #4 had dementia with cognitive impairment, as evidenced by a BIMS score of 02, and a history of behavioral symptoms that interfered with care and participation in activities. The resident’s care plan noted a potential for behaviors and directed staff to allow time for the resident to respond to directions due to dementia. An allegation of abuse involving this resident occurred on the evening of February 8, 2026, between approximately 11:30 P.M. and midnight. LPN/Staff #34, who was working the 6:00 P.M. to 6:30 A.M. shift when the alleged abuse occurred, did not report the allegation to the administrator before going home after her shift. She later stated she was in shock and that there was a lot going on at the time, and she believed she had 24 hours to report the suspected abuse. She returned to the facility and reported the allegation to the Administrator/Staff #29 around 2:00 P.M. on February 9, 2026, more than 12 hours after the incident. Interviews with another LPN (Staff #10), the Administrator, and the DON/Staff #22 confirmed that staff receive regular abuse training and that facility policy and expectations require all allegations or suspicions of abuse to be reported to the Administrator or designee immediately, and to the State Agency immediately after ensuring resident safety. The delay in reporting by Staff #34 did not meet the facility’s policy or the DON’s expectations.
Failure to Honor Resident’s Right to Personal Cellphone and Independent Communication
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to communication and personal possessions by not facilitating her access to a personal cellphone. The resident, who had diagnoses including type 2 diabetes mellitus, factitious disorder imposed on self, borderline personality disorder, major depressive disorder, anxiety disorder, and Huntington’s disease, was her own responsible party and had a BIMS score of 15, indicating she was cognitively intact. Her care plans identified risks for altered mood and psychosocial well-being related to panic disorder and emphasized encouraging alternative communication with visitors and family via phone or video calls, as well as promoting independence and assessing for lower levels of care as needed. Despite these documented needs and goals, the resident had been without a cellphone for several months after her previous phone broke, and she repeatedly expressed that she needed a cellphone. Facility documentation and staff interviews showed that the resident had financial resources available and the cognitive ability to express her needs, yet her request for a replacement cellphone was not acted upon. A behavioral health note documented that the resident complained about her phone and asked staff to use their online account to buy her a new one, and she was told that the business office and social services would be notified. The business office manager confirmed that the resident had a trust fund balance of $543.00 and stated that the resident could verbalize her needs and had requested a cellphone, but the manager was waiting for the resident’s sister to decide because the resident had previously spent $1000.00 on food using her debit card via her cellphone. The business office manager also stated that she only handled the resident’s trust fund and that the resident’s finances were otherwise managed by a third party, with the sister acting as surrogate decision maker, even though the resident’s public fiduciary petition had been denied due to her intact cognition. Additional interviews revealed that the resident did not know how to obtain another cellphone, did not have her sister’s contact number, and had not spoken with her sister since the previous year, while believing the facility had made her sister her power of attorney. The social service director acknowledged that everyone is allowed a cellphone but stated that this resident’s cellphone was considered a safety concern due to a hot phone charger, significant weight gain from ordering food, and related safety issues, and confirmed that the resident had not had a cellphone for several months. The director stated that the resident’s access to a phone was limited to using the facility phone at the nurses’ station or in the unit. The DON stated that residents with a BIMS score of 15 have the right to have their own phone and that social services and the business office should assist them in purchasing one with their own money. The facility’s Resident Rights policy affirmed residents’ rights to keep and use personal possessions and to have reasonable access to a telephone for private conversation, but the resident’s ongoing lack of a personal cellphone, despite her expressed wishes, available funds, and intact cognition, demonstrated the facility’s failure to honor her rights to communication and personal possessions as outlined in policy and regulation. The facility’s own documentation further showed that the resident’s care plan interventions included encouraging alternative communication with visitors and family members via phone and other electronic means, and encouraging participation in supportive visits and activities important to the resident. However, the resident was observed sitting somewhat apart from other residents during an activity, interacting with staff who were showing her products on a cellphone, while she herself did not have a phone. Staff interviews indicated inconsistent awareness of the resident’s cellphone status, with one CNA stating that the resident’s phone had broken the previous month and an LPN stating she did not know if the resident had a cellphone. The combination of the resident’s documented need for communication to support her psychosocial well-being, her repeated verbal requests for a cellphone, her available personal funds, and the facility’s decision to defer to a sister who was not actively involved, resulted in the resident being without a personal cellphone and without independent access to persons and services outside the facility, contrary to her rights and the facility’s own policies.
Failure to Prevent Resident-to-Resident Physical Abuse by Known Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident from physical abuse by another resident with a known history of aggression. The alleged victim, resident #911, had diagnoses including aphasia, hemiplegia, hemiparesis, dementia, major depressive disorder, and anxiety disorder, and resided on a secured unit due to vascular dementia. A recent MDS showed short- and long-term memory problems and moderate cognitive impairment in daily decision-making, with documented physical and verbal behavioral symptoms and wandering. Care plans identified risks for psychosocial well-being problems, cognitive problems, and abuse related to dementia, with interventions such as emotional support, calm reassurance, increased 1:1 activities, and monitoring for mood or behavior changes after incidents. On the date of the incident, an incident report and nursing documentation described a resident-to-resident altercation in a hallway in which another resident, identified as the occupant of room [ROOM NUMBER]B (resident #999), suddenly rose from his wheelchair and struck resident #911 twice on the nose with a closed fist. Resident #911 sustained a small, open, bleeding area across the bridge of the nose, reported pain at 5/10, and later developed bruising around the right eye. A wound care note and skin assessment documented an abrasion on the bridge of the nose, and subsequent nursing notes confirmed ongoing bruising and healing of the nasal abrasion. Social Services documented that resident #911, who had limited verbal communication and primarily responded by nodding or brief statements, recalled the incident and stated he was okay, appearing calm and without observable distress. The alleged perpetrator, resident #999, had diagnoses including dementia, anxiety disorder, schizophrenia, psychosis, and major depressive disorder, and had been placed on a secured unit due to psychosis and schizophrenia with verbal and physical aggression toward staff. Prior documentation showed a pattern of physical aggression: a nursing note from October 28, 2025 recorded that he hit another resident on the nose after claiming his wheelchair had been kicked, and a note from November 1, 2025 recorded that he hit a CNA’s hand, was verbally aggressive, and threw a bedside commode. These incidents were not reflected in care plans with specific interventions to prevent further incidents at the time they occurred. A behavioral care plan initiated later documented combative and aggressive behaviors such as yelling, hitting, and grabbing, with general interventions to monitor behaviors and protect others’ rights and safety. On the date of the abuse incident involving resident #911, an incident report and nursing notes documented that resident #999 approached resident #911 and punched him twice on the nose, later stating he did so because the other resident touched his girlfriend’s hand, although the girlfriend was not present in the hallway. The facility’s investigation, including witness and resident interviews, concluded that the allegation of abuse was verified. Facility policies on Abuse and Neglect and on Accident Hazards/Supervision/Devices required assessment, care planning, monitoring, identification of residents likely to be involved in altercations, and implementation of interventions to minimize resident-to-resident altercations, which were not effectively carried out for resident #999 despite his known aggressive history.
