Advanced Center For Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 169 Davenport Avenue, New Haven, Connecticut 06519
- CMS Provider Number
- 075348
- Inspections on file
- 39
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Advanced Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
Two residents did not receive adequate nail and bathing care, and staff failed to effectively address and report ongoing care issues. One dependent resident with a contracted hand and multiple comorbidities resisted nail care, and NAs and an LPN reported persistent difficulty cleaning and trimming the nails on the affected hand. Despite foul odor, visible overgrown nails, and repeated resistance, the problem was not escalated to the supervisor or provider, and the APRN was not informed of specific nail care concerns until after the resident was hospitalized with a finger infection requiring nail removal and incision and drainage. Another cognitively impaired resident, care planned for assisted showers, went multiple weeks without a documented shower or complete bed bath, with no refusals noted, and was later found with feces under the fingernails requiring prolonged soaking to remove, contrary to facility policy requiring at least weekly bathing and routine nail care with grooming.
The facility failed to consistently obtain and document ordered and policy-required weights and meal intakes for three residents at risk for or experiencing significant weight loss and malnutrition. One resident with dementia and adult failure to thrive had long gaps without weights after admission and multiple readmissions, delayed post-readmission weights, and no timely re-weights after large weight changes, while meal intake was documented for only a small fraction of meals. Another resident with severe protein-calorie malnutrition, diabetes, and a stage 3 pressure ulcer had only three weights recorded over several months, with one month missing entirely and minimal meal intake documentation. A third resident with cancer, right heart failure, and HIV had a physician order for weekly weights that was not followed for multiple extended periods, including after readmission, and had incomplete meal percentage documentation. The RD and DON acknowledged expectations for timely admission/readmission weights, monthly and weekly weights per orders, re-weights after significant changes, and complete meal percentage recording, but weights, re-weights, and intake documentation were not consistently obtained or followed up.
Two residents experienced deficiencies in care planning and implementation. One cognitively intact resident with multiple medical conditions and a history of substance abuse had a physician order for an independent LOA, but the care plan was not updated to include goals or interventions related to the LOA, despite facility policy requiring LOAs to align with the care plan. Another resident with diabetes, a left hand contracture, and schizoaffective disorder had documented refusal-of-care behaviors and was to receive nail care on bath days, yet staff reported ongoing difficulty providing nail care due to the contracture and resistance. An LPN was unable to fully assess the nails and did not notify supervisors or the provider, and the DON was unaware of the problem, resulting in no alternative nail care interventions being arranged.
Two residents did not receive necessary assistance with personal hygiene and bathing. A resident with diabetes, a contracted hand, and behavioral symptoms was dependent for ADLs and repeatedly resisted left hand care, leading staff to perform only limited cleaning of the contracted hand; despite ongoing difficulty, nurses did not escalate the issue to supervisors or the provider, and the DNS was unaware of the problem until after the resident developed a severe finger infection requiring hospitalization and nail removal. Another cognitively impaired resident with vascular dementia and failure to thrive, care planned for weekly showers, went multiple weeks without a documented shower or complete bed bath, and there were no recorded refusals; this resident was later found with feces under the fingernails requiring prolonged soaking to remove. These failures occurred despite a facility policy requiring assistance with ADLs to maintain grooming and hygiene and specific guidance on managing care resistance in cognitively impaired residents.
The facility failed to maintain complete and accurate clinical records showing that required weekly hygiene care was provided to two residents who were dependent on staff for ADLs and had significant cognitive impairment and medical conditions, including severe protein calorie malnutrition, adult failure to thrive, type II DM, vascular dementia, and a stage 3 pressure ulcer. Point of Care records over several months showed only sporadic showers or bed baths with multiple weeks lacking any documented bathing, and there was no documentation of refusals. In one instance, a resident was found with feces under the nails requiring soaking to remove. The DON confirmed that residents are expected to receive at least weekly showers or complete bed baths with documentation each shift, and the facility’s bathing and grooming policy required at least weekly showers and associated grooming.
The facility failed to provide timely notification to the State LTC Ombudsman when several residents with complex medical and behavioral conditions were discharged or planned for discharge. Although 30‑day Notices of Intent to Discharge were issued and discharge planning meetings were documented, the facility did not upload the required discharge notices to the Aging and Disability Services portal at the same time notices were given to residents and their representatives. In one case, a resident on an independent LOA later died in the ED, and no discharge notice was uploaded because staff considered it a transfer. For the other residents, uploads to the portal occurred days to over a month after the written discharge notices, and interviews with facility staff revealed they were unaware of a specific timeframe for notifying the ombudsman, contrary to CMS requirements and the facility’s own transfer/discharge policy.
A resident with vascular dementia and adult failure to thrive experienced a documented weight decrease from 122.0 lbs to 108.6 lbs over six months, exceeding a 10% loss, and was care planned as at risk for malnutrition with interventions to monitor weights and intakes. However, the quarterly MDS did not code a 5% or greater one-month or 10% or greater six-month weight loss. The RD, responsible for Section K, acknowledged using an incorrect baseline weight and not applying the correct six-month look-back period, resulting in inaccurate coding of swallowing and nutritional status, and the DON confirmed the MDS did not accurately reflect the resident’s significant weight loss.
A resident dependent on supplemental oxygen experienced acute respiratory distress and death after staff failed to assess, monitor, and report the resident's worsening condition, did not ensure the availability of functioning oxygen equipment, and did not communicate critical changes to supervisors or providers. Multiple staff members did not follow facility policies for change of condition and oxygen management, resulting in Immediate Jeopardy.
A resident with a history of respiratory issues reported shortness of breath to staff, but the LPN did not assess the resident or notify the provider and nursing supervisor for several hours, despite repeated reports from nurse aides. The situation escalated to a medical emergency, with the provider only being notified after the resident became unresponsive. This delay was contrary to the facility's policy and the resident's care plan.
Three residents requiring supplemental oxygen did not have their oxygen tubing changed every seven days as required by facility policy. Observations and record reviews showed that tubing was left in place beyond the scheduled change date, and documentation did not match actual practice. Interviews with the DON and an LPN confirmed that staff were expected to change and document tubing weekly, but this was not consistently done.
A resident with acute respiratory failure, COPD, and anxiety disorder was receiving supplemental oxygen as ordered by a physician, but the facility did not develop a care plan to address the resident's respiratory diagnoses and oxygen use. This deficiency was identified through record review, observation, and staff interviews, revealing that the required care plan was not in place at the time of assessment.
A resident with a history of respiratory failure, COPD, and CHF, who was dependent on supplemental oxygen, experienced shortness of breath that was reported multiple times by nurse aides to an LPN. The LPN did not assess the resident, take vital signs, or notify the nursing supervisor or provider, despite facility policy requiring prompt intervention for changes in condition. The resident later became unresponsive and died despite emergency intervention.
A medication cart was found unlocked and unattended in a hallway, with the keys left on top and various items including medications, a glucometer, and personal items left exposed. A resident walked by the cart while the assigned LPN was inside a resident's room, and the LPN later acknowledged leaving the cart unsecured without requesting staff assistance. Facility policy requires medication carts to be locked and secured at all times when unattended.
Two residents did not have physician-ordered blood work obtained or documented, and there was no record of refusal or provider notification. Staff interviews confirmed the lack of documentation, and the NP was unaware the orders were not followed. Facility policy requires lab services to be provided and documented per physician orders, which was not done in these cases.
Two residents with significant respiratory conditions were found using oxygen concentrators that were five months overdue for annual inspection, and one unit had a thick layer of dust on its filter. The vendor was not given a full list or locations of concentrators, and staff did not consistently monitor or clean the equipment as required.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident was not protected from the wrongful use of their belongings or money, as facility staff failed to safeguard the resident's property or funds, resulting in unauthorized or improper use.
The facility did not maintain proper controls or documentation for narcotic medications, as staff signed out controlled substances without corresponding entries in the MAR or physician orders, and required monthly audits were not documented or available. The DON and Administrator could not provide evidence of completed audits or explain the audit process, and completed CSDR sheets were found stored without audit records, in violation of facility policy.
