Sunview Respiratory And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Youngtown, Arizona.
- Location
- 12207 North 113th Avenue, Youngtown, Arizona 85363
- CMS Provider Number
- 035245
- Inspections on file
- 22
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Sunview Respiratory And Rehabilitation during CMS and state inspections, most recent first.
A minor with TBI, psychosis, ADHD, and other behavioral risks was admitted under legal guardianship and required supervision and assistance with decision-making, yet was allowed to roam freely and spend extensive unsupervised time with an adult resident with schizophrenia and other mental health diagnoses. Staff and the guardian were aware that the two residents were frequently together and expressed concern that something inappropriate might occur, but no formal care-planned supervision or separation interventions were implemented, and prior sexually inappropriate behaviors by the minor toward staff were not addressed in the care plan. One evening, an LPN entered another resident’s room and observed the adult on her knees in the bathroom in front of the minor, who had his pants down, consistent with oral sex; the residents were separated and the incident was reported. The facility’s internal investigation and report to the State Agency characterized the encounter as consensual between two cognitively intact residents and did not document it in the minor’s record as sexual abuse, and the facility did not notify child protective authorities, who only became involved after the hospital reported the incident. Surveyors found no evidence of timely protective interventions on the date of the incident, no clear documentation of the event as the reason for psychosocial monitoring and psychiatric evaluation, and no care-planned measures to supervise or discourage the relationship, leading to a finding that the facility failed to protect the minor from sexual abuse and failed to correctly identify and report the event.
A minor with TBI, ADHD, anxiety, and depression, whose healthcare decisions were made by a legal guardian and who required supervision with all decision-making, developed a close relationship with an adult resident with serious mental illness. Staff had prior concerns and had warned the adult that the other resident was a minor, and the guardian had been notified that the minor was to remain in public areas. One evening, an LPN entered another resident’s room and observed the adult on her knees in front of the minor, whose pants were down, in the bathroom; the residents were separated and the DON was notified. Both residents later acknowledged a sexual encounter, describing it as consensual and initiated by the minor, and the police classified the event as sexual assault of a minor and completed statutory rape. The facility’s 5-day investigation did not identify the younger resident as a minor in reports to the State Agency, concluded the event was between consenting individuals, omitted a statement from the nurse who discovered the incident, did not interview the room’s assigned resident or other residents about what they saw or heard, did not document protective interventions on the date of the incident, and did not report to child protective authorities at the time, despite policy requirements for prompt recognition, reporting, and thorough investigation of abuse.
The facility failed to use its QAPI processes to adequately address a sexual abuse incident between two residents. The Quality Improvement Plan focused only on the issue of admitting minors and on monitoring dates of birth, without conducting a root cause analysis of the abuse event itself. The plan did not clearly define the abuse-related problem, lacked measurable goals, timelines, and assigned responsibilities, and did not specify how effectiveness would be evaluated. It also did not identify any abuse-related policy or practice changes or provide detailed, abuse-focused staff training content, leaving the incident unaddressed from a systemic quality improvement standpoint.
The deficiency centers on the facility’s failure to recognize and report an incident of sexual abuse involving a minor resident and an adult resident in accordance with federal requirements. An LPN discovered the two residents in another resident’s bathroom in a position consistent with oral sex, and both residents later described a sexual encounter that was interrupted by staff. Although the facility knew one resident was a minor and the other an adult with serious mental illness, its initial and 5‑day reports characterized the event as a consensual encounter between cognitively intact individuals, omitted the minor’s status, and did not classify the incident as sexual abuse. The incident was reported to police nearly a day after it occurred, was not reported by the facility to child protective authorities, and the internal investigation lacked key details and documentation, leading to a cited failure to properly identify, document, and report the abuse and to assess and monitor other residents at risk.
The facility failed to recognize and thoroughly investigate a sexual encounter between a minor and an adult resident as potential sexual abuse, instead documenting it as a consensual event between cognitively intact individuals. An LPN reported finding the two in a bathroom during the act and notified a supervisor, but the facility’s internal investigation omitted a written statement from this nurse, did not interview the roommate or other residents (including other minors), and relied on interviews with staff who had not worked the shift when the incident occurred. Clinical records showed only vague references to a “reported event” and did not document timely protective interventions on the date of the incident, nor any prior supervision or measures to limit the pair’s unsupervised contact despite staff awareness that one was a minor. The facility did not identify the younger resident as a minor in reports to the State Agency, did not report the incident to DCS, and did not follow its abuse policy requiring prompt, comprehensive investigation, resident protection, and mandated external reporting.
