Payson Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Payson, Arizona.
- Location
- 107 East Lone Pine Drive, Payson, Arizona 85541
- CMS Provider Number
- 035117
- Inspections on file
- 19
- Latest survey
- April 17, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Payson Care Center during CMS and state inspections, most recent first.
A resident with multiple health conditions and high risk for skin breakdown did not receive consistent weekly skin assessments as required by facility policy. CNAs documented several new skin issues, including blisters and bruising, but there was no evidence that nurses performed further assessments, notified providers, or obtained new treatment orders. The DON confirmed that scheduled skin checks were missed and follow-up on new findings was not documented.
A facility failed to obtain informed consent from a resident before administering Duloxetine and Trazodone for depression. The resident's care plan included these medications, but the required consents were not completed, as confirmed by staff interviews. The facility's policy mandates obtaining consent before starting psychotropic medications, which was not adhered to in this case.
The facility failed to maintain an effective training program for five staff members, leading to incomplete training in dementia, infection prevention, resident rights, and abuse. Personnel files and interviews confirmed the lack of documentation for required training, despite multiple requests. The facility's policy mandates regular training, which was not adhered to, resulting in a deficiency.
The facility failed to ensure that five staff members received ongoing education on abuse, neglect, exploitation, and dementia care. Personnel files and interviews revealed that required annual training for 2024 and 2025 was not completed by a CNA, OT, LPN, another CNA, and an RN. Interviews with management highlighted the facility's expectations for training completion, but documentation was lacking. This deficiency could lead to a deficit in staff knowledge and skills, potentially affecting resident care.
Two residents with severe cognitive impairment were involved in an altercation, resulting in a deficiency due to the facility's failure to prevent abuse. The incident involved physical aggression, and the facility's investigation was incomplete, lacking documentation and assessments of harm. Staff interviews revealed both residents exhibited aggressive behaviors, but the facility did not adequately address the situation.
A facility failed to document and retain evidence of an investigation into an altercation between two residents with severe cognitive impairments. The incident involved physical aggression, but the facility did not complete a thorough investigation or retain necessary documentation. Staff interviews revealed that both residents exhibited aggressive behaviors, making altercations plausible. Despite understanding the importance of proper investigation, the facility did not meet its own expectations for documentation and evidence retention.
The facility failed to issue timely Medicare Non-Coverage notices to two residents. One resident with Alzheimer's was informed of the end of Medicare services on the same day, leaving no time for appeal. Another resident, cognitively intact, did not receive the required SNF ABN form. Staff interviews revealed confusion about determining the last covered day of service.
A resident with bilateral lower extremity amputations experienced a delay in receiving a left leg prosthetic due to missing documentation, despite measurements being completed. The resident was not included in the restorative therapy caseload, and the facility's records lacked a care plan for the amputation. This delay hindered the resident's ability to ambulate, contrary to the facility's Prosthesis Care and Management policy.
A resident admitted for orthopedic aftercare following a lower extremity amputation did not receive necessary restorative nursing services, despite recommendations from therapy discharge summaries. The resident was not on the facility's restorative therapy caseload, and there was no documentation of a Restorative Care Referral form. Interviews with staff confirmed the lack of evidence supporting the resident's participation in restorative therapy, which does not meet facility expectations.
A resident with moderate cognitive impairment and mobility issues experienced multiple falls, resulting in injuries, due to inadequate supervision and failure to implement fall prevention measures. Despite having a care plan, there was no evidence of specific interventions, and staff interviews revealed inconsistencies in communication and execution of fall checks. The facility's policy required updates to the care plan after falls, but this was not done, highlighting a deficiency in fall prevention.
A resident with a history of falls and moderate cognitive impairment experienced a fall due to inadequate supervision and failure to address behavioral changes. Despite signs of restlessness and confusion, the facility did not implement effective interventions, resulting in the resident being found on the floor with labored breathing. Incomplete documentation and lack of communication among staff contributed to the deficiency.
A resident with multiple health issues required continuous oxygen therapy, but the facility failed to provide a specific oxygen dose in the physician's order and did not consistently document the dose. Interviews with staff revealed that the facility's process for administering oxygen was not followed, as the order lacked necessary parameters and the care plan did not include oxygen use details.
A resident with a history of falls was found on the floor with labored breathing and twitching, but the facility failed to document the incident accurately. Despite staff observations and actions taken, the clinical record lacked evidence of the fall and necessary assessments, contrary to facility policies. Interviews revealed that the facility's process for handling falls was not followed, resulting in incomplete documentation.
Multiple residents with cognitive impairments engaged in physical altercations, resulting in injuries and a lack of timely care plan updates or skin assessments. Staff supervision was inconsistent, with periods where residents were left unsupervised despite known behavioral risks. Additionally, a CNA was reported by several residents and a family member for verbal and physical abuse, with evidence of neglect in care provision. The facility's documentation revealed failures to follow internal and federal reporting and investigation procedures for abuse incidents.
A resident with dementia and behavioral issues struck another resident and used inappropriate language, but the facility did not complete an incident report, conduct an investigation, or update the care plan. The DON was unaware of the event, and required abuse prevention and reporting procedures were not followed.
A resident with dementia struck another resident with a rolled-up newspaper and used inappropriate language, but the incident was not reported, assessed, or investigated by staff. The DON and Administrator were unaware of the event until the survey, and there was no evidence of timely reporting to the State Agency or mandated entities as required by policy and regulation.
A resident with dementia and ongoing behavioral issues struck another resident with a rolled-up newspaper and used inappropriate language, but the facility did not complete an incident report, conduct an investigation, or update the care plan. The DON and Administrator confirmed the event was not reported or managed according to policy, and no interventions were documented to ensure resident safety.
A resident with dementia and behavioral issues struck another resident and used inappropriate language, but staff failed to complete an incident report, conduct an assessment, or update the care plan. The DON was unaware of the event, and required documentation and investigation procedures were not followed.
Failure to Adequately Assess and Treat Resident Skin Conditions
Penalty
Summary
The facility failed to ensure that a resident's skin was adequately assessed and treated according to professional standards and facility policy. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, obesity, and recent orthopedic aftercare, was identified as high risk for skin breakdown. The care plan required weekly skin checks and treatment as ordered, but there was no evidence of a physician's order for weekly skin checks, and documentation of these assessments was inconsistent or missing. Multiple skin issues were documented by CNAs on shower sheets, including a popped blister on the sacral region, blisters on the chest, red spots on the abdomen, and bruising on the arm. Despite these findings, there was no evidence that nurses completed further skin assessments, notified providers, or obtained new treatment orders for the newly identified skin conditions. The clinical record lacked documentation of follow-up assessments or interventions for these issues, and scheduled skin assessments were missed without follow-up. Interviews with staff confirmed that the expected process was for CNAs to report new skin findings to nurses, who would then assess, notify providers, and document actions taken. The Director of Nursing acknowledged that the required weekly skin assessment was not completed and that there was no documentation or follow-up on new skin issues identified by CNAs. The facility's policy required comprehensive skin assessments on admission and weekly thereafter, but these procedures were not consistently followed for this resident.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from a resident before administering psychotropic medications, specifically Duloxetine and Trazodone. Resident #23, who was admitted with diagnoses including pneumonitis, respiratory failure, and chronic obstructive pulmonary disease, was prescribed Duloxetine for depression. However, the consent form for this medication was not signed by the resident or a representative, and it lacked information on non-drug approaches, the reason for the prescription, and expected benefits. The resident's care plan included the use of antidepressants, and the Medication Administration Records showed that Duloxetine and Trazodone were administered. Despite this, there was no evidence of a signed informed consent for Trazodone prior to March 5, 2025. Interviews with staff, including an LPN and the interim DON, confirmed that the required consents were not completed before administering these medications, which did not meet facility expectations. The facility's policy on psychotropic medication informed consent, reviewed in September 2024, mandates obtaining consent before starting such medications. The policy emphasizes that the resident or their representative must understand the benefits and risks associated with the medication. The lack of completed consents for Duloxetine and Trazodone before administration indicates a failure to adhere to this policy, potentially impacting the resident's ability to make informed decisions about their treatment.
