Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Haven Of Safford during CMS and state inspections, most recent first.
A resident with a history of behavioral issues and prior attempts to hit staff became agitated after family left the building and later confronted another resident with quadriplegia and intact cognition in a hallway. Witnesses, including staff and another resident, reported that the aggressive resident yelled at and then physically struck the disabled resident, and while being escorted away, also struck a second resident with dementia and moderate cognitive impairment who was seated in a doorway. The second resident was later observed with reddish/grey marks and a documented scratch/abrasion on the forearm, but the clinical records for both victims contained no incident documentation, despite multiple staff and resident accounts and police involvement. The DON and social services staff confirmed that the aggressive behavior constituted abuse under the facility’s abuse-prevention policy and acknowledged that required documentation in the clinical records was not completed, resulting in a failure to protect residents from abuse and to properly document the events and injuries.
A resident with moderate cognitive impairment and multiple comorbidities asked a staff member to help set up a checking account not linked to family, resulting in two $500 transfers intended to establish a new account in the resident’s name. The account was never created, and the funds were instead sent to the staff member, who minimized the issue when the resident repeatedly requested the money back. The resident reported feeling abused, taken advantage of, embarrassed, and betrayed, while the DON and an RN acknowledged that the incident met the definition of financial abuse under the facility’s abuse, neglect, exploitation, and misappropriation prevention policy.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in a bed with one resident’s shirt off and the other hovering over them. Staff acknowledged that both residents were not alert and oriented and could not consent, and one nurse had previously documented kissing behavior between them and recommended separating or moving them. Despite this, the facility did not revise either resident’s care plan to address the sexual behaviors, did not document the incident in progress notes beyond a single behavior entry, did not change room assignments even though their rooms were directly across from each other, and did not submit a facility-reported incident to the state agency, contrary to its abuse, neglect, and exploitation prevention policy requiring investigation, reporting, and protection of residents during investigations.
Two cognitively impaired residents, one with severe Alzheimer’s and one with dementia and a history of sexually inappropriate behavior, were housed in rooms directly across from each other. One day, staff later documented that one resident was found in the other’s bed with her shirt off while the other resident hovered over her, after prior notes had described kissing and the need for close supervision and redirection. Multiple staff acknowledged that the resident in bed could not consent to sexual activity, yet the abuse coordinator and DON concluded there was no abuse and did not report the incident as an allegation of abuse to the State Agency, despite a facility policy requiring investigation and reporting of any allegations within federal timeframes. Care plans for both residents were not revised to address the documented sexual behaviors, and progress notes lacked documentation of the incident and the female resident’s tendency to expose her breasts, leading to a cited deficiency for failure to timely report suspected abuse and the investigation results to proper authorities.
Two cognitively impaired residents with dementia-related diagnoses and documented behavioral issues, including sexually inappropriate behavior and lifting clothing, were found together in one resident’s room, with one resident in bed, shirt off, and the other hovering over her after staff briefly lost sight of them. Staff acknowledged that neither resident could consent, but documentation in the clinical record lacked detailed notes about the incident, additional skin assessments around the time of the event, or revisions to either resident’s care plan to address sexual behaviors. The facility’s internal investigation was limited to a few staff statements, did not reflect broader evidence collection as outlined in the SOM, did not result in documented protective measures despite staff concerns about room proximity, and the incident was not reported to the State Agency as required by facility policy and federal guidelines.
Surveyors identified that the facility did not consistently follow procedures for controlled substance reconciliation, as multiple narcotic count sheets and shift change sign-off sheets were missing one or both required nurse signatures over several weeks. Interviews with nursing staff and the DON confirmed that the expected process of dual-nurse counts and signatures was not reliably performed, resulting in incomplete documentation for controlled substances.
Surveyors identified failures in infection control practices, including uncovered soiled laundry, improper handling of dirty linens, and unlabeled medications and insulin pens in medication carts. Staff were observed drawing insulin from multi-dose pens without proper labeling, and home medications were stored in medication carts against policy. Interviews confirmed staff uncertainty and non-compliance with established infection prevention protocols.
A resident with cognitive and communication impairments was repeatedly subjected to loud arguments and profanity by a CNA, including being told to "shut the fuck up." Multiple staff and a student CNA witnessed or overheard these interactions, and the resident reported that such incidents were frequent. Despite facility policies prohibiting such behavior, staff often failed to report or intervene, and the CNA had a history of unprofessional conduct.
A resident's privacy was compromised when their personal and medical information was left visible on an unattended medication cart. Despite the facility's policies and staff training on maintaining confidentiality, staff acknowledged the breach, which went against professional standards.