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
The facility provided in-house dialysis services to multiple residents without obtaining the required state-approved license modification or documentation of the contracted dialysis provider's license. Staff believed that approval of architectural plans was sufficient, but could not produce evidence of proper licensure for the dialysis center or provider when requested by surveyors.
Two residents were found with medications left at their bedside without being assessed for self-administration. One resident with moderate cognitive impairment had a vitamin left unattended, while another resident with intact cognition admitted to discarding unwanted pills. The facility's policy requires medications to be administered as per physician orders, and deviations must be documented, which was not followed in these cases.
The facility failed to ensure proper food storage and cleanliness in the kitchen, with expired and undated food items found in refrigerators, dusty ceiling vents, and an inadequately cleaned ice machine. Staff interviews revealed non-compliance with facility policies, increasing the risk of foodborne illness.
The facility failed to notify providers of a resident's change in condition, including low blood sugar and respiratory distress, leading to a family complaint. Additionally, another resident was observed without necessary leg rests for her custom wheelchair, despite therapy recommendations, resulting in improper positioning and potential risk of injury.
An LPN failed to perform hand hygiene during medication administration, as observed in two instances where items were picked up from the floor without subsequent hand sanitization. This was confirmed by interviews with the LPN and the DON, who acknowledged the facility's hand hygiene policy was not followed.
A resident with cognitive and physical impairments was observed with food caked around his mouth and on his clothing, indicating a lack of dignity and grooming care. Despite staff protocols for regular checks and meal tray removal, the resident remained in this state for over two hours, highlighting a deficiency in maintaining resident dignity and respect.
The facility failed to obtain physician orders for oxygen use for two residents, leading to potential unnecessary oxygen administration. One resident was documented as receiving oxygen without an order for nearly a month, while another had no order for increased oxygen levels despite low saturation readings. Staff interviews confirmed the facility's policy requiring physician orders for oxygen therapy, which was not followed.
The facility failed to notify a resident's representative in writing of a hospital transfer. The resident, with multiple serious diagnoses, had a critically low hemoglobin level, prompting a physician-ordered transfer. The ADON could not provide documentation of the notification, violating the facility's policy.
The facility failed to provide a bed-hold policy notice to a resident or their representative prior to or upon transfer to a hospital. The resident, with multiple serious diagnoses, was transferred due to a critically low hemoglobin level, but the bed-hold policy was not communicated, as confirmed by the ADON.
Failure to Protect Minor Resident From Sexual Abuse and Misclassification of Incident as Consensual
Penalty
Summary
The deficiency involves the facility’s failure to protect a minor resident from sexual abuse by an adult resident and to correctly identify and report the incident as sexual abuse. The minor resident had a history of traumatic brain injury (TBI) with subarachnoid hemorrhage, diffuse axonal injury, psychosis, insomnia, ADHD, anxiety, and depression, and required that decisions and consents be made by a legal guardian/parent. Care plans documented that the minor was at risk for impaired cognitive function or impaired thought processes due to recent hospitalization and TBI-induced psychosis, with interventions stating the resident needed supervision/assistance with all decision making and behavioral monitoring. Despite this, the resident was allowed to ambulate freely around the facility without direct supervision prior to the incident, and there was no care-planned intervention addressing supervision or discouraging the minor from spending time with other residents. In the days leading up to the incident, multiple staff and the minor’s legal guardian were aware that the minor and an adult resident were spending significant time together. Staff reported that the two residents were often seen together, including eating meals together and walking the halls, and that staff had warned the adult resident that the minor was underage. The unit manager reported that, prior to the incident, there was fear among staff that something inappropriate might occur between the two residents, and she called the