Deficient Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for five out of nine sampled staff members, which could lead to a deficit in staff knowledge and skills affecting resident care. The personnel files and training records revealed that several staff members did not complete required annual training for dementia, infection prevention and control, resident rights, and abuse for the years 2024 and 2025. Specifically, a CNA hired in 2010, an OT hired in 2024, an LPN hired in 2020, another CNA hired in 2021, and an RN hired in 2023 were all found to have incomplete training records. Interviews with the Business Office Manager and other staff members confirmed the lack of documentation for training completion. The Business Office Manager was unable to provide proof of training completion for several staff members, despite multiple document requests. The interim director of nursing and the regional director of clinical services acknowledged the facility's expectations for training completion and the risks associated with not maintaining proper training records. The facility's policy on education and training requirements mandates that training on topics such as abuse, dementia management, infection control, and resident rights should be completed prior to providing services independently, annually, and as needed based on the facility's assessment. The facility's assessment requires quarterly training for resident rights and abuse, including dementia care, and annual training for infection prevention and control. The failure to adhere to these requirements was identified as a deficiency in the facility's training program.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to ensure that five out of nine sampled staff members received ongoing education on abuse, neglect, exploitation, and dementia care. This deficiency was identified through a review of personnel files, staff interviews, and facility policy review. Specifically, the certified nursing assistant (CNA), occupational therapist (OT), licensed practical nurse (LPN), another CNA, and a registered nurse (RN) did not complete the required annual training for dementia and abuse for the years 2024 and 2025. The lack of training could lead to a deficit in staff knowledge and skills, potentially affecting resident care and leading to harm. Interviews with the Business Office Manager, interim director of nursing, regional director of clinical services, and the executive director revealed that the facility had expectations for training completion and maintaining documentation. However, they were unable to provide proof of training completion for several staff members. The facility's policy required that training on topics such as abuse and dementia management be completed prior to independently providing services, annually, and as necessary based on the facility's assessment. Despite these requirements, the facility did not maintain adequate records of training completion, which could result in incompetent care and services being provided.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by each other, resulting in a deficiency. Resident #104, who was readmitted with severe cognitive impairment and multiple diagnoses including PTSD and vascular dementia, was involved in an altercation with Resident #400. The incident occurred when Resident #400 punched Resident #104 and attempted to push them, which was witnessed by a CNA. Both residents had a BIMS score of 00, indicating severe cognitive impairment, and exhibited behaviors such as exit-seeking and aggression. The facility's documentation and investigation into the incident were incomplete. The report submitted to the Department of Health Services lacked supporting documentation of the facility's investigation, and there were no assessments of the residents' cognition or psychosocial and physical harm following the incident. Interviews with staff revealed that both residents were ambulatory and had a history of aggressive behaviors, making altercations plausible. However, the facility did not adequately document or investigate the incident to prevent further occurrences. Interviews with the interim director of nursing and the executive director highlighted an understanding of the importance of identifying, reporting, and investigating incidents. However, the facility's expectations for notifying the chain of command and completing investigations were not met. The facility's policy on abuse identification outlined risk factors and defined abuse, but the failure to execute these expectations led to the deficiency.
Failure to Document and Investigate Resident Altercation
Penalty
Summary
The facility failed to ensure proper documentation and evidence retention of an investigation into an alleged incident between two residents. Resident #104, who was readmitted with severe cognitive impairment and other behavioral disturbances, was involved in an altercation with Resident #400, who also had severe cognitive impairment. The incident involved Resident #400 allegedly punching and attempting to push Resident #104, which was witnessed by a CNA. However, the facility did not retain documentation of a thorough investigation or assessments of the residents' cognition or harm following the incident. The report indicates that the facility submitted an incomplete reportable event record to the Department of Health Services, lacking documentation supporting the investigation. Interviews with staff revealed that both residents exhibited exit-seeking behaviors and aggression, making altercations plausible. Despite this, the facility was unable to provide documentation of the investigation when requested, indicating a failure to complete a thorough investigation and retain necessary evidence. Interviews with the executive director and other staff members highlighted an understanding of the importance of identifying, reporting, and investigating alleged incidents. However, the facility did not meet its own expectations for notifying the chain of command and ensuring a complete investigation. The facility's policies on abuse and investigation require thorough evidence collection and review, which were not adhered to in this case.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required written notices of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) to two residents within the mandated timeframe. One resident, who had Alzheimer's disease and other mobility-related diagnoses, was not issued the NOMNC and SNF ABN until the day Medicare services were set to end, which was February 3, 2025. The resident's power of attorney was verbally informed on the same day, which did not allow sufficient time for the resident to appeal the decision or prepare for discharge. The facility's policy requires these notices to be given at least two days before the end of Medicare Part A stay or when Part B therapies are ending. Another resident, who was cognitively intact and had undergone orthopedic aftercare, was not provided with the SNF ABN form at all, despite the end of Medicare services on December 20, 2024. Interviews with the Social Services Director and Business Office Manager revealed a lack of understanding of how to determine the last covered day of service and the necessity of issuing the SNF ABN form. The facility's policy states that the SNF ABN should be issued if the beneficiary intends to continue services that may not be covered by Medicare, informing them of potential financial liability.
Failure to Provide Timely Prosthetic Care
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthetic device, specifically in preparing the left prosthetic device for use. The resident, who was readmitted following an amputation of the left lower extremity, had a history of Type 2 Diabetes Mellitus, bilateral lower extremity amputations, muscle weakness, and limited activity due to disability. Despite the resident's eagerness to receive the left leg prosthetic and the completion of measurements, there was a significant delay in obtaining the prosthetic device, which was attributed to the need for additional documentation from the provider. The clinical records did not reflect a care plan for the left lower extremity amputation or an order for prosthetic follow-up. The resident expressed frustration and concern over the delay, fearing muscle weakness due to the prolonged wait. Interviews with staff revealed that the resident was not on the restorative therapy caseload, despite the existence of a special treatment plan for residents with prosthetic needs. The delay was further compounded by the lack of a signed and dated letter of medical necessity, which was only drafted on March 6, 2025. The facility's Prosthesis Care and Management policy mandates that residents with prosthetic devices receive the necessary care and assistance to use their prostheses. However, the resident's inability to ambulate due to the delay in receiving the prosthetic device highlights a failure to meet this policy. The resident attended prosthetic fitting appointments, but the lack of a timely follow-up and the absence of a comprehensive care plan contributed to the deficiency identified by the surveyors.
Failure to Provide Restorative Nursing Services
Penalty
Summary
The facility failed to ensure that a resident received the necessary restorative nursing services to attain their highest level of health and well-being. The resident, who was admitted for orthopedic aftercare following a lower extremity amputation, did not receive the recommended restorative nursing services, including training and skill practice in amputation/prostheses care. Despite recommendations from both Occupational and Physical Therapy discharge summaries, the resident did not participate in the restorative nursing program during the assessment period, and there was no documentation to support the initiation or completion of a Restorative Care Referral form. Interviews with the resident and staff revealed that the resident was not on the facility's restorative therapy program caseload, and the resident did not recall being offered participation in the program. The Rehabilitation Director and the RNA confirmed the lack of evidence supporting the resident's participation in restorative therapy, which does not meet facility expectations. The facility's policies on Activities of Daily Living and Restorative Nursing were not adhered to, as the resident's needs for restorative care were not addressed, despite being identified as a fall risk with decreased mobility and functional task participation.