Three residents did not receive ordered medications, including IV antibiotics and Methadone, due to unavailability and lack of communication among staff. Missed doses occurred when residents were out of the facility or when medications were not obtained from the clinic, and responsible staff did not notify supervisors or providers as required by facility policy.
A resident with severe cognitive impairment and depression was physically assaulted by another resident who entered their room and struck them with a telephone, resulting in facial and hand injuries. Staff responded after hearing calls for help, but the abuse had already occurred, indicating a failure to protect the resident from physical harm as required by facility policy.
A resident with multiple chronic conditions and a history of hypotension had a blood pressure medication discontinued, with a provider order to obtain vital signs every shift. Vital signs were not recorded for several shifts, and staff interviews revealed uncertainty about why this occurred. The facility did not provide a policy for obtaining vital signs when requested.
A resident with dementia and COPD experienced a significant change in mental status, including confusion and hallucinations, along with decreased oxygen saturation. Although these changes were documented by an LPN, the supervising nurse and on-call provider were not notified as required by facility policy. Interviews confirmed that the supervisor was unaware of the incident, and leadership acknowledged that proper notification procedures were not followed.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall, but the care plan was not updated with new interventions to prevent recurrence. Staff interviews and documentation review confirmed that required care plan revisions were not made following the incident, despite facility policies mandating such updates.
A resident with severe cognitive impairment and a history of brain injury experienced an unwitnessed fall. Although initial assessments were performed and no injuries were found, required neurological checks were not consistently completed or documented every shift for 72 hours as per facility policy. Interviews with nursing staff and the DON confirmed the monitoring was not carried out as required.
A resident with dementia and COPD experienced shortness of breath and low oxygen saturation. Although a breathing treatment was given and an APRN assessment was reportedly performed with new oxygen orders obtained, there was no documentation of the APRN's assessment in the medical record, resulting in an incomplete and inaccurate record.
A resident with multiple complex medical conditions did not receive a prescribed antineoplastic medication for two days due to supply issues, and the nursing staff failed to notify the physician or APRN as required. Although the pharmacy and family were contacted about the medication, there was no documentation or evidence that the provider was informed of the missed doses, and interviews confirmed the provider was unaware of the situation.
A resident with severe cognitive impairment and multiple medical conditions received a specialty medication brought in by family members, but facility staff failed to document verification of the medication as ordered by the physician or ensure its contents were checked by a licensed pharmacist, contrary to facility policy.
A resident with multiple risk factors for skin breakdown did not receive timely implementation of wound care physician recommendations, including specific wound treatments and use of a specialized air mattress and pressure-relieving boots. Documentation showed delays in both entering and carrying out orders, as well as incomplete skin assessments, resulting in the resident being transferred to the hospital for wound evaluation and later developing a viral skin eruption.
A resident with chronic conditions and alert mental status was involved in an incident where a recreational aide cursed during a verbal altercation. The aide admitted to cursing about the incident, which the resident overheard, violating the facility's policy on treating residents with dignity and respect.
A facility failed to provide a safe smoking environment for a resident with dementia and schizophrenia, as their smoking apron was not properly secured, and necessary safety equipment was unavailable. Additionally, another resident with visual hallucinations and insomnia posed a fire risk by placing paper over their overbed light, a behavior known to the maintenance director but not reported to the administration. These deficiencies highlight lapses in supervision and communication, resulting in unsafe conditions.
A resident with chronic kidney disease and atrial fibrillation did not receive timely physician visits as required by facility policy. Despite being cognitively intact and requesting to see their primary care physician, the last documented physician note was from over two years ago. Interviews revealed that the Medical Director and DNS could not account for the lack of documentation, indicating a failure to adhere to the policy of regular physician visits.
The facility did not complete annual performance evaluations for four nurse aides, as discovered during a review of employee files and interviews with HR and the DNS. No evaluations had been conducted since April 2022, and despite efforts to locate them, none were found.
The facility failed to maintain proper recordkeeping and chain of custody for methadone, affecting 28 residents. Methadone was self-administered by residents without signing a chain of custody, and the medication nurse was solely responsible for signing off on the MAR. The facility did not maintain accurate records for methadone destruction, with only one nursing signature on destruction worksheets. Interviews revealed a lack of adherence to standard procedures and facility policies for controlled substance handling.
The facility failed to serve food at appropriate temperatures, as observed during a dietary department tour. Scrambled eggs and hot cereal were initially at high temperatures but cooled significantly by the time they reached the third floor, unit D3. The food cart door was left open during transport, contributing to the temperature drop. The Food Service Director acknowledged the issue, citing timing and container limitations as factors.
The facility failed to maintain sanitary conditions in the dietary department. During a test tray observation, a black, thin, hair-like object was found in the vegetables. The Food Service Director suggested it might be a string from the vegetable bag lining and noted that defrosting and spreading out vegetables could prevent this issue.
The facility failed to maintain proper documentation and review of antibiotic use as part of its Infection Control Program. The IP, in the role for two months, was unable to provide evidence of ongoing infection surveillance and had not utilized McGeer's forms. The DNS confirmed that the previous IP had left with the infection tracking information, leaving the facility unable to provide evidence of infection control reviews since April 2022. The facility's policy required regular reviews and educational activities, which were not being conducted.
A resident with multiple health conditions reported feeling disrespected by a nurse aide who suggested they could clean up urine independently. The incident was investigated, and the aide confirmed the comment, leading to a deficiency in maintaining the resident's dignity.
A resident's furniture was not maintained properly, with closet cabinet doors ajar and peeling, and dresser drawers that would not stay closed. The Director of Maintenance acknowledged these issues, which posed a potential safety concern, but they persisted, indicating a deficiency in timely maintenance.
A resident with severe cognitive impairment had $50.00 given by a family member to a staff member, which was not deposited into the personal fund account as per policy. Instead, it was kept in the medication cart, and most of it was spent without proper documentation. The facility's policy required funds to be secured in a locked box in the resident's room, which was not done, leading to a deficiency in managing resident funds.
A facility failed to ensure the advanced directive paperwork for a resident with multiple chronic conditions was present in the medical record, as required by a physician's order and facility policy. Despite a Full Code status order, the advanced directive was missing from both paper and electronic records. An LPN and RN acknowledged the absence, with the RN suggesting the documents might have been misplaced, contrary to the facility's policy requiring documentation within 24 hours of admission.
A resident's medication was found missing, with staff unaware and lacking proper documentation. Two residents shared a room with a non-functioning sink for 20 days, requiring staff to use other bathrooms. Another resident's furniture was in disrepair, posing safety concerns. Maintenance and nursing staff were aware but had not resolved these issues.
The facility failed to implement its abuse prevention policies, resulting in two residents being inadequately protected following allegations of abuse. One resident continued to work with an LPN accused of inappropriate conduct, while another resident's concerns about a roommate's aggressive behavior were not promptly addressed. The facility did not ensure timely psychiatric evaluation or monitoring to confirm the safety of the residents involved.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease, omitting specific interventions for dialysis access. Additionally, another resident's sensory needs were neglected, as their care plan did not address the need for corrective lenses, despite the resident having broken glasses and informing staff. These deficiencies highlight a lack of adherence to the facility's policy for comprehensive, person-centered care plans.
The facility failed to update care plans for two residents, one with urinary retention and another with incontinence. The first resident's care plan lacked interventions for urinary retention after a hospital stay, while the second resident's care plan did not reflect their preference for independence or include an evaluation for a bowel and bladder retraining program. Staff interviews revealed a lack of awareness and documentation of the residents' care needs and preferences.
A resident who required assistance with toileting was not provided incontinent care during the night shift, resulting in the resident being soaked with urine. The assigned nursing assistant did not wake the resident for care, contrary to the care plan and facility policy. The interim DNS confirmed the deficiency and provided education to the staff member involved.
