Desert Terrace Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 2509 North 24th Street, Phoenix, Arizona 85008
- CMS Provider Number
- 035014
- Inspections on file
- 23
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Desert Terrace Healthcare Center during CMS and state inspections, most recent first.
A nurse was hired and worked as an RN for an extended period without a valid Arizona RN license after HR verified the wrong individual’s license based on a similar name and did not obtain a copy of the actual license. The nurse functioned as a floor RN, passing meds and assessing residents, while only holding an RN license from a non-compact state and awaiting Arizona endorsement. AZBN later informed HR that the nurse did not have an active Arizona license and should not be working as an RN, but the nurse continued to be scheduled for several days after this notification. The Administrator and DON initially believed or assumed the out-of-state license allowed practice, and only later confirmed that the other state was not part of the Nurse Licensure Compact, contrary to facility policy requiring verification and documentation of valid licensure before staff work in licensed roles.
A resident with vascular dementia and moderate cognitive impairment became private pay after insurance coverage ended, and the business office processed a credit card payment using a "Credit Card Authorization Form" that lacked the resident’s signature and did not document the time of completion. Staff recorded detailed card information and the amount to be charged, but only wrote "via phone" on the signature line to reflect the resident’s telephone consent, without any additional documentation of the exchange. Financial records showed room and board charges, a partial payment, and an outstanding balance, while the resident’s later-appointed fiduciary reported that funds were taken during the resident’s stay and that financial mail was left unsecured in the room. Review of federal guidance and facility policies showed that required systems for written authorization and complete documentation of resident fund transactions were not followed.
A resident with vascular dementia and moderate cognitive impairment, who transitioned from insurance coverage to private pay, had large sums of money allegedly drained from personal accounts while residing in the facility. The resident’s private fiduciary reported suspected fraud to the facility and police, requested records, and stated that the resident’s financial mail and retirement statements were kept unsecured in a nightstand accessible to anyone entering the room. Although the Business Manager notified the then-administrator of the fiduciary’s allegations and request that facility staff be investigated, the current administrator later acknowledged that no investigation was conducted, contrary to the facility’s abuse policy requiring prompt, thorough investigation of all allegations of misappropriation and exploitation.
A resident with vascular dementia and moderate cognitive impairment had a private fiduciary who reported that the resident’s account had been drained of a large sum of money and that police were investigating possible fraud involving facility staff. The BM documented the fiduciary’s allegations and informed the administrator, who indicated he would seek further advice, but no investigation or self-report to the state agency was completed. Later, the fiduciary stated that money had been taken while the resident was in the facility and that she could not pay the facility, yet records confirmed there were no self-reports, despite facility policies requiring external reporting of suspected crimes, abuse, and misappropriation.
A resident with multiple chronic conditions and a cognitively intact BIMS score was found with two medications, including Fluticasone nasal spray and Bacitracin ointment, left at the bedside without any care plan, physician order, or interdisciplinary documentation authorizing self-administration. The resident reported using the medications independently, and a follow-up observation with the DON again confirmed the medications at the bedside, contrary to facility policies requiring interdisciplinary assessment for self-administration and locked storage of all drugs and biologicals.
A resident with cognitive and physical impairments was physically assaulted by a roommate, resulting in multiple facial lacerations. The incident was discovered after another resident alerted a CNA, who found the injured resident and the aggressor in the room. The aggressor admitted to the assault following a verbal altercation. Facility documentation and staff interviews confirmed the event, which occurred despite policies prohibiting abuse and requiring resident protection.
Two residents with significant cognitive and physical impairments, both dependent on staff for personal hygiene, were found with markedly overgrown and discolored toenails, and in one case long fingernails with food debris, indicating that nail care was not consistently provided as part of ADL assistance. Observations over several days showed one resident’s toenails curling over the tops and pads of the toes despite an existing podiatry-related order and shower documentation noting the need for nail clipping, with no corresponding podiatry visit ordered or documented. For the other resident, shower sheets were inconsistently completed regarding nail care, and toenails remained long even after fingernails were clipped. Staff interviews across CNAs, an RN, an LPN, MDS, social services, and case management revealed confusion and conflicting understandings about who was responsible for arranging nail care and podiatry services, contributing to the failure to meet grooming and hygiene needs as required by facility policy.