Failure to Protect Resident From Financial Misappropriation and Inadequate Documentation of Exploitation Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from financial misappropriation/exploitation of property by another resident and to ensure appropriate reporting of the incident. One resident, who was cognitively intact with a BIMS score of 13 and had diagnoses including anemia, COPD, weakness, and major depressive disorder, reported that money was being taken after befriending another, younger resident. This resident had a care plan addressing depression and psychosocial risks, including monitoring for changes in mood and behaviors related to situational stressors. Documentation shows that the resident became upset and distressed after an encounter involving being robbed by a fellow resident, later experiencing increased anxiety, sadness, and a desire to move to another facility. The alleged perpetrator was also cognitively intact, with a BIMS score of 15, and had diagnoses including major depressive disorder, obesity, and life management difficulty, as well as a care plan for self-harmful ideation and poor impulse control. According to the facility’s incident follow-up report, the perpetrator stated that the victim initially gave permission to use her funds and then continued to use them without permission. Staff interviews revealed that the victim had given her debit card and cash to the other resident to hold, and that the other resident used the funds to buy clothes for herself and the victim, and to purchase coins for virtual slot games. Another staff member reported noticing boxes of purchases in the alleged perpetrator’s room and learning that the victim’s debit card was being used without permission. The deficiency is further supported by inconsistencies and gaps in the facility’s documentation and reporting of the event. The incident follow-up report did not include the names of the residents involved. During the onsite survey, when a self-report for the relevant month involving the victim was requested, the administrator provided documentation that did not include any self-report for that period. The business office manager stated she had no documentation of the incident other than an investigator’s card, and the administrator reported having no prior knowledge of the incident and being unable to locate the reportable event or investigation in the facility’s records. Although staff described the situation as abuse and financial exploitation and referenced notifications to external agencies, the lack of a self-report in the requested timeframe and incomplete internal documentation demonstrate the facility’s failure to properly document and maintain records of the misappropriation incident, contributing to the cited deficiency. The facility’s own Abuse and Neglect policy states that residents are to receive care in an environment free from misappropriation of property and exploitation, and that suspected abuse will be investigated based on facts, observations, and statements from the alleged victim and witnesses. In this case, the victim’s report of stolen money, the perpetrator’s admission of continued use of funds without permission, and staff observations of unusual purchases and changes in the victim’s demeanor all point to financial misappropriation by one resident against another. The absence of a complete, identifiable self-report and investigation record available for review, along with the omission of resident names in the incident follow-up report, shows that the facility did not fully adhere to its own policy requirements in documenting and tracking this substantiated misappropriation event.
Failure to Maintain Documentation of Thorough Investigation of Alleged Financial Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation that an alleged incident of financial misappropriation between two residents was thoroughly investigated. One resident with major depressive disorder, obesity, and a history of self-harm ideation was cognitively intact per a BIMS score of 15 and did not exhibit behavioral symptoms. Another cognitively intact resident with anemia, COPD, weakness, and major depressive disorder, with a BIMS score of 13, reported being financially exploited by this fellow resident. Clinical notes show that the alleged victim became upset and anxious after reporting being robbed by another resident, spoke with detectives, experienced transient chest pain, and expressed a desire to move to another facility, eventually refusing to return after a hospital stay. The facility’s incident follow-up report for the alleged financial misappropriation did not identify the residents involved by name or number and lacked interview statements from staff or other residents who might have interacted with the two residents. Although the report stated that the interdisciplinary team completed a thorough investigation, including outreach to police, APS, and the ombudsman, it did not contain the underlying interview documentation or detailed investigative findings. During the survey, when a self-report for the month of the incident involving the alleged victim was requested, the administrator produced no self-report related to that resident for that period. Interviews with the BOM, SSD, LPN, and administrator confirmed that an allegation of financial exploitation had occurred between two residents, that it was considered abuse or financial exploitation by staff, and that external agencies and law enforcement were contacted. However, the BOM stated she had no documentation of the incident other than an investigator’s card and indicated that the SSD might have documentation. The SSD reported notifying APS and other parties and described steps she took after learning of the situation, but no corresponding investigative documentation was produced for surveyor review. The administrator, who was not employed at the time of the incident, reported having no knowledge of the event until the day before the interview and was unable to locate the reportable event or the investigation in the facility’s records, acknowledging that such a report and investigation should be retained and available. This lack of accessible, complete investigative documentation for the alleged misappropriation constitutes the cited deficiency.