Haven Of Camp Verde
Inspection history, citations, penalties and survey trends for this long-term care facility in Camp Verde, Arizona.
- Location
- 86 West Salt Mine Road, Camp Verde, Arizona 86322
- CMS Provider Number
- 035118
- Inspections on file
- 20
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Haven Of Camp Verde during CMS and state inspections, most recent first.
A resident with multiple medical conditions, impaired cognition, and existing skin issues was ordered to receive weekly complete skin checks and was care planned for regular skin inspections during routine care and per bath schedule. Facility records showed only one documented skin assessment over several weeks, despite the standing order and care plan interventions. The resident was scheduled for twice-weekly showers, but documentation reflected only two showers during the review period, with large gaps where no showers were recorded. An LPN and the interim DON confirmed that weekly skin assessments were not documented as required, and a CNA reported that although the resident was on the shower schedule, she did not provide any showers and that shower sheets for this resident could not be located. These actions and omissions did not follow facility ADL and bathing policies, which require provision of hygiene care and skin observation during showers.
A resident with multiple medical and psychiatric conditions, including epilepsy and recent seizure activity, was admitted with an advance directive and physician order specifying full code status and desire for CPR. On the day of the incident, the resident was last documented as well during morning rounds and later was found on the floor of his room, unresponsive and not breathing. Staff interviews, a 911 call transcript, and a police report showed that no CPR was in progress when the emergency call was made, no AED was brought to the room, and officers found the resident cold to the touch but without rigor mortis. The DON gave conflicting accounts about whether CPR was initiated, while other staff reported they did not see CPR performed, and there was no clinical documentation of CPR or AED use despite facility policy requiring immediate and continuous CPR/BLS for unresponsive full‑code individuals until EMS arrival. These actions and omissions resulted in the resident not receiving ordered life‑saving measures.
A resident with severe cognitive impairment was physically struck by his roommate, who was cognitively intact at the time. The incident was witnessed by a CNA, who described the contact as aggressive, but the event was not properly documented in the clinical record, and no immediate medical assessment or provider notification occurred. This failure to follow required procedures for reporting and responding to abuse allegations resulted in a deficiency.
A resident with cognitive impairment was physically struck by a roommate after calling for help, with a CNA witnessing the aggressive contact. Despite facility policy requiring immediate investigation, monitoring, and documentation for suspected abuse, the clinical record lacked evidence of these actions, and the incident was not substantiated as abuse by administration, resulting in a failure to implement the abuse policy.
A resident with severe cognitive impairment and multiple medical conditions was admitted and re-admitted without a baseline care plan being developed within 48 hours, as required by facility policy. The absence of this care plan meant staff lacked documented instructions to address the resident's impaired cognition and immediate needs.
After a physical altercation between two residents, the facility failed to document the incident, post-incident monitoring, provider notification, and injury assessment in the affected resident's medical record, as required by policy. This omission was confirmed by staff interviews and review of the clinical record.
A resident with multiple health conditions did not receive showering assistance according to her preferences and facility policy. Despite the facility's policy to offer showers twice weekly, the resident reported infrequent showers. Coordination issues between the facility and hospice staff, including staffing shortages and unclear responsibilities, contributed to the deficiency.
The facility failed to ensure sufficient nursing staff on a 24-hour basis as per their facility assessment. On multiple sampled dates in November and December 2023, the facility did not meet the required staffing levels, with eight shifts having only one licensed nurse and three shifts having only one CNA. The DON confirmed that a CMA should not be counted as a CNA, yet the staffing schedule often included one licensed nurse, one CMA, and two CNAs, leading to the deficiency.
The facility failed to ensure that the nurse staffing information was accurately posted on a daily basis, omitting the actual hours worked by licensed and unlicensed nursing staff. A review of the daily staff postings for November and December 2023 revealed this deficiency, which was confirmed during an interview with the Administrator.
The facility failed to submit accurate staffing information to CMS, as revealed by a review of the PBJ Staffing Data Report. The facility was flagged for low weekend staffing across multiple fiscal quarters, and it was discovered that staff were missing hours in their pay period due to a possible software issue.
