Mi Casa Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mesa, Arizona.
- Location
- 330 South Pinnule Circle, Mesa, Arizona 85206
- CMS Provider Number
- 035120
- Inspections on file
- 23
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mi Casa Nursing Center during CMS and state inspections, most recent first.
A resident with multiple neurologic and functional impairments, but intact cognition, reported feeling neglected after being left in a wet brief and requested that law enforcement be called. The resident’s spouse alleged that an RN and CNA provided rough care during a brief change, ignored the resident after he asked them to stop, and left his bed remote out of reach, and she filed police reports for abuse and neglect on two occasions. The ED documented the concern, briefly interviewed the resident and spouse, concluded that care had been provided, and decided not to report the later allegation to the State Survey Agency, APS, or other required entities because the resident’s account differed from his wife’s, despite facility policy requiring that all alleged violations of abuse or neglect be reported within specified timeframes regardless of how the allegation is characterized.
A resident with multiple neurologic and medical conditions, but intact cognition, reported feeling neglected after being left in a wet brief for several hours and requested that law enforcement be called. The resident’s wife alleged that an RN and CNA provided rough incontinence care after a urinal spill, ignored the resident’s pleas to stop, then ignored him for the rest of the night and left his bed remote out of reach; she stated that police reports were filed for two separate incidents and that the later allegation was not reported to any state agency. The Executive Director documented the concern, interviewed the resident and his wife, obtained staff statements, and concluded that care had been provided, deciding not to report the later allegation to the State Survey Agency, APS, or other required officials. This decision conflicted with facility policy, which required that all alleged violations of abuse or neglect, whether or not explicitly labeled as such and regardless of conflicting accounts, be reported within specified timeframes to the administrator and appropriate state authorities.
A resident with a PEG tube and intact cognition, dependent on staff for nutrition, repeatedly refused a bolus feeding and water flush, verbally saying no and physically pushing the tube away. An LPN, assisted by two CNAs, proceeded with the midnight bolus and flush while the resident attempted to kick and push the feeding away, and the CNAs held the resident’s hands and knees down so the LPN could continue the treatment. Facility documentation and staff records show that the staff forcefully administered the tube feeding flush against the resident’s expressed wishes, in violation of the resident’s rights to be free from abuse and to refuse treatment.
A resident with complex medical needs did not receive a required wound dressing change as ordered, and the LPN on duty charted the treatment as completed despite not performing it. The DON confirmed the omission after the resident reported the missed care, and facility policy requires accurate documentation of all treatments provided.
Two residents experienced deficiencies in bowel and bladder care, including a resident with severe cognitive impairment who did not receive timely intervention for constipation, resulting in hospitalization for severe fecal impaction, and another resident with an indwelling catheter who did not receive catheter care as ordered, with inconsistent documentation and no evidence of physician notification regarding missed care.
Staff were observed delivering and transporting uncovered beverages, such as coffee, water, and juice, to residents' rooms and bedside tables, including in areas with Enhanced Barrier Precautions. These actions did not follow facility expectations or infection control policies, as confirmed by interviews with dietary and nursing staff.
A resident with significant physical and cognitive impairments was found with a severely torn fall mat next to their bed, exposing internal materials and creating an infection control concern. Staff confirmed the mat could not be properly cleaned and should have been removed according to facility policy, which requires the removal of compromised equipment to prevent infection risks.
A resident with multiple health conditions and a recent fracture was not allowed to make an informed choice about continuing specialized rehab services, despite being cognitively intact and expressing a desire to continue therapy. The care plan did not reflect the resident's wishes, and staff communication failures led to the discontinuation of therapy, even though insurance coverage was still active.
A resident with a documented DNR advance directive did not have their code status entered into the electronic clinical record or incorporated into the care plan, as required by facility policy. The DNR order was only present in the hard chart, making it inaccessible to staff using electronic records, and the process for entering such directives was not consistently followed.
A resident admitted for orthopedic aftercare with multiple comorbidities did not receive ordered PT and OT services for an extended period, despite ongoing insurance coverage and medical necessity. Miscommunication among staff led to a gap in therapy, with no physician order for discharge and no documentation of the resident's rehab goals in the care plan. The resident was not included in care planning discussions and reported not understanding why therapy was stopped, resulting in unmet rehabilitation needs.