minor’s legal guardian to report that the minor was spending time with another resident and that the facility did not want anything inappropriate to happen. The legal guardian stated that she was asked by facility staff to speak to the minor about the relationship but was unable to come to the facility, and she believed it was the facility’s responsibility to ensure the minor’s safety. There was also staff report that the minor had demonstrated sexually inappropriate behavior toward staff, yet there was no documented care plan addressing supervision or specific interventions to manage these behaviors or to prevent unsupervised interactions with other residents. On the night of the incident, an LPN entered another resident’s room and observed the adult resident on her knees in the bathroom in front of the minor, who was standing with his pants down, which the LPN interpreted as the adult performing oral sex on the minor. The residents were separated and the incident was reported to the DON. The police report later documented that both residents stated that oral sex occurred in the bathroom after the minor asked for it, and that the adult resident knew the minor’s age. The facility’s 5-day investigation report characterized the encounter as consensual between two cognitively intact residents with BIMS scores of 15 and concluded that abuse could not be substantiated, reporting to the State Agency that the incident was consensual. The clinical record for the minor did not contain documentation that the resident had been sexually abused, did not describe the incident as sexual abuse, and did not document the specific event that led to psychosocial monitoring and transfer for pediatric psychiatric evaluation. Additionally, the facility did not notify the Department of Child Services; DCS only became involved after the hospital reported the incident. Adult Protective Services later verified neglect of the adult resident as a vulnerable adult and verified that a sexual assault occurred. The surveyors found no evidence that, prior to the incident, the facility implemented supervision or preventive measures to separate or monitor the two residents despite staff concerns and knowledge of the minor’s age and vulnerabilities. The deficiency also includes the facility’s failure to implement immediate protective interventions for the minor on the date the incident occurred. Although documentation shows that the minor was placed on change-of-condition monitoring and assigned a one-to-one sitter starting the night after the incident and continuing until discharge, there was no evidence that protective interventions were put in place on the date of the incident itself. Staff interviews indicated that prior to the incident the minor was not directly supervised and had freedom to roam the facility, and that one-to-one supervision was only initiated after the event. The facility’s own investigation and reporting documents did not identify the sexual contact between an adult and a minor as sexual abuse, instead framing it as a consensual encounter, despite internal staff, APS, and DCS statements that a minor could not legally consent. The surveyors concluded that the facility failed to address the minor’s inappropriate interactions with staff, failed to provide supervision when the minor was noted to spend time with a cognitively impaired adult resident, and failed to identify and report the sexual contact between a minor and an adult as sexual abuse, resulting in a finding of Immediate Jeopardy and Substandard Quality of Care. Additional documentation in the clinical record and staff interviews further demonstrate gaps in assessment and follow-through related to the incident. Although multiple provider notes referenced plans for psychiatric consultation for both residents, there was no evidence that the minor ever received a psychiatric consult while at the facility, and the clinical record lacked clear documentation of the incident as the reason for psychosocial monitoring or hospital transfer for pediatric psychiatric evaluation. For the adult resident, psychiatric evaluation occurred after the incident and focused on anxiety and worrying about a recent event, without detailing the nature of the event in the clinical record. The facility’s care plans for both residents referenced a “reported event” and potential psychosocial well-being problems but did not specify the sexual incident or outline concrete supervision strategies to prevent recurrence. Staff interviews consistently indicated that the two residents had been spending time together, that staff were informally “keeping an eye” on the minor, and that there was concern something might happen, yet these concerns were not translated into documented, formalized interventions or timely recognition and reporting of the incident as sexual abuse of a minor by an adult resident.