Failure to Provide Ordered Weekly Skin Assessments and Scheduled Showers for One Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including bathing and required skin assessments, to one resident in accordance with physician orders, the care plan, and facility policy. The resident was admitted with diagnoses including a right femur fracture, type 2 diabetes mellitus with hyperglycemia, muscle weakness, and right knee osteoarthritis, and had a BIMS score of 8 indicating moderately impaired cognition. On admission, the resident had a red coccyx, a thigh rash, and a scab on the right knee, and an order dated January 16, 2026, required a complete weekly skin check. The care plan identified the resident as at risk for functional self-care deficits and skin impairment, with interventions including skin inspection during routine care and per bath schedule, and monitoring for redness, open areas, scratches, cuts, bruises, and reporting changes to the nurse. Record review showed that only one skin assessment was documented on January 16, 2026, with no evidence of any weekly skin assessments from January 17 through February 11, 2026, despite the standing order. A Braden scale assessment on January 30, 2026, documented that the resident’s skin was occasionally moist, and a Braden scale on February 9, 2026, documented skin occasionally moist, activity chairfast, and mobility slightly limited, but there was no documentation of follow-up weekly skin assessments or of the previously noted coccyx redness after January 16. The interim DON confirmed that there was only one documented weekly skin assessment despite the order, and the LPN stated she was not aware until February 16 that LPNs were responsible for weekly skin assessments. Both the LPN and DON acknowledged that weekly skin assessments were expected and that the previous DON had followed up with nurses on resident skin assessments. The facility’s shower schedule indicated the resident was to receive showers twice weekly on the evening shift, and the CNA reported the resident was scheduled for showers every Tuesday and Friday, with an option for Sunday if preferred. However, shower documentation showed only two showers provided, on January 30 and February 7, 2026, with no evidence of showers from January 16 through January 29, from February 1 through February 6, and from February 8 through February 11, 2026. The CNA stated she did not provide any showers to this resident and that during showers, staff were expected to assess skin and document any skin conditions or refusals on shower sheets, which nurses would review and sign. The LPN reported she could not locate the resident’s shower sheets in the binder. Facility policies on Personal Care: ADLs and Bathing and Showers required that appropriate hygiene care be provided per the plan of care and that showers be used as an opportunity to observe and document the condition of the resident’s skin, but the documented care for this resident did not meet these requirements.
Failure to Provide CPR and AED Use for Full-Code Resident Found Unresponsive
Penalty
Summary
The deficiency involves the facility’s failure to provide life‑saving measures, including CPR and use of an AED, to a resident with full code status who was found unresponsive. The resident had multiple medical and psychiatric diagnoses, including pneumonia due to pseudomonas, osteomyelitis, bacteremia, autistic disorder, bipolar disorder, mood disorder, epilepsy, and a need for assistance with personal care. An advance directive signed by the resident indicated he wanted CPR if his breathing and heart stopped, along with other life‑prolonging treatments. A physician order dated January 26, 2026, confirmed the resident’s status as full code and indicated CPR was to be provided. In the days prior to the incident, the resident was documented as having behavioral issues, aggressive outbursts, and a fall from bed shortly after an OT evaluation, with staff noting he might not be appropriate for the facility due to the need for 1:1 care. The resident was also identified as a high fall risk and had a witnessed seizure lasting about 50 seconds on January 25, 2026, after which neurological checks were initiated and the DON and a provider were notified. On the morning of January 26, 2026, facility self‑report documentation indicated the resident received medications around 7:00 a.m., breakfast at 8:30 a.m., and was checked at 9:30 a.m., at which time he was reportedly well. Around late morning, a CNA delivering lunch found the resident on the floor and notified the DON. Multiple accounts, including the police report, CNA, RN, and corporate clinical resource nurse interviews, and the 911 call transcript, consistently indicated that when staff found the resident unresponsive and not breathing, CPR was not being performed. The 911 operator twice asked if CPR was in progress, and the staff member replied that no one was doing CPR and stated the resident was deceased. The police report documented that upon arrival, officers found the resident on the floor, unresponsive, cold to the touch, with a small laceration on the back of the head and dried blood on the floor, and noted that rigor mortis had not yet set in. The report also described the fall mats as not in use as claimed and the bed as freshly made, suggesting inconsistencies with the account that the resident had fallen from bed. The DON gave conflicting statements, at one point telling police