A resident with severe cognitive impairment was subjected to inappropriate behavior by another resident with a history of verbal and sexual misconduct. Despite staff awareness and documentation of the incidents, the facility failed to take adequate action to prevent further occurrences. The facility's policy on abuse prevention was not effectively implemented, leading to a deficiency identified by surveyors.
A resident with severe cognitive impairment was subjected to inappropriate behavior by another resident with a history of verbal and inappropriate sexual behaviors. Despite multiple incidents, the facility failed to report these behaviors to the state agency as required by their abuse prevention policy. Staff were aware of the behaviors and reported them internally, but the Administrator was not informed of a specific incident and acknowledged it should have been reported as abuse.
A resident with severe cognitive impairment was subjected to inappropriate sexual behavior by another resident, also with severe cognitive impairment, in an LTC facility. Despite multiple documented incidents of inappropriate behavior, the facility failed to report these incidents to the state agency. Staff, including LPNs, CNAs, and the DON, were aware of the behavior, but the facility's administration did not adhere to its policy requiring the reporting of abuse allegations.
A facility failed to investigate and report an allegation of abuse involving a resident with severe cognitive impairment and a history of inappropriate sexual behaviors. Despite staff awareness and documentation of the resident's misconduct, the administration did not take appropriate action, leading to a deficiency in abuse prevention and reporting.
The facility failed to administer medications according to physician orders for two residents, leading to potential negative outcomes. One resident received Tramadol outside the prescribed pain scale, while another was given Midodrine despite high blood pressure. Staff interviews and record reviews confirmed these deviations from professional standards and facility policy.
A resident with left-sided paralysis and cognitive impairment was found without access to a call light, despite their care plan requiring it to prevent falls. The call light cord was inaccessible, sandwiched between the mattress and wall, leading to the resident's inability to communicate with staff. Staff confirmed the deficiency, acknowledging the importance of accessible call lights for all residents.
The facility failed to protect residents from abuse, resulting in incidents where a resident with cognitive impairment was hit by another resident, and another resident was inappropriately touched. Despite having care plans and interventions in place, these measures were insufficient to prevent the incidents, highlighting issues such as understaffing and inadequate implementation of preventive measures.
A resident with moderate cognitive impairment physically abused two other residents, resulting in injuries. The aggressive resident's care plan lacked interventions for wandering and physical behaviors, contributing to the incidents. Staff interviews indicated escalating behaviors and challenges in managing the resident's aggression.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident and to properly assess and document the incidents in the clinical records. One victim, Resident #10, had hemiplegia, a history of CVA, dementia, and moderate cognitive impairment (BIMS 10), and was care-planned for behavior problems related to impaired cognition and safety awareness. Another victim, Resident #20, had diagnoses including cerebral ischemia, COPD, quadriplegia, TIA, and depression, with an intact cognition (BIMS 15) and a care plan noting that this resident had previously been the recipient of physical and verbal behaviors from another resident, with interventions to provide for safety and prevent such interactions. Despite these care plans, there were no progress notes in either Resident #10’s or Resident #20’s clinical records documenting any incident involving Resident #50. Resident #50, identified as the perpetrator, had vascular dementia and other medical conditions, with a BIMS score of 15 and a care plan for behavior problems including impaired safety awareness, physical and verbal behaviors, and resistance to care. Prior documentation for Resident #50 included a note that this resident had attempted to hit staff during a separate elopement incident and required 24-hour supervision for safety. On the day of the incident, multiple witnesses, including residents, staff, and the Ombudsman, described escalating behavior by Resident #50 after becoming upset about family leaving the facility. Staff reported that Resident #50 was yelling, pushing a wheelchair with blankets, and verbally agitated. Staff #45 and a nurse initially redirected Resident #50 back to her room, but shortly thereafter, commotion was heard in the hallway where Resident #50 was observed yelling at Resident #20. According to interviews, Resident #50 began physically striking Resident #20 while staff attempted to intervene. Resident #20, who is disabled and unable to walk, reported that Resident #50 grabbed and hit her, hurt her arm, mocked her, and made her feel afraid and abused. Resident #10, who was nearby, reported seeing Resident #50 return down the hall and