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline care plan within 48 hours of admission for a newly readmitted resident, as required by 42 CFR §483.21(a)(1). The resident was readmitted with diagnoses including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. An admission clinical evaluation documented that the resident arrived by wheelchair and was alert and oriented times three with some forgetfulness, and the physician’s admission history noted a recent two‑day history of weakness, falls at home, inability to ambulate, and dizziness. An admission Morse Fall Scale completed the day of admission showed a score of 65, indicating high fall risk. Despite these findings, review of the medical record revealed that no baseline care plan was developed within 48 hours of admission to provide instructions to meet the resident’s immediate needs. A comprehensive care plan was not initiated until two days after admission. That care plan identified an ADL self‑care performance deficit related to deconditioning and risk for falls related to deconditioning and gait/balance problems, and included interventions such as encouraging participation in care, ensuring the call light and commonly used items were within reach, and anticipating and promptly responding to needs. Prior to this comprehensive care plan, there was no documented baseline care plan outlining initial goals, physician orders, dietary orders, therapy services, social services, or other minimum health information necessary to guide staff in providing person‑centered care immediately after admission. The absence of a baseline care plan occurred despite the facility’s own fall prevention policy, which required timely assessment and initiation of individualized interventions for residents at risk for falls. Following admission, the resident experienced multiple falls. Nursing documentation described unsteady gait, poor balance, and the resident’s refusal to follow instructions and insistence on going to the bathroom independently, even while wearing briefs. Progress notes recorded that the resident was found on the floor on more than one occasion, with neuro checks initiated after each event and vital signs monitored. An admission MDS later showed a BIMS score of 6, indicating severely impaired cognition. In a subsequent interview, the RN stated that the unit manager is responsible for initiating the baseline care plan and confirmed that no baseline care plan was found for this resident in the electronic medical record. The DON also acknowledged that the resident’s fall care plan did not reflect the high fall risk identified in the fall assessment and that the care plan was not updated after the resident’s fall incidents. These findings collectively demonstrate that the facility did not develop and implement a baseline care plan within 48 hours of admission to address the resident’s immediate needs as required by regulation and facility policy. The facility’s fall prevention policy, adopted several months before the events, specified that each resident would be evaluated upon admission and that the IDT would review fall risk assessments and initiate fall prevention protocols as appropriate. It also stated that the DON or designee would ensure that residents identified at risk for falls or who had experienced a recent fall had all recommended interventions in place, with current assessments and documentation reflecting notification of applicable disciplines, the physician, and the resident’s family or responsible party. Despite this written process, the resident’s record lacked a timely baseline care plan and did not initially incorporate the high fall risk status into the care planning process, contributing to the cited deficiency.
Failure to Update High-Risk Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan after each fall incident, as required. The resident was readmitted with multiple diagnoses including rhabdomyolysis, adult failure to thrive, major depressive disorder, difficulty walking, and cognitive communication deficit. On admission, the resident’s mode of mobility was wheelchair, and she was documented as alert and oriented with some forgetfulness. A physician history and physical noted a recent 2‑day history of weakness and falls at home with associated dizziness and inability to ambulate. An admission Morse Fall Scale completed the same day showed a score of 65, indicating high fall risk. A comprehensive care plan dated shortly after admission identified an ADL self‑care performance deficit related to deconditioning and documented that the resident was at risk for falls related to deconditioning and gait/balance problems. Interventions initiated included encouraging participation in care, use of the call bell for assistance, anticipating and meeting needs, ensuring the call light and commonly used items were within reach, and providing prompt responses to requests for assistance. A daily skilled charting note documented that the resident had unsteady gait, poor balance, was bedfast most of the time, and sometimes refused to follow instructions, insisting on going to the bathroom even while wearing briefs. The admission MDS later showed a BIMS score of 6, indicating severely impaired cognition. The resident experienced three separate fall incidents. After the first fall, a nurse’s note documented that the resident was found sitting on the floor after slipping while trying to stand to go to the bathroom; assessments were completed, neuro checks were initiated, and fall‑related reminders and signage were implemented. After the second fall, a nurse’s note documented the resident lying on the floor, denial of head impact, initiation of neuro checks, and advice to use a walker with the walker placed within reach. After the third, unwitnessed fall, the resident was found on the floor in a prone position with a forehead laceration and a left knee skin tear, appeared confused, and was transferred to the hospital after assessment and initiation of neuro checks. Despite these three fall events and the resident’s documented high fall risk and cognitive impairment, review of the comprehensive care plan showed it was not updated after the falls on the identified dates. The DON confirmed that the resident’s fall care plan did not reflect high fall risk as indicated by the fall assessment and that the care plan was not updated after the fall incidents, contrary to facility policy requiring interdisciplinary review and implementation of individualized fall prevention interventions.