Inadequate Supervision and Fall Prevention for Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident with moderate cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including osteoporosis and mobility issues, experienced multiple falls within a short period. Despite having a care plan, there was no evidence of specific interventions related to falls before or after each incident. The resident's clinical record documented falls on several occasions, resulting in injuries such as rib fractures and a T1 compression fracture. Interviews with staff revealed inconsistencies in the communication and implementation of fall interventions. A CNA mentioned being informed of fall interventions through nurses or fall packets, while an LPN noted the resident was on a restorative program and had an active order for 15-minute checks. However, another CNA was unaware of any 15-minute checks being conducted, and there was no documentation to support that these checks were performed. The health information management director confirmed the absence of 15-minute check forms for the resident, indicating a lapse in the facility's monitoring process. The facility's policy on fall management required assessment and intervention updates following a fall event, but the care plan was not revised accordingly. The Director of Nursing acknowledged the importance of 15-minute checks to prevent further falls and injuries, yet the lack of documentation and execution of these checks highlighted a deficiency in the facility's fall prevention measures. The failure to implement and document appropriate interventions placed the resident at risk of additional harm.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall for a resident with a history of falls and moderate cognitive impairment. The resident, who was admitted with diagnoses including spinal stenosis and chronic kidney disease, experienced a significant change in behavior, including hallucinations and agitation, which was not promptly addressed by the staff. Despite the resident's increased restlessness and confusion, the facility did not implement effective interventions to prevent a fall. On the morning of the incident, the resident was found on the floor by a CNA, exhibiting labored breathing and twitching. The resident had been restless and pulling off his oxygen cannula earlier, but the staff did not adequately monitor or intervene to prevent the fall. The facility's documentation was incomplete, with missing progress notes, fall assessments, and neurochecks, indicating a lack of proper follow-up and communication regarding the resident's condition. Interviews with staff revealed inconsistencies in the reporting and handling of the resident's condition. The DON was unaware of the resident's hallucinations and confusion prior to the fall, and the facility's policies on incident management and change in condition were not followed. The failure to recognize and address the resident's behavioral changes and the lack of documentation and communication contributed to the deficiency in providing a safe environment for the resident.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide respiratory services according to professional standards for a resident who required continuous oxygen therapy. The resident, who had a history of spinal stenosis, chronic kidney disease, polyneuropathy, and falls, was admitted with a physician's order for continuous oxygen via nasal cannula. However, the order lacked specific instructions or information regarding the oxygen dose. The care plan for the resident did not include any details about oxygen use, and the O2 Sats Summary log showed inconsistencies in documenting the oxygen dose, with only one entry specifying a dose of 3 liters. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, revealed that the facility's process for administering oxygen was not followed. The RN stated that every resident on oxygen should have a physician's order specifying the dose, which was not the case for this resident. The DON confirmed that the oxygen order lacked parameters for the dose and that the dose was not consistently charted, which did not meet the facility's expectations for providing respiratory care. The facility's policy on oxygen administration required a specific liter flow to be indicated in the order, which was not adhered to in this instance.
Incomplete Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate, which could lead to interdisciplinary team members not being aware of the resident's status and potentially result in a gap in care. The resident, who was admitted with diagnoses including spinal stenosis, chronic kidney disease, polyneuropathy, and a history of falling, experienced an incident on January 19, 2025. The resident was found on the floor by a CNA, exhibiting labored breathing and twitching, and was subsequently sent to the hospital. However, the clinical record lacked documentation of any falls or incidents where the resident was found on the ground, and the fall assessments and neurocheck documents were incomplete and unsigned. The report details that on the morning of the incident, the resident was restless and anxious, removing his nasal cannula and attempting to climb out of bed. Despite these observations, there was no evidence in the clinical record of a fall event or the necessary documentation following such an incident. A witness statement from a CNA indicated that the resident was found face down on the floor with labored breathing, and the nurse on duty assessed the resident and called for emergency services. However, the facility's documentation did not reflect these events accurately, as required by their policies. Interviews with staff, including the DON, revealed that the facility's process for handling falls was not followed. The DON acknowledged the absence of documentation regarding the falls, post-fall assessments, neurochecks, and skin or pain assessments. The facility's policies require that any change in a resident's condition, such as a fall, be documented thoroughly, including assessments and notifications to relevant parties. The lack of complete and accurate documentation in this case did not meet the facility's expectations and standards.
Failure to Prevent and Address Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving both resident-to-resident and staff-to-resident abuse. In several cases, residents with significant cognitive impairments and behavioral disturbances engaged in physical altercations with each other. For example, one resident with dementia and a history of behavioral issues struck another resident with a rolled-up newspaper and later with a book, causing a skin tear. There was no evidence that the care plan was updated after these incidents, nor that a skin assessment was completed following the injury. Additionally, there was no documentation of room changes or increased staff monitoring to ensure resident safety after these altercations. Another incident involved two residents, both with severe cognitive impairments, where one resident sat on another who was sleeping, resulting in the latter striking the former in the face. Although the residents were separated and placed on 15-minute checks, the documentation and interviews revealed that staff supervision was inconsistent, and staff were not always present or able to effectively monitor and redirect residents exhibiting aggressive behaviors. Staff interviews confirmed that staffing levels were sometimes insufficient to provide adequate supervision, and that staff had to leave residents unsupervised while attending to other duties. The facility also failed to prevent and address staff-to-resident abuse. One resident, who was cognitively intact but physically dependent, reported that a CNA was rude, rough, and failed to provide necessary care, such as changing and responding to call lights. Additional complaints from other residents and a family member corroborated these allegations, indicating a pattern of neglect and verbal abuse by the same staff member. The facility's policies required prompt investigation and separation of alleged abusers, but the report identified discrepancies between facility policy and federal guidelines regarding the timeliness of reporting abuse. The documentation showed that the facility did not always follow its own procedures for reporting, investigating, and updating care plans in response to abuse allegations.
Failure to Implement Abuse Prevention and Investigation Procedures
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, as evidenced by the handling of an incident involving a resident with dementia and other medical conditions. The resident, who was rarely or never understood according to the MDS assessment, exhibited ongoing behavioral issues, including removing items from nurse carts, interfering with care, and entering peers' rooms. On one occasion, the resident struck another resident with a rolled-up newspaper and used inappropriate language, but there was no evidence that an incident report or assessment was completed following this event. Additionally, the facility did not conduct a thorough investigation of the incident, nor were interventions put in place to ensure resident safety during the investigation. The care plan for the resident was not updated after the incident, and the DON was unaware of the event until it was brought to her attention during the survey. Facility policy required prompt investigation, reporting, and implementation of safety interventions in cases of alleged abuse, but these procedures were not followed in this instance.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately, but not later than two hours, to the State Agency and mandated entities. Specifically, a resident with dementia and other medical conditions struck another resident with a rolled-up newspaper and used inappropriate language during an interaction. Documentation showed that no incident report or assessment was completed following this event, and there was no evidence that the incident was reported to the appropriate authorities as required. Interviews with the DON and Administrator revealed that neither was aware of the incident until it was brought to their attention during the survey. The DON confirmed that the event was not reported, investigated, or communicated to the state agency, which did not meet her expectations for handling resident-to-resident incidents. Review of facility policies and federal regulations highlighted a discrepancy in reporting timeframes, but the facility's failure was in not reporting the incident at all within the required period.