A resident with a history of mood disorders and substance abuse assaulted another resident on the smoking patio, resulting in a physical altercation. Despite staff training on deescalation and supervision, the incident occurred, indicating a lapse in monitoring and intervention. The facility's policy on preventing abuse was not effectively implemented, leading to a deficiency in resident protection.
Two residents were involved in separate incidents of abuse by another resident with behavioral issues. The first incident involved a verbal altercation where a cellphone was thrown, and the second involved a physical kick. Both incidents were witnessed by staff, who noted the aggressor's history of verbal aggression and behavioral issues.
A resident with type 2 diabetes and other conditions had missing documentation of blood sugar results and vital signs in their medical records. Insulin was administered without recorded blood glucose monitoring, contrary to facility policy. Staff interviews revealed inconsistencies in documentation practices, and the Director of Nursing acknowledged the failure to meet facility expectations.
Unlicensed RN Allowed to Work Due to Faulty License Verification
Penalty
Summary
The facility failed to ensure that a licensed nursing staff member possessed a valid Arizona RN license during the entire period of her employment as an RN. The staff member applied for employment in March 2025 and indicated on her application that she held a valid RN license, with a handwritten note that she was to be endorsed upon arrival. A license verification report dated March 31, 2025, in her personnel file showed an active, unencumbered RN license for a different individual with the same first and last name but a different middle initial. There was no evidence in the personnel file of a valid Arizona RN license or any other state license verification belonging to this staff member, despite her being hired and classified as an RN. Staffing and payroll records showed that the staff member worked as a floor RN from mid-April 2025 until mid-February 2026, passing medications and assessing and caring for residents. A CNA reported that this RN functioned as a floor nurse, and that floor nurses are responsible for assessing residents when notified of changes in condition. The Arizona State Board of Nursing (AZBN) confirmed that the staff member had only been an RN license applicant by endorsement in Arizona and that she was considered foreign-educated, requiring additional steps such as language proficiency testing and third-party education verification. The AZBN stated that the staff member never held an Arizona RN license until April 6, 2026, and that she had been working at the facility as an RN without Arizona licensure or endorsement. The AZBN notified the facility’s HR Director on February 4, 2026, that the staff member did not have an active Arizona RN license and should not be working as an RN. The HR Director acknowledged that she was responsible for obtaining onboarding documents and verifying licenses via an online portal, and that the process did not include requesting a copy of the nursing license. She recognized that the verification in the file belonged to a different person and described this as an oversight. Despite the AZBN notification, payroll records showed that the staff member continued to work until February 11, 2026. The Administrator and DON both stated that they believed the staff member had an active license from another state and, at least initially, believed or assumed that this allowed her to practice, though the other state was not part of the Nurse Licensure Compact. The DON later confirmed via the compact website that the other state was not a compact state and that endorsement through Arizona was required. The facility’s written policy required verification of current, valid licensure and placement of license verification documents in the applicant’s file, which was not done correctly for this staff member, resulting in her working as an RN without a valid Arizona license for an extended period. The staff member herself stated that she first applied for an Arizona RN license sometime in 2024, did not receive it, then obtained an RN license from another state in March 2025 and subsequently applied for Arizona licensure by endorsement. She reported ongoing difficulties completing Arizona’s requirements, including language proficiency testing and education verification, while she was working at the facility. She stated that she believed she could work under her other state license and assumed it would be acceptable. She also reported that the HR Director had asked her shortly before the AZBN’s February 2026 call whether her Arizona license had arrived, and she replied that she was still working on the requirements. The Administrator later acknowledged that the license verification in the file was for another person and that, per facility policy, the staff member had not been qualified to work as an RN during the time she was employed in that role.