Failure to Recognize and Properly Investigate Sexual Abuse of a Minor by an Adult Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize, report, and investigate non-consensual sexual acts between a minor resident and an adult resident as sexual abuse, in accordance with its own policies and regulatory requirements. A minor resident with traumatic brain injury, ADHD, anxiety, and depression was admitted with a care plan indicating impaired cognitive function or thought process due to recent hospitalization, and requiring supervision/assistance with all decision making, with all consents made by a legal guardian/parent. Despite a BIMS score of 15 and documentation of being alert and oriented, the resident’s status as a minor and need for supervision and guardian consent were known to the facility. Staff had observed the minor and an adult resident spending significant time together prior to the incident, and staff had warned the adult resident that the other resident was a minor. The unit manager reported that there was concern among staff that something inappropriate might occur between the two residents, and the legal guardian was notified in advance that the minor was spending time with another resident and had been instructed to stay in public areas. On the night of the incident, an LPN from another unit entered a resident’s room and observed the adult resident on her knees in front of the minor resident, who was standing with his pants down in the bathroom. The LPN reported that it appeared the adult resident was performing oral sex on the minor, and the residents were separated and the DON was notified. Another LPN corroborated that the nurse who discovered the incident described finding the two residents in the bathroom in this position, and that the room’s assigned resident was upset and unaware of what was happening in his bathroom. The minor later told staff that the adult resident had performed oral sex on him, and both residents separately acknowledged a sexual encounter, describing it as consensual and initiated by the minor. The police report classified the event as sexual assault of a minor, with the adult resident reporting that she performed oral sex on the minor for approximately two minutes after he asked for it, and acknowledging that she knew his age. The police report documented the offense as completed statutory rape and sexual conduct with a minor. Despite this information, the facility’s internal 5-day investigation report concluded that the incident was between two consenting individuals and that abuse could not be substantiated. The facility’s reports to the State Agency did not identify the younger resident as a minor, even though the facility knew he was under 18 and that healthcare consents were obtained from his legal guardian. The investigation did not include an interview or written statement from the nurse who discovered the incident, did not interview the resident whose room and bathroom were used, and did not document what interviewed residents had seen or heard. The facility also did not assess or monitor other residents, including other minors, for potential risk or impact, and there was no evidence of protective interventions being implemented on the date the incident occurred. The incident was reported to police nearly 24 hours after it occurred, and there was no evidence that the facility reported the incident to the Department of Child Services/Child Protective Services at the time, despite later acknowledgment by the former DON that CPS should have been notified as soon as possible. The facility’s actions and omissions were inconsistent with its abuse prevention policy, which required prompt identification of sexual abuse, immediate reporting to appropriate agencies, and thorough investigation including interviews with all relevant witnesses and review of all circumstances surrounding the event. Interviews with facility leadership and staff further demonstrated misunderstanding and misapplication of abuse definitions and consent standards as they relate to minors. The former DON stated that any alert and oriented resident, including minors, could consent to sexual activity with an adult and initially did not consider the incident to be sexual abuse because she believed it was not unwanted, although she later acknowledged that a minor cannot give consent for sexual activity and that the incident should have been reported to CPS. The former administrator stated that he viewed the incident as a crime involving an adult and a minor but did not know if it was sexual abuse. In contrast, the current DON and current administrator described sexual abuse and statutory rape as involving a minor who cannot legally consent and emphasized that it is not acceptable for an adult to sexually touch a minor. The social services supervisor and unit manager also stated that it was inappropriate and illegal for an adult resident and a pediatric/minor resident to have a sexual relationship, and that a child in the facility could not consent to sex with an adult. Despite these understandings, at the time of the incident the facility failed to apply these principles, failed to identify the event as sexual abuse of a minor, and failed to conduct and document a thorough investigation and timely reporting as required by policy and law. The APS investigative report later verified neglect of a vulnerable adult (the adult resident with serious mental illness) and confirmed that the sexual assault occurred. The DCS child safety specialist and the minor’s legal guardian both reported that the incident and its aftermath had a negative psychosocial effect on the minor. Staff interviews indicated that prior to the incident the minor was not directly supervised and was allowed to roam the facility freely, despite his minor status and TBI-related behaviors, and the social services supervisor was unsure what supervision measures were in place for pediatric/minor residents. These facts, combined with the facility’s failure to recognize the incident as sexual abuse, failure to identify and report the minor’s status in regulatory reports, failure to notify child protective authorities at the time, and failure to conduct a comprehensive investigation with all relevant witnesses and residents, formed the basis of the cited deficiency for not implementing policies and procedures to prevent abuse, neglect, and theft, specifically in relation to preventing and responding to sexual abuse of a minor by an adult resident.
Failure to Use QAPI to Address Sexual Abuse Incident Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to systematically address all care and services related to a sexual abuse incident between two residents. The facility’s Quality Improvement Plan/Action Plan dated May 20, 2025 identified the problem only as the admission of minors to the facility and cited a lack of communication to the IDT regarding admission of minors as the causal factor. The plan focused on monitoring dates of birth on admission, in-servicing admission and marketing staff on a new process for admitting minors, reviewing census in daily stand-up meetings, and conducting a full-house review of dates of birth for all current residents. However, the plan did not address the root cause of the sexual abuse incident itself or demonstrate that the facility fully investigated why the incident occurred between the two residents. The QAPI documentation did not clearly define the specific problem related to the abuse event, nor did it outline specific corrective actions tied to that event. It lacked measurable goals, timelines, and identification of who would be responsible for each step, and it did not describe how the facility would evaluate whether any interventions were effective in preventing similar incidents. The report further notes that the QAPI plan did not identify any specific changes to policies, procedures, or practices directly related to the abuse incident. Staff training described in the plan was limited to a new process for admitting minors and did not focus on the abuse-related deficiency. The plan omitted key details about the training, such as the content, who would be trained, when it would be completed, and how it would be documented and verified. Additionally, the plan did not include any system-wide changes made or planned in direct response to the sexual abuse incident, despite facility policies stating that QAPI should include systemic analysis and systemic action for high-risk, high-volume, or problem-prone issues.