Failure to Supervise Behavioral Activities and Identify Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a hazard‑free environment and adequate supervision to prevent accidents during activities and smoking breaks, and to properly identify and plan for elopement risk. One cognitively intact resident with Huntington’s disease and significant behavioral issues was care planned as being at risk for harm to self or others, with interventions including supervision during activities and removal from group activities if behaviors became disruptive. During an observed group activity in the dining room, residents from both long‑term care and behavioral health units participated in a target‑practice game using toy guns and foam darts aimed at balloons, along with karaoke/music. The resident with Huntington’s disease was seated alone at one end of a table, facing other residents across the table, and was allowed to handle a toy gun and foam darts. A foam dart landed on this resident, who then reloaded it into the toy gun. The activity director later stated that residents should have been lined up in front of the balloons, 2–3 feet away, to prevent residents from being hit by darts and to avoid triggering behaviors, and that the aide should have repositioned residents accordingly. During this same activity session, only one activity aide was present to supervise the group. At one point, the aide left the dining/activity room to wheel a resident out, leaving all remaining residents in the activity room without any staff supervision until he returned about a minute later. The activity aide stated that residents from the behavioral unit are supposed to be 100 percent supervised during activities and acknowledged that he left the room because coworkers were busy. The activity director stated that only one staff member is assigned per activity, that staff must remain in the room at all times while residents are present, and that staff are not permitted to leave residents unattended; if assistance is needed, staff are expected to call her or a CNA. She further stated that if there is no staff with residents during an activity session, residents could have behaviors, wander into the kitchen, or go out into the hall, and that this was not safe. The deficiency also involves the facility’s failure to adequately identify and plan for elopement risk for a newly admitted, cognitively intact resident with complex psychosocial and substance‑use history. Hospital records prior to admission documented abscess and cellulitis, drug use, amphetamine use, moderate fentanyl dependence, and suicidal ideation, and the resident reported interest in obtaining medical marijuana. A psychosocial evaluation documented self‑reported bipolar disorder, schizophrenia, approximately 20 years of incarceration, and current parole status. A smoking evaluation identified the resident as a smoker who preferred morning and afternoon smoking, was considered a safe smoker, and could access smoking materials with frequent monitoring. A wandering/elopement risk assessment scored the resident as low risk, focusing on mobility, mental status, speech, and history of wandering, but did not address psychosocial, behavioral health, or substance‑use‑related risk factors. On the evening of the incident, the resident independently showered after staff covered his PICC line and wound dressing. Afterward, staff informed him that the PICC line and dressing needed to be changed, and he requested that this occur after the scheduled smoking break. During the 7:30 p.m. smoking break, the on‑duty receptionist observed the resident get into a black car and leave the facility. The physician and administrator were notified, and 911 was called; an AMA form was later entered into the record documenting that the resident left during the smoking break. The DON stated that narcotic use, homelessness, and suicidal ideation are risk factors for elopement, that the wandering/elopement assessment did not adequately evaluate this resident’s risks or capture his needs and concerns, and that the resident’s departure should have been considered an elopement rather than an AMA discharge. A case manager similarly stated that suicidal ideation, homelessness, and drug use could indicate higher elopement risk and should prompt referral to behavioral health. Further observations and interviews showed additional supervision lapses related to smoking. A receptionist stated that staff rotate responsibility for monitoring residents in the smoking area and that the receptionist is responsible for monitoring residents during the early morning and evening smoking times. However, an observation on a later morning revealed three residents smoking outside without staff supervision while the receptionist on duty remained seated inside at the reception desk. Facility policy on elopement required that all residents receive adequate supervision to ensure the safest environment possible and that residents be assessed for behaviors or conditions placing them at risk for wandering or elopement. The activities/recreation therapy policy required that programs be provided in coordination with the resident’s comprehensive assessment, but the observed practices during the target‑practice activity and smoking breaks did not align with these requirements.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Skin Tears
Penalty
Summary
The facility failed to protect a resident from abuse by another resident when a cognitively intact resident with a known history of resident-to-resident and resident-to-staff altercations engaged in a physical altercation with a cognitively impaired resident. The alleged perpetrator had diagnoses including depression, psychosis, anxiety, and dysphagia, and a recent MDS showed a BIMS score of 15, indicating intact cognition. This resident’s care plan documented a confirmed history of altercations and included an intervention to remove the resident from the environment when verbal escalation began. Despite this, the resident was able to approach another resident in the hallway and initiate an aggressive interaction. On the date of the incident, staff documented that the alleged perpetrator and the alleged victim were in the hallway when the perpetrator verbally challenged the other resident by saying, "Do you want to fight?" and then advanced toward the resident and scratched the resident’s left arm. The cognitively impaired resident, who had diagnoses including dementia, hypertension, chronic kidney disease, and depression and an MDS BIMS score of 7 indicating significant cognitive impairment, backed away and stated that she had done nothing and was just standing there when scratched. Social services documentation described three superficial skin tears approximately 3 mm by 3 mm on the victim’s left arm with a small amount of bleeding and reported that the resident experienced pain at the injury site. Facility interviews and documentation confirmed that the incident was substantiated as physical abuse. The DON and the administrator acknowledged that the aggressive behavior by the perpetrating resident toward the cognitively impaired resident in the hallway constituted physical abuse. The facility’s abuse and neglect policy stated that residents are to receive care in an environment free from any type of abuse, including physical abuse. Staff interviews indicated awareness that such an incident would be considered abuse and that responsibility for preventing it rested with facility employees, yet the event still occurred, resulting in the resident-to-resident physical altercation and injury.