Failure to Investigate and Prevent Further Abuse Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and did not implement measures to prevent further potential abuse during the investigation of an incident involving a resident. Specifically, after a resident with dementia and a history of behavioral issues struck another resident with a rolled-up newspaper and used inappropriate language, there was no evidence that an incident report or assessment was completed. The clinical record did not show that the incident was reported to the Director of Nursing (DON) or the state agency, nor was there documentation of an internal investigation or any interventions to ensure resident safety during the period following the incident. Additionally, the resident's care plan, which already noted behavioral issues, was not updated after the incident. Interviews with the DON and Administrator confirmed that the incident was not reported or investigated according to facility policy, which requires prompt reporting, investigation, and implementation of safety interventions. Facility policies reviewed also mandate separation of residents and assessment for injury in such cases, but there was no evidence these steps were taken.
Failure to Document and Investigate Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including dementia, anemia, type 2 diabetes mellitus, and dysphagia. The resident had a history of behavioral issues, as documented in both the quarterly MDS assessment and behavior notes, which included actions such as removing items from walls and nurse carts, urinating in the hallway, interfering with peers' care, and tampering with safety equipment. On a specific date, a health status note documented that the resident struck another resident with a rolled-up newspaper and used inappropriate language, but there was no evidence that an incident report or assessment was completed following this event. Further review revealed that the facility did not conduct a thorough investigation of the incident, nor were interventions implemented to ensure resident safety during the period following the event. The resident's care plan, which previously addressed behavioral issues, was not updated to reflect the new incident. The Director of Nursing confirmed during an interview that she was unaware of the incident and acknowledged that the expected procedures for managing and documenting resident-to-resident incidents were not followed. Facility policies require comprehensive documentation and investigation of such events, but these standards were not met in this case.
Latest citations in Arizona
Failure to notify the Ombudsman of a resident discharge. A resident with metabolic encephalopathy, DM2, and HTN was admitted for therapy, then the family raised concerns about room space and chose to take the resident home AMA. Record review and staff interview showed the discharge notice was not sent to the Ombudsman, despite the regulatory requirement to do so.
Two residents with known behavioral issues and cognitive/neurologic conditions were involved in a patio altercation where one resident struck another on the head after a verbal interaction and dispute over a book. Care plans for both residents already identified behavioral disturbances, including verbal and physical aggression, and outlined interventions such as providing a calm environment, diverting attention, and intervening to protect others. Despite these plans and prior documented episodes of verbal aggression and a previous physical altercation involving one of the residents, staff‑witness accounts and later review of video footage confirmed that one resident approached and hit another on the head, causing the victim to report pain and fear, demonstrating a failure to protect residents from physical abuse.
A resident with multiple comorbidities, intact cognition, and a care plan requiring two-person assistance for toileting repeatedly requested help for a brief change using the call light and by wheeling to the nurses’ station. A CNA, who had documented training on professional language and abuse prevention, allegedly failed to respond to the call light, refused to assist because a second staff member was not available, and used profanity toward the resident in the context of the resident’s complaints about delayed care, causing the resident to cry and feel unsafe. Another staff member reported seeing the CNA on her phone while call lights were on, hearing the profane statement directed at the resident, and later comforting the resident, while additional staff confirmed the resident’s report that the CNA was rude and blamed her for not receiving care. The facility’s abuse policy defined mental and verbal abuse to include profane, insulting, or degrading language and depriving a resident of care, which aligned with the described interaction.
A resident with CHF, CKD, atrial fibrillation, and moderate dementia had a physician order for a regular diet with thin liquids and food cut into bite-sized pieces with large protein portions. This cut-up requirement was documented in the diet order and Menu Wizard tray card notes but was omitted from the care plan and not consistently recognized or implemented by nursing and CNA staff, some of whom believed it was only a preference. On a weekend breakfast, the resident was served an egg burrito that was only cut in half, and the CNA who delivered the tray did not recall reviewing the meal ticket or knowing of any need to cut food into bite-sized pieces. Later that morning, an LPN found the resident unresponsive in bed with mushy food in and around his mouth, initiated manual removal and suctioning, and, with the charge nurse, continued suction and use of a LifeVac device before EMS transport. Hospital records documented aspiration of eggs into the airway with respiratory failure, and the resident, who was DNR/DNI, subsequently died. The survey found that the facility failed to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and followed for this resident, and identified a similar failure for another resident whose diet orders were not properly implemented.
The facility failed to provide required transfer/discharge notices to residents and to send copies of those notices to the State Long-Term Care Ombudsman. Several residents with conditions such as hemiplegia after stroke, COPD, atherosclerotic heart disease, hepatic encephalopathy, and cirrhosis were discharged to home, hospice, another SNF, or an acute hospital without documentation that the ombudsman received a copy of the discharge/transfer notification. In multiple cases, discharge summaries and forms documented the discharge destination, services, and follow-up appointments, but did not include ombudsman contact information or appeal rights, and there were no physician discharge orders for some residents. Staff, including the Resident Relations Manager, Business Office Manager, and ED, reported that the NOMNC was the only form used as a discharge/transfer notice, acknowledged that it lacked ombudsman and advocacy contact information, and confirmed that they did not send copies of discharge/transfer notifications to the ombudsman, instead emailing only a monthly list of discharged or transferred residents.
A resident with hemiplegia, psychiatric diagnoses, and dependence on staff for ADLs required assistance with toileting hygiene and bathing per the care plan and MDS, which documented bilateral extremity impairment and wheelchair use. CNA task logs for bowel/bladder and toilet use contained multiple blank shifts, leaving it unclear whether toileting and hygiene care was provided or refused, despite the EHR having specific codes for refusals and unavailability. Behavior and NP notes described the resident’s verbal aggression, sexually inappropriate comments, resistance to care, shower refusals, and repeated complaints that peri care was inadequate, while a nurse documented finding the peri area clean after one such complaint. A CNA and an LPN both stated that blank entries likely reflected a failure to chart and that all ADL care should be documented, consistent with facility policies requiring provision and documentation of ADL services. Surveyors concluded that the facility failed to ensure and document necessary ADL care, specifically toileting hygiene, for this resident.
A resident with spinal conditions, a history of lumbar compression fracture, and documented ADL self-care deficits was care planned and Kardexed for two-person maximum assist transfers for bathing and wheelchair transfers. Despite this, a CNA transferred the resident alone multiple times between a recliner, wheelchair, and shower chair using only a gait belt, during which the resident reported the CNA was rough, fast, and caused pain. An LPN received the resident’s complaint that the CNA was not caring and was the only staff present, while another CNA and a regional clinical specialist confirmed that the Kardex required two-person assist and that the CNA had performed the transfers without assistance, in violation of the plan of care and facility expectations.
Two residents with known behavioral issues, one with severe cognitive impairment and one cognitively intact, were involved in a resident-to-resident physical altercation. A resident with a history of behavioral problems, including prior physical altercations, entered another resident’s room and allegedly punched him multiple times in the face and twisted his arm, resulting in a black eye, skin tears, bruising, and minor cuts. Staff later observed the injured resident approaching the nurses’ station with these injuries, and leadership confirmed via camera review that the aggressor had entered the victim’s room and that a physical altercation occurred, despite an existing abuse policy intended to protect residents from abuse.