that CPR was not initiated, and at another time stating she began life‑saving measures but believed the resident was beyond help and did not move him to a flat position on the floor. The corporate clinical resource nurse reported that the DON later said she performed a sternal rub, checked for a pulse, and attempted only two chest compressions before stopping because the chest felt “mushy.” Other staff present, including the CNA who discovered the resident and the RN who assessed him, stated they did not observe CPR being performed at any time. There was no documentation in the clinical record of CPR being initiated, no evidence that an AED was brought to or used in the room, and no documentation of the head laceration noted by police. Facility policy required that licensed staff certified in CPR/BLS initiate CPR for an unresponsive individual not breathing normally unless a DNR order existed or there were obvious signs of irreversible death, and that CPR and BLS, including AED use, be continued until emergency medical personnel arrived. These actions were not carried out for this full‑code resident. The facility’s policy on documenting death required that all information pertaining to a resident’s death, including time of death and the name and title of the individual pronouncing death, be recorded in the nurse’s notes, and that the attending physician document the cause of death. The record contained an e‑MAR note indicating the resident was deceased and an MDS death in facility assessment, as well as a vital records form listing a time of death, but there was no contemporaneous nursing documentation of CPR attempts or detailed description of the circumstances of death consistent with policy. The combination of staff failure to initiate and maintain CPR and use an AED for a full‑code resident, conflicting staff accounts, lack of documentation of life‑saving measures, and discrepancies between the physical scene and staff descriptions formed the basis of the cited deficiency.
Failure to Protect Resident from Physical Abuse by Another Resident
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 severe cognitive impairment who was calling for help, which disturbed his roommate. The roommate, who was cognitively intact at the time, moved across the room and made physical contact with the resident, striking him on the chest and head. This event was witnessed by a CNA, who described the contact as aggressive and stated that the resident was struck with a backhanded motion on the chin and then on the top of the head. The CNA immediately intervened and separated the residents. The clinical record review revealed that there was no documentation of the incident in the resident's record, no notification to the medical provider, and no assessment for injury following the incident. Although both residents were later assessed and found to have no visible injuries, the initial lack of documentation and assessment represented a failure to follow required procedures for reporting and responding to abuse allegations. Interviews with staff confirmed that the incident was reported verbally, but the necessary documentation and immediate medical evaluation were not completed as required. The facility's policy defines abuse as the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and requires prompt reporting and investigation. Despite the policy, the facility did not substantiate the incident as abuse due to a perceived lack of evidence, even though a staff member witnessed aggressive physical contact. The absence of proper documentation and immediate assessment after the incident contributed to the deficiency.
Failure to Implement Abuse Policy Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy following an incident involving two residents, one of whom had significant cognitive and medical impairments, including dementia and a cognitive communication deficit. On the date of the incident, one resident was calling for help, which agitated his roommate. The roommate physically interacted with the resident, making contact with his chest and head. A CNA witnessed the event, describing the contact as aggressive, with the resident being struck on the chin and head. The CNA intervened, separated the residents, and reported the incident to nursing and administrative staff. Despite the facility's policy requiring immediate notification, monitoring, alert charting, and assessment for injury following any suspected abuse, the clinical record lacked documentation of the incident, monitoring, alert charting, notification to the medical provider, or assessment for injury for the resident involved. Interviews with staff revealed inconsistent interpretations of the event, with the CNA describing it as aggressive and the administrator characterizing the contact as unintentional and not abusive. The facility ultimately did not substantiate the incident as abuse, citing a lack of evidence, despite direct witness testimony to the contrary. The facility's abuse policy outlined specific steps to be taken when abuse is witnessed or suspected, including immediate investigation, notification of relevant parties, and monitoring of the resident. However, these procedures were not followed as required, as evidenced by the absence of documentation and monitoring in the resident's clinical record after the incident. This failure to implement the abuse policy constituted a deficiency that could lead to harm for residents.
