27 Reports
Inspection Report — Feb 4, 2026
Complaint Investigation
Date: Feb 4, 2026
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On-site complaint investigation of intakes 2723379, 2263523, 2263524, and 2263534 at a Nursing Care Institution, conducted 4 February 2026.
Complaint Details
An onsite complaint survey was conducted on February 4, 2026 for the investigation of intakes #2723379, #2263523, #2263524, and #2263534. There are no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 4
Inspection Report — Jan 20, 2026
Complaint Investigation
Date: Jan 20, 2026
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On-site complaint investigation of intakes 00154713 and 00154752 at a Nursing Care Institution, conducted 20 January 2026.
Complaint Details
Investigation of intakes # 00154713 and 00154752 was conducted on January 20, 2026. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 23, 2025
Complaint Investigation
Date: Dec 23, 2025
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On-site complaint investigation of complaints 00153874, 00154025, 2683026, 00152474, and 2263525 at a Nursing Care Institution, conducted 23 December 2025.
Complaint Details
The investigation of Complaints 00153874, 00154025, 2683026, 00152474, and 2263525 was conducted on December 23, 2025. The investigation of Complaints 2697676, 2698667, 2683026, 2686027, and 2263525 was conducted on December 23, 2025.
Findings
The inspection found two deficiencies related to the administration of blood pressure medication not following physician orders for one sampled resident. Both deficiencies were cited and plans of correction were provided.
Deficiencies (2)
§483.21(b)(3) — The facility failed to ensure that blood pressure medication was administered in accordance with physician ordered parameters for 1 out of 3 sampled residents, risking uncontrolled blood pressure.
R9-10-407 — The facility failed to ensure that blood pressure medication was administered in accordance with physician ordered parameters for 1 out of 3 sampled residents.
Report Facts
Deficiencies cited: 2
Complaints investigated: 10
Inspection Report — Nov 21, 2025
Complaint Investigation
Date: Nov 21, 2025
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On-site complaint investigation of intakes 2599117, 2613588, 2612907, 2263551, 2663552, 2263389, and 2263547 at a Nursing Care Institution, conducted 24 September 2025.
Complaint Details
An onsite complaint survey was conducted on September 24, 2025 for the investigation of intakes #2599117, #2613588, #2612907, #2263551, #2663552, #2263389, and #2263547. There are no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Report Facts
Complaints investigated: 7
Inspection Report — May 27, 2025
Date: May 27, 2025
Visit Reason
On-site inspection of type Other at a Nursing Care Institution, conducted 27 May 2025.
Findings
One deficiency was found related to corridor doors, but no evidence text was provided. Federal comments noted noncompliance with Life Safety Code requirements and compliance with Emergency Preparedness standards.
Deficiencies (1)
Corridor doors deficiency noted, but no evidence text was provided to specify the violation.
Report Facts
Deficiencies cited: 1
Inspection Report — May 23, 2025
Annual Inspection
Date: May 23, 2025
Visit Reason
On-site combined complaint investigation and annual recertification survey conducted 20 to 23 May 2025 at a Nursing Care Institution. Complaints investigated included AZ00202774, AZ00203426, AZ00203907, AZ00205762, AZ00206715, AZ00207455, AZ00207918, AZ00210973, AZ00212440, AZ00213122, and AZ00213177.
Complaint Details
The Recertification survey was conducted in conjunction with the investigation of complaints # AZ00202774, AZ00203426(FRI), AZ00203907(FRI), AZ00205762, AZ00206715, AZ00207455, AZ00207918, AZ00210973, AZ00212440, AZ00213122, AZ00213177. Federal comments noted investigation of complaints #AZ00202775, AZ00203426 (FRI), AZ00203907(FRI), AZ00205761, AZ00206714, AZ00207453, AZ00207915, AZ00210970, AZ00212439, AZ00213120, AZ00213183.
Findings
No deficiencies were cited during this inspection.
Report Facts
Complaints investigated: 11
Inspection Report — May 21, 2025
Complaint Investigation
Date: May 21, 2025
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On-site complaint investigation of intakes AZ00165128, AZ00168609, AZ00170048, AZ00176261, AZ00179132, AZ00179712, and AZ00182167 at a Nursing Care Institution, conducted 20-21 May 2025.