The facility failed to provide adequate staffing, resulting in delayed care for residents. A resident at risk for skin breakdown did not receive timely continence care, while another resident requiring assistance with transfers reported long wait times for call-light responses. Staff interviews confirmed the challenges posed by staffing shortages, with the facility's management acknowledging the issue but failing to resolve it effectively.
The facility failed to maintain adequate staffing levels, resulting in prolonged call light response times and unmet resident needs. Observations and interviews revealed that residents often waited over 30 minutes for assistance, with staffing levels falling short of the facility's requirements. The DON and Staffing Coordinator acknowledged the challenges in hiring sufficient CNAs, impacting the quality of care and posing risks to residents.
A resident with multiple health issues reported that a CNA was mean and disrespectful, turning off the call light without providing care. The CNA rudely told the resident to watch her tone and refused to let another CNA take over care. The DON confirmed the incident and noted the CNA's history of attitude concerns.
A facility failed to protect a resident from verbal abuse by a CNA, who had a history of inappropriate behavior. Additionally, the facility did not prevent physical and emotional abuse between two residents, one of whom used a backscratcher to hit the other. Interviews revealed a lack of staff intervention and inadequate implementation of abuse prevention policies, leading to an unsafe environment.
The facility failed to provide consistent showers to three residents, leading to hygiene issues and skin conditions. A resident who is completely dependent on staff for showers missed numerous scheduled showers, resulting in a rash. Another resident required extensive assistance and missed several showers, leading to untreated skin conditions. A third resident experienced long periods without showers, contributing to a recurring yeast rash. Interviews revealed ongoing staffing issues and unaddressed concerns despite repeated discussions.
A facility failed to protect residents from abuse, resulting in two incidents. In one case, a resident reported an LPN threw a remote at him, which the LPN denied, but another LPN corroborated the resident's account. The facility deemed the abuse unsubstantiated but terminated the LPN for poor service. In another case, a cognitively impaired resident gripped another resident's shoulders, causing pain. The facility substantiated this abuse. The facility's abuse prevention policy was not effectively implemented.
A resident with multiple chronic conditions experienced inadequate wound care management, leading to hospitalization. Despite treatment orders for cellulitis and blisters, the facility failed to consistently administer care, and the resident's noncompliance was not addressed in the care plan. Maggots were later found in the wound, prompting another hospital transfer. Interviews revealed that staff nurses were responsible for wound treatments, but documentation was lacking.
Failure to Report and Investigate Allegation of Staff-to-Resident Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse and neglect reporting policy after an allegation of staff-to-resident abuse and neglect involving Resident #70. Resident #70 had multiple significant diagnoses, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors. A care plan initiated in late December identified the resident as being at risk for alteration in psychosocial well-being due to staff failure to honor resident choices during care. On December 27, 2025, the Executive Director (ED) documented a Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The form noted that the concern was reported to the ED and that the ED spoke with the resident and his wife that afternoon. The resident and his wife reported that he did not receive care upon arrival from the hospital. The ED’s handwritten investigation notes concluded the same day that the resident had received care throughout the night, including at arrival, at midnight, and when the nurse checked his feeding pump. The ED documented that the concern was resolved at the time it was shared and that the investigation findings were concluded within about 40 minutes. In a later interview, the resident’s wife reported that during the night in question, an RN and a CNA responded to the resident’s call light for a brief change after he spilled his bedside urinal, and that they turned him back and forth aggressively during the brief change despite his request for them to stop. She stated that the RN made a comment to the assisting staff that they needed to get out of the room or else the resident would get them fired, and that staff then ignored the resident for the rest of the night and left his bed remote out of reach. She also stated that two police reports had been filed regarding abuse and neglect during his stay, and that the incident from December 27, 2025, was not reported by the facility to any state agency except the police. The ED confirmed in interview that he was informed of the wife’s allegation of neglect on December 27, that he spoke with both the wife and the resident, and that because the resident contradicted the wife’s allegation, he decided not to report the incident to the State Survey Agency, APS, or other required entities, despite facility policy requiring that all alleged violations be reported. Staff interviews further described the events and the facility’s handling of the allegation. The RN identified as being involved stated that she did not recall any allegation of abuse, neglect, or rough care being made to her or against her, and denied ignoring the resident or making the statement about staff being fired. A CNA who assisted with care that night reported that the resident had a history of making allegations and that he received two-person care at all times; she described assisting with a full bed change after the resident spilled his urinal and later being contacted by the previous DON to write a statement after the resident reported that night shift had neglected him. Another CNA stated she was instructed to provide care in pairs because the resident was having issues with staff and reporting that no care was being given. Despite these multiple accounts and the wife’s explicit allegation of neglect, the ED acknowledged that he did not report the December 27 allegation to state agencies, relying instead on his own assessment that the incident was not abuse or neglect. Review of the facility’s policies showed that abuse included the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and that neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The reporting policy required that all alleged violations be reported immediately, but no later than 2 hours if abuse or serious bodily injury was involved, or within 24 hours if not, to the administrator and to other officials, including the State Survey Agency and APS. The policy also specified that an individual reporting an alleged violation did not need to label it as abuse or neglect for it to trigger a facility investigation and reporting, and that all alleged violations, whether oral or written, must be reported to the administrator and other officials in accordance with state law. Despite this, the ED stated that he did not report the December 27 allegation to any state agency because he did not deem it necessary after the resident contradicted his wife’s account, thereby failing to follow the facility’s abuse and neglect reporting policy for this allegation.