Failure to Develop Baseline Care Plan for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident who was admitted and later re-admitted with multiple diagnoses, including cognitive communication deficit, pressure ulcer of the sacrum, laceration of the right foot with a foreign body, and unspecified dementia. The resident's admission MDS assessment indicated a BIMS score of 6, reflecting severe cognitive impairment. Despite these significant health concerns, there was no evidence that a baseline care plan was created to address the resident's impaired cognition. Interviews and record reviews confirmed that the facility's policy requires a baseline care plan to be developed within 48 hours of admission to address immediate health and safety needs, including instructions for person-centered care. The DON acknowledged that impaired cognition and dementia are always risk factors for abuse and should be included in care planning to ensure staff awareness and appropriate care. However, the absence of a baseline care plan meant that staff did not have documented guidance to address the resident's cognitive impairment upon admission.
Incomplete Documentation Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate following an incident involving resident-to-resident physical contact. The incident occurred when one resident, who had diagnoses including cognitive communication deficit, pressure ulcer, laceration, and dementia, was physically struck by his roommate after a verbal disagreement. The event was witnessed by a CNA, who intervened and reported the incident to nursing and administrative staff. However, there was no documentation in the clinical record describing the incident, evidence of monitoring or alert charting, notification to the medical provider, or assessment for injury following the event. Interviews with staff confirmed that the required post-incident assessments and notifications were not documented as per facility policy, which mandates that all services, changes in condition, and notifications be recorded in the resident's medical record. The Director of Nursing acknowledged that the initiation of 15-minute checks was missed and that documentation of assessments and notifications should have been completed in the risk management and progress notes. The lack of documentation could result in care team members being unaware of the resident's status and missing or delaying necessary treatment.
Failure to Provide Showering Assistance as Per Resident Preference
Penalty
Summary
The facility failed to ensure that a resident received showering assistance according to the facility policy and the resident's preferences. The resident, who was readmitted with multiple diagnoses including pulmonary hypertension, chronic obstructive pulmonary disease, congestive heart failure, and dementia, expressed dissatisfaction with the care plan that provided only bed baths instead of showers. The resident's care plan did not specifically address her preference for showers, and documentation revealed inconsistencies in the provision of showers over several months. Interviews with facility staff, including the Director of Nursing (DON) and the Vice President of Clinical Operations, highlighted a lack of clarity and communication regarding the responsibility for providing showers. The facility's policy required showers to be offered twice weekly, but the resident reported not receiving showers as frequently as desired. The hospice company, which was involved in the resident's care, was expected to provide showers once a week, but there were issues with staffing and coordination between the hospice and facility staff. The hospice executive director noted that the resident required two staff members for safe showering due to safety concerns, but the hospice often sent only one staff member, relying on the facility to provide additional assistance. This lack of coordination and communication between the facility and hospice staff resulted in the resident not receiving showers as per her preference and the facility's policy, leading to a deficiency in the quality of care provided to the resident.
Insufficient Nursing Staff on Night Shifts
Penalty
Summary
The facility failed to ensure sufficient nursing staff on a 24-hour basis as per their facility assessment. The assessment indicated that there should be two licensed nurses per shift and a specific number of CNAs for each shift. However, on multiple sampled dates in November and December 2023, the facility did not meet these staffing requirements. Specifically, there were eight shifts with only one licensed nurse and three shifts with only one CNA. The Director of Nursing confirmed that the expectation was to have two CNAs scheduled for night shifts and that a Certified Medication Assistant (CMA) should not be counted as a CNA. Despite this, the staffing schedule often included one licensed nurse, one CMA, and two CNAs, leading to the deficiency.
Failure to Accurately Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was accurately posted on a daily basis, which included the actual hours worked by licensed and unlicensed nursing staff. A review of the sampled daily staff postings for November and December of 2023 revealed they did not contain the total actual hours worked by licensed and unlicensed staff. During an interview with the Administrator on December 7, 2023, it was noted that the actual hours worked were not on the daily staff postings. The facility's Staffing Policy requires that the Daily Posted Staffing Schedule must include the total number and the actual number of hours worked by Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides per shift.
Inaccurate Staffing Information Submission
Penalty
Summary
The facility failed to submit accurate staffing information based on payroll data in a uniform format to CMS. A review of the PBJ Staffing Data Report run on November 30, 2023, revealed that the facility was flagged for excessively low weekend staffing for multiple fiscal quarters spanning from July 2022 to June 2023. During the review of sampled staff postings for November and December 2023 with the Regional Support Nurse and the Regional President, it was discovered that the facility was not accurately reporting hours to CMS. Staff were missing hours in their pay period, which was attributed to a possible software issue.
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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