Complaint Details
The Risk-Based complaint survey was conducted on May 20, 2025 through May 21, 2025 for investigation of intakes #s:AZ00165128, AZ00168609, AZ00170048, AZ00176261, AZ00179132, AZ00179712, AZ00182167.
Findings
One deficiency was cited during this complaint investigation. No evidence text was provided for the deficiency.
Deficiencies (1)
R9-10-425 — No evidence text provided for the cited deficiency regarding premises and equipment safety.
Report Facts
Deficiencies cited: 1
Inspection Report — May 5, 2025
Complaint Investigation
Date: May 5, 2025
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On-site complaint investigation of complaints AZ00213274, AZ00213275, and AZ00224320 at a Nursing Care Institution, conducted 5 May 2025.
Complaint Details
The complaint survey was conducted on May 5, 2025 for the following complaint #'s AZ00213274, AZ00213275, and AZ00224320. There were no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 3
Inspection Report — Mar 11, 2025
Complaint Investigation
Date: Mar 11, 2025
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On-site complaint investigation of complaints AZ00212850, SF00115515, AZ00212849, and AZ00223565 at a Nursing Care Institution, conducted 11 March 2025.
Complaint Details
An onsite complaint survey was conducted on March 11, 2025 for the investigation of the following intakes: AZ00212850 and SF00115515. An onsite complaint survey was conducted on March 11, 2025 for the investigation of the following intakes: AZ00212849 and AZ00223565.
Findings
Two deficiencies were cited related to resident abuse protections. No evidence text was provided for either deficiency.
Deficiencies (2)
§483.12 — The facility failed to demonstrate compliance with requirements to ensure residents are free from abuse, neglect, misappropriation of property, and exploitation.
R9-10-410 — The administrator failed to ensure that a resident was not subjected to abuse.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 11, 2025
Date: Mar 11, 2025
Visit Reason
The inspection was conducted to assess compliance with care standards related to bowel and bladder care for residents, specifically focusing on one resident (#3) out of three sampled.
Findings
The facility failed to ensure adequate bowel and bladder care was provided to resident #3, which could result in skin breakdown and pressure ulcers. Documentation of care was inconsistent and incomplete, indicating that care may not have been provided as required.
Deficiencies (1)
Failure to ensure bowel and bladder care was provided for one resident (#3) out of 3 sampled, risking skin breakdown and pressure ulcers.
Report Facts
Residents sampled: 3
Residents affected: 1
Dates of care documented: 3
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (staff #56) | Interviewed regarding bowel and bladder care documentation and practices | |
| Registered Nurse (staff #1) | Interviewed regarding documentation expectations for bowel and bladder care | |
| Director of Nursing (staff #41) | Interviewed regarding inconsistencies in bowel and bladder care documentation |
Inspection Report — Jan 29, 2025
Complaint Investigation
Date: Jan 29, 2025
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On-site complaint investigation of complaints AZ00221683 and AZ00221765 at a Nursing Care Institution, conducted 29 January 2025.
Complaint Details
An onsite complaint survey was conducted on January 29th, 2025 for the investigation of the following intakes: AZ00221683 and AZ00221765. There are no deficiencies cited.
Findings
This inspection resulted in no deficiencies or citations.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 16, 2024
Complaint Investigation
Date: Dec 16, 2024
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On-site complaint investigation of intakes AZ00219762, AZ00212917, and AZ00212898 at a Nursing Care Institution, conducted 12 December 2024 through 16 December 2024.
Complaint Details
An onsite complaint survey was conducted for the investigation of intake # AZ00219762, AZ00212917, AZ00212898. Federal comments also reference intakes AZ00219760, AZ00212916, AZ00212898. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Inspection Report — Sep 9, 2024
Complaint Investigation
Date: Sep 9, 2024
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On-site complaint investigation of intake AZ00215652 and intake AZ00215650 at a Nursing Care Institution, conducted 9 September 2024.
Complaint Details
An onsite complaint survey was conducted on September 9, 2024 for the investigation of intake #AZ00215652 and intake AZ00215650. There were no deficiencies cited.
Findings
This inspection found no deficiencies.