Failure to Report Alleged Staff-to-Resident Abuse and Neglect to Required Agencies
Penalty
Summary
The facility failed to report an incident involving alleged staff-to-resident abuse and neglect to the required state agencies after a resident and his wife reported concerns about his care. The resident had multiple significant medical conditions, including hemiplegia and hemiparesis, protein-calorie malnutrition, facial weakness, dysphagia, muscle weakness, aphasia following cerebral infarction, cognitive, social, or emotional deficit, frontal lobe and executive function deficit, atrial fibrillation, hydrocephalus, convulsions, and headache. An admission MDS showed a BIMS score of 14, indicating intact cognition, and documented that the resident had exhibited rejecting care behaviors for 1–3 days. A care plan focus was initiated for risk of alteration in psychosocial well-being related to staff failure to honor resident choices during care on a prior date. On a later date, the Executive Director (ED) completed a handwritten Concern & Comment Form after the resident stated he felt neglected because he had been left in a wet brief for a few hours and requested that law enforcement be called for neglect. The ED documented that the resident and his wife reported that he did not receive care upon arrival from the hospital, and the ED’s investigation concluded that the resident had received care throughout the night, including at midnight and when his feeding pump was checked. The ED recorded that the concern was resolved at the time it was shared and that the resident was informed that a specific RN would no longer provide his care, as requested. The facility’s internal investigation included obtaining written statements from staff about the incident. In a subsequent interview, the resident’s wife stated that during the night in question, an RN and a CNA responded to the resident’s call light after he spilled his bedside urinal and that they turned him aggressively during a brief change, ignored his requests to stop, and then ignored him for the rest of the night, leaving his bed remote out of reach. She reported that two police reports were filed during his stay, one for an earlier incident and another for this night, and asserted that the later incident was not reported by the facility to any state agency except the police. The ED confirmed that he was aware of the allegation of neglect made by the wife, that he spoke with both the wife and the resident, and that the resident contradicted the wife’s allegation. The ED stated that, because he had conflicting statements and did not deem the later incident to be abuse, he did not report it to the State Survey Agency, APS, or other required state entities, despite facility policy requiring that all alleged violations be reported within specified timeframes regardless of how they are characterized. Additional staff interviews showed that staff were aware of the requirement to report allegations of abuse and neglect promptly to facility leadership. The RN identified as involved denied that any allegation of rough care or neglect had been made to or about her and denied ignoring the resident or making threatening statements. Other CNAs and an LPN recalled that the resident had a history of making allegations, that he was to receive two-person care, and that there had been prior incidents involving staff being fired. One CNA reported being contacted by the previous DON and asked to provide a written statement after the resident alleged that night-shift staff had neglected him. The facility’s abuse and neglect policies defined abuse and neglect broadly and required that all alleged violations, whether oral or written, be reported immediately (within 2 hours if abuse or serious bodily injury was involved, or within 24 hours otherwise) to the administrator and appropriate state officials, and that staff did not need to explicitly label an event as abuse or neglect for it to be considered reportable. Despite these policy requirements, the ED acknowledged that the later allegation of neglect was not reported to the required state agencies.