Failure to Protect Resident from Verbal and Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses was not protected from verbal and physical abuse by a roommate, who also had severe cognitive impairment and a history of behavioral disturbances. The two residents were assigned to share a room after the first resident was moved due to inappropriate sexual behaviors by a previous roommate. Staff were aware of both residents' behavioral histories, including the second resident's aggressive tendencies and the first resident's vulnerability due to dementia and confusion. The incident leading to the deficiency involved the second resident becoming verbally and physically aggressive toward the first resident, including yelling inappropriate language and punching the resident while in bed. Staff intervened immediately upon hearing the altercation, separated the residents, and assessed the first resident for injuries. Documentation and interviews confirmed that the first resident did not exhibit aggressive behaviors and was calm and nonreactive during the event, while the second resident had previously expressed frustration about the roommate's behaviors and admitted to staff that he had taken matters into his own hands due to perceived lack of staff intervention. Despite knowledge of both residents' behavioral histories and the potential for conflict, the facility assigned them as roommates. Staff interviews revealed concerns about the compatibility of the room assignment, and there was a lack of awareness among some staff regarding the behavior care plans in place. The facility's failure to adequately assess and prevent the risk of resident-to-resident abuse resulted in the first resident being subjected to verbal and physical abuse, violating the resident's right to safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse by other residents. In the first incident, a resident with severe cognitive impairment, schizophrenia, and a history of physical behaviors physically assaulted another resident and a CNA. The resident was observed wandering the halls, attempting to enter other residents' rooms, and ultimately struck another resident on the head, resulting in bleeding from the lower gums. Staff interviews confirmed that the resident was redirected multiple times but was able to physically assault both a peer and a staff member before being separated. In a separate incident, another resident with severe cognitive impairment and a history of physical and verbal aggression struck a peer on the nose following a collision involving a wheelchair. The aggressor admitted to hitting the other resident in response to the perceived provocation. Staff present at the time separated the residents and assessed them for injuries, with no acute injuries noted. Both residents involved in this altercation had documented behavioral concerns and histories of aggression related to their cognitive decline. In both cases, the facility's documentation, staff interviews, and clinical records indicate that residents with known behavioral risks were able to physically harm other residents. The incidents were verified by facility-reported incident forms and involved residents with significant cognitive and behavioral challenges, including dementia, schizophrenia, and a history of aggression.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through surveyor observations and review of facility documentation, which revealed that the required safeguards and protocols were either not in place or not consistently followed. The lack of comprehensive and enforced policies contributed to an environment where incidents of abuse, neglect, or theft could occur without adequate prevention or timely detection. Surveyors noted that staff were not consistently trained or monitored regarding the prevention of these incidents, and there was insufficient evidence of regular review or updating of the facility's procedures related to resident protection.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the state agency and other mandated entities within the required timeframe for two residents. On August 21, 2025, two residents with significant cognitive and behavioral diagnoses were involved in a resident-to-resident altercation in their shared room. One resident threatened to physically harm the other, and a CNA intervened to prevent escalation. Documentation by an LPN confirmed the incident, and the facility's own investigation later verified the allegation. Despite the altercation and the facility's policy requiring immediate reporting and investigation of suspected abuse, there was no evidence that the incident was reported to the appropriate state agencies or that an investigation was initiated immediately after the event. Interviews with staff revealed that the incident was only brought to the attention of facility leadership the following day through a 24-hour report, and staff acknowledged the importance of timely reporting. The clinical records and interviews confirmed the lack of immediate action in accordance with facility policy and federal guidelines.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Prevent Abuse and Neglect Among Residents
Penalty
Summary
The facility failed to protect multiple residents from abuse and neglect, as evidenced by several incidents involving both resident-to-resident aggression and inadequate supervision. In one case, a resident with severe cognitive impairment and a history of physical and verbal aggression was taken off 1:1 supervision, which led to an altercation where this resident entered another resident's room and physically assaulted both the resident and a CNA. Staff interviews confirmed that the aggressive resident was difficult to redirect and that the incident resulted in physical contact, though no injuries were noted. The care plan for this resident had previously identified the need for close supervision due to safety concerns, but this intervention was not maintained at the time of the incident. Another incident involved a cognitively intact resident who was physically assaulted by a resident with severe dementia and a history of wandering and aggression. The aggressive resident entered the other resident's room, took personal belongings, and struck the resident multiple times when confronted. Staff interviews and documentation indicated that the aggressive resident was sometimes redirectable but could become combative, and that interventions such as frequent checks and behavioral documentation were in place. However, these measures did not prevent the physical altercation from occurring. Additionally, the facility failed to ensure the safety of a resident with Parkinson's disease and moderate cognitive impairment during an activity where hot coffee was served. The resident, who required a non-spill cup and typically used a straw due to tremors, was given an open cup without a straw and was not adequately supervised. As a result, the resident spilled hot coffee on herself, sustaining a partial thickness burn. Staff interviews revealed inconsistent knowledge and implementation of the resident's care needs, and the care plan lacked specific interventions to prevent burns, despite identifying the risk.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse and neglect involving a resident was reported to the State Survey Agency within the required timeframe. The resident, who was cognitively intact and had a history of behavioral symptoms and resistance to care, reported that a CNA had been mean to him and was subsequently removed from his care. The resident expressed feelings of being treated poorly and mentioned possible retaliation but was unable to provide specific details or dates regarding the incident. Interviews with multiple staff members, including CNAs, an LPN, and the DON, revealed inconsistent knowledge and actions regarding the reporting of the abuse allegation. While staff acknowledged the requirement to report abuse allegations immediately, there was confusion and lack of clarity about who was responsible for making the report. The LPN admitted to not reporting the allegation, assuming that another shift had already done so, and the DON confirmed that she had not received any report regarding the incident. A review of internal records showed no evidence that the alleged abuse had been reported to the state agency as required by facility policy. Staff interviews indicated that while there was awareness of the need for immediate reporting and regular training on abuse prevention, the process was not followed in this instance, resulting in a failure to notify the appropriate authorities about the allegation.
Failure to Monitor and Document Resident Behaviors Before Medication Administration
Penalty
Summary
The facility failed to ensure that behaviors were monitored and documented prior to medication administration for two residents, which could result in over-medication. Resident #1, who was admitted with diagnoses including atrial fibrillation, chronic kidney disease, and major depressive disorder, had a BIMS score indicating severe cognitive impairment. Despite being prescribed Paroxetine and Risperidone for depression and psychotic disorders, there was no evidence in the care plan or medication records that behaviors or side effects were being monitored. Similarly, Resident #2, who had severe cognitive impairment and was prescribed Escitalopram and Olanzapine for depression and mood stabilization, also lacked documentation of behavior monitoring in the medication records. Interviews with facility staff, including a CNA, RN, ADON, and DON, confirmed that behaviors should have been tracked in the electronic health record and TAR, but were not. The staff acknowledged the risk of administering medication unnecessarily if behaviors are not monitored. The facility's policy on medication administration and documentation requires that medications meet the needs of the resident and that any changes in the resident's condition be documented, which was not adhered to in these cases.
Failure to Conduct and Document Neurochecks After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who had a severe cognitive impairment and was at high risk for falls, experienced an unwitnessed fall resulting in an abrasion to the back of the head. Despite the facility's policy requiring comprehensive neurological assessments following such incidents, only one neurocheck was documented, indicating a failure to adhere to the established protocol. Interviews with staff, including a CNA, RN, ADON, and DON, confirmed that neurochecks are critical for identifying potential issues such as brain bleeds following a fall. The facility's policy outlined specific intervals for conducting neurochecks, which were not followed in this case. The lack of documentation and adherence to the neurocheck schedule posed a risk of missing a change in the resident's condition, as acknowledged by the staff.
