Villa Maria Post Acute And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Tucson, Arizona.
- Location
- 4310 East Grant Road, Tucson, Arizona 85712
- CMS Provider Number
- 035147
- Inspections on file
- 17
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Villa Maria Post Acute And Rehabilitation during CMS and state inspections, most recent first.
Multiple residents with documented mental health diagnoses and active psychotropic treatment did not receive accurate PASRR Level I screenings or required Level II referrals. In several cases, PASRR forms from referring facilities and the facility itself marked "no" history of serious mental illness, omitted diagnoses such as PTSD, bipolar disorder, borderline personality disorder, schizophrenia, and depression, and failed to reflect recent inpatient psychiatric hospitalization or suicidal ideation, despite these being clearly documented in the clinical record, MDS assessments, psychiatric notes, and care plans. Some PASRR forms also incorrectly indicated that residents were not on psychotropic medications, or left the Level II referral determination section blank, even though the same records listed multiple psychotropic agents for mood, anxiety, and psychotic disorders. No Level II referrals were found for these residents. In interviews, the Social Services Director acknowledged that PASRRs were inaccurate or incomplete, that Level II referrals should have been submitted but were not, that the facility is responsible for PASRR accuracy, and that she lacked clear training and consistent oversight on PASRR update requirements and tracking.
A hospice resident with multiple chronic conditions experienced a decline marked by lethargy and decreasing O2 saturations, including documented hypoxia, but there was no corresponding physician order for oxygen or change-of-condition monitoring in the EMR when oxygen was applied at the bedside. Hospice notes indicated that oxygen was ordered and used, yet the facility lacked a hospice binder for the resident, did not upload hospice visit notes, and did not document O2 saturation checks for several days while other vital signs were recorded each shift. Observations showed an oxygen concentrator in use before a physician order was entered, and interviews with an LPN, ADON, DON, and hospice staff confirmed that required physician notification, oxygen orders, and care plan updates were not completed in accordance with facility policies on vital signs, change-of-condition reporting, oxygen administration, physician orders, and hospice care.
Surveyors found that the facility failed to maintain complete dual-nurse narcotic reconciliation logs for two medication carts, with multiple shifts lacking required nurse signatures despite a policy requiring incoming and outgoing licensed nurses to reconcile controlled medications at each shift change. An LPN confirmed that two nurses are required to complete the narcotic count and that missing signatures mean it cannot be proven that the counts were performed as required, and facility leadership acknowledged that the submitted logs did not meet their own expectations.
A resident with multiple psychiatric and pain diagnoses experienced distress and verbal altercations during two roommate changes, including reported threatening and mocking comments, crying, yelling, and behavioral escalation. Staff contacted the ADON and intervened, but did not document the behavioral episodes, roommate conflicts, or change-of-condition monitoring in the clinical record, despite facility policies and staff expectations that such events be charted. In a separate case, another resident with diabetes, chronic pain, cancer, and a stage 4 pressure ulcer was on hospice and had declining oxygen saturation, with hospice staff applying oxygen at 2L via nasal cannula and documenting hypoxia. However, the facility’s EMR lacked timely physician orders for oxygen, did not include a care plan for oxygen therapy until later, had no documented oxygen saturation monitoring for several days, and was missing hospice visit notes and a hospice binder, resulting in an incomplete and inaccurate medical record of the resident’s oxygen use and change in condition.
A resident with Type 2 DM, chronic kidney disease, and other comorbidities had a provider order for 20 units of Insulin Glargine daily, to be held if blood glucose was less than 110. Review of the MAR showed that insulin was administered on five occasions when the resident’s blood glucose was documented as below 110, without any provider authorization to give insulin under those conditions. Staff interviews confirmed that CMAs and CNAs are trained to follow ordered parameters, hold medications when parameters are not met, and notify nursing and the provider of abnormal values, and the DON acknowledged that the expectation for medication administration according to orders and facility policy was not met.
A resident with no cognitive impairment attempted to slap another resident, leading to a physical altercation where the second resident retaliated, causing injury. Despite staff intervention, the facility failed to prevent the incident, highlighting inadequate management of resident interactions and lack of de-escalation policies.
A resident with epilepsy experienced a seizure, but the facility failed to provide timely emergency response. The nurse delayed calling 911 and did not administer seizure medication, leaving the resident unattended and at risk. The Director of Nursing confirmed the delay was unacceptable, and the facility's policy was not followed.
The facility failed to provide catheter-related care as ordered for three residents, leading to missed opportunities for catheter care and emptying drainage bags. Staff interviews confirmed inconsistent care and documentation, and the facility was often understaffed, affecting the quality of care provided.