hit Resident #20 in the head, prompting Resident #10 to yell for help. Staff #25 (a CNA) placed herself between the residents and reported being hit while acting as a barrier. After staff began escorting Resident #50 away, Resident #50 then approached Resident #10, who was sitting in her doorway, and struck her in the arm and head. Resident #10 later showed reddish/grey marks on her right forearm, which she attributed to the incident, and a skin assessment documented a small scratch/abrasion on that arm without any cause noted. Staff interviews, including with the DON and social services director, confirmed that Resident #50 physically struck both residents and that no documentation of the incident, its details, or the resulting injuries was entered into the victims’ clinical records, despite the DON acknowledging that this conduct met the facility’s definition of abuse and that policy requiring documentation was not followed. The Ombudsman, who was in the building at the time, reported hearing screaming and being told by staff that Resident #50 had struck two residents, and was aware that police came to the facility. Staff #45 confirmed that she saw Resident #50 yelling at and then swinging on Resident #20, and later saw Resident #50 swing at Resident #10 while the DON attempted to block the contact. The CNA corroborated that Resident #50 and Resident #20 had a history of not getting along, that arguments tended to escalate, and that during this incident Resident #50 physically struck both residents. Resident #20 became visibly distraught and tearful when recounting the event to the surveyor and stated ongoing fear of Resident #50. Despite these events and the facility’s written policy stating residents have the right to be free from abuse, neglect, and related mistreatment, the clinical records for Residents #10 and #20 contained no incident documentation, and the single skin assessment for Resident #10 lacked any explanation of the cause of the injury, demonstrating a failure to protect residents from abuse and to document the abusive incidents in accordance with facility policy. A review of the facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program” effective January 1, 2024, stated that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. The DON acknowledged that the events involving Resident #50 and the two residents constituted abuse under this policy and that the policy was not followed with respect to documentation in the clinical records. The lack of contemporaneous clinical documentation of the incidents, injuries, and assessments for the victims, despite multiple staff and resident witnesses and involvement of law enforcement, was a central factor leading to the cited deficiency. In summary, the facility failed to prevent resident-to-resident physical abuse by a known behaviorally challenging resident and failed to document the incidents and resulting injuries in the victims’ clinical records, contrary to the facility’s own abuse prevention policy and standard documentation practices. This failure was established through clinical record review, interviews with the victims, staff, the Ombudsman, and observation of physical findings on Resident #10’s arm, as well as the absence of any incident-related entries in the clinical records of Residents #10 and #20.
Failure to Protect Resident From Financial Misappropriation by Staff
Penalty
Summary
The facility failed to protect a resident’s right to be free from misappropriation of property when a staff member became involved in the resident’s personal finances and received funds that were never used for their intended purpose. The resident, who had hemiplegia, CVA, dementia, UTI, type 2 DM, and sepsis, had a BIMS score of 10 indicating moderate cognitive impairment and required assistance and supervision with ambulation and various ADLs. According to the resident, she asked a staff member (identified as staff #200) to help her set up a checking account, and two monthly transfers of $500 each were arranged, for a total of $1,000. The resident reported that the account was never set up, that her son discovered the transfers and involved the police, and that she repeatedly asked the staff member for the money back. The resident stated that the staff member minimized the situation by saying it was “only money,” and that she felt abused, taken advantage of, embarrassed, and betrayed. The DON confirmed awareness of the incident and stated that the resident had requested an account not linked to her family and that staff #200 agreed to assist, with the understanding that the payments would be used to establish a new account in the resident’s name. The DON reported that the account was never created and that their investigation confirmed the money had been sent to staff #200. A registered nurse, when interviewed, stated that based on the details, the situation constituted abuse and defined abuse to include financial abuse as a violation of resident rights. The facility’s policy on abuse, neglect, exploitation, and misappropriation states that residents have the right to be free from misappropriation of resident property and exploitation, including financial abuse. Despite this policy, the resident’s funds were misappropriated by a staff member who had agreed to manage the resident’s financial transaction and did not carry out the agreed purpose.