The facility failed to prevent resident-to-resident verbal and physical abuse involving two separate pairs of residents with known psychiatric and behavioral issues. In one case, a cognitively intact resident with a history of agitation and verbal aggression insulted another cognitively intact resident with schizoaffective disorder and intermittent explosive disorder during dinner; after repeated verbal exchanges, the second resident stood up, shoved the table, and punched the first resident in the eye, resulting in an orbital fracture and retrobulbar hemorrhage. In another case, a resident with schizophrenia, bipolar disorder, and documented verbal aggression argued over a soda with a peer who had borderline personality disorder and a care plan for bullying and physical aggression; the argument escalated from name-calling to one resident standing and swinging at the other, with the alleged victim later reporting facial and chin pain despite no visible injury on assessment. In both incidents, residents with identified behavior risks and existing behavior plans engaged in escalating verbal conflicts in common areas that were not effectively de-escalated before they became physical or attempted physical assaults.
Multiple residents with dementia and other psychiatric conditions physically abused other residents in common areas and on an outside ramp when staff supervision was inadequate. In one case, a resident with schizoaffective disorder and a known history of verbal and physical aggression, already agitated over smoking restrictions and having threatened and struck staff, was allowed to remain in a common area and struck another resident on the shoulder. In another incident, a resident with dementia and documented combative behavior picked up a folded tray table and hit a non-verbal resident who was seated nearby, while scheduled CNAs and an LPN later reported they did not witness the event and trainees described the assault. In a third event, a resident with violent behavior blocked a narrow ramp and pushed another resident’s wheelchair backward using his hands and feet, causing the wheelchair to flip and the resident to fall and hit his head, with the incident observed and reported by housekeeping rather than direct care staff. These events reflect failures to provide continuous observation and to prevent resident-to-resident physical abuse despite known behavioral risks.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to send a notice of discharge to the State Ombudsman for one resident. Resident #59 was admitted with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension, and the hospital discharge summary showed the resident was transferred to the facility for therapy services. The discharge planning and discharge progress notes dated 2/15/2026 documented that the resident arrived with family, and the family expressed concern that the assigned room did not have adequate space for the resident's belongings. The same documentation showed the family elected to take the resident home against medical advice, and the electronic medical record, including the AMA Release Form dated 2/15/2026, showed the resident was discharged home with the responsible party. During record review, the Administrator was asked to provide documentation of discharge notices sent to the Ombudsman for the prior 6 months. The Administrator documented that the Ombudsman did not require the facility to send discharge notices directly to her, while also acknowledging that discharge notices had not been sent and that the facility would send notices for discharged residents moving forward. The Ombudsman stated she had periodically received discharge notices in the past but had not received discharge notices from the facility after 12/4/2026, and confirmed the facility is required to provide discharge notices per regulation.
Failure to Prevent Resident-to-Resident Physical Abuse on Patio
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. One resident had multiple diagnoses including cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment, with a BIMS score indicating severe cognitive impairment. This resident had care plans addressing impaired cognitive function and behavioral disturbances, including verbal and physical abuse, with interventions such as providing a calm environment, diverting attention, and intervening as necessary to protect the rights and safety of others. Despite these identified needs and planned interventions, this resident was involved in a resident‑to‑resident altercation on the patio in which another resident struck him on the head after a verbal interaction. The second resident involved had diagnoses including metabolic encephalopathy and pain, and a care plan for behavioral disturbances such as refusal of care, refusal of medication, and verbal and physical abuse. This care plan also included interventions to document behaviors, reinforce why inappropriate behavior is unacceptable, and intervene as necessary to protect the rights and safety of others, including removing the resident from situations as needed. Prior to the incident on the patio, this resident had a documented history of involvement in a physical altercation with another resident, where he was described as the non‑aggressor, and had ongoing behavioral charting for verbal aggression and argumentative behavior. Behavior notes documented episodes of verbal aggression, cursing at staff, and yelling related to environmental changes. On the date of the incident leading to the deficiency, an internal incident report documented that the second resident slapped the first resident on the back of the head on the patio after a verbal confrontation. Witness accounts varied: the activities assistant reported hearing a loud slapping sound and seeing the second resident standing, then intervening, while another resident witness stated she saw the second resident hit the first resident on the head with a book because of a dispute over ownership of the book, and that there had been no argument beforehand. The DON reported that camera footage showed the two residents conversing about three feet apart on the smoking patio, then the second resident wheeled up to the first resident and hit him on the head, which the DON characterized as physical abuse. The administrator also acknowledged that video footage showed the second resident tapping the first resident’s head. The first resident later indicated he was in pain afterward and felt scared. These events occurred despite existing behavior care plans and interventions intended to prevent such incidents, resulting in a failure to ensure residents were free from physical abuse by another resident.
Verbal Abuse and Failure to Respond to Resident’s Request for Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by a CNA. The resident, who had type 2 diabetes mellitus with foot ulcers, absence of the left foot, morbid obesity, and a mood disorder, was care planned for ADL self-care deficits and required maximum assistance for toileting and two-person dependent assistance with transfers. A quarterly MDS showed the resident had a BIMS score of 14, indicating intact cognition, and required substantial assistance for toilet transfers. On the morning in question, an event note documented that the resident was wheeling herself in her wheelchair in the hallway to the nurses’ station to request assistance with a brief change when a CNA seated at the nurses’ station heard her, turned around, and made an inappropriate comment, after which the resident began crying. The facility’s investigation materials described differing accounts of the interaction but consistently referenced the use of profanity by the CNA in the context of the resident’s request for care. The resident reported that she had not received care that morning, had urinated on herself, and had activated her call light, but the CNA would not answer it. The resident stated that when she told the CNA she was going to notify someone about the lack of assistance, the CNA became angry, stood up, and told her, “it’s your fucking fault,” which made her cry and feel unsafe. A staff member (Staff #118) provided a written statement and interview indicating that around 5:15 a.m. he observed multiple call lights on, including the resident’s, and saw the CNA sitting at the nurses’ station on her phone. He stated that the resident came out of her room begging for help with a brief change, that the CNA refused because she did not have a second person to assist, and that at one point the CNA told the resident, “it was [the] resident’s fucking fault,” after which the resident went back to her room crying. The CNA involved had documented training on professional language and on abuse, neglect, exploitation, resident rights, respect in the workplace, and prevention of abuse, including mental and verbal abuse. Her written statement acknowledged that the resident’s call light had been on since about 4:00 a.m. and that the resident later came out of her room angry about the wait; she claimed she agreed with the resident and went downstairs to get another CNA, and admitted she may have used the term “fuck” but denied directing it at the resident. Another CNA (Staff #24) stated that the resident was on “cares in pairs” because she accused staff of not helping her, that the resident used her call light frequently and wanted care immediately, and that delays could occur due to the need for two staff, though communication about delays could ease the situation. A staff member (Staff #38) reported that the resident later said she had a rough morning because she needed help and the CNA was rude and blamed her for not getting care due to the “cares in pairs.” The facility’s abuse policy defined mental and verbal abuse as conduct, including the use of profanity, that can cause humiliation, intimidation, fear, shame, agitation, or degradation, and included mocking, insulting, ridiculing, and threatening residents, including depriving a resident of care, as examples of mental and verbal abuse. The facility’s documentation also showed that the CNA had signed an education acknowledgment form stating she was trained to use professional language and that profanity was prohibited at work. The investigation report and staff interviews consistently placed the resident in a position of repeatedly requesting assistance for incontinence care, with her call light on and her coming into the hallway to seek help, while the CNA did not provide the requested care and used or was alleged to have used profanity in response to the resident’s complaints. The DON acknowledged receiving a report that the CNA was not helping the resident and had sworn at her, and stated that verbal abuse of residents can affect a resident’s psychological well-being. The combination of the resident’s report, corroborating staff statements, and the facility’s own policy definitions formed the basis for the finding that the resident was not kept free from verbal abuse.