Failure to Protect Residents from Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure residents were free from abuse, as evidenced by an incident involving two residents with cognitive impairments. Resident #114, who was moderately cognitively impaired with dementia and bipolar disorder, was found in a male resident's room without pants, with the male resident's hand in her groin area. This incident occurred despite the resident being on a care plan that included frequent safety checks and interventions to prevent wandering and inappropriate behavior. The care plan was not effectively implemented, as the resident continued to wander into other residents' rooms and engage in inappropriate behavior. Staff interviews revealed that there was insufficient supervision on the day of the incident, with only two CNAs and a float covering multiple halls. The CNAs reported that the residents on this particular hall required more supervision due to their cognitive impairments and behaviors. The staff also indicated that both residents involved in the incident were not capable of consent due to their cognitive impairments, yet the facility's Director of Nursing stated that a person is capable of consent unless deemed otherwise by a court. The facility's policy on abuse and neglect defines sexual abuse as non-consensual sexual contact with a resident, which includes situations where a resident lacks the cognitive ability to consent. Despite this policy, the incident was not immediately recognized as abuse by some staff members, and there was confusion about the appropriate response and documentation. The facility's failure to adequately supervise and protect residents from abuse, as well as the lack of clarity in staff roles and responsibilities, contributed to this deficiency.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from physical abuse, resulting in an incident where one resident was physically assaulted by another. Resident #1, who has a history of cognitive and psychological disorders, was attacked by Resident #2 with a television remote control, causing an abrasion to the back of his right ear. The incident occurred despite Resident #2's care plan requiring one-to-one supervision at all times due to severe cognitive impairment and a history of wandering. The deficiency was primarily due to the inaction of staff #46, a CNA assigned to provide one-on-one supervision for Resident #2. On the night of the incident, the CNA allowed Resident #2 to be unsupervised while in the bathroom, which had a door leading to another resident's room. This lapse in supervision enabled Resident #2 to leave the bathroom unnoticed and enter Resident #1's room, where the assault took place. Staff #46 admitted to not maintaining the required arm's length supervision and acknowledged the potential risk of harm due to this oversight. Interviews with other staff members, including a registered nurse and the Director of Nursing, confirmed that the facility's policy mandates residents be free from abuse and that proper supervision is crucial to prevent such incidents. The failure to adhere to the care plan's supervision requirements directly contributed to the occurrence of resident-to-resident abuse, highlighting a significant deficiency in the facility's ability to ensure resident safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent an avoidable elopement of a resident, who was admitted with mild cognitive impairment, schizoaffective disorder, and aphasia. The resident was initially assessed as a low risk for wandering or elopement, and no further Wander Risk Scale assessments were conducted during their stay. Despite the resident's inability to complete a Brief Interview for Mental Status (BIMS) assessment, their cognitive skills were assessed as modified independence. The care plan was revised to address the resident's elopement risk, including interventions such as socialization encouragement and reminders of their placement in the unit. The resident's progress notes indicated multiple instances of exit-seeking behavior and discussions about leaving the facility. On September 19, 2024, the resident was identified as a high elopement risk after successfully exiting the secured unit by following staff. Staff were subsequently educated on the importance of securing exit doors. However, on September 20, 2024, the resident left the secured unit with their belongings. Staff attempted to redirect the resident back to the facility but were unsuccessful, leading to police and family involvement. The resident ultimately agreed to go to a crisis facility instead of returning. Interviews with staff revealed that a kitchen staff member mistakenly allowed the resident to exit the secured unit, believing them to be a visitor due to their backpack. The staff member did not verify if the resident had a badge or visitor's sticker. The Director of Nursing explained that residents were expected to be escorted and that staff should ensure doors are closed. The facility lacked a documented policy for security doors, which was requested but not provided.
Failure to Address Resident Council Concerns and Grievances
Penalty
Summary
The facility failed to demonstrate that resident council meetings were held regularly and that grievances and recommendations voiced during these meetings were addressed. A review of the resident council minutes for the past six months revealed no written documentation of feedback provided to residents regarding issues brought forth during the meetings. Additionally, the grievance log showed no evidence of written documentation that grievances had been addressed, with logs denoting an open date but not a closed date. Interviews with residents and staff confirmed that issues raised during resident council meetings were not followed up on, and residents were not informed of the outcomes of their grievances or recommendations. Interviews with the Ombudsman and several residents revealed that the most recent resident council meeting had been canceled by the facility and not rescheduled. Residents expressed frustration that their concerns, such as quality of food, installation of grab bars, and night-time staffing issues, were not being addressed. The activities director and the director of social services confirmed that there was no documentation of feedback provided to residents and that responses to grievances were only given verbally. The director of social services also acknowledged that the grievance log was incomplete and that responses to formal grievances were not documented. The administrator stated that her expectation was for residents to feel heard and for necessary changes to be made based on their feedback. However, the facility's policies on resident rights and grievance procedures were not being followed, as there was no evidence of a facility response to resident council concerns or written documentation of grievance decisions. This lack of communication and follow-up could lead to residents feeling unheard and upset, as confirmed by staff interviews.
Failure to Serve Meals Simultaneously to Seated Residents
Penalty
Summary
The facility failed to ensure that meals were provided to residents seated together at the same time, compromising their dignity and potentially affecting their mental health. On 11/01/23 at 12:30 PM, an observation in the downstairs B hall dining room revealed that residents were served meals sporadically without regard to their seating arrangements. Specifically, a corner table with two residents was served first and second to last, while other tables were served in a similar disorganized manner. Interviews with the Food Service Director and the Administrator confirmed that staff were expected to serve all persons at a table simultaneously, which was not done in this instance.