Failure to Accurately Complete PASRR Screenings and Level II Referrals for Multiple Residents With Mental Disorders
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion, updating, and referral of PASRR Level I screenings and Level II evaluations for multiple residents with serious mental illness (SMI) or other mental disorders. For one resident with borderline personality disorder, PTSD, recurrent depression, anxiety disorders, and factitious disorder, hospital-generated PASRRs repeatedly documented “no” history of SMI, mental disorders, or psychotropic medications, despite extensive behavioral health diagnoses and active psychotropic orders. The facility did not correct these PASRRs or complete a Level I PASRR after the 30‑day convalescent period ended, even though the resident’s MDS assessments, psychiatric notes, care plans, and social services assessments consistently documented anxiety, depression, PTSD, borderline personality disorder, and ongoing psychiatric treatment. Another resident with PTSD, depression, generalized anxiety disorder, bipolar disorder, polysubstance abuse, and recent inpatient psychiatric hospitalization for suicidal ideation had a PASRR Level I that omitted major depression and bipolar disorder and incorrectly indicated no recent psychiatric hospitalization or suicidal ideation. A subsequent PASRR Level I, completed after re‑admission, documented bipolar disorder and anxiety disorder but again indicated no recent psychiatric hospitalization or suicidal ideation and concluded that no Level II referral was necessary. The clinical record showed no evidence of any PASRR Level II referral for this resident. A separate resident with diabetes, depression, and later‑added bipolar disorder exhibited altered mental status and psychotic‑like behavior, prompting a psychiatric consult. However, the quarterly MDS did not list bipolar disorder as an active diagnosis, and the PASRR Level I documented major and mild/situational depression but stated the resident did not have bipolar disorder and did not require a Level II referral, with no Level II referral found in the record. For another resident admitted and re‑admitted with anxiety disorder, schizophrenia, recurrent depressive disorder, chronic PTSD, and polysubstance abuse in remission, multiple PASRR Level I tools were inconsistent with the clinical record. One hospital PASRR identified bipolar disorder and personality disorder and psychotropic use but did not document whether a Level II referral was needed. A subsequent facility PASRR Level I documented schizophrenia and anxiety disorder but stated the resident was not prescribed psychotropic medications, despite the admission MDS showing active anxiety, depression, schizophrenia, and use of antianxiety, antidepressant, antipsychotic, and anticonvulsant medications. A later PASRR Level I listed schizophrenia only, omitted depression, anxiety, and other mental disorders, and left the Level II referral determination section blank, even though the same form listed multiple psychotropic medications for depression, anxiety, and schizophrenia. No Level II referral was present in the record. Additional residents with multiple psychiatric diagnoses and psychotropic treatment also lacked accurate PASRR documentation and appropriate Level II referrals. One resident with anxiety disorder, bipolar disorder (current episode depressed), and schizophrenia had a PASRR Level I that correctly listed these diagnoses and related psychotropic medications but indicated no Level II referral; a later PASRR for the same resident omitted all mental illness diagnoses and psychotropic medications, again indicating no Level II referral, despite MDS documentation of anxiety disorder, bipolar disorder, schizophrenia, and use of antipsychotics and antidepressants. Another resident with aphasia, anxiety disorder, recurrent depressive disorder, mood disorder, personality and behavioral disorder due to physiological condition, and adjustment disorder had an initial PASRR listing anxiety and depression with no Level II referral, followed by a second PASRR that omitted all diagnoses and psychotropic medications, again indicating no Level II referral, despite orders and care plans for Depakote and anticonvulsant therapy for mood disorder. In interviews, the Director of Social Services acknowledged that PASRRs were inaccurate or incomplete, that required Level II referrals had not been submitted for several residents, that the facility was responsible for ensuring PASRR accuracy, and that she was uncertain about PASRR update requirements and tracking for residents needing Level II evaluations. The Director of Social Services further stated that the facility’s process for identifying residents with mental disorders or intellectual disabilities involved review of diagnoses such as depression, anxiety, bipolar disorder, and schizophrenia, and review of psychiatric medications, and that residents with more than one or two psychiatric diagnoses and stays longer than 30 days should automatically have a Level II PASRR referral submitted. She confirmed that she was responsible for completing Level I PASRRs and submitting Level II referrals, that PASRR resource reviews were infrequent and random, and that she had not received formal performance evaluation or sufficient training to identify knowledge gaps. She also stated that inaccurate or incomplete PASRR screening and referral processes could result in residents not receiving the services they need, and that accurate PASRR completion is critical to resident safety and quality of care.