Failure to Follow Physician-Ordered Cut-Up Diet Leads to Fatal Aspiration Event
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician-ordered diet specifying that a resident’s food be cut into bite-sized pieces, and to ensure that this requirement was consistently communicated and implemented by nursing and dietary staff. Resident #9 had multiple diagnoses including heart failure, chronic atrial fibrillation, chronic kidney disease, and moderate vascular dementia with anxiety. A physician order dated December 23, 2024, prescribed a regular diet with regular texture, thin liquids, and explicitly directed that food be cut into bite-sized pieces with large protein portions. The facility’s nutrition care plan initiated on December 30, 2024, referenced the regular diet with large protein portions but did not include the requirement to cut food into bite-sized pieces. The cognition and ADL care plans addressed cognitive impairment and self-care deficits but did not incorporate the ordered cut-up diet or any specific swallowing precautions, despite the resident’s cognitive impairment and upper extremity limitations documented on the MDS. The dietary management and electronic systems in use contained the cut-up order, but this information was not reliably translated into practice. The Menu Wizard tray card history, as reviewed by the senior menu specialist, showed a diet order of regular, regular, thin liquids with notes to cut food into bite-sized pieces and provide large protein portions, and this instruction had been in place since December 23, 2024. The dietary manager stated that dietary staff are responsible for cutting food and that bite-sized pieces would include items like burritos, with food expected to arrive on the unit already cut. However, he also indicated he could not retrieve prior diet slips after discharge and relied on nursing to relay changes. The DON asserted that the “cut into bite-sized pieces” language was a preference rather than part of the actual diet order and stated that only the basic diet components (regular texture, thin liquids) transfer to the kitchen, while additional information such as cutting food does not cross over. In contrast, the prescribing physician confirmed that he ordered regular food, thin liquids, cut into bite-sized pieces, and large protein portions as a single diet order and expected the entire order, including cutting food into bite-sized pieces, to be followed. On the day of the choking event, breakfast trays were delivered to Resident #9’s room, and the resident was served an egg burrito, oatmeal, and cranberry juice. CNA staff reported that the burrito was cut in half but not further cut into bite-sized pieces, and CNA #6 stated she did not know the resident’s diet, did not recall reviewing the meal ticket, and believed his meals did not need to be cut up. She also stated she was unaware of any special instructions to cut the resident’s food into bite-sized pieces and that she typically relied on dietary and nursing to communicate such needs. Multiple CNAs and the charge nurse indicated they were not aware of any formal special diet instructions beyond a regular diet, although the charge nurse acknowledged knowing the family’s preference for cut-up food and finger foods and that dietary did not always cut up his meals, requiring nursing to do so. The resident’s family member reported repeated concerns to the dietary manager, charge nurse, DON, and CNAs about the resident’s food not being cut up, and stated that both she and a hired companion frequently found his meals served uncut despite his upper extremity weakness and motor decline. Later that morning, an LPN who had just started her shift and was not familiar with the resident found him in bed with his breakfast tray in front of him, food apparently eaten, and “mushy” food around and in his mouth. The resident appeared to be sleeping, did not respond to his name, and was grunting and moaning with snoring-type respirations. The LPN manually removed food from his mouth and began suctioning, and the charge nurse arrived with a suction machine and a LifeVac device. Staff observed egg on the resident’s chest and in his mouth, and suctioning removed egg and mucus secretions. EMS was called, and the resident was transported to the hospital. Hospital emergency department documentation recorded that the resident had been eating eggs, was later found choking and unresponsive, and presented with aspiration into the airway and respiratory failure with hypoxia and hypercapnia. The resident was documented as DNR/DNI and was ultimately pronounced deceased. The survey findings attribute this event to the facility’s failure to ensure the physician-ordered diet, including cutting food into bite-sized pieces, was accurately care planned, communicated, and implemented by staff. The report also notes that for Resident #9 there were no active orders for PT/OT/ST evaluation or treatment on the Order Summary Report despite a NP/PA progress note planning for such services, and that the SLP evaluation focused on cognition and compensatory strategies rather than swallowing, with no active speech therapy orders in the diet context. Staff interviews revealed inconsistent understanding of the resident’s diet requirements, with some staff describing cut-up food and finger foods as a preference rather than an order, and others stating they had no knowledge of any special diet instructions. The grievance logs contained no formal grievances from the family member despite her statements that she had repeatedly complained about meals not being cut up and about the resident not being taken to the dining room as he preferred. Collectively, these documented actions and inactions show that the facility did not ensure the physician-ordered diet specifying cut-up, bite-sized food was integrated into the care plan, reliably communicated to dietary and direct care staff, or consistently implemented at the bedside for Resident #9, culminating in a choking and aspiration event requiring hospitalization and resulting in death.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required transfer/discharge notices to residents and to send copies of those notices to the Office of the State Long-Term Care Ombudsman for multiple residents. Surveyors found that the facility relied on the Notice of Medicare Non-Coverage (NOMNC) as its only discharge/transfer notice and did not use any separate form that met regulatory content requirements. The NOMNC used by the facility did not include the effective date of transfer/discharge, the location to which the resident would be transferred or discharged, the name, address, and telephone number of the State Long-Term Care Ombudsman, or contact information for protection and advocacy agencies for individuals with developmental disabilities or mental disorders. Staff interviews confirmed that the Resident Relations Manager and Business Office Manager considered the NOMNC to be the facility’s discharge/transfer notice and that they did not provide ombudsman information to residents or send copies of discharge/transfer notifications to the ombudsman. For Resident #107, who had hemiplegia and hemiparesis following cerebral infarction, systolic congestive heart failure, muscle issues, and gait and mobility abnormalities, the physician documented that the resident would transfer to another SNF at the family’s request, and a subsequent note showed the resident was discharged via transport van. The discharge MDS documented an unplanned discharge to a SNF. However, review of the clinical record revealed no evidence that a discharge notification was sent to the State Long-Term Ombudsman. The facility’s Admissions, Transfers and Discharges policy referenced reporting information in accordance with facility policy and professional standards but did not include requirements for notifying the ombudsman. For Resident #8, admitted with COPD, palliative care, and paroxysmal atrial fibrillation, the care plan included goals for pre-discharge planning. A discharge order and a discharge-transfer note/summary documented discharge home with oxygen equipment, home health services, narcotic medications, and a scheduled PCP appointment, and this summary was signed by the resident’s family. The documentation given to the family did not include the ombudsman’s contact information or an explanation of appeal rights. The discharge MDS showed an unplanned discharge home with return not anticipated, and there was no evidence in the clinical record that the ombudsman was notified of the discharge. An email sent about 19 days after discharge contained only a list of residents who were discharged, deceased, or transferred, and for this resident it listed a discharge/transfer to another hospital without the reason for discharge or the same information provided to the family. For Resident #12, admitted with atherosclerotic heart disease, the discharge MDS documented an unplanned discharge to hospice at home. A discharge/transfer/LOA form indicated discharge to the community with hospice services at a private home/apartment, initiated by the resident or representative, and a discharge summary and progress note documented discharge home with belongings, medications, and paperwork. There was no physician order for discharge in the order summary report, and the clinical record did not show that a copy of the discharge notification was sent to the ombudsman. In an interview, the Resident Relations Manager stated that a copy of the notification is not sent to the ombudsman and that ombudsman information is not provided to residents. For Resident #100, admitted with COPD, an order directed transfer to the ED for shortness of breath, and a discharge summary documented respiratory distress and transport via ambulance to an acute care hospital. A social services note stated that the resident or representative was provided written notice of transfer, bed-hold notice, readmission policy, ombudsman and appeals information. However, the clinical record contained no evidence that a copy of the transfer notice was sent to the State Long-Term Care Ombudsman. For Resident #102, admitted and later readmitted with hepatic encephalopathy, influenza, and cirrhosis, clinical documentation showed an anticipated discharge to the community, an NP note indicating discharge to prior living arrangements, and an unplanned discharge home/community on the MDS. A discharge/transfer/LOA form and discharge summary documented discharge to a private home/apartment without hospice, initiated by the resident or representative, and a social services note recorded that the family picked the resident up and took him back to the reservation. There was no physician discharge order, and no indication in the record that a copy of the discharge notification was sent to the ombudsman. Interviews with the ombudsman and facility staff further described the deficient practice. The ombudsman reported that their office previously received a list of discharged/transferred residents but had not received anything for recent months and that they were sent only a list, not copies of discharge/transfer notifications. The Resident Relations Manager and Business Office Manager stated that Resident Relations is responsible for presenting the notice of proposed discharge/transfer, that the notice is presented up to 72 hours prior to discharge, and that a copy of the notification is not sent to the ombudsman. They also stated they were unsure if any policy or guidance outlined what information must be included in the notice and confirmed that the NOMNC was the only form used as a discharge/transfer notice, even though it lacked ombudsman and advocacy contact information. The acting DON reported being unfamiliar with discharge/transfer notification requirements, and the Executive Director stated that the facility used only the NOMNC, believed no paper notice was required beyond that, and understood the facility’s obligation as sending a monthly list of discharged/transferred residents to the ombudsman, not copies of the actual transfer/discharge notifications.