Abusive Administration of Tube Feeding Flush Despite Resident Refusal
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to honor the resident’s right to refuse treatment during enteral feeding care. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, malnutrition, facial weakness, and dysarthria, and had a PEG tube due to dysphagia and dependence on staff for eating. A care plan and enteral feeding order directed Jevity 1.5 bolus feeds every four hours with a 50 mL purified water flush after each feeding. Documentation showed the resident occasionally became confused and resistive with care, including PEG tube care, and had been known to reject care. On one occasion, a behavior note documented that during a bolus feeding the resident became combative, pushed the nurse’s hands away, and said “no more food and water,” after which the LPN explained the need for the water flush and the resident agreed to the flush. A subsequent behavior note recorded that at a midnight bolus feeding, the LPN, assisted by two CNAs, proceeded with the bolus and water flush while the resident tried to kick staff and push the food away, repeatedly saying “no more food, no more water.” During this episode, the two CNAs held the resident’s hands and knees down while the LPN administered the bolus and flush. A later note the same night documented that the resident refused food and the bolus was not given. The resident’s admission MDS showed a BIMS score of 14, indicating cognitively intact status, and confirmed dependence on staff for eating and use of a PEG tube, with a history of rejecting care. In an interview, the resident reported refusing multiple times by pushing the tube away and verbally stating he did not want the treatment or the flush because it caused him to go to the bathroom, and stated that when he tried to push it away, the nurse brought more staff to hold him down while she flushed against his wishes. Personnel and termination documents for the LPN and both CNAs indicated that they participated in resident abuse by forcefully administering treatment and physically holding the resident’s extremities so that the tube feeding flush could be given despite the resident’s clear refusals. Facility policies in effect at the time stated that residents have the right to be free from abuse, including physical restraint not required to treat medical symptoms, and the right to request, refuse, and discontinue treatment.
Failure to Accurately Document and Perform Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to accurately document and perform wound treatment for a resident with multiple complex medical conditions, including surgical aftercare, diabetes, infection, and an abdominal surgical wound. The resident was admitted with an order for specific wound care, including cleansing with normal saline, application of Adaptic on biological mesh, packing with acetic acid-soaked gauze, and covering with a dry dressing, to be performed every shift. Documentation showed that the wound care was charted as completed on both the day and night shifts of a specific date. However, during an interview, the LPN assigned to the night shift admitted that she did not perform the wound care due to a busy shift and was unaware of a change in the wound care order. She also stated that she mistakenly charted the treatment as completed. The DON confirmed that the wound care was missed on the night shift, as reported by both the resident and the LPN, despite documentation indicating otherwise. The facility's policy requires that nursing documentation accurately reflect the care provided and the resident's progress. The inaccurate documentation and failure to perform the ordered wound care resulted in a deficiency, as the medical record did not provide an accurate representation of the resident's experience or care received.
Deficient Bowel and Catheter Care for Two Residents
Penalty
Summary
A deficiency was identified regarding the care and services provided to two residents with bowel and bladder management needs. One resident with a history of intracranial injury, full fecal incontinence, and severe cognitive impairment did not have a documented bowel movement for more than three days, as evidenced by CNA task documentation. Despite facility protocols and staff interviews indicating that lack of bowel movement should trigger nursing intervention and physician notification, there was no evidence that the resident received any medication or intervention for constipation until after the resident was hospitalized for severe constipation. The clinical record showed no physician order for stool softeners or laxatives until after the hospital admission, and the resident was ultimately diagnosed with a large, retained stool mass requiring medical intervention. Another resident with an indwelling catheter for neurogenic bladder and severe cognitive impairment did not receive catheter care as ordered by the physician. The care plan and physician orders required catheter care and securing the catheter with an anchoring device every shift, as well as regular monitoring of the catheter tubing and bag. However, review of the CNA Bowel and Bladder Elimination Report revealed inconsistent and infrequent documentation of catheter care, with several days showing only a single check or no documentation at all. There was no evidence that the physician was notified about the missed catheter care, nor any documentation explaining the lapses. Staff interviews confirmed that both CNAs and nurses were responsible for monitoring and documenting bowel movements and catheter care, and that the facility's electronic medical record system was designed to alert staff to issues such as missed bowel movements. Despite these systems and protocols, the required care was not consistently provided or documented for the two residents, resulting in deficiencies related to the management of constipation and catheter care.