Failure to Obtain Timely Oxygen Orders and Monitor Change in Condition for Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and services, including physician notification and obtaining a physician order for oxygen, in response to a resident’s change in condition. The resident was admitted with multiple diagnoses including type 2 diabetes mellitus, chronic pain syndrome, spinal stenosis, breast cancer, and a stage 4 sacral pressure ulcer. A care plan focus initiated shortly after admission identified an alteration in gastrointestinal status due to a colostomy, with an intervention to monitor vital signs as ordered and notify the provider of significant abnormalities. Despite this, the clinical record contained no physician order for vital sign monitoring, and the admission MDS showed no oxygen therapy in the 14 days prior to or at admission. Oxygen saturation logs for January showed readings in the mid-90s on room air on several dates, but hospice documentation later recorded a decline. Hospice notes indicated that on one visit the resident was lethargic and nonverbal with an oxygen saturation of 93% on room air, and on a subsequent visit the resident was difficult to awaken, lethargic, and reported not feeling well, with an oxygen saturation of 90% on room air. The hospice note for that visit stated that oxygen was ordered and that the resident was added to a decline list, but there was no evidence of a corresponding physician order for oxygen in either the hospice records or the facility’s medical record on that date. A physician order from that date only authorized emergent PRN nursing visits due to change in decline status. Later hospice documentation recorded an oxygen saturation of 87% on room air, noted that oxygen was applied at 2L via nasal cannula after staff filled the concentrator’s water reservoir, yet there was still no physician order for oxygen in the clinical record on that date. Surveyors found that the facility’s MAR/TAR documented blood pressure, temperature, pulse, and respirations every day and night shift, but did not include oxygen saturation monitoring until several days after the hospice note documenting hypoxia. The electronic medical record showed no oxygen saturation documentation between mid-January and the date when an oxygen order was finally entered. Observations showed the resident in bed with an oxygen concentrator present and turned on at 2L, initially with the nasal cannula draped over the concentrator and later with the cannula in place, before a physician order for oxygen was documented. Interviews with an LPN revealed there was no hospice binder for the resident, no oxygen order or oxygen care plan in the EMR at the time oxygen was observed in use, and that the nurse first became aware the resident was on oxygen during the surveyor’s observation. The ADON and DON both stated that any new need for oxygen or hypoxic episode should prompt immediate physician notification, a physician order for oxygen and change-of-condition monitoring, and oxygen saturation checks every shift, and that oxygen should only be administered with a physician order except as an emergency measure until an order is obtained. Review of facility policies on vital signs, change of condition reporting, oxygen administration, physician orders, and hospice/end-of-life care confirmed that changes in condition were to be promptly communicated to a physician, documented, and incorporated into the care plan, and that oxygen therapy was to be administered and documented only under appropriate physician orders, which did not occur in this case until several days after hypoxia and oxygen use were documented by hospice. Additionally, hospice staff interviews and records showed that hospice communicated via emailed documentation and that each hospice resident should have a hospice binder at the nurses’ station containing hospice notes and updates. For this resident, there was no hospice binder available, and hospice notes from key visits were not uploaded into the facility’s EMR at the time of review. The hospice RN who visited the resident on the date hypoxia was documented reported that the resident was hypoxic with oxygen saturation around 88–90%, that an oxygen concentrator was already at the bedside when she arrived, and that she notified facility staff that the concentrator’s distilled water reservoir was empty. The DON stated she believed the resident was placed on oxygen by hospice on the morning of the date the order was eventually written and that the oxygen was for comfort measures, and she was not aware of any hypoxic episodes. Review of the clinical record with the DON confirmed that there was no documentation that a provider was notified of a change in condition related to hypoxia and that the first oxygen order was not entered until that same day, despite earlier hospice documentation of hypoxia and oxygen use.
Failure to Maintain Complete Dual-Nurse Narcotic Reconciliation Logs
Penalty
Summary
The facility failed to ensure accurate reconciliation and accounting of controlled substances on two of three sampled medication carts. During review of the narcotic reconciliation log for the 100 medication cart, surveyors and an LPN identified missing nurse signature entries on six shifts within a specified date range, despite the expectation that these entries not be left blank. A similar review of the 300 medication cart narcotic reconciliation log revealed missing nurse signature entries on five shifts in the same period. The facility’s policy, revised in June 2025, instructed staff to reconcile controlled medications every shift by both incoming and outgoing licensed nurses at change of shift, but the documentation did not show that this process was consistently followed. Interviews with nursing staff and leadership confirmed that two nurses are required to complete the narcotic count and reconciliation log at each shift change to ensure accountability and verify that residents receive required medications. An LPN stated that there should be no missing signature entries for the dates in question because, without signatures, it cannot be proven that two nurses performed the narcotic counts for those shifts. The ADON and DON acknowledged that the narcotic reconciliation logs contained missing entries that did not meet facility expectations and that the logs with these deficiencies were provided to the survey team. The deficient practice was identified through observations, interviews, and review of facility documentation and policy.