Failure to Ensure and Document Toileting Hygiene Assistance for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident dependent on staff for ADLs, including toileting hygiene, consistently received and had documented assistance with these needs. The resident was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the left, non-dominant side, along with schizophrenia and major depressive disorder. The care plan identified the resident as being at risk for functional self-care deficits and functional mobility limitations and specified that he required assistance with toileting hygiene and bathing/showering, including washing, rinsing, and drying, with baths/showers to be provided per his schedule and preferences. The admission MDS documented that the resident was cognitively intact, had bilateral upper and lower extremity impairment interfering with daily function, used a wheelchair, and was dependent on staff for toileting hygiene, shower/bathing, oral and personal hygiene, dressing, and footwear. Review of the December CNA task logs for bowel and bladder and toilet use showed multiple shifts left unmarked/undocumented, meaning it was unclear whether toileting and bowel/bladder care were provided or refused on those shifts. The bowel and bladder task log had blank entries on several specific dates and shifts, and the toilet use task log also contained numerous blank entries across day, evening, and night shifts. A CNA explained that CNA care is documented in the EHR using specific codes, including codes for refusal and resident unavailability, and that if a task is left blank it likely means the CNA did not chart, making it questionable whether the care was provided. The CNA stated that blank areas mean one would not know if care was provided, and that everything should be charted so that care conferences and assessments have accurate data. An LPN similarly stated that blanks on the bowel and bladder task log made her think that either someone did not chart or the resident did not have a bowel movement, and that whoever was on shift should have charted appropriately so that others could determine whether care was provided. The resident’s record also contained multiple behavior and NP notes describing ongoing verbal aggression, sexually inappropriate comments, resistance to care, and specific complaints about how peri care and showers were provided. Notes documented that the resident sometimes refused showers, stated he only needed one shower a week, and complained that staff did not clean his peri area adequately after bowel movements, including an incident where he alleged staff did not clean under his penis despite a nurse finding his peri area and brief clean and dry. Another note described the resident demonstrating that he could clean his own peri area and then verbally abusing staff. Additional documentation described the resident’s frequent agitation, oppositional behavior, verbal aggression, and disruptive behavior during care interactions, including cursing at staff, making derogatory comments, and repeatedly activating the call light. Despite these behaviors and complaints, the facility’s own policies required that residents unable to carry out ADLs independently receive appropriate support and assistance with toileting and personal hygiene, and that all services provided, refusals, and care-specific details be documented in the medical record. The combination of the resident’s dependence on staff for toileting hygiene and the numerous undocumented shifts on CNA task logs led surveyors to determine that the facility failed to ensure ADL care such as toileting hygiene was provided and properly documented for this resident. Facility staff interviews reinforced the importance of ADL care and documentation and highlighted the gap between expectations and practice. The CNA familiar with the resident described him as a two-person assist due to behaviors, using briefs rather than the toilet, being very sexual, refusing care from male staff, and demanding extra wiping and frequent changes, which led staff to implement cares-in-pairs and show him wipes after each wipe to prove cleanliness. The CNA acknowledged that blank documentation entries likely meant CNAs did not chart and that this created uncertainty about whether care was provided. The LPN stated that residents should be rounded on at least every two hours for ADL care, emphasized that ADL care is important for dignity and to prevent skin breakdown, and confirmed that uncharted tasks prevent others from concluding whether care was provided. These findings, combined with the facility’s policies requiring provision and documentation of ADL services, formed the basis for the deficiency that the facility failed to ensure ADL care, specifically toileting hygiene, was provided and documented for this resident.
Improper Single-Staff Transfer During Shower Contrary to Two-Person Assist Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was transferred in accordance with the care plan and transfer orders during bathing and showering. The resident had diagnoses including a wedge compression fracture of the 3rd lumbar vertebra, surgical aftercare, cauda equina syndrome, spinal stenosis, and a need for assistance with personal care. A care plan initiated on April 10, 2026 documented that the resident required assistance with bathing and showering and had an ADL self-care performance deficit. Interventions initiated on April 20, 2026 and resident task documentation revised on April 14, 2026 indicated that the resident required a two-person maximum assist for transfers to the wheelchair. Despite these documented requirements, a facility investigation dated April 22, 2026 revealed that a CNA (Staff #79) transferred the resident alone from a recliner to a wheelchair, from the wheelchair to a shower chair, and then back from the shower chair to the wheelchair and into bed, using only a gait belt and without a second staff member. The resident reported that the CNA was alone during all transfers, was very rough, and that the transfers were painful, and also stated that the CNA did not speak to him during the shower. An LPN (Staff #96) confirmed receiving a complaint from the resident that the CNA was not caring and was very fast during the shower, and that the CNA was the only staff member present. Another CNA (Staff #72) stated that the Kardex identifies the resident as a two-person assist and that she always obtains another person to help with transfers, noting that transferring the resident alone could cause pain and injury. The Regional Clinical Specialist (Staff #102) stated that CNAs are expected to follow the Kardex for transfer assistance levels and confirmed that the investigation determined the CNA had transferred the resident without assistance, contrary to policy and the plan of care.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident. Resident #1 had severe cognitive impairment with a BIMS score of 05 and a care plan identifying behavioral problems, including taking others’ belongings, eating other residents’ food, inappropriate contact with other residents’ belongings and clothing, giving food to other residents without permission, refusing medication and care, and initiating a physical altercation with another resident. Despite these identified behaviors and the existence of a care plan focused on behavior problems, Resident #1 was able to enter Resident #2’s room and engage in a physical altercation. Resident #2 was cognitively intact with a BIMS score of 14 and had a care plan for behavior problems related to verbal and physical behaviors, including prior verbal altercations with other residents, use of profanity, striking another resident in the head, spitting water on staff, kicking at staff during care, cursing at staff, and refusing brief checks and changes. On the day of the incident, Resident #2 approached the nurses’ station with a hematoma to the left eye, a large skin tear to the right forearm, minor cuts to the nose, lip, and right hand, and bruising to the left hand. Resident #2 reported that Resident #1 had entered his room, punched him multiple times in the face, grabbed and twisted his arm, and then left the room. Staff interviews and facility documentation confirmed that no staff witnessed any verbal altercation between the two residents prior to the event, and that earlier in the day Resident #2 did not have any injuries. After the incident, staff observed Resident #2 with a swollen eye and face, bruising, and lacerations consistent with his report. The Administrator and DON stated that review of camera footage showed Resident #1 entering Resident #2’s room and that a physical altercation occurred, confirming that Resident #1 went into Resident #2’s room, hit him in the face, and then exited. The facility’s abuse policy stated an objective to provide a safe haven for residents through preventive measures that protect every resident’s right to freedom from abuse, but the documented resident-to-resident physical abuse occurred despite these stated objectives.