Failure to Obtain Proper Written Authorization for Resident Financial Transaction
Penalty
Summary
The facility failed to ensure proper safeguarding of a resident’s personal funds by not obtaining written authorization as required for financial transactions. A resident with a history of anxiety disorder, ureteral calculus, mood affective disorder, and vascular dementia was admitted and later became private pay after insurance coverage ended. An MDS assessment showed a BIMS score of 11, indicating moderate cognitive impairment. When the resident transitioned to private pay, the business office processed a credit card payment using a "Credit Card Authorization Form" that was completed by the Assistant Business Manager but did not contain the resident’s signature or a documented time of completion. The Credit Card Authorization Form listed the resident as the cardholder, described the services as private pay room and board for specific dates, and included the credit card number, expiration date, security code, and total amount to be charged. The form also contained a pre-printed statement agreeing to pay the total amount according to the card issuer agreement. However, in the signature section, staff documented only the words "via phone" instead of obtaining the resident’s written signature. Facility staff, including the Business Manager and Assistant Business Manager, stated that the form was required for each monetary transaction and that the resident had insisted on paying over the phone while away from the facility, but they did not document the details of the phone consent anywhere other than the notation "via phone" on the form. Financial records, including the Resident Ledger Report and Resident Activity Reports, showed the posting of room and board charges, a partial payment, and an outstanding balance. Later documentation indicated that, after the resident’s death, the resident’s private fiduciary reported to the facility that money had been taken from the resident while at the facility and that she was unable to pay the remaining balance. The fiduciary also reported that the resident’s mail, including financial statements and retirement fund information, had been kept in a nightstand drawer and left vulnerable to anyone entering the room. Review of the State Operations Manual and the facility’s job descriptions and policies showed that the facility was required to have systems and internal controls to ensure resident funds were maintained in accordance with federal and state regulations, including written authorization and documentation of date, time, amount, and source or recipient of funds, which were not followed in this case.
Failure to Investigate Alleged Financial Misappropriation and Protect Resident Financial Information
Penalty
Summary
The facility failed to implement its policies prohibiting financial misappropriation for one resident when it did not investigate allegations of fraud involving the resident’s finances. The resident had a history of anxiety disorder, calculus of the ureter, mood affective disorder, and vascular dementia, and an MDS BIMS score of 11 indicating moderate cognitive impairment. The resident was initially not private pay but became private pay after insurance coverage ended, and the business office monitored her financial status because private pay residents were considered rare and the office’s role was to collect money and be aware of when residents might need financial assistance. On a date in April, the Business Manager documented a call from the resident’s private fiduciary, who reported filing a Victim of Fraud claim on behalf of the resident, stating that the resident’s account had been drained of $265,000 and that the police were investigating. The fiduciary requested facility participation in the investigation and copies of financial statements and documentation of the resident’s private pay status. The Business Manager documented that she informed the then-Executive Director/Administrator of the fiduciary’s allegations, including that the fiduciary was asking for facility staff to be investigated for fraud. The fiduciary later stated in interview that the facility had paid itself from the resident’s accounts before she became the financial power of attorney, that she had reported the suspected fraud to both the police and the facility while the resident was still there, and that the resident kept a nightstand drawer full of mail and financial documents, including statements and retirement fund information, which were left vulnerable to anyone entering the room. In subsequent interviews, the current Administrator reported that he and the previous Administrator had gone over the fiduciary’s allegations with her, but that, after speaking with the previous Administrator, it appeared that nothing had been done in response to the fraud allegations and that the previous Administrator had determined there was nothing to investigate. The facility’s abuse policy, revised in October, stated that residents have the right to be free from misappropriation of resident property and exploitation, that staff with knowledge of an actual or potential violation must immediately report it to a supervisor or the Administrator, and that all allegations of abuse, neglect, misappropriation, or exploitation would be promptly and thoroughly investigated with interviews, record review, and documentation of the investigation and its results. Despite this policy, the allegation of financial misappropriation involving this resident was not investigated at the time it was reported.
Failure to Report Alleged Financial Misappropriation to Authorities
Penalty
Summary
The facility failed to report an alleged financial misappropriation involving a resident in accordance with state law and facility policy. The resident, who had vascular dementia and a BIMS score of 11 indicating moderate cognitive impairment, had a private fiduciary (RPF) managing finances. On April 22, 2025, the Business Manager documented that the RPF reported filing a victim of fraud claim on the resident’s behalf, stating the resident’s account had been drained of $265,000 and that the police were investigating. The RPF requested that the facility be part of the investigation and asked for copies of financial statements and documentation related to the resident’s private pay status. Shortly thereafter, the Business Manager documented that she informed the then-Executive Director/Administrator of the RPF’s allegations, including that the RPF was asking for facility staff to be investigated for fraud, and the Administrator stated he would reach out to another staff member for advice. Subsequent documentation on September 2, 2025, reflected that the resident had died and that the RPF stated money had been taken while the resident was at the facility, leaving her unable to pay the facility. During interviews, the Business Manager confirmed she recognized financial abuse as a form of abuse and that she immediately informed the Administrator when the RPF made the fraud allegation. The current Administrator, who had been operations manager at the time, stated that after reviewing the prior allegations and speaking with the former Administrator, it appeared that nothing was done in response and that the former Administrator had determined there was nothing to investigate. The Administrator also confirmed that the allegations of fraud were not reported to the state agency. A review of facility records showed no self-reports related to this resident, despite facility policies requiring that suspected crimes, including fraud and forgery, and allegations of abuse, misappropriation, or exploitation be reported to the State Survey Agency and other appropriate agencies within required timeframes.