Failure to Implement Abuse Prohibition Policy After Alleged Sexual Incident Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse prohibition policy and to investigate and report an allegation of possible sexual abuse between two cognitively impaired residents. One resident had early onset Alzheimer’s disease, aphasia, depression, a BIMS score of 00 indicating severe cognitive impairment, and a care plan noting behavior problems including poor safety awareness, wandering, exit seeking, and later, lifting her shirt and exposing her breasts. Despite this, the care plan interventions were not revised when the behavior of lifting her shirt was added, and there were no progress notes documenting this behavior or the alleged incident. The second resident had dementia with behavioral disturbances, type 2 diabetes, depression, a BIMS score of 09 indicating moderate cognitive impairment, and a care plan that identified sexually inappropriate behavior, but the care plan was not revised after the incident to reflect modified interventions related to sexual behaviors. Progress notes for the second resident showed that he was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note documented that he was observed kissing the first resident and that the first resident was reciprocating, but no additional progress notes were found related to this alleged incident. An observation showed that the two residents’ rooms were directly across the hallway from each other. Review of the state agency complaint portal revealed that no facility-reported incident had been submitted regarding these two residents, despite the facility’s policy requiring investigation and reporting of allegations of abuse within required timeframes and protection of residents from further harm during investigations. Multiple staff interviews revealed inconsistent and incomplete responses to the incident and a failure to treat it as a reportable allegation of abuse. A CNA stated that suspected abuse should be reported to the administrator, described the first resident as nonverbal and unable to give consent due to cognitive impairment, and expressed concern that having the residents’ rooms across from each other was not safe. An RN reported being told at shift change that there had been inappropriate behavior between the two residents but was unsure what occurred and noted that the residents should be moved. Another RN stated she had been told that the male resident was kissing the female resident on the cheek and that she had recommended moving them but was told only to keep them separated. The DON reported that both residents were found in the male resident’s room with the female resident’s shirt up, that they were separated, and that the facility concluded no sexual abuse had occurred; she acknowledged the incident was not reported to the state and could not say with 100% certainty that nothing had happened. The administrator, serving as abuse coordinator, confirmed that staff reported the residents were in bed together, fully clothed, and that the female resident could not consent, yet he did not consider the situation abuse and did not report it. The written statement from the witnessing RN described the female resident in bed with her shirt off and the male resident hovering over her; this RN stated she separated them and reported the incident because both residents were not alert and oriented and could not consent, but she personally did not label it as sexual abuse. Despite the facility’s policy defining abuse to include sexual abuse and requiring investigation and reporting of allegations, the incident was not reported to the state, the residents were not clearly protected through care plan revisions or room changes, and the facility did not fully implement its abuse prohibition policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Agency as required by its own policy and federal requirements. One resident, identified as Resident #5, had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00, indicating severe cognitive impairment. Her care plan, initiated in August 2025, documented behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, the care plan was updated to note that she lifted her shirt and exposed her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to this behavior or to the alleged incident. Another resident, identified as Resident #8, had dementia with behavioral disturbances, type 2 diabetes, and depression, and a BIMS score of 09, indicating moderate cognitive impairment. His care plan, revised in August 2025, documented behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to protect the rights and safety of others. Behavior notes from early January 2026 showed that he was placed on 1:1 activity for increased supervision and required redirection and supervision around other residents. A behavior note documented that he was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this incident, and his care plan was not revised after the incident to reflect modified interventions for sexual behaviors. Staff interviews and the facility’s internal investigation revealed that a nurse (Staff #9) found Resident #5 in Resident #8’s room, in his bed, with her shirt off and Resident #8 hovering over her after she had briefly lost sight of them. Staff #9 separated the residents and reported the incident to the DON (Staff #17). Multiple staff, including a CNA and RNs, stated that Resident #5 was not able to give consent due to cognitive impairment, and the abuse coordinator (Staff #2) confirmed that Resident #5 could not consent to being in bed with another person because she was not alert and oriented. Despite this, the abuse coordinator and DON concluded, based on staff statements and their belief that there was insufficient time for sexual contact, that no sexual abuse had occurred and therefore did not report the incident as an allegation of abuse to the State Agency. The abuse coordinator stated he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse, even though Resident #5 could not consent. Review of the State Agency complaint portal showed no facility-reported incident related to these residents, and the facility’s policy required investigation and reporting of any allegations within required federal timeframes. Resident room placement was also relevant to the events leading to the deficiency. Observations showed that the rooms of Resident #5 and Resident #8 were directly across the hallway from each other. Staff interviews indicated concerns about this proximity, with a CNA stating that this arrangement was not safe for Resident #5 because Resident #8 could easily access her, and RNs reporting that they had raised concerns and suggested moving the residents to different rooms. Nonetheless, the residents remained in close proximity. The combination of documented cognitive impairment, inability to consent, prior sexually inappropriate behavior, the observed incident of one resident in bed with clothing removed and another hovering over her, and the facility’s decision not to treat this as a reportable allegation of abuse led to the cited failure to timely report suspected abuse and the results of the investigation to the proper authorities, contrary to the facility’s abuse prevention policy. The facility’s policy titled “Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program,” effective January 1, 2024, required the facility to investigate and report any allegations within timeframes required by federal requirements. Despite this policy, the DON acknowledged that she could not say with 100% certainty that nothing took place between the two residents during the time they were unsupervised. The abuse coordinator described the situation as merely a nurse reporting an incident and maintained that there was no allegation of abuse, even though he acknowledged that Resident #5 could not consent. The investigative report, which documented that Resident #5 was in bed with her shirt up and Resident #8 hovering or leaning over her, was not part of the clinical record and was initially characterized as a quality measurement document. These facts demonstrate that an allegation of potential sexual abuse involving a resident who could not consent was not reported to the State Agency as required, constituting the deficiency. Review of the State Agency’s complaint portal confirmed that no facility-reported incident related to these residents had been submitted. Staff interviews consistently described the internal reporting chain, with suspected abuse to be reported to the administrator/abuse coordinator or the DON, who would then determine whether to report to external agencies. In this case, although staff recognized that both residents were not alert and oriented and that Resident #5 could not consent, the leadership determined that the situation did not constitute abuse and did not submit a report. This failure to report an allegation of sexual abuse, despite the circumstances and the facility’s own policy requiring reporting of any allegations, is the central deficiency identified by the surveyors.