Failure to Recognize and Report Sexual Abuse of a Minor Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report an allegation of sexual abuse involving a minor resident in accordance with federal requirements. A cognitively intact minor resident, identified as Resident #444, with diagnoses including traumatic brain injury, ADHD, anxiety, and depression, reported having received sexual acts from an adult resident, identified as Resident #3, who had diagnoses of ADHD, schizophrenia, and mood disorder. Both residents were documented as cognitively intact with BIMS scores of 15. The facility’s self-report and 5‑day investigation characterized the incident as a consensual sexual encounter between two cognitively intact residents and did not identify Resident #444 as a minor, despite the facility’s knowledge of his age. The events began when an LPN observed the two residents in another resident’s bathroom, with Resident #3 on her knees in front of Resident #444, whose pants were down, and the LPN believed oral sex was occurring. The LPN reported the incident to her supervisor and the residents were separated. Another LPN confirmed that she and the first LPN went to the room, found the assigned resident upset and unaware of the sexual encounter in his bathroom, and then separated the two residents and reported the incident to the DON. The police report later classified the event as a sexual assault of a minor and documented that Resident #3 admitted performing oral sex on Resident #444 after he asked for it, and that she knew his age. Resident #444 also reported that he asked Resident #3 for oral sex, went into the bathroom, closed the door, and that oral sex occurred until they were interrupted by staff. Despite these observations and statements, the facility’s initial and 5‑day reports to the State Agency did not identify Resident #444 as a minor and concluded that the facility was unable to substantiate that abuse occurred, describing the incident as occurring between two consenting individuals. The facility’s documentation of change‑of‑condition monitoring for both residents referenced a “reported event” but did not specify the nature of the event. The incident was reported to police nearly 24 hours after it occurred, and there was no evidence that the facility reported the incident to the Department of Child Services, even though staff and leadership acknowledged that the incident involved an adult and a minor and that the minor could not legally consent. Adult Protective Services later verified an allegation of neglect of a vulnerable adult, identified as Resident #3, and confirmed that Resident #3 sexually assaulted Resident #444 while at the facility. Interviews with the former administrator and former DON showed that they were aware the incident involved an adult and a minor and that it appeared to be a crime, yet the facility’s written investigation did not document the minor status, did not classify the event as sexual abuse, and omitted certain investigative details such as the interview with the resident whose room and bathroom were used. The current DON, who was not employed at the time of the incident, reviewed the investigation and stated she could not determine key details from the documentation, including the exact room where the incident occurred, whether anyone else was present, whether assessments were conducted for the involved residents, or whether DCS was notified. A DCS child safety specialist later reported that the incident and its aftermath had a negative psychosocial effect on Resident #444 and confirmed that, based on his age, he was not able to give consent. These documented failures to properly identify, classify, and report the incident as sexual abuse of a minor, and to notify all mandated entities, constitute the core of the deficiency. The facility also failed to take broader protective steps for other residents at risk as part of its response to the incident. The report notes that the facility did not identify the incident as sexual abuse and therefore did not implement measures such as assessment and monitoring of other residents at risk or interventions and supervision to protect other residents from possible abuse. The APS investigative report verified neglect of a vulnerable adult, Resident #3, due to serious mental illness and confirmed that the sexual assault occurred. Collectively, the record reviews, staff interviews, and external investigative findings demonstrate that the facility did not timely and accurately report the allegation of sexual abuse involving a minor to all required authorities and did not appropriately classify and respond to the event as sexual abuse, leading to the cited deficiency.