Failure to Maintain Accurate Clinical Records for Behavioral Events and Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and readily available clinical records that reflected residents’ actual experiences and care. For one resident with borderline personality disorder, PTSD, chronic pain, insomnia, depression, anxiety, and factitious disorder, the record did not contain documentation of significant behavioral events and roommate conflicts that occurred during room changes, despite facility policies requiring documentation of changes of condition and related nursing actions. This resident was cognitively intact, had a care plan addressing confabulation and false accusations, and had a grievance on file about room placement. A facility-reported incident later concluded that an allegation of resident-to-resident abuse was unverified and characterized the event as a verbal disagreement, but there was no corresponding documentation in the clinical record of the verbal disagreement or room-change-related distress during the 72-hour significant change-of-condition period. The resident reported to surveyors that she was placed in two different roommate situations that she felt compromised her mental health and safety, including one roommate who required the door to remain open, which she stated exacerbated her neurological condition and pain, and another roommate who allegedly mocked her and threatened to suffocate her. She described repeated verbal altercations, a screaming match, and subsequent night terrors related to her PTSD. Staff interviews confirmed that the ADON received calls about the resident crying and hollering during room changes, that staff reported the roommate’s comments such as questioning if the resident was a child and saying she would die there anyway, and that staff intervened and moved the resident. The LPN acknowledged hearing the resident yelling, receiving CNA reports that the conflict was related to the roommate’s comments about the resident’s dolls and behavior, and contacting the ADON, but admitted he did not document the episode, despite recognizing in hindsight that it met criteria for a behavioral incident and change-of-condition documentation. Other staff, including the DSS and DON, stated they expected documentation of these events in the clinical record and that such documentation is used for assessments, grievances, and investigations. For another resident with type 2 diabetes, chronic pain syndrome, spinal stenosis, breast cancer, and a stage 4 sacral pressure ulcer, the facility failed to ensure the clinical record accurately reflected vital sign monitoring, oxygen therapy, hospice involvement, and related physician orders. The care plan included an intervention to monitor vital signs as ordered and record them, but there was no physician order for vital sign monitoring. The MAR/TAR showed routine documentation of blood pressure, temperature, pulse, and respirations, but no oxygen saturation entries until later in the month, and the EMR lacked oxygen saturation documentation for several days. The resident was observed with an oxygen concentrator at bedside, initially turned on without the nasal cannula in place and later with the cannula in use, yet there was no corresponding physician order for oxygen therapy until a later date, no oxygen therapy care plan until that order, and no evidence of change-of-condition monitoring orders or documentation of provider notification when the resident was hypoxic according to hospice records. Hospice documentation, obtained after a formal request, showed that the resident’s oxygen saturation had declined on room air and that oxygen was ordered and applied by hospice staff prior to the facility obtaining a physician order. The hospice notes indicated hypoxic readings and use of oxygen at 2L via nasal cannula, but these details were not present in the facility’s EMR at the time of survey, and hospice visit notes for specific dates were not available in the record or in a hospice binder. Facility staff, including an LPN, the ADON, the medical records director, and the DON, confirmed that there was no hospice binder for the resident, no oxygen order in the EMR until later, no care plan for oxygen therapy before that order, and no documented oxygen saturation monitoring for several days. The DON acknowledged that the clinical record did not show provider notification of a change of condition or oxygen saturation monitoring and stated that if the clinical record did not accurately reflect a resident’s current status or capture a change of condition, the resident could have an adverse outcome. Facility policies on documentation, change-of-condition reporting, abuse reporting, and comprehensive care planning required complete, timely, and accurate records to support care, assessments, and investigations, which were not met in these cases.