A facility failed to manage a resident's pain effectively, as the resident refused acetaminophen and was not assessed further, leading to inadequate pain management. Additionally, another resident missed a cardiologist appointment due to the absence of a staff escort, with no alternative arrangements made. These incidents highlight lapses in communication and coordination among staff.
The facility failed to follow physician orders for a resident with urinary retention, lacking documentation of required bladder scans and catheterizations due to the absence of a bladder scanner. Additionally, another resident frequently incontinent of bowel and bladder was not assessed for a bowel and bladder retraining program, despite facility policy requirements. Staff interviews revealed a lack of awareness and documentation regarding the residents' incontinence management needs.
A facility failed to monitor a resident's weight accurately, leading to a deficiency in maintaining the resident's health. The resident, at nutritional risk, did not have a timely readmission weight recorded, and subsequent weights were inconsistently documented, with invalid entries noted. Despite dietician requests for reweights, the nursing staff did not obtain them promptly, contributing to the deficiency.
A resident with respiratory needs was left without power for their suction machine due to a tripped breaker. Despite reporting the issue, staff were unaware, and the problem persisted over the weekend. The facility lacked a power outage policy and battery-powered equipment, compromising the resident's care.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Provide Nail and Bathing Care Resulting in Infection and Poor Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care and to respond effectively to care refusals for a dependent resident with a contracted hand, resulting in an infected finger that required surgical intervention. Resident #2, who had Type 2 diabetes, a chronic left hand contracture, and schizoaffective disorder, was care planned as dependent for toileting, bathing, and lower body dressing and known to refuse care at times. Nursing assistants reported ongoing difficulty opening the resident’s contracted left hand, with the resident expressing pain, pulling away, and allowing only limited cleaning and nail trimming on some digits. Staff described being able only occasionally to slide a thin washcloth under the contracted fingers, noting a strong foul odor afterward, and reported that nail care to the left hand was an ongoing issue. Despite these persistent difficulties, nursing staff did not escalate the problem according to facility practice. One LPN stated that nail care had been an ongoing issue since the resident’s transfer to her unit prior to January 2026, that she could not adequately visualize the nails due to the contracture, and that she did not inform the nursing supervisor or provider because she believed the issue was common knowledge. The APRN reported being aware that the resident resisted staff touching or opening the left hand but was not informed of specific nail care issues until after the resident’s hospitalization for septic shock, during which a left fourth finger paronychial infection was identified and treated with nail removal and incision and drainage. Photographs from the hospitalization showed overgrown, unkempt fingernails on the contracted hand. The DNS stated he/she was unaware of any difficulties performing nail care for this resident and therefore no alternative nail care interventions were implemented. The deficiency also includes the facility’s failure to provide regular bathing and grooming care, including nail care, for a cognitively impaired resident, resulting in poor hygiene and fecal matter under the fingernails. Resident #14, who had vascular dementia with severely impaired cognition and required assistance with ADLs, was care planned to receive assistance with showering on a scheduled shift. Point of Care documentation showed multiple weeks in December, January, and March during which the resident did not receive a shower or complete bed bath at least weekly, and the clinical record contained no documentation of refusals. A grievance documented that the resident was found with feces under the nails requiring hand soaks in warm soapy water to remove. The DNS confirmed that each resident should receive at least a weekly shower or complete bed bath and that the record did not show such care in the week leading up to the grievance, despite facility policies requiring weekly bathing and routine nail care as part of standard grooming.
Failure to Monitor Weights and Meal Intake Leading to Ongoing Weight Loss and Malnutrition
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional monitoring and intervention to prevent significant weight loss and malnutrition for three residents by not following its own weight and intake monitoring policies and physician orders. For one resident with vascular dementia and adult failure to thrive, the care plan identified risk for malnutrition and called for assessing intakes, bloodwork, and weights, and monitoring for significant changes. However, no weights were obtained between early June and early July, and there was no weight order in the physician’s orders over several months. After multiple hospitalizations and readmissions, weights were not obtained within 24 hours of readmission as required by policy, and there were long gaps before weights were recorded. A readmission nutrition assessment documented poor to fair intake and requested an updated weight, but the next weight was not obtained until 19 days after readmission. Subsequent weights showed significant unplanned weight loss, including a loss of over 10% in six months and an 11.694% loss in one month, and the resident met criteria for severe malnutrition related to inadequate oral intake. Despite these significant changes, re-weights were not obtained within two days of the large loss and subsequent large gain, and the record did not show refusals of readmission weights or re-weights. For a second resident with severe protein-calorie malnutrition, adult failure to thrive, diabetes, and a stage 3 pressure ulcer, the MDS identified significant weight loss not associated with a prescribed weight-loss regimen, and the care plan called for monitoring weight for significant changes and encouraging and monitoring oral intake. Physician orders over several months did not include an order to obtain weights. The clinical record showed only three weights over a three-month period, with no weight obtained in one of those months, and there was no documentation that the resident refused the missing monthly weight. Meal percentage documentation for this resident was also sparse, with only 42 of 270 meals having recorded intake percentages. For a third resident with malignant neoplasm of the gallbladder, acute on chronic right heart failure, and HIV, there was a physician’s order for weekly weights on Mondays. The MDS identified significant weight loss not associated with a prescribed weight-loss regimen, and the care plan included monitoring weight for significant changes and encouraging and monitoring oral intake. The clinical record showed weights obtained on scattered dates, but there were multiple extended periods where weekly weights were not documented, and there was no documentation that the resident refused weights during those gaps. After a hospitalization and readmission, weekly weights were again not obtained for several weeks despite the standing order, and the first post-readmission weight was not recorded until 25 days after return. Across all three residents, meal intake documentation was incomplete: only 74 of 459 meals were recorded for the first resident and 269 of 453 meals for the third resident, which the RD stated prevented her from obtaining a clear picture of intake when assessing significant weight loss. Interviews and policy review further described the actions and inactions contributing to the deficiency. The RD stated that all non-hospice residents should have weight orders and be weighed at least monthly, that readmission weights should be obtained within 24–48 hours, and that residents with a 5% or more weight change should be reweighed within two days and she should be notified. She acknowledged that she ordered weights and re-weights for residents with significant weight loss but was inconsistent with follow-up when weights were not obtained, and that incomplete meal documentation limited her ability to assess intake; she also stated she did not report the documentation issues to the DNS or provider and did not recommend more frequent weight monitoring for the resident who met criteria for severe malnutrition. The DON reported that residents with weight loss or gain should have physician orders directing weight frequency, that she was unaware residents were missing weight orders, and that nursing staff were responsible for entering weight orders on admission/readmission. She stated that residents should have weights at least monthly or per orders, on readmission, and with any significant change, and that admission/readmission weights and re-weights should be obtained within 24 hours and documented before the end of the shift. She also stated that meal percentages should be recorded for every resident and refusals documented, and she was unaware that meal percentages were not being documented consistently. The facility’s weight policy required admission and readmission weights within 24 hours, weekly weights for four weeks, monthly weights by the 10th of each month, re-weighing and RD notification for significant weight changes, and RD review and dietary interventions for significant changes, but the facility did not provide additional policies for significant weight loss and re-weights despite request.
Failure to Update Care Plans for Leave of Absence and Contracture-Related Nail Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables that addressed all identified needs for two residents. For one resident with Type 2 diabetes mellitus, chronic osteomyelitis of the right foot and ankle, cellulitis of the right lower limb, and a history or active diagnosis of substance abuse, the resident was cognitively intact and had a physician’s order for an independent leave of absence (LOA). Although the facility’s LOA policy required that temporary LOAs be in accordance with the resident’s care plan and physician orders, the resident’s care plan did not include goals of care or interventions related to the independent LOA. The DNS confirmed that goals and interventions for residents with active LOA orders should be implemented into the care plan once the LOA order was approved, but this was not done for this resident. For a second resident with Type 2 diabetes mellitus with diabetic autonomic neuropathy, a contracture of the left hand, and schizoaffective disorder, bipolar type, the care plan identified refusal of care behaviors and included interventions such as re-approaching the resident, monitoring mood/behavior changes, and reporting to the medical doctor. Nail care was to be performed on bath days, but staff interviews revealed ongoing difficulty performing nail care due to the resident’s left hand contracture and resistance to having the hand cleaned or opened. An LPN reported being unable to adequately visualize or assess the nails and did not inform the nursing supervisor or provider, believing the issue was common knowledge. The DNS stated being unaware of the difficulties performing nail care, so no alternative nail care treatments were offered, despite facility practice requiring escalation to nursing supervisors or the provider when care tasks such as nail care could not be completed. This reflects a failure to implement care plan interventions related to physician notification for refusal of contracture-related care.