Failure to Recognize and Thoroughly Investigate Sexual Abuse Allegation Involving a Minor
Penalty
Summary
The deficiency involves the facility’s failure to recognize and investigate an allegation of sexual abuse involving a minor resident and an adult resident, and to implement required protections and notifications. A self-report submitted by the former DON stated that a staff member overheard a cognitively intact resident (BIMS 15) say he had received sexual acts from another cognitively intact resident, and that both residents later acknowledged a consensual sexual encounter that occurred the previous day. The facility’s reports to the State Agency did not identify the younger resident as a minor and characterized the incident as a consensual encounter between two residents, rather than as potential sexual abuse. The facility’s 5‑day investigation concluded that abuse could not be substantiated and that the incident occurred between consenting individuals, despite the younger resident’s minor status and the nature of the sexual act. The incident was reported in a police report as a sexual assault that occurred in the evening, with the adult resident performing oral sex on the minor in a bathroom after being asked by him, and the adult resident acknowledging she knew his age. The police report documented that an LPN entered another resident’s room, saw the adult resident on her knees with the minor in the bathroom, and reported the incident to her supervisor; the adult resident was then moved to a separate wing. However, the facility’s internal investigation did not include a written statement from this LPN and instead documented that she had only seen the two residents together watching videos with no inappropriate behavior. Staff schedules showed that none of the six staff interviewed by the facility for its investigation had worked the night shift when the incident occurred. The facility also did not document interviews with the resident whose room was used or with other residents, including other minors, who might have had information about the event. Clinical records for both residents showed they were placed on change of condition monitoring for psychosocial well-being due to a “reported event,” and care plans were initiated the day after the incident, but the documentation did not specify the nature of the event. There was no evidence in the clinical record that protective interventions were implemented on the date the incident occurred to protect the minor from further abuse or to protect other residents from the alleged perpetrator. Staff interviews indicated that prior to the incident the two residents had been “hanging out together a lot,” that staff had warned the adult resident that the younger resident was a minor, and that the minor had freedom to roam the facility without direct supervision. There was no documentation of interventions to supervise or discourage their contact, or of increased supervision or monitoring of either resident prior to the incident. The facility did not report the incident to the Department of Child Services, and DCS later confirmed it only became involved when the minor was discharged to a hospital that reported the incident. The facility’s own abuse policy required prompt, thorough investigation of all abuse allegations, interviews with all relevant staff and residents on all shifts, review of all circumstances surrounding the incident, immediate protection of the alleged victim, increased supervision, and appropriate external reporting, but the actions taken did not meet these requirements as described in the report. An APS investigation later verified neglect of the adult resident, identified as a vulnerable adult with serious mental illness, and verified that a sexual assault occurred. The former DON stated that she did not consider the incident to be sexual abuse because she believed it was not unwanted and that the minor could consent to sexual activity with an adult, and she acknowledged that the incident was not reported or investigated until the following day after a staff member overheard the minor describe the sexual act. The current DON and current administrator, interviewed later, described that a minor cannot legally consent to sexual activity with an adult, that such an incident would be considered sexual abuse or statutory rape, and that such events require immediate reporting and investigation, but they were not employed at the time of the incident and did not participate in the original response. The report concludes that because the facility failed to recognize the incident as potential abuse, it did not initiate a thorough investigation, did not take appropriate corrective actions to protect residents from possible abuse, did not assess and monitor other residents at risk, and did not notify law enforcement and DCS as required, thereby placing residents at risk for harm.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Dialysis Services Provided Without Required State License Modification
Penalty
Summary
The facility failed to ensure that a request for modification of its health care institution license was approved by the state agency prior to establishing and providing in-house dialysis services. Despite submitting building plans and receiving approval for architectural plans and specifications, the facility did not obtain the required modified license to operate a dialysis center within the premises. The administrator believed that the approval of the architectural plans was sufficient to begin providing dialysis services, but was unable to provide documentation of a modified facility license or the license of the contracted dialysis provider when requested by surveyors. From March 1, 2024 through March 7, 2025, dialysis treatments were provided to nine residents within the facility, utilizing a multipurpose room and bedside services. The facility assessment indicated an average of 16 residents receiving dialysis services daily, with a total of approximately 55 residents having end stage renal disease. Observations during the survey revealed the presence of six dialysis machines and residents actively receiving dialysis treatments in-house, managed by a contracted dialysis provider whose licensure could not be produced by the facility. Interviews with staff confirmed that the in-house dialysis program had been operating under the assumption that the architectural approval sufficed for licensure modification. The facility was unable to provide evidence of the required state approval for the modification of its license to include dialysis services, nor could it provide the license for the contracted dialysis provider. This resulted in the facility operating and providing dialysis services without compliance with all applicable federal, state, and local laws and regulations.