Insulin Administered Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s insulin regimen was administered according to the provider’s parameters, resulting in the use of insulin when it was not ordered to be given. A cognitively intact resident with Type 2 DM, chronic kidney disease, moderate protein-calorie malnutrition, generalized muscle weakness, and sequelae of cerebral infarction had a physician order for 20 units of Insulin Glargine once daily unless the blood sugar was less than 110. The resident’s care plan indicated noncompliance with a therapeutic diet and directed that diabetes medications be given as ordered by the physician. Review of the MAR for a specified month showed that Insulin Glargine was administered on five occasions when the documented blood glucose levels were below 110, despite no evidence in the clinical record that the provider had authorized insulin administration when blood sugars were under that threshold. During interviews, a CMA stated that staff are expected to follow medication orders with parameters as written and that administering medications outside those parameters can overmedicate a resident and must be reported to the charge nurse and physician. The DON stated that insulin lowers blood glucose and that administering it outside prescribed parameters can cause hypoglycemia, and staff are expected to notify the provider when blood glucose values fall outside ordered parameters. A CNA reported being trained to perform finger-stick blood glucose monitoring, to notify the nurse immediately for low readings or signs of hypoglycemia, and to follow provider orders. The DON-by-proxy confirmed that documentation showed five instances where Insulin Glargine was given when blood glucose was below 110 and acknowledged that the expectation for medications to be administered in accordance with provider orders was not met. Facility policies on medication administration and MRR required holding medications when parameters are not met and obtaining clarification when there is any question about dosage, as well as identifying medication-related errors and unnecessary drugs.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a physical altercation. Resident #1, who had no cognitive impairment, was involved in an incident where he attempted to slap Resident #2, who then retaliated by striking Resident #1. This altercation led to Resident #1 sustaining a laceration on the forehead, requiring hospital treatment. The incident occurred despite staff attempts to intervene, highlighting a failure in preventing resident-to-resident abuse. Resident #1 had been moved to a different unit prior to the incident due to feeling threatened by Resident #2, following an earlier conflict where Resident #1 had defecated on the floor of their shared room. Resident #2, who also had no cognitive impairment, expressed dissatisfaction with Resident #1's behavior and had previously threatened to keep his TV volume high until Resident #1 was moved. This ongoing tension between the two residents was not adequately managed by the facility, leading to the altercation. Interviews with staff revealed that they were not fully aware of the history between the two residents, and there was no policy in place for de-escalation management with aggressive residents. The facility's policy on resident rights emphasized freedom from physical abuse, yet the lack of effective intervention and management of resident interactions contributed to the failure to uphold these rights.
Failure to Provide Timely Emergency Response for Resident with Seizure
Penalty
Summary
The facility failed to provide timely treatment and care for a resident with a history of epilepsy, major depressive disorder, and hemiplegia following a stroke. The resident was found on the floor and later experienced a seizure, but the nurse in charge delayed calling emergency services and did not administer any seizure medication. The resident was left unattended while actively vomiting and unable to protect their airway, which was observed by the fire department upon their arrival. The nurse in charge, identified as staff #28, waited almost two hours to call 911 after the resident began experiencing seizure activity. The nurse did not have eyes on the resident when emergency services arrived and was unfamiliar with the resident's condition. The nurse practitioner was contacted late, and the order to send the resident to the hospital was delayed. Interviews with other staff members indicated that the situation was considered a medical emergency, and the delay in contacting emergency services was not acceptable. The Director of Nursing confirmed that the delay in care was not acceptable and that the expectation was for staff to contact a provider immediately in such emergencies. The facility's policy required licensed nurses to initiate appropriate first aid measures until emergency personnel arrived, which was not followed in this case. The deficiency in timely response and care had the potential to result in severe consequences for the resident.
Failure to Provide Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that three residents were provided catheter-related care as ordered, leading to missed opportunities for catheter care and emptying drainage bags. Resident #6, who was admitted with paraplegia and neuromuscular dysfunction of the bladder, had multiple missed opportunities for catheter care and emptying the drainage bag in November and December 2023. Additionally, orders for urinary analysis were not transcribed or implemented, and the resident reported having to change his own catheter due to staff unavailability. Interviews with staff confirmed that catheter care was not consistently performed or documented, and the facility was often understaffed, affecting the quality of care provided to residents with catheters. Resident #2, admitted with bladder neck obstruction and other diagnoses, also experienced missed opportunities for catheter care and emptying the drainage bag in December 2023, January 2024, and February 2024. The resident's care plan and physician's orders were not consistently followed, and interviews with staff revealed that catheter care was not performed every shift as required. The Director of Nursing acknowledged that the orders were not transcribed or implemented as expected, and the facility's policy for catheter care was not met. Resident #8, who had a suprapubic catheter and was at risk for recurring urinary tract infections, had missed opportunities for catheter care and emptying the drainage bag in November 2023, December 2023, and January 2024. The resident's care plan and physician's orders were not consistently followed, and staff interviews indicated that catheter care was not always provided or documented. The Director of Nursing confirmed that the facility's expectations for catheter care and documentation were not met, and the facility's policies and procedures were not adequately followed.
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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