Failure to Thoroughly Investigate and Respond to Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and appropriately respond to an allegation of possible sexual abuse between two cognitively impaired residents and to take steps to correct the situation. Resident #5, who had early onset Alzheimer’s disease, aphasia, depression, and a BIMS score of 00 indicating severe cognitive impairment, had a care plan initiated in August 2025 for behavior problems including poor safety awareness, wandering, and exit seeking, with interventions to protect the rights and safety of others. In January 2026, this care plan was updated to note that Resident #5 lifted her shirt exposing her breasts at times, but no new or revised interventions were added to address this behavior. Progress notes contained no entries related to the alleged incident or to Resident #5’s tendency to lift her shirt and expose her breasts. Resident #8 had dementia with behavioral disturbances, type 2 diabetes, depression, and a BIMS score of 09 indicating moderate cognitive impairment. His care plan, revised in August 2025, identified behavior problems including wandering, exit seeking, and sexually inappropriate behavior, with interventions to intervene as necessary to protect the rights and safety of others. After the incident involving Resident #5, there was no indication that his care plan was revised to reflect modified interventions related to sexual behaviors. Behavior notes documented that Resident #8 was placed on 1:1 activity for increased supervision and monitoring and that he required redirection and supervision around other residents. A behavior note on January 2, 2026, documented that Resident #8 was observed kissing Resident #5 and that she was reciprocating, but no additional progress notes were found related to this alleged incident. Interviews and the facility’s investigative documentation revealed inconsistencies and gaps in the investigation of the incident. Staff reported that Resident #5 and Resident #8 resided in rooms directly across from each other, and multiple staff expressed concern that this proximity was not safe for Resident #5. The DON stated that both residents were found in Resident #8’s room with Resident #5’s shirt up and that the residents were separated, and she reported that they concluded no sexual abuse had occurred, though she could not say with 100% certainty that nothing took place. The abuse coordinator stated that he was told the residents were in bed together with clothes on and that they liked to flirt, and he did not consider Resident #5 having her shirt up with Resident #8 hovering over her to be abuse, even though he acknowledged Resident #5 could not consent. The written investigation consisted only of statements from the witnessing RN, a CNA who did not witness the event, and the DON, with no evidence of broader interviews, additional observations, or further record review around the time of the incident, including no additional skin assessments beyond those dated December 22, 2025 and January 5, 2026. The incident was not reported to the State Agency’s complaint portal, despite facility policy and the State Operations Manual requiring investigation and reporting of allegations within required timeframes and the collection of evidence through observations, interviews, and record reviews, as well as immediate measures to protect residents from further abuse during the investigation. Further, the RN who witnessed the incident later described finding Resident #5 in Resident #8’s room, in bed with her shirt off and Resident #8 hovering over her, after hearing giggling and having lost sight of them for a few minutes. She separated the residents and reported the situation to the DON, acknowledging that both residents were not alert and oriented and could not consent, which was why she intervened. She stated that she did not personally consider it sexual abuse because she believed they were two consenting adults and that there was not enough time for anything to happen, but she recognized that determining whether it was abuse and whether to report it was the responsibility of leadership. Review of the State Agency’s complaint portal showed no facility-reported incident related to these residents, and the facility’s own policy on abuse, neglect, exploitation, and misappropriation prevention required investigation and reporting of any allegations within federal timeframes. The combination of incomplete documentation, limited investigative steps, lack of care plan revisions, and failure to report the allegation to the State constituted the deficient practice identified by surveyors. The facility also did not document any additional protective measures or environmental changes in the clinical record related to the proximity of the residents’ rooms, despite staff concerns that having the two residents directly across from each other was unsafe for Resident #5. CNA and RN staff interviews indicated that suspected abuse was to be reported to the administrator or DON, and that this process was followed in terms of initial reporting, but the subsequent investigation did not include comprehensive evidence collection as outlined in the State Operations Manual. The investigative report was treated as a quality measurement document and not part of the clinical record, and it did not demonstrate that the facility had thoroughly collected evidence through broader staff interviews, resident observations, or expanded record review around the time of the incident. These actions and omissions led to the finding that the facility failed to thoroughly investigate the allegation of abuse and to take steps to correct it.
