Unlicensed In-House Dialysis Services Provided Without State Approval
Summary
The facility failed to obtain approval from the state agency for a modification of its health care institution license prior to establishing and providing in-house dialysis services. Despite this, bedside hemodialysis treatments were administered to three residents with end stage renal disease over a period of several months. Documentation requests during the survey revealed that the facility could not provide a modified license for in-house dialysis services or a license for the contracted dialysis provider. The facility assessment did not specify the number of residents with end stage renal disease or those receiving bedside hemodialysis. Staff interviews confirmed awareness of the ongoing bedside dialysis treatments, with both a CNA and an LPN acknowledging that residents were receiving hemodialysis in their rooms. The Executive Director stated that the facility was unable to obtain the required license to provide dialysis services. The deficiency was identified through clinical record review, staff interviews, and policy review, and it was noted that the facility did not comply with Arizona Administrative Code requirements for providing dialysis services on the premises.
Penalty
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The facility did not ensure that its social services department was directed and supervised by a qualified social worker, resulting in all residents receiving social services from unqualified staff. The Social Services Director reported having a bachelor's degree in engineering, while the facility’s job descriptions required a bachelor's degree in Social Work or Human Services. Human Resources confirmed the lack of appropriate educational qualifications, and the administrator acknowledged that there was no qualified social worker overseeing the department. This was inconsistent with the facility assessment, facility policy, and state Title 22 regulations, all of which required a qualified social worker to organize, direct, and supervise social work services.
Surveyors found that the social services department was directed for many years by an SSD who had only a high school education and an old certificate course, with no additional training, and no qualified social worker supervising or directing the department. The OM acknowledged that the facility had revised the SSD job description to remove minimum education and experience requirements, despite earlier versions requiring a BSW and experience. The ADM confirmed that the SSD was the sole social services staff member and that there was no qualified social worker overseeing the unit, even though facility policy and the facility assessment called for a qualified social worker and full-time social worker coverage, resulting in all residents receiving social services from unqualified staff.
The facility failed to notify CMS and receive authorization for a facility name change. Surveyors observed the outside sign using the Excelcare name, and the LNHA stated the name change had been sent to the state but not completed through CMS. The DON’s business card and the Facility Assessment also used the Excelcare name, and a letter showed written notice to the Assistant Commissioner about new management, but no CMS approval was provided.
Staff failed to consistently wear required identification badges while on duty, contrary to facility policy and state regulations. Surveyors observed an LVN wearing an ID badge clipped below the waist, a care coordinator assisting a resident with documents without a badge, a hairdresser moving between rooms without a badge, a newly hired treatment nurse without a badge, and another LVN at the nurses’ station who had forgotten to put a badge back on after lunch. One resident with anorexia nervosa, schizophrenia, and anxiety disorder, who was cognitively intact and dependent on staff for several ADLs, reported that multiple staff did not wear badges and stated a need for staff to wear them to know who was providing care. Another resident with a right arm fracture, T2DM, and lack of coordination, with moderately impaired cognition and ADL dependence, was also involved in these observations.
Surveyors found that the facility failed to comply with state requirements that resident beds be kept at least three feet from radiators, resulting in harm to a resident whose bed had been placed too close to a radiator. During an abbreviated survey triggered by this incident, interviews and room measurements showed that multiple beds in sampled rooms were positioned less than 36 inches from radiators, confirming that resident equipment was not consistently maintained at the required distance.
Failure to Verify Licensure at Hire: The facility failed to verify licensure at the time of hire for two LPNs and two CNAs reviewed. Staff could not provide evidence that the required license checks were completed when the employees were hired, despite the HR Director stating that license verification is part of the hiring process and the facility's abuse prevention program.
Unqualified Staff Directing Social Services Department
Penalty
Summary
The facility failed to comply with Federal and California Title 22 requirements, as well as its own policies and facility assessment, by not ensuring that the social services department was staffed and supervised by a qualified social worker. The Social Services Director (SSD), identified as the primary staff responsible for the social services department, reported having a bachelor's degree in engineering. Human Resources confirmed that the SSD’s two job descriptions for Social Services Director, dated 3/2017 and 2/2024, required a minimum of a bachelor's degree in Social Work or Human Services, and that the facility had no record of the SSD having such qualifications. The administrator acknowledged awareness that the SSD did not meet the qualifications outlined in the facility job description and that the facility did not have a qualified social worker to supervise or direct the department. The facility assessment dated 2/26 documented that the facility’s staffing plan included a full-time social worker, and the facility’s policy and procedure titled “Social Services,” dated 2001, stated that the director of social services is a qualified social worker. State regulations reviewed by surveyors defined social work services and required that the social work service unit be organized, directed, and supervised by a social worker responsible for supervising other social work staff, including social work assistants. Despite these requirements, all 98 residents were receiving medically related social services from staff who did not meet the regulatory or facility-defined qualifications for a social worker or social services director.
Unqualified Staff Directing Social Services Department
Penalty
Summary
The facility failed to ensure that its social services department was directed and supervised by a qualified social worker as required by State regulation for more than nine years. The Social Services Director (SSD) reported being the only staff member in the social services department and confirmed having worked in that role for over nine years without holding a bachelor's degree in any field. The SSD stated their only training for the position was a certificate course completed in 1997, with no continuing education or additional training since that time. Review of the SSD's 1997 resume showed high school as the highest level of education completed. Review of two SSD job descriptions dated July 2022 and December 2025 showed that the earlier version required a Bachelor of Science in Social Work and two years of experience, with an MSW preferred, while the later version listed those qualifications only as preferred and, according to the Operations Manager (OM), effectively removed any minimum education or experience requirements. The Administrator (ADM) confirmed that the SSD was the only staff member in the social services department and that there was no qualified social worker supervising or directing the department, and acknowledged awareness that the SSD did not meet qualified social worker requirements. Facility policy dated February 2024 stated that the director of social services was a qualified social worker, and the facility assessment from December 2025 identified a need for a full-time social worker on AM and PM shifts. State regulations reviewed defined social work services and required that the social work service unit be organized, directed, and supervised by a social worker, which was not met in this facility, resulting in all residents receiving social services from unqualified staff.