Failure to Provide Adequate Nail Care and Regular Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with personal hygiene and nail care for a dependent resident with a contracted hand. Resident #2, who had Type 2 diabetes, a left hand contracture, and schizoaffective disorder, was care planned as dependent for toileting, bathing, and lower body dressing and known to sometimes refuse care. Staff interviews revealed that nail care was typically done on shower days by NAs, and multiple staff members reported ongoing difficulty accessing and cleaning the resident’s contracted left hand due to pain responses and resistance. Despite these persistent issues, nursing staff did not notify the nursing supervisor, DNS, or provider that nail care could not be adequately performed, and no alternative interventions or referrals were initiated. The DNS stated he/she was unaware of the difficulties and therefore no alternative nail care treatments were offered. Resident #2 was later hospitalized with septic shock due to MSSA, pneumonia, UTI, and respiratory failure, and was found to have a left fourth finger paronychial infection and chronic contracture requiring nail removal and incision and drainage, with cultures growing MSSA and Staphylococcus lugdunensis. Photographs documented overgrown, unkempt fingernails on the contracted hand, and the APRN reported not being informed of nail care issues until after the hospitalization, although he/she was aware of the resident’s resistance to staff touching/opening the left hand. The APRN indicated that regular nail care could have prevented the nail infection identified during the hospitalization. Staff interviews confirmed that resistance to left hand care was longstanding, that only limited cleaning (such as sliding a thin washcloth under the fingers) was sometimes possible, and that foul odor was present after cleaning, yet this problem was not escalated as required by facility practice. The deficiency also includes failure to provide regular bathing and nail hygiene for a cognitively impaired resident. Resident #14, diagnosed with vascular dementia and adult failure to thrive, required assistance with ADLs and was care planned to receive a shower every Monday on the 3:00 PM–11:00 PM shift. Point of Care documentation showed that this resident did not receive at least weekly showers or complete bed baths during multiple date ranges in December, January, and March, and the clinical record contained no documentation of refusals of showers or bed baths during those periods. A grievance documented that the resident was found with feces under the nails, requiring hand soaks in warm soapy water to remove, and noted that staff were educated regarding daily nail/foot care. The facility’s ADL policy required that residents unable to perform ADLs independently receive services to maintain grooming and personal hygiene and directed staff caring for cognitively impaired residents who resisted care to identify underlying causes and re-approach or use different staff, but the record did not show that such approaches were implemented for this resident during the identified periods of missed bathing care.
Incomplete Documentation of Required Bathing and Grooming Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records reflecting the provision of required hygiene care, including weekly showers or bed baths, for two residents. For one resident with severe protein calorie malnutrition, adult failure to thrive, type II diabetes mellitus, and a stage 3 pressure ulcer, the MDS showed moderately impaired cognition and dependence on staff for most ADLs, with the care plan calling for total care for showering and grooming. Point of Care (POC) documentation for December and January showed only one shower and a few partial bed baths, with multiple week-long gaps where no shower or bed bath was recorded, and the clinical record contained no documentation of refusals during those periods. For another resident with vascular dementia without behavioral disturbances and adult failure to thrive, the MDS showed severely impaired cognition and a need for assistance with ADLs, and the care plan specified assistance with showering on a set weekly schedule. POC records for December, January, and March showed only sporadic showers or bed baths, with several weeks lacking any documented shower or bed bath, and no refusals recorded in the clinical record. A grievance documented that this resident was found with feces under the nails requiring soaking to remove. The DON stated that residents should receive at least a weekly shower or complete bed bath and that care should be documented before the end of the shift, and acknowledged that the record did not show a shower or bed bath for the week preceding the grievance. The facility’s Bathing and Grooming Care policy required at least weekly showers and associated grooming, but requested policies for nurse aide documentation or Kardex/Care Card were not available.
Failure to Timely Notify Ombudsman of Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide timely notification to the State LTC Ombudsman via the Aging and Disability Services application portal when residents were discharged or planned for discharge. For one resident with type 2 DM with foot ulcer, chronic osteomyelitis, and cellulitis, the facility granted an independent leave of absence, documented the expected return time, and later documented that the resident would return the following morning and would miss medications. The resident was subsequently found intoxicated, hypothermic, and later expired in the ED, and the facility could not provide evidence that a discharge notice was uploaded to the portal. Interviews with the social worker and DNS confirmed that this resident’s situation was considered a transfer rather than a discharge and that no ombudsman notification was made. For multiple other residents with complex medical conditions, including osteomyelitis, peripheral vascular disease, gas gangrene, coronary artery disease, renal insufficiency, COPD, heart failure, respiratory failure, depression, multiple sclerosis, schizoaffective and anxiety disorders, the facility issued written Notices of Intent to Discharge, generally providing 30‑day notices due to improved health, acceptance into Money Follows the Person programs, or family choice to return home. Social service notes documented discharge planning meetings with residents, families, therapy, and MFP representatives, as well as the actual discharge dates. However, the corresponding discharge notices were not uploaded to the Aging and Disability Services application portal at the time the notices were given to the residents. Instead, the discharge notifications for these residents were uploaded days to more than a month after the Notices of Intent to Discharge were issued, with delays ranging from 1 to 37 days. Interviews with the social worker and DNS showed that facility staff were unable to identify a specific timeframe for when discharge notices must be created and uploaded to the portal and believed there was no defined deadline. This practice conflicted with the facility’s Transfer/Discharge policy and the CMS regulation requiring that a copy of the discharge notice be sent to the State LTC Ombudsman at least 30 days prior to discharge or as soon as possible, and at the same time the notice is provided to the resident and resident representative.
Inaccurate MDS Coding of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s comprehensive assessment accurately reflected a significant weight loss of more than 10% over six months. The resident had diagnoses including vascular dementia without behavioral disturbances and adult failure to thrive. A weight of 122.0 lbs was recorded on 5/13/25, and the resident’s care plan dated 6/10/25 identified risk for malnutrition related to adult failure to thrive, altered nutrition-related bloodwork, a BMI less than 23, and significant weight changes, with interventions to assess intakes, bloodwork, and weights, and to monitor for significant changes. A subsequent weight of 108.6 lbs on 11/16/25 represented a 13.4 lb (10.984%) loss over six months compared to the 5/13/25 weight. Despite this documented weight loss, the quarterly MDS assessment dated [DATE] did not identify that the resident had experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. The RD, who was responsible for completing Section K (Swallowing and Nutritional Status) of the MDS, acknowledged that Section K of the 12/4/25 MDS was coded incorrectly, explaining that she used an incorrect baseline weight and failed to calculate the weight change using the appropriate six-month look-back period from the Assessment Reference Date. The DON stated that the MDS should accurately reflect a resident’s care for all sections, including swallowing and nutritional status, and acknowledged that this MDS did not accurately reflect the resident’s significant weight loss. When requested, the facility did not provide a policy on comprehensive assessments.