Failure to Ensure Accurate Narcotic Count and Documentation
Penalty
Summary
The facility failed to ensure proper safeguards and systems for the accurate reconciliation and accounting of controlled substances on one of three medication carts. During an observation of a medication cart with an LPN, surveyors reviewed narcotic count reconciliation sheets and shift change sign-off sheets for several months. Multiple entries were found to be missing one or both required nurse signatures, with some days having no entries at all. The facility was unable to provide all requested medication cart logs, submitting only the shift change sign-off sheets. Interviews with nursing staff and the DON confirmed that the established procedure requires two nurses to count and sign for controlled substances at each shift change, but this was not consistently followed as evidenced by the missing signatures and incomplete documentation. The facility's policy requires that both the nurse receiving and the person delivering controlled substances count and sign together, and that the consultant pharmacist routinely monitors these records. Despite this, the review of documentation revealed repeated failures to obtain the necessary signatures and maintain complete records for controlled substances over multiple weeks. Staff interviews acknowledged that these omissions did not meet facility expectations and that the dual-nurse count is intended to ensure accuracy and accountability for narcotic medications.
Infection Control Deficiencies in Laundry and Medication Management
Penalty
Summary
The facility failed to adhere to infection control guidelines in multiple areas, including laundry services, medication preparation, and medication storage. In the laundry area, surveyors observed several deficiencies: dirty linen carts and storage containers were left uncovered or improperly covered, soiled blankets with visible debris were found under machines, and trash containers were not properly lidded. Additionally, a leaking washing machine was managed by placing blankets on the floor, which were replaced only when visibly soiled. Staff interviews revealed uncertainty and inconsistency regarding the requirement to keep dirty laundry covered and the proper handling of soiled items, with some staff unaware of the facility's expectations. In the area of medication preparation and storage, surveyors found open multi-dose insulin vials and insulin pens in medication carts without resident identifiers. Some insulin pens were being used as a substitute for unavailable insulin vials, with staff drawing insulin from the pens using syringes after swabbing the cartridge tops. This practice was described as common by nursing staff, despite facility policy prohibiting the use of multi-dose pens for more than one resident and requiring clear labeling with resident identifiers. Additionally, a cluttered medication cart contained a pill organizer and various medication bottles without proper labeling, and home medications were stored in the cart due to renovations, contrary to policy. Interviews with staff, including the DON and Infection Preventionist, confirmed that these practices did not meet infection control expectations. The DON acknowledged that dirty laundry should be bagged and tied at the source, kept covered, and separated from clean laundry, and that trash cans should be lidded. The DON also stated that insulin pens must be labeled and used only for the assigned resident, and that the observed medication storage practices were not compliant with facility policy. The facility's own policies require strict labeling and storage procedures for medications and biologicals, and prohibit transferring medications between containers or using multi-dose pens for multiple residents.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with multiple medical and cognitive conditions, including cerebral infarction, legal blindness, chronic pain syndrome, and moderate cognitive impairment, was not protected from verbal abuse by a staff member. The resident had a documented history of communication impairment and behavioral challenges, including agitation, use of profane language, and making false accusations. Despite these challenges, the care plans in place directed staff to anticipate and meet the resident's needs, maintain effective communication, and support the resident's comfort and dignity. On several occasions, staff and witnesses reported that a CNA engaged in loud arguments and used profanity toward the resident, including telling the resident to "shut the fuck up." Multiple interviews with staff, a student CNA, and the resident confirmed that such interactions were not isolated incidents but rather frequent occurrences. The resident consistently reported that CNAs yelled and used profanity, and a student CNA and other staff corroborated hearing the CNA argue and use inappropriate language. Facility documentation and interviews revealed that staff often did not report these incidents, considering them unprofessional but not necessarily abuse, and some staff justified the loud tone due to the resident's hearing deficit. The facility's own policies strictly prohibited demeaning, intimidating, or harassing behavior, including swearing and shouting, and required staff to treat residents with kindness, respect, and dignity. Despite these policies, the CNA in question had a documented history of unprofessional conduct, including previous incidents of arguing with residents and staff. The facility's investigation into the verbal abuse allegations was ultimately inconclusive, but firsthand accounts and interviews indicated that the resident was subjected to repeated verbal abuse, and staff failed to consistently recognize, report, or intervene in these situations as required by policy.