Inspection Report — Jun 19, 2024
Complaint Investigation
Date: Jun 19, 2024
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On-site complaint investigation of intake numbers AZ00211933, AZ00211807, AZ00206737, and AZ00206552 at a Nursing Care Institution, conducted 19 June 2024.
Complaint Details
An onsite complaint survey was conducted on June 19, 2024 for the investigation of intake #s AZ00211933, AZ00211807, AZ00206737, AZ00206552. Federal comments note investigation of intake #s AZ00211932, AZ00211806, AZ00206737, AZ00206551. There were no deficiencies cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 4
Inspection Report — Nov 2, 2023
Complaint Investigation
Date: Nov 2, 2023
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On-site complaint investigation of intakes AZ00199598, AZ00202192, AZ00202650 and AZ00202642 at a Nursing Care Institution, conducted 1 through 2 November 2023.
Complaint Details
A complaint survey was conducted on November 1 through November 2, 2023 for the investigation of intake #s: AZ00199598, AZ00202192, AZ00202650 and AZ00202642. Federal comments noted investigation of intakes AZ00199598, AZ00202190, AZ00202649 and AZ00202642 with no deficiencies cited.
Findings
This inspection resulted in no deficiencies cited.
Inspection Report — Oct 19, 2023
Complaint Investigation
Date: Oct 19, 2023
Visit Reason
On-site complaint investigation of multiple complaints including AZ00201796, AZ00195578, AZ00195723, AZ00195862, AZ00195918, AZ00197633, AZ00198821, AZ00199575, AZ00201331, and AZ00201362 at a Nursing Care Institution, conducted 18-19 October 2023.
Complaint Details
A complaint survey was conducted on October 18 through October 19, 2023 for the investigation of intake numbers AZ00201796, AZ00195578, AZ00195723, AZ00195862, AZ00195918, AZ00197633, AZ00198821, AZ00199575, AZ00201331, and AZ00201362. Federal comments referenced additional intake numbers including AZ00201791, AZ00195577, AZ00195722, AZ00195861, AZ00195862, AZ00195917, AZ00195918, AZ00197630, AZ00198820, AZ00199572, AZ00201330, and AZ00201361.
Findings
The inspection found four deficiencies related to failure to implement proper transmission-based precautions and hand hygiene during incontinence care, and failure to ensure a resident was free from abuse by family members. The facility provided plans of correction for all deficiencies.
Deficiencies (4)
R9-10-403 — The facility failed to ensure transmission-based precautions and proper hand hygiene were implemented during incontinence care, including failure of an LPN to perform hand hygiene before donning gloves and reusing gloves during pericare.
§483.12 — The facility failed to ensure one resident was free from abuse, as the resident was physically abused by family members who were subsequently arrested for domestic violence assault.
§483.80 — The facility failed to maintain an infection prevention and control program ensuring proper hand hygiene and transmission-based precautions during incontinence care, risking transmission of infections to residents.
R9-10-410 — The facility failed to ensure one resident was free from abuse, with documented physical abuse by family members witnessed by staff and resulting in police intervention.
Report Facts
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #60 | Certified Nurse Assistant | Observed incontinence care and witnessed family abuse incident. |
| Staff #91 | Licensed Practical Nurse | Observed performing pericare with improper hand hygiene. |
| Staff #50 | Certified Nurse Assistant | Interviewed regarding pericare procedures. |
| Staff #84 | Licensed Practical Nurse | Interviewed about hand hygiene training. |
| Staff #3 | Director of Nursing | Interviewed about facility policies on pericare and hand hygiene. |
| Staff #41 | Environmental Services Director | Witnessed family abuse incident and intervened. |
Inspection Report — Sep 26, 2023
Complaint Investigation
Date: Sep 26, 2023
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On-site complaint investigation of intake numbers AZ00200588 and AZ00200587 at a Nursing Care Institution, conducted 26 September 2023.
Complaint Details
A complaint survey was conducted on September 26, 2023 for the investigation of intake #AZ00200588. A complaint survey was conducted on September 26, 2023 for the investigation of intake #AZ00200587. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 7, 2023
Complaint Investigation
Date: Aug 7, 2023
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On-site complaint investigation of complaints AZ00198475 and AZ00198473 at a Nursing Care Institution, conducted 7 August 2023.