Failure to Provide Safe and Timely Respiratory Care Resulting in Resident Death
Penalty
Summary
A resident with a history of acute respiratory failure with hypercapnia, COPD, CHF, and dependence on supplemental oxygen experienced a critical event due to the facility's failure to provide safe and appropriate respiratory care. The resident had a physician's order for continuous oxygen at 3.0 liters per minute via nasal cannula. Over the course of several shifts, the resident's oxygen concentrator was not functioning, and staff relied on portable oxygen tanks, some of which were empty or unavailable. Multiple staff members, including LPNs and nurse aides, failed to assess the resident's respiratory status, obtain vital signs or oxygen saturation levels, or notify the nursing supervisor and provider of the resident's ongoing shortness of breath and equipment issues. Communication breakdowns occurred between shifts and among staff. Nurse aides reported the resident's shortness of breath to the charge nurse, but the charge nurse did not assess the resident or escalate the issue to the supervisor or provider. The nursing supervisor and nurse practitioner were not made aware of the resident's deteriorating condition until the resident was in acute distress. Staff also failed to ensure the availability of functioning oxygen equipment, as all portable tanks on the unit and the emergency cart were found empty when urgently needed, requiring staff to retrieve tanks from another floor. The lack of timely assessment, failure to monitor and document the resident's condition, and inadequate communication and escalation of the resident's change in status resulted in the resident's condition deteriorating to acute respiratory arrest and ultimately death. The facility did not follow its own policies regarding change of condition and oxygen supply management, which required immediate assessment, documentation, and notification of the provider and supervisor in the event of respiratory distress or equipment malfunction. These failures led to a finding of Immediate Jeopardy.
Failure to Timely Notify Provider of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure, COPD, CHF, and dependence on supplemental oxygen reported shortness of breath to staff, but the provider was not notified until approximately three hours later. The resident's care plan required staff to monitor for signs of respiratory distress, check oxygen saturation as needed, and report abnormal findings to the provider. Despite these directives, nurse aides reported the resident's shortness of breath to the charge nurse shortly after the start of the shift and again later in the morning, but the charge nurse did not assess the resident, take vital signs, or notify the provider or nursing supervisor at that time. The charge nurse was informed by the previous shift that the resident's oxygen concentrator was not functioning and that portable oxygen was being used. Although the nurse aides followed protocol by reporting the resident's symptoms, the charge nurse only instructed them to bring additional portable oxygen tanks and did not perform a respiratory assessment or further evaluate the resident's condition. The nursing supervisor was on the unit during this period but was not made aware of the resident's complaints or the issues with the oxygen equipment until a critical event occurred. The situation escalated when the resident began calling out for help, stating they could not breathe. At this point, the nursing supervisor and a nurse practitioner responded immediately, assessed the resident, and initiated emergency interventions, including calling 911 and performing CPR. Despite these efforts, the resident was pronounced deceased. Interviews confirmed that the provider and nursing supervisor were not notified of the resident's change in condition in a timely manner, contrary to facility policy and the resident's care plan.
Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to ensure that oxygen tubing for residents requiring supplemental oxygen was changed every seven days as per facility policy. For three of seven sampled residents, clinical record reviews and direct observations revealed that the oxygen tubing was not changed within the required timeframe. One resident with acute respiratory failure, COPD, and anxiety disorder was observed using oxygen tubing labeled with a date ten days prior, despite documentation indicating it had been changed more recently. Another resident with pneumonia, heart failure, and COPD was found with oxygen tubing labeled with a date seven days past the scheduled change, and there was no active physician's order to change the tubing weekly. A third resident with acute and chronic respiratory failure, CHF, and COPD was observed with oxygen tubing that had not been changed for over two weeks, and similarly lacked an active physician's order for weekly tubing changes. Interviews with the DON and a regional nurse confirmed that the facility's policy required weekly tubing changes on the 11PM-7AM shift, and that staff were expected to document these changes accurately. However, the observations and record reviews indicated that the tubing was not changed as required, and documentation did not reflect actual practice. The facility's policy, dated 01/19/18, directed that standard nasal cannula/tubing be changed every seven days or sooner if soiled, and that change dates be documented in the medical record, but these procedures were not consistently followed for the residents reviewed.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a care plan addressing the need for supplemental oxygen use for one resident with significant respiratory diagnoses. The resident had acute respiratory failure with hypoxia, COPD, and an anxiety disorder, and a physician's order directed the use of oxygen via nasal cannula or non-rebreather at two to three liters per minute as needed to maintain oxygen saturation above 92%. Despite these orders and the resident's ongoing use of oxygen therapy, clinical record reviews and observations revealed that there was no care plan in place to address the resident's respiratory conditions and oxygen utilization at the time of review. The deficiency was identified through clinical record reviews, direct observation of the resident using oxygen, and interviews with facility staff. The facility's own policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and interventions based on thorough assessment. However, the care plan for this resident was not developed until several days after the deficiency was noted, and staff interviews confirmed that a care plan should have been in place to address the resident's respiratory needs and oxygen use.
Failure to Assess and Intervene for Resident with Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypercapnia, COPD, CHF, and dependence on supplemental oxygen experienced shortness of breath and did not receive timely assessment or intervention from nursing staff. The resident had a physician's order for continuous oxygen and a care plan directing staff to monitor for respiratory distress, check oxygen saturation as needed, and report abnormal findings to the provider. On the day of the incident, nurse aides reported the resident's shortness of breath to the charge nurse shortly after the start of the shift and again later in the morning, but did not observe the nurse assess the resident at either time. The charge nurse acknowledged being notified by the nurse aides about the resident's symptoms and directed them to bring portable oxygen tanks due to a malfunctioning concentrator, but did not personally check on or assess the resident, nor did she take vital signs or oxygen saturation levels. The nursing supervisor was not informed of the resident's condition until later in the morning, at which point the resident was found in severe respiratory distress. The nurse practitioner and supervisor responded immediately, but the resident became unresponsive and, despite CPR and emergency services intervention, was pronounced deceased. Facility policy required that any change in a resident's condition be identified and addressed promptly, with the LPN responsible for collecting data and administering treatments, and the RN/supervisor to be notified for further assessment and provider notification. In this case, the failure of the charge nurse to assess the resident and notify the supervisor or provider in a timely manner led to a lack of appropriate intervention for the resident's acute respiratory symptoms.
Unattended Unlocked Medication Cart with Keys Left Exposed
Penalty
Summary
A medication cart was observed unlocked and unattended in the hallway near the nurse's station, with the cart keys left on top of the cart. Items found on the cart included an open bottle of docusate sodium, a glucometer, glucometer test strips, several empty blister packs of medication, six pre-poured cups of water without covers, an insulin syringe cover, and a cell phone. During this time, a resident was seen walking by the cart while the assigned nurse was inside a resident's room with the door closed. The nurse later confirmed that she left the cart unlocked and unattended, with the keys on top, because she needed to attend to a resident quickly and did not request assistance from other staff. The nursing supervisor stated that the medication cart should be locked at all times when unattended and that items, including keys, should not be left on top of the cart. Facility policy requires medication carts to be locked and secured at all times when unattended, with keys kept in the possession of the assigned nurse, and prohibits storage of unrelated items on the cart.
Failure to Obtain and Document Physician-Ordered Blood Work
Penalty
Summary
The facility failed to ensure that blood work was obtained as ordered by physicians for two residents. For one resident with diagnoses including pneumonia, respiratory failure, CHF, anemia, generalized edema, and hypocalcemia, a physician's order directed that a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) with differential be obtained on a specific date. Review of the clinical record did not show that the blood work was completed or that the resident refused the procedure. A subsequent order for different blood work was later carried out, but the initial order was not addressed. For another resident with alcohol abuse, hypothyroidism, and peripheral vascular disease, a physician's order directed that a BMP and CBC with differential be obtained on a specific date. The clinical record did not indicate that the blood work was completed or refused. Interviews with facility staff confirmed that documentation was lacking for both residents, and the nurse practitioner was unaware that the blood work had not been obtained. Facility policy requires that laboratory services be provided per physician orders, with results documented and communicated appropriately, but this was not followed in these cases.