Resident Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the privacy of a resident during medication administration, which was observed during a survey. Resident #23, who has a history of Non-St Elevation Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Atherosclerotic Heart Disease, and Gastrointestinal Hemorrhage, was affected by this deficiency. The resident's information, including their name, date of birth, photo, and medications, was left visible on a device atop an unattended medication cart. This incident occurred despite the facility's policy and staff training emphasizing the importance of resident privacy and confidentiality. Interviews with staff, including a Registered Nurse and Unit Manager, a Licensed Practical Nurse, and the Director of Nursing, revealed that the facility's expectations were not met. Staff acknowledged that leaving resident information exposed and unattended was against professional standards. The facility's policy on resident rights and dignity clearly states that residents have the right to privacy and confidentiality regarding their medical records, and any breach of this policy could lead to further violations of resident privacy.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a deficiency. Resident #128, who has severe cognitive impairment and depression, was subjected to inappropriate behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. On July 7, 2024, Resident #128 was found yelling for Resident #66 to stop touching her, as staff witnessed Resident #66 reaching for her and attempting to expose himself. This incident was documented in progress notes, indicating that Resident #66 frequently engaged in inappropriate behavior towards female residents. Despite being aware of Resident #66's behavior, the facility's staff, including CNAs, LPNs, and the DON, failed to adequately address the situation. Interviews with staff revealed that Resident #66 had a history of touching female residents inappropriately and making sexual comments. Staff reported these incidents to their supervisors, but the facility did not take sufficient action to prevent further occurrences. The facility's policy on abuse prevention was not effectively implemented, as the administrator was unaware of the July 7 incident until it was brought to his attention during the survey. The facility's response to Resident #66's behavior was inadequate, as evidenced by the continued inappropriate conduct documented in subsequent progress notes. Staff interviews indicated that Resident #66's behavior persisted, with reports of him touching other female residents and making inappropriate comments. The facility's failure to report the July 7 incident to the state agency and to implement effective interventions to prevent further abuse contributed to the deficiency identified by the surveyors.
Failure to Report and Address Inappropriate Resident Behavior
Penalty
Summary
The facility failed to follow its abuse policy for a resident, leading to a deficiency. Resident #128, who has severe cognitive impairment due to dementia, was subjected to inappropriate behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. Despite multiple incidents of Resident #66 attempting to touch female residents inappropriately, including Resident #128, the facility did not adequately address or report these behaviors as required by their abuse prevention policy. Resident #66 was admitted to the facility with a history of dementia and depression and exhibited inappropriate sexual behaviors towards staff and residents. The facility's care plan for Resident #66 included interventions such as anticipating needs, identifying behavior triggers, and referring to a psychiatric provider. However, despite these measures, Resident #66 continued to engage in inappropriate behaviors, including touching female residents' private areas and making inappropriate comments. These incidents were documented in progress notes, but the facility failed to report them to the state agency as required. Interviews with staff revealed that they were aware of Resident #66's behaviors and had reported them to supervisors, including the Director of Nursing and the Administrator. However, the Administrator admitted to not being aware of the July incident involving Resident #128 and acknowledged that it should have been reported as abuse. The facility's policy requires immediate reporting of suspected abuse to the state agency, but this was not done, resulting in a deficiency in following the abuse prevention policy.
Failure to Report Resident Abuse
Penalty
Summary
The facility failed to report an incident of abuse involving two residents to the state agency, as required by professional standards. Resident #128, who has severe cognitive impairment due to dementia, was subjected to inappropriate sexual behavior by Resident #66, who also has severe cognitive impairment and a history of verbal and inappropriate sexual behaviors. Despite multiple documented incidents of Resident #66's inappropriate behavior towards female residents, including touching and groping, the facility did not report these incidents to the state agency. The deficiency was identified through clinical record reviews, staff and resident interviews, and facility documentation. Staff members, including LPNs, CNAs, and the DON, were aware of Resident #66's behavior, which included touching female residents inappropriately and making sexual advances. Despite being aware of these behaviors, the facility's administration, including the DON and the administrator, failed to report the incidents to the state agency. The administrator acknowledged that the incident involving Resident #66 and Resident #128 should have been reported as abuse but was not. The facility's policy requires the identification, investigation, and reporting of any allegations of abuse within the timeframes required by federal requirements. However, the facility did not adhere to this policy, as evidenced by the lack of reporting of Resident #66's behavior. The failure to report these incidents could result in further unreported incidents of abuse, neglect, or exploitation, as the facility did not follow its own protocols for preventing and identifying abuse.