Failure to Obtain CMS Approval for Facility Name Change
Penalty
Summary
The facility failed to notify CMS and obtain authorization for a change in facility name in accordance with 42 CFR 424.516. During surveyor observation on 3/26/26 at 8:55 AM, the sign outside the facility identified the building as Excelcare at [NAME] rather than [NAME] at [NAME]. When interviewed later that morning, the LNHA stated that the facility was now owned by Excelcare and that a request for the name change had been sent to the state, but the change had not yet been completed through CMS. Additional documents reviewed by the surveyor reflected the Excelcare name on the DON’s business card and on the cover pages of the Facility Assessment. On 3/27/26, the LNHA provided a letter dated February 28, 2025 showing written notification to the Assistant Commissioner regarding an agreement for new management. The survey team met with the LNHA and DON to discuss the use of the ExcelCare at [NAME] facility name without CMS approval, and no further information or documentation was provided to refute the findings.
Staff Failure to Wear Required Identification Badges
Penalty
Summary
The facility failed to ensure staff complied with state regulations and its own policy requiring employees to wear identification name badges at all times while on duty. Surveyors observed multiple staff members either not wearing ID badges or wearing them improperly. One LVN had an ID badge clipped to a pants pocket below the waist and stated this was their usual practice. A care coordinator working with a resident in the lobby to sign documents was not wearing an ID badge and stated they did not have it with them. The hairdresser was observed going from room to room without an ID badge and stated they did not have one. A treatment nurse, identified as a newly hired staff member, was not wearing an ID badge and stated they had not yet been given one. Another LVN at the nurses’ station was not wearing an ID badge and stated they had forgotten to put it on after returning from lunch. Resident records showed that one resident admitted with anorexia nervosa, schizophrenia, and anxiety disorder had no cognitive impairment and required varying levels of assistance with ADLs such as bathing, toileting hygiene, oral hygiene, and dressing. Another resident, admitted with a right arm fracture, type 2 diabetes mellitus, and lack of coordination, had moderately impaired cognitive skills and required substantial to partial assistance with ADLs including bathing, dressing, toileting hygiene, and oral hygiene. During an interview, the cognitively intact resident stated that multiple staff did not wear ID badges while working and expressed a need for staff to wear badges so the resident would know who was providing their care. Review of the facility’s “Identification Name Badges” policy indicated that each employee must wear an identification name badge at all times while on duty, and state regulation (California Code of Regulations, Title 22, Section 72501(h)) requires all employees serving patients or the public to wear name and title badges unless contraindicated.
Noncompliant Bed Placement Near Radiators Resulting in Resident Harm
Penalty
Summary
The deficiency involves the facility’s failure to comply with N.Y. Comp. Codes R. & Regs. Tit. 10 § 713-1.3(h)(1), which requires that resident beds be placed so they can be approached from at least one side and one end and that no bed be closer than three feet to a window, radiator, or an adjacent bed. During an abbreviated survey conducted in response to an incident, surveyors determined that at least one resident’s bed had been positioned less than three feet from a radiator. This improper placement of the resident’s bed resulted in harm to that resident. The report identifies this as a failure to ensure compliance with applicable State and local laws governing the design and equipment of resident bedrooms for adequate nursing care, comfort, and privacy. Interviews and record review during the survey confirmed that the facility had not consistently maintained the required minimum three-foot distance between resident beds and radiators prior to the incident. The Maintenance Director reported that the bed in the involved room had been moved away from the radiator after the incident, preventing assessment of the original distance from the radiator. A sample of rooms measured by surveyors showed several beds with distances from the radiator to the mattress of less than 36 inches, including measurements of 32, 34, and 35 inches, indicating that the deficiency was not isolated to a single room. These findings support that the facility did not ensure resident equipment (beds) was kept at the minimum required distance from radiators, leading to the cited harm to a resident.
Failure to Verify Licensure at Hire
Penalty
Summary
The facility failed to follow state regulations at the time of hire for four of five staff records reviewed: LPN #8, LPN #9, CNA #10, and CNA #11. Based on staff interviews and facility document review, the facility did not provide evidence that professional licensure was verified at the time these employees were hired. Virginia state regulation 12VAC5-371-210 requires the nursing facility to verify that a nurse aide is a certified nurse aide in good standing before allowing the individual to perform resident care duties. On 2/23/26, facility staff were asked to provide evidence of license verification at the time of hire for the four employees, whose hire dates were identified by the Director of HR as 3/18/25 for LPN #8, 3/24/25 for LPN #9, 5/13/25 for CNA #10, and 10/10/25 for CNA #11. Despite multiple requests, no evidence of verification at the time of hire was provided. The administrator and DON were informed of the concern, and the DON stated that license verification at the time of hire is important to make sure staff members are competent and to prevent resident abuse. The Director of HR stated she was responsible for overall license verification and described a process that included obtaining a copy of the license during the initial interview and later verifying it through the state department of health professions, with an additional verification by the employee's manager after the employee had started work with residents.
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