Failure to Ensure Timely Inspection and Maintenance of Oxygen Concentrators
Penalty
Summary
The facility failed to ensure that oxygen concentrators used by two residents were inspected annually for function and safety, as required. Both residents had significant respiratory diagnoses, including COPD, CHF, and chronic respiratory failure, and were receiving supplemental oxygen via concentrators. Observations revealed that the inspection stickers on both concentrators indicated the last inspection occurred over a year ago, making them five months overdue for their required annual inspection. Additionally, one concentrator was observed to have a thick covering of dust on its filter. Interviews with facility staff and the oxygen concentrator servicing vendor revealed that the vendor was not provided with a complete list or locations of all concentrators, resulting in some units not being inspected during their visit. The Director of Environmental Services did not accompany the vendor during the inspection, which contributed to the oversight. Maintenance staff were responsible for weekly filter checks, and housekeeping was to monitor filters daily, but the presence of thick dust on one unit indicated this process was not consistently followed. Requested policies on servicing and cleaning oxygen concentrators were not provided by the facility.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or improper use. Specific actions or omissions by facility staff led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Maintain Proper Controls and Documentation for Narcotic Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality regarding the control and documentation of narcotic medications for three residents reviewed for medication administration. Clinical record and facility documentation reviews revealed that staff signed out Hydromorphone on the Controlled Substance Distribution Record (CSDR) for multiple dates, but there was no corresponding documentation in the residents' medical records or Medication Administration Records (MAR) to confirm that the medication was actually administered. In some instances, narcotic medications were signed out on the CSDR when there were no physician orders, and there was a lack of required witness signatures for medication wastage. The Director of Nursing (DON) was unable to explain these discrepancies or provide documentation of the required monthly or bi-monthly audits of controlled substances for the relevant months, as stipulated by facility policy. Further investigation found that completed CSDR sheets were stored in the medical records office, but there was no evidence of audit results or documentation of audits being completed. Interviews with the DON and Administrator indicated that there was no established process or tracking system for current audits of controlled medications, and the DON could not explain how previous audits were conducted or why issues were not identified. The facility's Controlled Substance Handling Policy required monthly audits to monitor for discrepancies, unexplained wastage, and patterns of high usage, as well as the retention of accountability and audit records for at least five years, but these requirements were not met.
Failure to Ensure Medication Availability and Administration per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were available and administered in accordance with physician orders for three residents. One resident with chronic pain syndrome, opioid dependence, osteomyelitis, and bacteremia was ordered to receive IV Cefazolin every eight hours. On two occasions, the resident did not receive the scheduled 2 PM dose because they were out of the facility at the hospital for another medication. The LPN responsible did not notify the nursing supervisor, physician, or APRN about the missed doses, and the supervisor was unaware of the omission. The APRN and DON both stated they would have expected to be notified of the missed antibiotic doses. Another resident with a history of substance use disorder was ordered to receive Methadone 115 mg daily. The medication was not available in the facility for four consecutive days, and the resident missed multiple doses. The resident was subsequently transferred to the hospital for Methadone administration after experiencing withdrawal. Facility staff interviews revealed that the Methadone nurse, responsible for obtaining the medication from the clinic, was not aware of the unavailability, and the RN supervisor was not notified of the missed doses until after several had been omitted. The APRN was also not notified of the missed doses until after the resident was transferred to the hospital. A third resident, also with opioid abuse, was ordered Methadone 75 mg daily. The medication was not available for administration on one occasion, and the reason for the unavailability could not be identified. The RN supervisor was not aware of the missed dose, and the DNS could not explain why the medication was not available. Facility policy directed that Methadone should be retrieved and administered as ordered, but this was not followed in these cases.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, major depression, and significant physical care needs was physically abused by another resident who entered the victim's room and struck them multiple times with a telephone. The incident resulted in visible injuries, including bruising and lacerations to the face, mouth, and hand, as well as swelling of the left thumb and index finger. The injured resident was on a blood thinner and was alert and oriented at the time of the event. The attack was unprovoked, and the resident reported not recognizing the assailant. Staff became aware of the incident when they heard the resident calling for help and observed the aggressor exiting the room. Immediate observations and interviews confirmed the sequence of events, and medical evaluation documented the extent of the injuries. Facility documentation and camera footage corroborated that staff responded after the resident called for help, but the abuse had already occurred. The facility's policies require residents to be free from abuse, but in this case, the resident was not protected from physical harm inflicted by another resident.
Failure to Monitor and Document Vital Signs After Medication Discontinuation
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document vital signs according to a provider order for a resident who required monitoring after the discontinuation of a blood pressure medication. The resident, who had multiple sclerosis, functional quadriplegia, neurogenic bladder, and a pressure ulcer, was identified as having intermittent hypotension and had their metoprolol succinate discontinued. The provider ordered that vital signs be obtained every shift following this change. However, review of the medical record revealed that vital signs were not recorded for several specified shifts. Interviews with staff indicated that nursing assistants were responsible for obtaining vital signs, which were then to be reviewed and entered into the electronic medical record by the assigned nurse. The LPN assigned to the resident during the missed shifts could not recall if she had reviewed the vital signs and did not know why they were not recorded. The APRN confirmed the importance of monitoring vital signs after discontinuing the medication, and the DNS stated that nurses are expected to follow provider orders. The facility did not provide a policy for obtaining vital signs when requested.
Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely notification of a medical provider following a significant change in condition for a resident with dementia and chronic obstructive pulmonary disease (COPD). The resident, who was alert and oriented with a history of stable oxygen saturation, experienced episodes of shortness of breath and a drop in oxygen saturation, which were managed with breathing treatments and supplemental oxygen. However, on one occasion, the resident exhibited a change in mental status, including confusion and hallucinations, along with a further decrease in oxygen saturation. Despite these significant changes, there was no documentation that the supervising nurse or the on-call provider was notified as required by facility policy. Interviews with facility staff confirmed that the LPN who observed the change in mental status did not notify the nursing supervisor, and the supervisor was unaware of the resident's altered condition. The DON and Medical Director both acknowledged that the change in mental status constituted a significant change in condition and that the supervisor and provider should have been contacted. Facility policy directs that every resident's change in condition must be reported to the physician, but this protocol was not followed in this instance.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to revise a resident's care plan in a timely manner following a fall. The resident, who had a history of traumatic brain hemorrhage, Schizophrenia, severely impaired cognition, and required extensive assistance for mobility and transfers, was identified as being at risk for falls. The care plan in place included interventions such as reminding the resident to use the call bell and to toilet promptly. However, after the resident experienced an unwitnessed fall, which was documented in an incident report and nursing note, no new interventions were added to the care plan to address the circumstances of the fall or to prevent recurrence. Interviews with facility staff, including the charge nurse and the Director of Nursing (DON), confirmed that the care plan was not updated after the incident, despite facility policies requiring care plan revisions when a resident's condition changes or when desired outcomes are not met. The DON was unable to provide documentation of any care plan update following the fall, and the charge nurse could not recall if any changes were made. The facility's Fall Prevention Policy and Comprehensive Care-Planning Policy both direct staff to implement and revise interventions as needed, but these procedures were not followed in this case.
Failure to Complete Timely Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that neurological assessments were completed in a timely manner following an unwitnessed fall, as required by facility policy. A resident with a history of traumatic brain hemorrhage, severe cognitive impairment, and a high risk for falls experienced an unwitnessed fall and was found on the floor by housekeeping staff. Initial assessments were performed, and the resident was found to have no injuries or pain. However, documentation revealed that neurological checks were not consistently completed every shift for 72 hours post-fall, as directed by the facility's Post Accident & Incident Monitoring Sheet. Only a few assessments were documented, leaving several required checks unaccounted for during the monitoring period. Interviews with nursing staff and the Director of Nursing confirmed that neurological assessments should have been performed and documented every shift for 72 hours following the fall. The Director of Nursing was unable to provide documentation that these assessments were completed according to policy and acknowledged that the required monitoring was not carried out. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which collectively demonstrated a failure to meet professional standards of quality in post-fall monitoring.