Uncovered Beverage Delivery During Meal Service
Penalty
Summary
Staff failed to follow proper food handling practices during the distribution of beverages to residents, as observed on multiple occasions. Beverages, including coffee, water, juice, and dairy, were repeatedly transported and delivered to resident rooms and bedside tables without covers. These uncovered beverages were observed being carried through hallways, placed on bedside tables, and retrieved from food trolleys, including in areas where residents were on Enhanced Barrier Precautions (EBP). Staff members, including nursing and dietary staff, were seen handling and delivering these uncovered drinks over varying distances within the facility. Interviews with facility staff, including the Kitchen Manager and Registered Dietitian, confirmed that the expectation was for all beverages to be covered during delivery to prevent contamination. However, the observed practice did not align with this expectation, as staff distributed uncovered beverages to residents. Facility policies on infection prevention and control, as well as surveillance of infection-related practices, were referenced, but the observed actions did not adhere to these standards.
Failure to Remove Damaged Fall Mat Creates Infection Control Deficiency
Penalty
Summary
A resident with quadriplegia, legal blindness, and aphasia was admitted to the facility and identified as being at risk for falls, with a fall mat care plan in place. During an observation, a blue fall mat next to the resident's bed was found to be ripped apart approximately three-quarters of the way, exposing the internal sponge-like material. This condition was noted in the presence of the resident and their representatives. The resident's clinical records indicated severely impaired decision-making abilities. Staff, including a Registered Nurse and the Infection Preventionist, confirmed that the torn mat could not be properly cleaned and posed an infection control concern, as it could harbor potentially infectious organisms. The facility's policies required removal of products with compromised integrity and identified proper cleaning, disinfection, and disposal of equipment as essential to infection prevention. The presence of the damaged fall mat in the resident's environment demonstrated a failure to implement effective infection control measures as outlined in facility policy.
Failure to Honor Resident Choice in Continuation of Therapy Services
Penalty
Summary
A resident admitted for orthopedic aftercare with multiple comorbidities, including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking, was found to have been denied the right to make choices regarding the continuation of specialized rehabilitative services. Despite being cognitively intact and expressing a clear desire to continue therapy to meet personal mobility goals, the resident's care plan did not reflect this preference. The resident reported confusion about the discontinuation of therapy services and stated that therapy sessions were only missed due to illness. The resident also indicated a lack of communication regarding therapy options, insurance coverage, and care plan meetings, and did not recall any discussions with the insurance company or staff about the continuation of therapy. Interviews with facility staff, including the case manager and a panel of leadership, confirmed that the resident was eligible for continued therapy services and that insurance coverage was still active. However, a breakdown in communication among staff resulted in the resident not receiving the requested therapy services. Facility policies require that residents be informed of changes to their care plan and be allowed to make informed choices about their treatment, but these procedures were not followed in this case.
Failure to Enter and Care Plan DNR Order in Clinical Record
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Non-Hodgkin lymphoma, muscle weakness, and an indwelling urinary catheter, had a documented advance directive indicating Do Not Resuscitate (DNR) status. Despite this, the resident's DNR order was not entered into the electronic clinical record upon admission or readmission, nor was it incorporated into the resident's care plan as required by facility policy. The advance directive was only found in the hard chart at the nursing station and not reflected in the electronic system, making it inaccessible to staff relying on electronic records for code status information. Interviews with nursing staff revealed that the process for entering advance directives into the electronic record was not consistently followed, and there was no centralized system, such as a code book, to alert staff to residents' code statuses. The responsible nurse was unable to locate the code status in the electronic record until after the deficiency was identified, at which point the order was entered. Facility policy requires a physician's order for DNR status and mandates that it be flagged in the chart and included in the care plan, but these steps were not completed for this resident.