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for two residents who were not assessed to be clinically appropriate for self-administration of medications. Resident #62, who was readmitted with acute respiratory failure, pleural effusion, and pneumonia, had a BIMS score indicating moderate cognitive impairment. Despite this, a medication cup with a large capsule was found on the resident's bedside table. The resident expressed a preference to take the vitamin later, but there was no evidence of an assessment for self-administration. The RN involved was unaware of any residents permitted to self-administer medications and acknowledged the risks of leaving medications unattended. Resident #71, diagnosed with end-stage renal disease, had a BIMS score indicating intact cognition. However, there was no evidence of a self-administration assessment or physician orders for self-administration. During an observation, a medication cup with five tablets was found on the resident's bedside table, and the resident admitted to discarding unwanted pills. The RN responsible did not observe the resident taking the medications and was unaware of the resident's actions. The facility's protocol requires documentation of medication refusal and proper disposal, which was not followed in this case. Interviews with the Director of Nursing confirmed that medications should not be left at the bedside unless there is an order for self-administration. The facility's policy mandates that medications be administered according to physician orders and that any deviations be documented. The failure to adhere to these policies resulted in medications being left unattended, posing risks of incorrect administration or non-administration.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a kitchen inspection. Several food items in the refrigerator were found to be beyond their use-by dates, including grated parmesan cheese, lettuce salad bags, and milk cartons. Additionally, opened food items such as orange juice, turkey deli meat, and pizza were not dated, posing a risk of foodborne illness. Interviews with staff revealed a lack of adherence to the facility's policy, which mandates that potentially hazardous foods be covered, labeled, and dated. The facility also neglected to maintain cleanliness in the kitchen, particularly concerning the ceiling vents and the ice machine. The ceiling vent above the food tray line was coated with dust and debris, which extended to the surrounding ceiling and light fixture. The Dietary Manager admitted that the vent cleaning schedule was overlooked, and the Maintenance Director confirmed that the vents had not been cleaned since a previous date. This oversight contradicts the facility's policy requiring monthly cleaning of vent fans. Furthermore, the ice machine was found to be inadequately cleaned, with a black-brown discoloration on the interior plastic shroud. The cleaning log indicated a lack of regular maintenance, with no entries for several weeks. The Dietary Manager and Maintenance Director acknowledged that the ice machine had not been cleaned since a contracted deep clean, despite the facility's policy requiring monthly cleaning. This failure to maintain sanitary conditions in the kitchen increases the risk of contamination and foodborne illness.
Failure to Address Change in Condition and Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who experienced a change in condition. The resident, admitted with multiple diagnoses including diabetes mellitus and pneumonia, had physician orders for insulin and glucose monitoring. Despite documented low blood sugar levels and symptoms such as lethargy and labored breathing, there was no evidence that the provider was notified of these changes. The resident's condition worsened, leading to a complaint from the family about inadequate response to the resident's health decline. Another deficiency involved a resident who required a custom tilt-in-space wheelchair with leg rests for proper positioning due to mobility impairments. Observations revealed that the resident was frequently without leg rests, causing her legs to dangle unsupported. Despite therapy recommendations and the resident's care plan, the leg rests were missing for an extended period, and staff failed to ensure the resident was properly positioned, increasing the risk of injury and discomfort. Interviews with staff highlighted a lack of communication and documentation regarding the residents' conditions and needs. Nursing staff did not consistently notify providers of significant changes in residents' health status, and there was inadequate follow-up on missing equipment necessary for resident care. These deficiencies indicate a failure to adhere to facility policies on change of condition reporting and the provision of necessary mobility aids.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration, as observed during a survey. On September 17, 2024, an LPN was seen dropping a used plastic vial of normal saline on the floor. The LPN picked up the vial with bare hands and disposed of it in the sharps container without sanitizing her hands. She then proceeded to open medication cart drawers and prepare medications for administration without performing hand hygiene. In another instance, the same LPN dropped a packet from her pocket onto the floor, picked it up with bare hands, and placed it back in her pocket. She did not sanitize her hands before locking the medication cart, picking up prepared medications, and entering a resident's room. Interviews with the LPN and the DON confirmed that the facility's hand hygiene policy requires sanitizing hands after picking items up off the floor, which was not followed in these instances.