Failure to Document APRN Assessment Following Respiratory Event
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate, specifically lacking timely documentation of a medical evaluation. The resident, who had diagnoses including dementia and COPD, was noted to be alert, oriented, and independent with mobility. The care plan directed staff to assess for changes in respiratory status and notify the physician as needed. On the date in question, the resident was observed with shortness of breath and a low oxygen saturation of 88% on room air, compared to a baseline of 92-95%. A breathing treatment was administered, oxygen was applied, and the resident's oxygen saturation improved to 90%. It was documented that the resident was assessed by an APRN and new orders for nasal oxygen were obtained. However, upon review, there was no documentation of the APRN's assessment in the medical record for that date. The facility's policy required that a progress note be written, signed, and dated for each visit. The Medical Director confirmed that if the APRN had assessed the resident, this should have been documented. The absence of this documentation resulted in an incomplete and inaccurate medical record for the resident.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician or APRN after a resident did not receive a prescribed medication, Abiraterone, for two consecutive days. The resident, who had diagnoses including dementia, prostate cancer, schizophrenia, diabetes mellitus, seizures, and encephalopathy, was dependent on staff for activities of daily living and had severely impaired cognition. The physician's order required daily administration of Abiraterone, but documentation showed the medication was not given on two days because the supply was not available, as it was being delivered to the family rather than the facility. Nursing notes indicated that the pharmacy and the resident's family were contacted regarding the medication supply, and the nursing supervisor was updated about the situation. However, there was no evidence in the clinical record that the physician or APRN was notified about the missed doses. Interviews confirmed that the APRN was not informed and would have taken further action if notified. The LPN involved stated that he did not notify the physician/APRN, believing it was the supervisor's responsibility, but the facility could not provide information on who the supervisor was during the relevant period. The DON confirmed that the expectation was for the nursing team to notify the provider when a resident does not receive scheduled medication, but could not explain why this did not occur.
Failure to Verify Family-Provided Medication Prior to Administration
Penalty
Summary
The facility failed to ensure that a medication provided by a resident's family for administration by facility staff was properly verified as the drug ordered by the physician, and did not ensure that the contents of the medication container were verified by a licensed pharmacist, as required by facility policy. Specifically, a resident with multiple complex diagnoses, including dementia, prostate cancer, schizophrenia, diabetes, seizures, and encephalopathy, was ordered to receive Abiraterone 1000 mg daily. Due to the facility pharmacy not supplying the medication, the resident's family brought the medication to the facility. There was no documentation or evidence that nursing staff verified the medication prior to administration, nor was there a record of the process followed when the medication was delivered by the family. Interviews with facility staff, including the DON and pharmacy personnel, confirmed that the medication was dispensed by an outside pharmacy and brought in by the family, but could not provide documentation of verification by a licensed pharmacist or details on how the medication was checked before administration. The facility's policy requires that medications brought in from outside be verified by the nursing staff, the attending physician, and the consultant pharmacist, but this process was not documented or followed in this case. The medication in question was also not available for review, as it had been destroyed after the resident's discharge.
Failure to Implement Timely Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure that the treatment plans recommended by the wound care physician for a resident with multiple risk factors, including pressure ulcer, diabetes mellitus, malnutrition, peripheral vascular disease, and dementia, were promptly entered into the clinical record and implemented. Although the resident's care plan included interventions such as applying barrier cream, turning and repositioning every two hours, and weekly skin checks, documentation revealed lapses in weekly skin assessments and incomplete records regarding the resident's skin condition. After re-admission from an acute care facility, the resident was found to have a non-stageable sacral pressure ulcer and a deep tissue injury to the right heel, with the wound care physician recommending specific treatments and preventative measures, including a specialized air mattress and pressure-relieving boots. Despite these recommendations, the clinical record and Treatment Administration Records showed that the recommended sacral wound treatment was not initiated until five days after the physician's order, and the specialized air mattress and boots were never applied. Interviews with facility staff, including the wound nurse and DON, confirmed delays in entering orders and implementing the recommended interventions, with no clear explanation for the lapses. The resident was subsequently transferred to the hospital for evaluation and treatment of the sacral wound, and later developed a viral skin eruption involving the groin, perineum, and sacrum. Facility policy required timely implementation of interventions consistent with residents' needs, but this was not followed in this case.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as required by the Resident Rights policy. The incident involved a resident with diagnoses including chronic pulmonary edema, depression, anxiety, and chronic pain, who was alert and oriented with a BIMS score of 15. During a recreational activity, the resident was verbally disruptive, leading to an altercation with a recreational aide. The aide, in frustration, cursed about the incident, which the resident overheard. This behavior was contrary to the facility's policy that mandates treating all residents with dignity and respect. The incident was reported by the resident to the social worker the following day, prompting an investigation. The recreation aide admitted to cursing during the incident, although she claimed it was not directed at the resident. The Director of Nursing confirmed the aide's admission and the violation of the facility's policy. The facility's policy, last revised in 2018, emphasizes the importance of treating residents with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this situation.
Failure to Ensure Safe Smoking Environment and Address Fire Hazard
Penalty
Summary
The facility failed to provide a safe smoking environment for Resident #21, who was identified as a smoker with diagnoses of dementia and schizophrenia. During a smoking break, Resident #21 was observed with a smoking apron that was not properly secured, leaving their legs uncovered. The security staff responsible for supervision was distracted with other tasks and did not maintain a direct line of sight on the residents. Additionally, the facility's smoking policy was not adhered to, as the last smoking safety assessment for Resident #21 was conducted several months prior, and necessary smoking safety equipment, such as a cigarette filter, was not available. The facility also failed to address a fire hazard involving Resident #187, who had diagnoses of visual hallucinations and insomnia. Resident #187 was observed placing thin pink paper over their overbed light to dim the room, which posed a fire risk. The Director of Maintenance was aware of this behavior but did not report it to the Administrator or the Director of Nursing Services. Consequently, the facility was unaware of the safety concern and had not implemented any interventions to mitigate the risk. Both deficiencies highlight lapses in supervision and communication within the facility. The staff failed to adhere to established policies for smoking safety assessments and did not report hazardous behaviors that could compromise resident safety. These oversights resulted in unsafe conditions for the residents involved, with potential risks that were not addressed in a timely manner.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits for a resident with chronic kidney disease and atrial fibrillation. The resident, who was cognitively intact and had clear speech, expressed a desire to see their primary care physician to coordinate care. However, the clinical record review revealed that the last note by a physician was an admission history and physical dated over two years ago. Subsequent notes categorized as physician notes were written by non-physician providers, indicating a lack of direct physician involvement in the resident's ongoing care. Interviews with the Medical Director and the Director of Nursing Services (DNS) highlighted discrepancies in the facility's process for physician visits. The Medical Director mentioned that he examines residents every sixty days and signs orders, but there was no documentation of such visits for the resident in question. The DNS confirmed the absence of physician notes since the resident's admission and could not explain the lack of documentation. The facility's policy requires a physician to see a resident at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter, which was not adhered to in this case.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for four nurse aides, identified as Nurse Aides #5, #6, #7, and #8. This deficiency was discovered during a review of employee files and interviews with the Human Resource Director and the Director of Nursing Services. The review revealed that no performance evaluations had been conducted for these nurse aides since April 4, 2022. Despite the Director of Nursing Services indicating a willingness to search for the missing evaluations in the nursing offices, no evaluations were found or provided.
Deficiencies in Methadone Management and Recordkeeping
Penalty
Summary
The facility failed to develop and implement adequate policies for the recordkeeping and chain of custody of controlled substances, specifically methadone, for 28 residents. The report highlights that the facility did not maintain an unbroken chain of custody for controlled medications once received and distributed to nursing units. There was a lack of documentation for inventory across shifts, and the facility did not maintain an accurate disposition log for the destruction and return of unused controlled medication. Observations revealed that residents self-administered methadone without signing a chain of custody, and the medication nurse was solely responsible for signing off on the Medication Administration Record (MAR). Interviews with staff, including LPNs and the interim Director of Nursing Services (DNS), revealed that the facility's practice did not align with standard procedures followed in other facilities. The methadone nurse, LPN #5, was responsible for acquiring and maintaining the chain of custody of methadone but did not require a second nurse to sign off after the medication was received by the facility. Additionally, there was no documented chain of custody when methadone was brought to nursing units for weekend dispensing, and no accounting between shifts by nursing staff. The facility's policy for methadone maintenance failed to include resident participation in self-medication administration and individual recordkeeping of tapering doses. The facility also failed to maintain complete and accurate recordkeeping for methadone destruction. A review of Methadone Destruction Worksheets showed only one nursing signature, belonging to LPN #5, without a second licensed staff signature or the resident's signature when able. Interviews with the DNS and nursing staff indicated a lack of awareness and adherence to facility policies regarding controlled substance handling. The facility's policy directed that methadone be stored and counted like any other controlled substance, but the revised policy did not include this requirement, leading to deficiencies in the management of methadone within the facility.