Failure to Provide Ordered Rehabilitative Services Due to Communication Breakdown
Penalty
Summary
A resident was admitted for orthopedic aftercare following a right fibula fracture, with additional diagnoses including severe osteoporosis, depression, chronic pain, muscle weakness, and difficulty walking. Upon admission, orders were written for both physical therapy (PT) and occupational therapy (OT) evaluations and treatments, with plans specifying services five times a week for several weeks. The resident was cognitively intact and expressed a desire to participate in therapy to regain strength and mobility, specifically aiming to reduce fall risk and improve ability to use a bedside commode. Despite having insurance coverage for the entire stay, the resident experienced a discontinuation of both PT and OT services after March 20, even though the treatment plans and insurance authorizations extended beyond that date. The clinical record did not reflect a physician order to discharge rehabilitative services, nor did the nursing care plan document the resident's goals for specialized rehab services. The resident reported not receiving therapy for approximately two weeks prior to discharge and was unclear about the reason, despite inquiring with staff. Interviews with facility staff confirmed that there was a miscommunication regarding the resident's coverage and discharge status, resulting in the resident not being re-evaluated or transitioned to restorative or continued rehabilitative services during the gap period. The resident expressed frustration and discouragement about not receiving therapy, feeling weaker, and not achieving her rehabilitation goals. She was not included in care plan meetings or discussions about her therapy, and staff interviews confirmed that the extension of her stay and continued eligibility for services were not effectively communicated to the rehabilitation department. Facility policies required individualized, person-centered care planning and the provision of specialized rehabilitative services as assessed, but these were not followed in this case.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, resulting in several instances where residents did not receive timely care. Resident #22, who was at risk for skin breakdown, did not receive continence care on a specific day, leading a family member to provide care due to unresponsive staff. The facility's records confirmed that staff did not attend to the resident during the day shift, highlighting a lapse in care provision. Resident #77, who required substantial assistance with transfers, reported waiting over two hours for call-light responses and experiencing delays in receiving necessary care. The resident's care plan lacked specific instructions for assistance with activities of daily living, such as transfers, further complicating the situation. Interviews with other residents revealed similar issues, with reports of long wait times for assistance, particularly during peak hours like lunch. Staff interviews corroborated the residents' complaints, with CNAs acknowledging the challenges posed by staffing shortages. The facility's staffing coordinator and DON admitted to being aware of the staffing issues, which were exacerbated by call-offs and inadequate scheduling adjustments. Despite attempts to manage the situation, the facility's staffing levels were insufficient to meet the residents' needs, as evidenced by the numerous complaints and documented instances of delayed care.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by multiple instances of prolonged call light response times and insufficient staff coverage. Resident Council meeting minutes and grievance logs highlighted ongoing concerns about staffing, particularly on weekends and during night shifts. Residents reported waiting excessively long for assistance, with some call lights remaining unanswered for over 30 minutes. Observations confirmed these delays, with staff often unavailable or occupied with other tasks, leaving residents without timely care. On specific dates, the facility was notably understaffed, with insufficient numbers of CNAs and nurses to cover the resident census. For instance, on March 16, 2023, the facility had only 3 RNs, 2 LPNs, and 4 CNAs during the day for 116 residents, which did not meet the facility's own staffing requirements. Interviews with staff, including the DON and Staffing Coordinator, acknowledged the staffing shortages and the challenges in hiring and retaining sufficient staff, particularly CNAs. The facility's staffing assessment indicated a need for more staff than were present, leading to compromised resident care. The deficiency was further highlighted by specific incidents where residents' needs were not promptly addressed. For example, a resident reported waiting over an hour for assistance off a bedside commode, and another resident's call light was on for over two hours before receiving medication. These incidents, along with staff interviews, revealed systemic issues in staffing that affected the quality of care provided to residents, with risks of falls, skin issues, and unmet care needs being directly linked to the understaffing problem.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident who was readmitted with multiple diagnoses, including acute and chronic respiratory failure, Type 2 diabetes mellitus with diabetic neuropathy, and chronic obstructive pulmonary disease. The resident was alert and oriented, with no documented behavior or mood issues. An incident occurred where the resident reported that a CNA was mean, turned off the call light without providing care, and was disrespectful during an interaction. The resident expressed upset feelings about the delayed care, and the CNA responded rudely, telling the resident to watch her tone and insisting on continuing care despite another CNA offering to take over. The incident was documented in a facility investigation report, and a corrective action form was issued to the CNA involved. The Director of Nursing confirmed that staff are trained on dignity and respect and expressed that the incident was not conducive to the resident's health. The DON also noted that the CNA had previous attitude concerns and had been written up for insubordination in the past. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity.