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving two residents, one of whom was identified as having severe cognitive impairment and a history of inappropriate sexual behaviors. The incident involved a resident with dementia and depression, who was observed reaching for another resident and attempting to expose himself. Despite being aware of the behavior, the facility did not report the incident to the state agency as required. The resident with inappropriate behaviors had a documented history of verbal and physical sexual misconduct towards female residents and staff. Multiple staff members reported witnessing these behaviors and had informed their supervisors, including the Director of Nursing and the Executive Director. However, the facility's administration did not take appropriate action to investigate or report these incidents, as evidenced by the lack of documentation and acknowledgment of the July incident involving the two residents. Interviews with staff revealed that the resident's behaviors were known and had been ongoing, yet the facility's response was inadequate. The Director of Nursing and the Administrator were not fully aware of the extent of the resident's behaviors, and the facility's policy on abuse prevention and reporting was not followed. This failure to act and report the abuse allegations could lead to further incidents of resident abuse.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents, leading to potential negative outcomes. For one resident, who was admitted with conditions including surgical aftercare and end-stage renal disease, the facility administered Tramadol 50mg for a pain level of 4, which was outside the prescribed parameters of a pain scale of 6-10. This was confirmed through a review of the Medication Administration Record and staff interviews, where it was acknowledged that the medication was given out of order parameters, contrary to professional standards and facility policy. Another resident, admitted with diagnoses including hypotension and rheumatoid arthritis, received Midodrine 5mg despite having a systolic blood pressure greater than 130, which was against the physician's order. The Medication Administration Record showed multiple instances of this medication being administered outside the prescribed parameters. Interviews with staff, including a pharmacist and a unit manager, confirmed that the medication should have been given only within the specified parameters unless cleared by the provider. The facility's policies on medication administration and resident assessment emphasize adherence to physician orders and the importance of notifying the physician of any abnormal vital signs.
Resident Lacks Access to Call Light
Penalty
Summary
The facility failed to ensure that a resident had access to a call light, which is crucial for communication with staff. The resident, who was admitted with diagnoses including left-sided paralysis, stroke, Type-2 Diabetes, repeated falls, and depression, was observed without access to a call light on multiple occasions. The resident's care plan specifically noted the need for the call light to be within reach to prevent falls and ensure prompt assistance. However, the call light cord was found sandwiched between the mattress and the wall, making it inaccessible to the resident. During interviews, the resident expressed concerns about not having a call light and mentioned previous falls. The resident's cognitive impairment and physical limitations further exacerbated the issue, as they were unable to reach the call light. Staff interviews confirmed that the call light was not easily accessible, and it was acknowledged that all residents should have easy access to their call lights. The deficiency was identified through observations, interviews, and a review of facility policies and resident records.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by other residents, resulting in injuries. Resident #15, who has moderate cognitive impairment, was hit in the head with a hairbrush by resident #50, who also has moderate cognitive impairment and a history of abusive behaviors. The incident was confirmed by staff interviews, but there were no detailed progress notes in resident #15's clinical record about the incident. Resident #50's behavioral care plan included interventions to prevent escalation of agitation, but these were not effectively implemented to prevent the incident. In another incident, resident #50 was inappropriately touched by resident #75, who has significant cognitive impairment and a history of inappropriate sexual behaviors. This incident was witnessed by staff and reported, but resident #50 expressed feeling abused by the encounter. Staff interviews revealed that resident #75 has a pattern of inappropriate behaviors, and there were interventions in place to identify behavior triggers and meet the resident's needs, but these measures were insufficient to prevent the incident. The facility's abuse policy acknowledges the challenges of preventing abuse among residents with dementia and mental illnesses, but the incidents indicate a failure to adequately protect residents from abuse. Staff interviews highlighted issues such as understaffing, which may have contributed to the inability to prevent these incidents. The Director of Nursing confirmed the incidents and noted that interventions were in place, but the incidents were considered outliers, suggesting a lack of consistent implementation of preventive measures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, leading to injuries. Resident #30, who has significant cognitive impairment, was hit in the face by resident #90 after an incident involving a wheelchair. Resident #30 was admitted with diagnoses including gout, alcohol dependence, and hypertension, and had a care plan to maintain a consistent routine to reduce confusion. Despite these measures, resident #30 suffered a bruise to the right eye after being struck by resident #90. Resident #90, who has moderate cognitive impairment and a history of physical behaviors, was involved in multiple incidents of aggression. The resident's care plan noted risks of wandering and physical behaviors but lacked specific interventions to address these issues. Progress notes indicated that resident #90 had several angry outbursts and was difficult to redirect, culminating in the physical altercation with resident #30. Additionally, resident #90 was reported to have caused an abrasion on the face of resident #60, another resident with significant cognitive impairment. Interviews with staff revealed that resident #90's behavior had escalated over time, with incidents of physical aggression towards other residents. The facility's abuse policy acknowledges the challenges of preventing abuse among residents with dementia and other mental illnesses. However, the lack of effective interventions for resident #90's behaviors contributed to the incidents of abuse, highlighting a deficiency in ensuring resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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