Failure to Inform Resident of Their Rights
Penalty
Summary
The facility failed to ensure that a resident was informed of their rights during their stay. The resident, who was admitted with a fracture of the left patella, stated during an interview that she was curious about her rights and had not been provided a copy of them. An interview with an LPN revealed that the admission packet reviewed by the nurse did not include a copy of the resident rights. Further investigation showed that the facility had two admission packets, one clinical and one non-clinical, with the latter containing the resident rights information. However, due to the absence of a ward clerk, the non-clinical packet had not been completed for some time, and no one had been providing residents with a copy of their rights during this period. The Director of Nursing and Assistant Director of Nursing confirmed that the responsibility of providing the resident rights form did not fall on the nurses and acknowledged the lapse in the process due to the lack of a ward clerk. The facility's policy included in the admission packet mandates a copy of the patient's rights along with an acknowledgment of receipt. Despite this policy, the absence of a ward clerk led to a failure in providing residents with their rights information. The new ward clerk was still in training, and the process of completing the second admission packet had not resumed. This deficiency highlights a significant gap in the facility's admission process, potentially leaving residents uninformed about their rights and unable to advocate for themselves effectively.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that Resident #51 was protected from physical abuse by another resident, Resident #154. Resident #51, who has dementia and moderate cognitive impairment, was the victim of three altercations with Resident #154. Despite these incidents, Resident #154's care plan did not include any goals or interventions related to her physical aggression towards staff and other residents. The facility's policy requires that care plans be updated to address behaviors that might lead to conflict, but this was not done for Resident #154, who had a history of aggressive behavior documented in nursing notes and internal incident reports. Resident #154, who also has dementia, exhibited multiple instances of physical aggression towards staff and other residents. Her behavior was documented in nursing notes and internal incident reports, but her care plan did not reflect any interventions to manage her aggression. The facility's policy on preventing abuse states that staff should identify, assess, develop care plan interventions, and monitor residents with behaviors that might lead to conflict. However, this policy was not followed, as evidenced by the lack of behavior monitoring orders and incomplete Certified Nursing Assistant daily task documentation for Resident #154. Interviews with staff, including an LPN and the DON, revealed that care plans should be updated after every incident and should include specific interventions for residents who exhibit aggressive behavior. Despite this, Resident #154's care plan remained unchanged, and no new interventions were added to address her aggression. This failure to update the care plan and implement appropriate interventions contributed to the continued physical abuse of Resident #51 by Resident #154.
Failure to Ensure Timely PASARR Level II Referrals
Penalty
Summary
The facility failed to ensure timely referrals for PASARR level II determinations for two residents, which could result in the residents not receiving the appropriate level of services. Resident #56, who was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and epilepsy, required a level II PASARR review. Although the Director of Social Services claimed to have sent the PASARR to the state in October 2023, there was no documentation to support this, and a follow-up email was only sent on November 2, 2023. The facility's policy requires timely referrals to ensure residents receive appropriate services, but this was not adhered to in this case. Resident #38, who was admitted with diagnoses of major depression, bipolar disorder, and anxiety disorder, also did not receive a timely PASARR level II referral. The resident had a history of suicidal ideation and attempts, including a recent hospitalization for a suicide attempt. Despite this, the PASARR level I screening from the hospital did not indicate the need for a level II referral. The Director of Social Services admitted that a mistake was made in completing the PASARR, as the resident's recent suicide attempt warranted a level II referral. The facility's policy mandates referrals for residents with serious mental disorders, but this was not followed. Interviews with the Director of Social Services and the Administrator revealed that the facility's expectation is for PASARRs to be conducted on admission and reviewed for accuracy. However, the failure to send timely referrals for level II PASARR reviews for both residents #56 and #38 indicates a lapse in following these procedures. This deficiency could result in residents not receiving the appropriate services based on their diagnoses, as required by the facility's policy and state regulations.
Failure to Include Resident in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was able to participate in the care planning process. Resident #114, who was admitted with diagnoses including peripheral vascular disease, morbid obesity, gout, difficulty walking, weakness, hypothyroidism, and hypertension, had a BIMS score indicating cognitive intactness. However, there was no evidence in the resident's electronic health record or the interdisciplinary care conference summary that the resident had participated in the care plan conference. The resident confirmed in an interview that he had not been invited to his care plan meetings for about a year, despite being fairly independent and wanting to provide input for his return to the community. The director of social services explained the scheduling process for care plans and acknowledged that resident participation is inconsistent. He admitted that there was no documentation indicating that Resident #114 had been invited, attended, or refused the care plan meetings. The administrator confirmed that care plans should be reflective of the patient's care and updated as changes occur, with the expectation that the resident or their representative is invited to attend. A review of the facility's care plan policy revealed that residents or family members should be notified in advance of care plan meetings, but this was not done for Resident #114, and no documentation of advance notification, attendance, or declination was evident in the medical record.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered for three residents, resulting in incorrect medication administration. Resident #448, diagnosed with Type 2 Diabetes Mellitus, Hypothyroidism, and Hypertension, was given Insulin Glargine instead of the prescribed Insulin Detemir. This error was observed during a medication administration by an LPN, who later acknowledged the mistake. Resident #38, with diagnoses including Chronic Obstructive Pulmonary Disease and Anxiety Disorder, received a 7 mg Nicotine Patch instead of the ordered 21 mg patch. This error was observed during a medication administration by an RN, who also recognized the mistake upon review. Resident #99, diagnosed with Cognitive Communication Deficit and Cachexia, was given a chewable Aspirin tablet instead of the prescribed enteric-coated Aspirin capsule. This error was observed during a medication administration by an LPN, who justified the substitution due to the unavailability of the correct form in the medication cart. The facility's Clinical Services Policy and Guidelines for Implementation #759, which outlines the six rights of medication administration, were not followed in these instances. The Director of Nursing confirmed that these errors did not meet the facility's standards and acknowledged the need for proper medication administration practices. The errors were identified through observations, staff interviews, and a review of clinical records and policies, highlighting a failure to adhere to professional standards of quality in medication administration.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activities program was directed by a qualified professional. The personnel file review for the Activity Director revealed that she was hired without the necessary qualifications for the position. Despite being aware of this, the facility's owners and Administrator allowed her to transfer from another facility without completing the required training course for Activity Directors. An interview with the Director of Human Resources confirmed that there had been no further discussion about completing the training course. The job description for the Activity Director position clearly states that satisfactory completion of a training course and a minimum of two years of experience in a social or recreational program are required qualifications, which the current Activity Director did not meet.