Failure to Prevent Resident Abuse and Inadequate Staff Intervention
Penalty
Summary
The facility failed to protect Resident #47 from verbal abuse by an employee, identified as a certified nursing assistant (CNA). The resident, who had moderate cognitive impairment and required maximal assistance for certain activities, was subjected to inappropriate language by the CNA. The incident was reported by another staff member, and interviews with various staff members revealed a pattern of intimidating and inappropriate behavior by the CNA, who had previously received a second written warning for refusing assignments and making coworkers uncomfortable. Despite these warnings, there was no documentation of a first written warning or a complete investigation into the CNA's behavior. In another incident, the facility failed to prevent physical and emotional abuse between two residents, Resident #39 and Resident #41. Resident #39, who had severe cognitive impairment and was dependent on a wheelchair, was involved in an altercation with Resident #41, who was cognitively intact but had a history of behavioral disturbances. The altercation occurred when Resident #41 used a backscratcher to hit Resident #39's hand to stop him from moving a table. Interviews with other residents and staff indicated that such incidents were becoming more common, with residents often feeling the need to intervene due to a lack of staff presence. The facility's policies on abuse prevention and investigation were not effectively implemented, as evidenced by the lack of immediate staff intervention during the altercation and the absence of a thorough investigation into the verbal abuse incident. The Director of Nursing and Executive Director were aware of the incidents but did not take sufficient steps to prevent recurrence, such as separating the involved residents or ensuring adequate supervision in common areas. The facility's failure to address these issues created an unsafe environment for residents, as highlighted by the repeated instances of abuse and the residents' concerns about their safety.
Inconsistent Showering Practices in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents received consistent showers, which is a deficiency in providing care and assistance for activities of daily living. Resident #3, who is cognitively intact and completely dependent on staff for showers, missed numerous scheduled showers over several months. Despite the resident's preference for a female CNA, the facility did not accommodate this request, leading to missed showers and a rash on the resident's arms and groin. Resident #8, also cognitively intact, required extensive assistance for showers due to paralysis and other health conditions. The resident missed several scheduled showers, and a rash in the skin folds required treatment with anti-fungal powder. The resident expressed concerns about insufficient staffing and the inability to receive showers during the day shift, which contributed to the missed showers. Resident #11, who needs partial assistance with showering, also experienced missed showers, leading to a recurrence of a yeast rash. The resident reported long periods without showers and poor call light response, resulting in prolonged exposure to wet briefs. Interviews with staff and residents highlighted ongoing issues with staffing and the facility's failure to address these concerns, despite repeated discussions in resident council meetings.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect the rights of two residents to be free from abuse, resulting in a deficiency. In the first incident, a resident with moderate cognitive impairment reported that an LPN threw his television remote at him and removed the batteries because the TV volume was too high. The LPN denied throwing the remote and stated that she underhand tossed it into the resident's lap. Another LPN corroborated the resident's account, stating that the accused LPN admitted to taking the remote and removing the batteries. The facility's investigation concluded that the allegation of abuse was unsubstantiated, but the LPN was terminated for failing to provide good customer service. In the second incident, a resident with cognitive impairments and a history of aggressive behavior was involved in an altercation with another resident. The aggressor resident, who had moderately impaired cognitive skills, approached the victim from behind and gripped his shoulders, causing pain and a bruise. The victim was unable to free himself and called for help. Staff intervened and separated the residents. The facility's investigation substantiated the allegation of abuse, confirming that the aggressor resident's actions caused harm to the victim. The facility's policy on abuse prevention, which includes preventing physical abuse by any individual, was not effectively implemented in these cases. The policy outlines steps to prevent abuse, including monitoring residents identified as aggressors and separating involved residents. However, the incidents involving the two residents highlight a failure to adhere to these preventive measures, resulting in harm to the residents involved.
Failure to Administer Wound Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide care and treatment for a resident according to professional standards of practice, resulting in the resident's hospitalization. The resident, who had chronic hepatic failure, hypertension, congestive heart failure, chronic kidney disease with end-stage renal disease, and hyperkalemia, was admitted with a nutrition care plan goal for skin improvement. Despite documentation of cellulitis and blisters on the resident's lower extremities, treatment orders were inconsistently administered, and the resident's wounds were not care planned with interventions. The Treatment Administration Record (TAR) showed missed or refused treatments on several occasions, and the resident was eventually transferred to the hospital. Upon return from the hospital, new treatment orders were documented as administered, but the resident's refusal and noncompliance with wound care were not addressed in the care plan. The resident remained non-compliant with wound care, and maggots were found in the wound upon bandage removal, leading to another hospital transfer. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that wound care documentation was expected in the TAR, and staff nurses were responsible for the resident's wound treatments. The CDC notes that untreated or open wounds increase the risk of myiasis, a parasitic infection, which was a concern in this case.
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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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