Failure to Maintain Resident Dignity and Grooming
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by observations and interviews. The resident, who was admitted with diagnoses including muscle disuse atrophy, dysphagia, and cognitive communication deficit, required assistance with personal care and had a care plan that emphasized promoting dignity and ensuring privacy. Despite this, an observation revealed the resident lying supine in bed with pureed-like substance caked around his mouth and beard, wearing a shirt saturated with the same substance, and with one sock on and the other off. The resident's bed was in the lowest position with a visibly soiled fall mat on the floor, and the meal tray was placed on the side table. Interviews with staff indicated that breakfast trays were typically picked up around 9:30 a.m., and resident rounds were conducted every two hours or more frequently if needed. However, a subsequent observation approximately two and a half hours later found the resident still in the same condition, with the pureed-like substance still present around his mouth and beard, and his shirt still saturated. This indicates a failure to provide necessary services to maintain good nutrition and grooming, as outlined in the facility's policy for activities of daily living.
Lack of Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to ensure there was a physician order for the use of oxygen for two residents, which could result in unnecessary oxygen use. Resident #219 was readmitted with diagnoses including end-stage renal disease, respiratory failure, and type 2 diabetes mellitus. Despite being documented as receiving oxygen via nasal cannula on multiple occasions between February 17 and March 15, 2023, there was no physician order for oxygen use during this period. The care plan was updated on March 17, 2023, to include oxygen therapy, but the lack of a physician order prior to this date was confirmed by the Assistant Director of Nursing and the Respiratory Therapy Director. Resident #168 was admitted with diagnoses of urinary tract infection, pneumonia, and type 2 diabetes mellitus. The resident's oxygen saturation levels were recorded as low on several occasions, and the resident was documented as receiving oxygen via nasal cannula. However, there was no evidence of a physician order for oxygen use from February 9 through February 12, 2023. The care plan was revised on February 13, 2023, to include oxygen therapy, but there was no documentation of a physician order for the increased oxygen levels administered to the resident. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the facility's policy required a physician order for oxygen administration. The Director of Nursing stated that any change in a resident's condition, such as increased oxygen needs, should be documented and reported to the provider. The facility's policy on oxygen administration, revised in July 2013, also required a physician order for oxygen therapy, highlighting the deficiency in following established protocols.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure that the resident representative (RR) was notified in writing of a transfer to the hospital for one resident. Resident #6, who had diagnoses including respiratory failure, diabetes mellitus, quadriplegia, and seizure disorder, was found to have a critically low hemoglobin level of 5.7 grams per deciliter on October 23, 2023. Following this finding, the physician ordered the resident to be transferred to the hospital. However, there was no evidence in the clinical record that the RR was provided with a written notice of this transfer. During an interview conducted on November 9, 2023, the assistant director of nursing (ADON) was unable to provide documentation of the notification to the RR regarding the transfer of Resident #6 on October 23, 2023. The facility's policy on Admission, Transfer, and Discharge, dated May 2022, requires that the transfer or discharge be documented in the resident's medical record and that appropriate information be communicated to the receiving healthcare institution or provider. This policy was not followed in this instance, leading to the deficiency.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to ensure that the bed-hold policy or notice was provided to a resident or their representative prior to or upon transfer to a hospital. Resident #6, who had diagnoses including respiratory failure, diabetes mellitus, quadriplegia, and seizure disorder, was found to have a critically low hemoglobin level of 5.7 g/dl on October 23, 2023. Following this finding, the physician ordered the resident to be discharged to the hospital. However, there was no evidence in the clinical record that the bed-hold policy was communicated to the resident or their representative before or during the transfer. During an interview conducted on November 9, 2023, the assistant director of nursing (ADON) confirmed that the bed-hold notification was not provided to the resident or their representative. The facility's policy on Admission/Discharge/Transfer did not include a requirement for notifying residents or their representatives about the bed-hold policy. This oversight could result in residents and their representatives being unaware of their ability to return to the facility after hospitalization.
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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