Failure to Prevent Resident-to-Resident Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical and verbal abuse by other residents. One incident involved a resident with borderline personality disorder, schizophrenia, major depressive disorder, generalized anxiety disorder, a history of traumatic brain injury, and chronic pain syndrome, who had intact cognition and documented patterns of agitation, aggression, yelling, cursing, and threatening others. While in the dining room during dinner, this resident verbally insulted another cognitively intact resident with schizoaffective disorder, bipolar type, intermittent explosive disorder, and personality change due to a physiological condition. Multiple accounts from staff and both residents indicate that after being told not to talk to him, the verbally aggressive resident continued speaking, and the other resident stood up, shoved the table, and struck him in the left eye with a closed fist. As a result of this altercation, the assaulted resident reported pain, nausea, and later requested psychiatric support and antidepressant therapy. Clinical documentation and hospital imaging confirmed an acute left inferior orbital wall fracture and retrobulbar hemorrhage, with visible bruising to the left eye. Prior to this event, the aggressor had known psychiatric diagnoses and was receiving multiple psychotropic and mood-stabilizing medications for mood swings, aggression, disorganized thinking, paranoia, and intermittent explosive disorder. The facility’s records show that the aggressor had behavior care plans related to behavior problems and intermittent explosive disorder, but there is no indication in the report that staff anticipated or intervened to prevent this specific escalation in the dining room before the physical strike occurred. A second incident involved two other residents with significant psychiatric and behavioral histories. One resident had schizophrenia, bipolar disorder, anxiety disorder, intellectual disabilities, and obesity, with a behavioral care plan noting verbal aggression, demanding behaviors, and instructions for staff not to provide requests when made in a rude, threatening, or aggressive manner. The other resident had borderline personality disorder, bipolar disorder, pseudobulbar affect, anxiety disorder, PTSD, and type 1 diabetes, with a behavioral treatment plan for bullying or physical aggression toward peers and interventions directing staff to intervene promptly, remind the resident of respectful behavior expectations, and separate and redirect her if needed. Despite these identified risks and care plan directives, the two residents engaged in a verbal argument over a soda at the nurses’ station, during which one resident called the other a “fat b****” and continued name-calling after being told to stop, leading the other resident to stand up and swing at her. Documentation from behavior notes, incident notes, and the facility’s investigation shows that both residents stood up from their wheelchairs and approached each other during the argument. One resident reported being slapped in the face and later complained of chin pain, while the other resident was documented as having swung her arm at the peer. A skin assessment performed shortly after did not show visible injury, redness, trauma, or swelling, and witnesses, including staff and another resident, reported seeing a swing but were unsure if physical contact occurred. The facility’s investigation ultimately concluded that it could not determine whether physical contact was made, but the event was characterized as a verbal altercation that escalated to at least an attempted physical strike. In both sets of incidents, residents with known behavioral risks and existing behavior plans engaged in escalating verbal conflicts that were not effectively de-escalated or prevented from becoming physical, resulting in at least one resident sustaining a confirmed serious injury and another reporting pain after an alleged slap. Across these events, the facility had identified behavioral risks for the involved residents and had documented care plans and behavior interventions addressing aggression, bullying, and inciting peers. However, during the actual incidents, residents engaged in escalating verbal abuse in common areas (dining room and nurses’ station) that progressed to physical aggression or attempted physical aggression. The report describes that staff were present in the vicinity and, in some cases, intervened only after the physical act occurred or as the residents were already standing and approaching each other. The survey findings conclude that the facility failed to ensure that the affected residents were free from physical or verbal abuse by other residents, as required, resulting in resident-to-resident altercations that included verbal insults, threats, and at least one confirmed physical assault causing an orbital fracture and retrobulbar hemorrhage.
Failure to Prevent Resident-to-Resident Physical Abuse and Inadequate Supervision in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents and to provide adequate supervision in common areas. One cognitively impaired resident with dementia and depression was struck on the right shoulder by another resident with schizoaffective disorder and a history of verbal and physical aggression. Prior to the assault, the aggressive resident had been up all night, repeatedly demanding cigarettes outside of scheduled smoking times, threatening staff, calling 911, grabbing a housekeeper’s keys and injuring her shoulder, and punching a CNA in the abdomen. Despite these escalating behaviors and the resident’s known behavioral care plan identifying verbal and physical aggression and exit-seeking, the resident remained in the common area where he randomly hit the other resident’s shoulder in passing. Staff and police were present on campus, but the aggressive resident was still able to make physical contact with the other resident before being removed. Another deficiency occurred when a resident with dementia, bipolar disorder, major depressive disorder, and anxiety, who had a behavioral care plan for combative behavior, severe agitation, cursing, striking out, and threats, struck another cognitively impaired, non-verbal resident with a tray table in a common area. The victim had dementia, diabetes, and a cognitive communication deficit, and was known to wander and exhibit other non-directed behavioral symptoms. The incident was reported as occurring while the two residents were in a common area, and multiple scheduled CNAs and an LPN assigned to that unit later stated they did not witness the event. Statements from trainees indicated they observed the aggressor pick up a folded wooden table, yell profanities, and launch it at the victim’s head while the victim remained seated and non-verbal. The DON acknowledged that no CNA was physically present in the common area at the time, that trainees were only observing, and that the nurse preparing medications did not provide full attention to supervising the residents, resulting in no staff supervision in the room when the altercation occurred. A further deficiency involved a resident with mild cognitive impairment and no documented behavioral symptoms who was pushed backwards in his wheelchair by another resident with dementia, anxiety disorder, and violent behavior. The incident occurred on a narrow, steep ramp outside the dayroom, where only one person at a time could pass. The aggressor, also in a wheelchair, blocked the ramp and told the other resident he could not come up, then pushed the resident’s shoulder with his hand and used his feet to kick the wheelchair, causing it to flip and the resident to fall to the ground and hit his head. A housekeeping/laundry staff member witnessed the event and reported that the aggressor refused to let the other resident pass and then pushed him down the ramp. The DON stated that CNAs conduct rounding outside every 15 minutes, but the report does not indicate that any direct care staff were present at the ramp when the altercation occurred, and the event was instead discovered and reported by non-nursing staff after the fall. Across these incidents, the facility’s own documentation and staff interviews show that residents with known histories of aggression, agitation, or violent behavior were able to physically assault other residents in common areas and on an outside ramp without effective, continuous supervision by assigned nursing staff. Behavioral care plans identified risks such as verbal and physical aggression, striking out, and threats, and the DON stated that when residents are in common areas there should always be a staff member observing them. However, in the described events, residents were either not directly supervised by CNAs in the common areas, or staff attention was divided, allowing aggressive residents to hit, push, or otherwise physically abuse other residents before staff intervened. These actions and inactions led to resident-to-resident altercations that constituted physical abuse under the facility’s own definitions and policies.
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