Unauthorized Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
Surveyors identified a deficiency related to medication storage and self-administration when a resident was found with medications left at the bedside without authorization. The resident, who had a history of Type 2 Diabetes Mellitus with diabetic neuropathy, COPD, dementia, and major depressive disorder, had a quarterly MDS with a BIMS score of 13, indicating cognitive intactness. Review of the resident’s care plan, physician’s orders, and electronic medical record showed no care plan, orders, or interdisciplinary team documentation authorizing self-administration of medications. Despite this, during a room observation, two medications—Fluticasone Propionate Suspension 50 mcg/act and Bacitracin Zinc 400 units—were observed at the resident’s bedside. During interviews, the resident confirmed that one medication was used every other day on her toes and that the other was a nasal spray used occasionally. A subsequent observation with the DON again revealed the two medications at the bedside. The DON confirmed that residents without self-administration orders should not have medications left out and acknowledged that this situation did not meet facility expectations. Review of facility policies showed that self-administration requires an interdisciplinary assessment and documentation in the chart, and that all drugs and biologicals must be stored in locked compartments accessible only to authorized personnel, which was not followed in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with hemiplegia, major depressive disorder, and cataracts, who was found with multiple superficial wounds and blood on his face after being struck by his roommate. The aggressor, who was cognitively intact and had diagnoses including cellulitis and diabetes, admitted to hitting the victim following a verbal altercation involving a racial slur. The incident was not directly witnessed by staff, but was reported by another resident who heard the altercation and alerted a CNA. Upon entering the room, the CNA observed the aftermath, with the victim wheeling himself into the bathroom and the aggressor walking away. Clinical documentation and staff interviews confirmed that the injured resident sustained lacerations to the forehead, nose, lip, and chin, but was not transferred to the hospital. The aggressor left the facility against medical advice the same day. The facility's investigation concluded that the event was unanticipated and isolated, occurring in an area with adequate staff supervision. However, prior to the incident, there were indications of behavioral issues, as the aggressor had been observed yelling at another resident the day before. Facility policies reviewed indicated that residents have the right to be free from all forms of abuse, including physical abuse. Despite these policies, the facility failed to prevent the physical altercation between the two residents, resulting in injury. Staff interviews revealed an understanding of abuse protocols, but the incident still occurred, demonstrating a lapse in protecting resident rights as required by both facility policy and regulatory guidelines.
Failure to Provide Adequate Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care as part of activities of daily living (ADLs) for two residents who were unable to perform their own hygiene. One resident had generalized muscle weakness, lack of coordination, cognitive communication deficit, toxic encephalopathy, type 2 diabetes mellitus, and morbid obesity, with an MDS BIMS score indicating moderate cognitive impairment and a care plan identifying ADL deficits related to weakness. Observations over several days showed this resident in bed with feet exposed and toenails that were yellow-brown, markedly overgrown, and curling over the tops and onto the pads of the toes on both feet. Despite an active order stating the resident "may see Podiatry of Choice" and shower sheets on two dates indicating that nails needed clipping, there were no orders or documentation for a podiatry visit, and the toenails remained long and discolored on repeated observations. Multiple staff interviews revealed inconsistent and unclear processes for nail care and referrals. A CNA stated that podiatry would be called to clip nails and that the approach depended on whether the resident was diabetic or if nails were long and curving. An RN reported not knowing the process for clipping nails and needing to ask the CNA. An LPN described a process that began with asking a CNA, then notifying the physician for a podiatry order for diabetic residents, and stated that responsibility for clipping nails belonged to all staff. The MDS coordinator indicated that long toenails identified on assessment would be referred to social services, while the social services director stated she only scheduled podiatry and other services for long-term residents and that case managers handled skilled residents. The case manager, however, stated that she did not schedule appointments and believed social services did, indicating a breakdown in role clarity and follow-through. The second resident had hemiplegia and hemiparesis following cerebral infarction, opioid dependence, cognitive communication disorder, and anxiety disorder, with an MDS BIMS score indicating severe cognitive impairment and dependence on staff for personal hygiene with assistance of one staff member per