Complaint Details
The Complaint AZ00198475 was investigated on 8/7/23. The Complaint AZ00198473 was investigated on 8/7/23. No deficiencies were cited.
Findings
No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 17, 2023
Date: Jul 17, 2023
Visit Reason
On-site inspection of type Other at a Nursing Care Institution conducted 17 July 2023.
Findings
The inspection found one deficiency related to incomplete COVID-19 reporting to the CDC's National Healthcare Safety Network during a required seven-day period.
Deficiencies (1)
§483.80(g) — The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation, potentially causing more than minimal harm to all residents.
Report Facts
Deficiencies cited: 1
Inspection Report — May 9, 2023
Enforcement
Date: May 9, 2023
Visit Reason
Civil monetary penalty, action 00113382 (invoice INV-259716), assessed 9 May 2023.
Findings
A $500.00 penalty was assessed and paid in full on 25 May 2023.
Report Facts
Penalty amount: 500
Amount paid: 500
Amount remaining: 0
Inspection Report — Apr 13, 2023
Complaint Investigation
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to investigate complaints related to failure to notify responsible parties of resident falls and failure to implement fall prevention interventions for residents at risk of falls.
Complaint Details
The investigation was complaint-driven, focusing on notification failures and fall prevention practices. The deficiencies were substantiated based on clinical record reviews, staff interviews, and policy reviews.
Findings
The facility failed to notify the responsible party timely of a resident's fall with injury and failed to implement adequate interventions to prevent falls for another resident. Interviews with staff and review of clinical records and policies confirmed these deficiencies.
Deficiencies (2)
Failure to ensure that the responsible party was notified of a fall with injury for one resident (#186).
Failure to ensure intervention was implemented to prevent a fall for one resident (#29).
Report Facts
Sample size: 19
Fall risk score: 10
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #12 | Registered Nurse (RN) | Interviewed regarding notification of family or POA after resident fall |
| Staff #80 | Licensed Practical Nurse (LPN) | Interviewed about fall assessment and notification procedures |
| Director of Nursing (DON) | Director of Nursing | Interviewed about fall incident investigation and notification expectations |
| Staff #105 | Certified Nurse Assistant (CNA) | Involved in resident #29 fall incident and interviewed about the event |
| Staff #73 | Licensed Practical Nurse (LPN) | Interviewed about resident #29 fall and subsequent actions |
| Staff #50 | Certified Nurse Assistant (CNA) | Interviewed about staffing and assistance requirements for residents |
| Director of Rehabilitation (DOR) | Director of Rehabilitation | Interviewed about resident #29's functional status and assistance needs |
Inspection Report — Apr 13, 2023
Complaint Investigation
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify responsible parties of resident falls, inadequate fall prevention interventions, insufficient registered nurse coverage, improper medication administration, and expired medication storage.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify family or POA of resident falls, inadequate fall prevention, insufficient RN coverage, improper medication administration, and expired medication storage.
Findings
The facility failed to timely notify family or POA of resident falls, did not implement adequate fall prevention interventions for at-risk residents, lacked consistent RN coverage for at least eight consecutive hours daily, administered pain medication outside prescribed parameters, and stored expired medications and supplies accessible for resident use.
Deficiencies (5)
Failed to notify responsible party of a fall with injury for one resident (#186).
Failed to implement intervention to prevent a fall for one resident (#29).
Failed to use services of a registered nurse for at least eight consecutive hours a day, seven days a week.
Failed to ensure one resident (#11) was free from unnecessary pain medications given outside ordered parameters.
Failed to ensure expired supplies and medications were not available for resident use.