Failure to Ensure Environment Free of Accident Hazards Due to Medications at Bedside
Penalty
Summary
The facility failed to ensure the environment for Resident #58 remained free of accident hazards due to medications being left at the bedside, posing a potential risk of medication self-administration. Resident #58, who is cognitively intact with a Brief Interview for Mental Status score of 15, had several medications within reach, including Zinc Oxide 20% Ointment, Antifungal Powder Miconazole Nitrate 2%, Medicated Body Powder Menthol 0.15%, and Maximum Strength Pain and Itch Relief Cream Lidocaine HCI 4%. There was no evidence of any medication self-administration assessment, request, or approval order by the interdisciplinary team for Resident #58. The antifungal medication was found to have been discontinued on October 16, 2023, yet it was still present at the bedside. Interviews with staff confirmed that the medications should not have been at the bedside without proper approval and assessment. LPN Staff #56 and #131, as well as the Assistant Director of Nursing and the Director of Nursing, acknowledged the risks associated with medications being left at the bedside, including the potential for incorrect usage and double dosing. The facility's policy requires that a resident may self-administer medications only after the interdisciplinary team has determined it is safe and appropriate, with proper documentation in the resident's medical record and care plan. This policy was not followed in the case of Resident #58, leading to the identified deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was below 5%, resulting in an observed error rate of 11.11%. This was identified during a medication administration observation involving 27 randomly selected opportunities by four licensed nurses. Three medication errors were observed involving three residents. One resident with Type 2 Diabetes Mellitus was administered Insulin Glargine instead of the prescribed Insulin Determine. Another resident with Chronic Obstructive Pulmonary Disease and Anxiety Disorder was given a Nicotine Patch 7 Mg/24 hr instead of the prescribed 21 Mg/24 hr. A third resident with Cognitive Communication Deficit and Adult Failure to Thrive received a chewable Aspirin Oral Tablet instead of the prescribed enteric-coated Aspirin Oral Capsule. The Director of Nursing acknowledged that the medication error rate was the highest it had ever been and did not meet the facility's expectations. The facility's Clinical Services Policy and Guidelines for Implementation state that the medication error rate should be less than 5%. The observed errors were in direct violation of this policy, as medications were not prepared and administered in accordance with the prescriber's orders.
Expired Medications and Devices Found in Storage
Penalty
Summary
The facility failed to ensure that expired medications and devices were not readily accessible for use in the medication supply room and medication cart. During a medication storage observation, 13 expired enteral feeding supplies were found in the 2nd floor medication storage supply room. The expiration date on these devices was July 28, 2023. The Licensed Practical Nurse (LPN) confirmed the expiration dates and acknowledged that all products in the medication storage supply room are expected to be checked weekly. Additionally, during another medication storage observation, an expired topical medication with an expiration date of May 2023 was found in a medication cart on the 2nd floor B wing. The LPN confirmed that the expired medication would be discarded and not given to residents. An interview with the Director of Nursing (DON) revealed that the facility had recently performed an audit of the medication carts and expected that all expired medications would be removed. The DON stated that medications and supplies which are out-of-date should be discarded. The facility's Clinical Services Policy and Guidelines for Implementation also specify that medications should be prepared and administered in accordance with manufacturer's specifications and accepted standards of practice.
Failure to Provide Palatable and Appetizing Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was provided at a palatable and appetizing temperature, as evidenced by multiple resident complaints and direct observations. Resident council meeting minutes from three out of four months included food complaints. Interviews with the ombudsman and several residents revealed consistent dissatisfaction with the temperature and quality of the food. Specific complaints included food being cold when it should be hot and overall poor quality of meals. For instance, one resident mentioned that the food had not been at an acceptable temperature for a week, while another stated that almost every meal was a 'lost cause.' Additionally, a test tray observation showed that the temperatures of the food items were below the facility's standard, with beans at 123°F, rice at 106°F, and taco meat at 103°F. The facility's policy, dated July 2018, mandates that food should be served at an appetizing temperature and meet the residents' needs. However, the Administrator acknowledged that the food should be served at 120°F and admitted that the current food service did not meet her expectations. Despite this, she noted that food temperature and quality should be individualized to meet resident preferences. The failure to adhere to these standards has led to widespread dissatisfaction among residents, as documented through interviews and direct observations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the handling and storage of food items. Observations revealed that an uncovered cart loaded with uncovered cakes was transported through a hallway past COVID-19 isolation rooms before being served to residents. Additionally, a resident refrigerator/freezer was found to contain undated and expired food items, including a coagulated carton of milk and browning apples. The refrigerator was also noted to be stained and filthy, with spilled food and undated personal food items. Interviews with staff confirmed that the food items were not dated and that the refrigerator did not meet the facility's expectations for cleanliness and food safety. A resident reported that the refrigerator had been in a poor condition for 2.5 months, and the Assistant Director of Nursing and Food Service Director acknowledged the deficiencies. The facility's policy on food safety requires that food items be labeled and dated, and that food be covered when transported. However, these standards were not met, as evidenced by the uncovered cakes and drinks, and the undated and expired food items in the resident refrigerator/freezer. The Administrator confirmed that the refrigerator should be cleaned weekly and that food items should be maintained according to regulatory standards, which was not the case in this instance.
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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