the care plan. During a dining room observation, this resident was seen eating with the left hand while fingernails were long and had food noted under them, and the feet were covered. A later observation showed that the fingernails had been clipped, but the resident had no shoes or socks on and toenails on both feet were long and extended over the ends of the toes. Review of this resident’s shower sheets showed they were not consistently completed regarding whether nails were clipped or needed clipping, and on one date a CNA marked that nail clipping was not needed. The facility’s ADL policy stated that if a resident is unable to carry out ADLs, necessary services to maintain grooming and personal hygiene would be provided by qualified staff, but the documented observations and records showed that nail care needs for these two residents were not met.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #44, who has diagnoses including bipolar disorder and anxiety, was assaulted by Resident #55 on the smoking patio. The incident occurred when Resident #55, who has a history of aggressive behavior and was experiencing increased agitation, approached Resident #44 unprovoked and punched him behind the ear. A certified nursing assistant witnessed the event and intervened to separate the residents. Resident #44 sustained a reddened area behind the ear but refused further medical assessment. Resident #55 has a history of mood disorders and substance abuse, and was noted to have a significant change in mental status on the day of the incident. Despite being prescribed psychotropic medications for paranoid delusions, Resident #55 exhibited increased agitation and refused medication. The facility's staff, including a CNA and an LPN, acknowledged that they are trained to recognize and deescalate such situations, but the incident still occurred, indicating a lapse in supervision and intervention. Interviews with staff, including the Director of Nursing, revealed that there is an expectation for staff to monitor residents' behaviors and intervene when necessary to prevent harm. The facility's policy emphasizes the right of residents to be free from abuse, yet the incident highlights a failure to adhere to this policy, resulting in a deficiency in protecting residents from abuse.
Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, leading to incidents of resident-to-resident abuse. Resident #20, who had no cognitive impairment, was involved in a verbal altercation with resident #75, who also had no cognitive impairment but had a history of trauma and behavioral issues. During the altercation, resident #75 threatened resident #20 and threw her cellphone on the floor. A Certified Nursing Assistant (CNA) reported that resident #75 had previous altercations with other residents and was often the instigator. In another incident, resident #40, who also had no cognitive impairment, was involved in a verbal exchange with resident #75 in the hallway. During this exchange, resident #75 physically kicked resident #40 in the abdomen. A CNA witnessed the incident and confirmed that resident #75 had been verbally aggressive before but had not been physically aggressive until this incident. The Licensed Practical Nurse (LPN) noted that resident #75 was alert and oriented but had behavioral issues and made paranoid statements. The Director of Nursing (DON) acknowledged that resident #75 had not been at the facility long and was on psychiatric medications. The DON initially thought the first incident with resident #20 was isolated but recognized a pattern after the second incident with resident #40. The facility's policy on abuse prevention states that each resident has the right to be free from abuse, neglect, and exploitation, and that willful actions are deliberate, even if not intended to inflict harm.
Deficient Documentation of Vital Signs and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident, specifically regarding vital signs and blood glucose monitoring. The resident, who was readmitted with multiple diagnoses including type 2 diabetes mellitus and stage 4 pressure ulcers, had missing records of blood sugar results on two occasions when insulin glargine was administered. Additionally, there was no evidence of vital signs being recorded during specific evening shifts, which was against the facility's policy. Interviews with staff revealed inconsistencies in the documentation process. A CNA admitted to not completing documentation for the resident on a particular day, and an LPN confirmed that CNAs are responsible for charting vital signs. The Director of Nursing acknowledged that the lack of documentation did not meet facility expectations and could potentially lead to missing acute changes in the resident's condition. The facility's policies on documentation and insulin administration were not followed, as evidenced by the lack of blood glucose monitoring prior to insulin administration. Staff interviews highlighted that blood glucose levels should be checked before administering insulin, yet there was no record of such monitoring for the resident since a specific date. The Director of Nursing noted that insulin glargine is not held for low blood glucose levels, but the standard of care involves monitoring for hypoglycemia signs in the absence of specific physician orders.
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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