Report Facts
Sample size: 19
Fall risk score: 10
RN coverage missing dates: 10
Medication administration outside parameters: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #12 | Registered Nurse | Interviewed regarding notification of family or POA of resident condition |
| Staff #80 | Licensed Practical Nurse | Interviewed regarding fall assessment and expired medication observation |
| Staff #105 | Certified Nurse Assistant | Involved in resident #29 fall incident |
| Staff #50 | Certified Nurse Assistant | Interviewed about resident assistance requirements |
| Staff #73 | Licensed Practical Nurse | Interviewed regarding fall incident and assessment |
| Staff #98 | Director of Rehabilitation | Interviewed regarding resident #29 functional status and assistance needs |
| Staff #32 | Director of Nursing | Interviewed regarding fall notification, RN coverage, and medication administration |
| Staff #110 | Licensed Practical Nurse | Interviewed regarding pain medication administration |
| Staff #111 | Staffing Coordinator | Interviewed regarding RN coverage |
Inspection Report — Apr 13, 2023
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, fall prevention, and medication storage at Haven of Saguaro Valley nursing home.
Findings
The facility was found deficient in multiple areas including failure to timely notify responsible parties of resident falls, inadequate fall prevention interventions, insufficient registered nurse coverage, administration of pain medication outside prescribed parameters, and storage of expired medications and supplies.
Deficiencies (5)
Failure to notify resident's family or Power of Attorney of a fall with injury in a timely manner for resident #186.
Failure to implement interventions to prevent falls for resident #29, resulting in avoidable accidents.
Failure to ensure registered nurse coverage for at least eight consecutive hours daily, seven days a week.
Failure to ensure resident #11 was free from unnecessary pain medications; administration of oxycodone outside ordered pain scale parameters.
Failure to ensure expired supplies and medications were not available for resident use.
Report Facts
Sample size: 19
Registered nurse coverage missing days: 10
Medication administration outside parameters: 4
Fall risk score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding fall notification, RN coverage, and medication administration | |
| Licensed Practical Nurse (LPN) staff #80 | Interviewed regarding fall assessment and expired medication observation | |
| Certified Nurse Assistant (CNA) staff #105 | Involved in resident #29 fall incident | |
| Director of Rehabilitation (DOR) staff #98 | Interviewed regarding resident #29 functional status and assistance needs | |
| Licensed Practical Nurse (LPN) staff #110 | Interviewed regarding pain medication administration |
Inspection Report — Mar 21, 2023
Routine
Date: Mar 21, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards related to pressure ulcer prevention and treatment, as well as appropriate care to prevent urinary tract infections in residents.
Findings
The facility failed to provide appropriate pressure ulcer care and prevention, resulting in actual harm to a few residents, including inadequate wound assessments and incomplete documentation. Additionally, the facility failed to ensure proper care and timely provider notification for urinary tract infections in two residents, increasing risks of pain, infection, and rehospitalization.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including incomplete wound assessments and documentation.
Failure to provide appropriate care to prevent and treat urinary tract infections, including lack of timely provider notification and incomplete documentation.
Report Facts
Wound measurements: 8.5
Wound measurements: 2.5
Wound measurements: 2.2
Wound measurements: 0.7
Wound measurements: 6.5
Stage 3 pressure ulcer size: 6
Stage 3 pressure ulcer size: 10
Stage 3 pressure ulcer size: 9.5
Resident temperature: 102.3
Resident pulse: 100
Resident oxygen saturation: 87
UTI colony forming units: 100000
UTI colony forming units: 10000
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA/staff #70) | Interviewed regarding skin breakdown prevention and catheter care | |
| Licensed Practical Nurse (LPN/staff #90) | Interviewed regarding wound observation and UTI symptom monitoring | |
| Wound Nurse (staff #40) | Interviewed and observed wound care, described wound assessment procedures | |
| Director of Nursing (DON/staff #96) | Interviewed regarding wound care expectations and UTI management |
Inspection Report — Mar 25, 2022
Routine
Date: Mar 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident care, medication administration, notification procedures, care planning, respiratory care, pain management, staffing, medication safety, medical record accuracy, and staff training.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, inadequate notification of transfer/discharge rights, failure to implement care plans for assistive devices, lack of physician orders for oxygen administration, delayed and inconsistent pain management, missing nurse staffing postings, administration of medication outside ordered parameters without physician notification, inaccurate documentation of advance directives, and incomplete dementia training for some staff.
Deficiencies (9)
Failed to ensure call light was within reach of resident #50.
Failed to provide timely notification to resident #341 and representative of transfer/discharge rights and failed to send notice to Ombudsman.
Failed to implement care plan for resident #53 regarding providing a sippy type lid assistive device.
Failed to ensure residents #62 and #63 had physician orders for oxygen administration.
Failed to provide pain management consistent with standards for resident #241, including delayed administration of stronger pain medication and inadequate pain assessments.
Failed to retain all daily nurse staffing postings for a minimum of 18 months.
Failed to ensure resident #9's drug regimen was free from unnecessary drugs by administering blood pressure medication outside ordered parameters without physician notification.
Failed to accurately document resident #395's advance directives, resulting in conflicting code status information.
Failed to provide dementia training to 2 of 10 sampled staff (#24 and #15).
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Staff affected: 2
Missing daily staffing postings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #77 | Restorative Nursing Assistant | Named in call light deficiency finding |
| Staff #109 | Named in call light deficiency finding | |
| Staff #22 | Director of Nursing | Named in call light, transfer notification, oxygen order, pain management, staffing, and advance directive findings |
| Staff #103 | Licensed Practical Nurse | Named in transfer notification and oxygen order findings |
| Staff #9 | Licensed Practical Nurse | Named in assistive device care plan deficiency |
| Staff #7 | Director of Rehabilitation | Named in assistive device care plan and dementia training findings |
| Staff #45 | Certified Nursing Assistant | Named in oxygen order deficiency |
| Staff #44 | Licensed Practical Nurse | Named in medication regimen deficiency |
| Staff #57 | Licensed Practical Nurse | Named in pain management deficiency |
| Staff #82 | Licensed Practical Nurse | Named in pain management deficiency |
| Staff #24 | Speech Therapist | Named in dementia training deficiency |
| Staff #15 | Certified Occupational Therapy Assistant | Named in dementia training deficiency |
| Staff #1 | Human Resources | Named in dementia training deficiency |
Inspection Report — Sep 25, 2019
Complaint Investigation
Date: Sep 25, 2019
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate behavioral health treatment and services to a resident with mental disorder and psychosocial adjustment difficulties, as well as concerns about food service safety practices.
Complaint Details
The complaint investigation focused on a resident (#295) with adjustment disorder exhibiting frequent yelling and disruptive behaviors. The resident declined psychotropic medication and outpatient psychiatric services. The facility lacked timely and adequate behavioral interventions. Food service safety concerns were also observed, including improper handling of food by staff.
Findings
The facility failed to provide individualized behavioral health treatment and services for a resident with adjustment disorder, resulting in ongoing verbal outbursts and distress without adequate interventions. Additionally, the facility failed to serve food in accordance with professional food safety standards, risking foodborne illness.
Deficiencies (2)
Failure to provide appropriate behavioral health treatment and services to a resident with mental disorder and psychosocial adjustment difficulty.
Failure to serve food in accordance with professional standards for food service safety, including staff using bare hands to handle food.
Report Facts
Dates of documented verbal symptoms: 13
Dates of documented frequent crying: 13
Dates of yelling or screaming: 13
Dates of behavioral symptoms directed at others: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Manager | Spoke with resident about psychiatric services and yelling behavior; managed psychiatrist patient list | |
| Director of Nursing (DON) | Spoke with resident about yelling behavior; confirmed in-house psychiatric services availability; involved in medication order and refusal documentation | |
| Certified Nursing Assistant (staff #61) | Observed resident crying daily and attempted to calm resident | |
| Licensed Practical Nurse (LPN, staff #5) | Interacted with resident daily; documented medication refusals | |
| Kitchen Manager (staff #45) | Interviewed regarding food handling practices and policy | |
| Certified Nursing Assistant (staff #47) | Observed handling food with bare hands during resident feeding |
Report
8 CMS Surveys
CMS Survey — Mar 21, 2023
Mar 21, 2023
CMS Survey — Apr 13, 2023
Apr 13, 2023
CMS Survey — Oct 19, 2023
Oct 19, 2023
CMS Survey — Mar 11, 2025
Mar 11, 2025
CMS Survey — Dec 23, 2025
Dec 23, 2025
CMS Survey — Sep 25, 2019
Sep 25, 2019
CMS Survey — Mar 25, 2022
Mar 25, 2022
CMS Survey — Apr 13, 2023
Apr 13, 2023
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