Food Temperature Deficiency in Dietary Department
Penalty
Summary
The facility failed to ensure that food was served at an appropriate temperature to maintain palatable taste. During a tour of the dietary department, it was observed that scrambled eggs and hot cereal were initially at temperatures of 196 and 195 degrees Fahrenheit, respectively, when placed in a heating tray. However, by the time the food cart reached the third floor, unit D3, the scrambled eggs had cooled to 88.2 degrees, and the oatmeal was at 131.2 degrees. The food cart door was left open during transport, contributing to the temperature drop. The Food Service Director acknowledged that the food was not served at the correct temperature due to the timing of service and the containers' inability to maintain temperature during transport.
Sanitation Deficiency in Dietary Department
Penalty
Summary
The facility failed to serve food under sanitary conditions, as identified during a tour of the dietary department. On one occasion, a test tray containing baked chicken, rice, and assorted vegetables was ordered. During an observation, a black, thin, hair-like object was found in the assorted vegetables. The Food Service Director suggested that the object might be a string from the lining of the vegetable bag and acknowledged that defrosting and spreading out the vegetables could help prevent such occurrences in the future.
Failure in Antibiotic Stewardship and Infection Control Documentation
Penalty
Summary
The facility failed to ensure proper documentation and ongoing review of antibiotic use as part of its Infection Control Program, in accordance with Antibiotic Stewardship guidelines. During an interview and document review, the Infection Preventionist (IP), who had been in the role for two months, was unable to provide evidence of ongoing infection surveillance. The only documentation available was a binder containing a list of antibiotics used in 2023 and 2024, provided by the pharmacy. The IP had not utilized McGeer's forms for antibiotic surveillance and had been frequently pulled away from infection control duties to provide resident care. The IP was unaware of the need to track infections, check antibiotic appropriateness, and review trends with medical staff. Additionally, the IP was not aware of an infection control or pharmacy committee. The Director of Nursing Services (DNS) confirmed that the previous IP had left the position and taken the infection tracking information, leaving the facility unable to provide evidence of infection control reviews at medical staff meetings since April 2022. The facility's policy on Antibiotic Stewardship indicated that the Medical Director, IP, DNS, and consultant pharmacist should lead antibiotic stewardship activities, coordinated through the Pharmacy and Infection Control Committees. These activities were to include regular reviews of antibiotic utilization and sensitivity patterns, distribution of educational materials, and reports on potential mis-prescribing. However, these activities were not being conducted as required.
Failure to Ensure Respectful Interaction with Resident
Penalty
Summary
The facility failed to ensure respectful interaction with a resident, leading to a deficiency in maintaining the resident's dignity. Resident #70, who has diagnoses including chronic congestive heart failure, back pain, diabetes mellitus, anxiety, and depression, was found to be cognitively intact and independent with toileting hygiene. The resident reported an incident where urine was on the bedside floor, and while attempting to clean it, called for staff assistance. Nurse Aide (NA #8) responded by bringing an open bag for the soiled linens and suggested that the resident could have completed the task independently, which the resident found disrespectful. The incident was reported to the state agency, and an investigation was initiated. During the investigation, NA #8 confirmed telling the resident they could have cleaned the urine without assistance, based on previous observations of the resident's independence. The resident expressed feeling disrespected by NA #8's comment, although not abused, and agreed that further training in customer service was necessary. The Director of Nursing Services conducted an interview with NA #8, who was subsequently removed from the resident's assignment and received a discussion on customer service and respectful treatment of residents.
Deficiency in Resident Furniture Maintenance
Penalty
Summary
The facility failed to maintain resident furniture in proper working order for a resident, leading to a deficiency. During an observation, the resident's closet cabinet doors were found ajar with the wood at the edges peeling apart, and the doors did not stay closed due to missing magnets. Additionally, a 3-drawer dresser had drawers that would not stay closed, posing a potential safety concern. The Director of Maintenance confirmed these issues during an interview and attempted to address them, but the problems persisted, indicating a lack of timely maintenance and repair of the resident's furniture.
Failure to Secure Resident's Personal Funds
Penalty
Summary
The facility failed to ensure the security of personal funds for a resident diagnosed with cerebral palsy, mood disorder, and delusional disorder, who was identified as severely cognitively impaired and dependent on staff for personal care. The resident's family member provided $50.00 to a staff member for the resident's use, but the money was not deposited into the resident's personal fund account as per facility policy. Instead, the family member requested the money be left on the nursing medication cart for the resident's access, which was against the facility's policy. The Business Office Manager was aware of the situation but did not ensure the money was secured according to policy. The money was later found in the narcotics box in the medication cart, with only $1.25 remaining, indicating it had been spent without proper documentation or oversight. The facility's policy required that any funds not deposited into a personal account should be secured in a locked box in the resident's room, which was not done. The Administrator and Social Worker were initially unaware of the situation, highlighting a breakdown in communication and adherence to policy regarding the management of resident funds.
Missing Advanced Directive Documentation for Resident
Penalty
Summary
The facility failed to ensure that the advanced directive paperwork for Resident #89 was present in the medical record, as required by the physician's order and facility policy. Resident #89, who was diagnosed with chronic congestive heart failure, acute respiratory failure, chronic kidney disease, and type 2 diabetes mellitus, had a physician's order dated 6/28/2024 indicating a Full Code status with instructions to have the resident sign the advanced directives form and place a copy in the medical record. However, during a clinical record review and interviews, it was found that the advanced directive paperwork was missing from both the paper and electronic medical records. An interview with an LPN on 1/29/25 revealed that the advanced directive sheets were not found in the medical record, and the LPN was unsure of the reason for their absence. The LPN indicated they would contact the nursing supervisor for further clarification. The nursing supervisor, an RN, was interviewed on 1/30/2025 and suggested that the papers might have been misplaced but assured that they would look for them when time allowed. The facility's policy on advanced directives requires that residents without advanced directives be provided with a handout upon admission, and the completed form should be filed in the medical record within 24 hours, which was not adhered to in this case.
Medication Mismanagement and Environmental Deficiencies
Penalty
Summary
The facility failed to ensure the safety and proper management of a resident's personal medication. Resident #173, who has a diagnosis of carcinoma in situ of the prostate and Type 2 diabetes mellitus, was found to have missing doses of Revlimid, a medication prescribed for myeloma. Despite being cognitively intact and independent in some activities, the resident's medication was not properly accounted for, leading to a discrepancy in the medication count. Interviews with staff revealed a lack of awareness and documentation regarding the missing medication, and the facility's policy on handling medications brought in by family members was not adequately followed. The facility also failed to maintain a safe and functional environment for two residents sharing a room. Residents #164 and #181 were found to have a non-functioning bathroom sink for 20 days, with a sign indicating it was leaking. The maintenance staff was unaware of the sign and the issue persisted due to a delay in obtaining necessary parts for repair. This resulted in staff having to use other residents' bathrooms to provide care, which was acknowledged as unacceptable by the Director of Nursing Services. Additionally, the facility did not ensure that resident furniture was maintained in proper working order. Resident #118's closet cabinet doors were observed to be peeling and unable to stay closed, and the dresser drawers were malfunctioning, posing a potential safety concern. The Director of Maintenance acknowledged the issues and indicated that repairs or replacements were necessary, but the deficiencies had not been addressed at the time of observation.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies to ensure the protection of residents following allegations of abuse. In the case of Resident #144, who was cognitively intact and required assistance with ambulation and toileting, an allegation was made against LPN #6 for inappropriate conduct. Despite the facility's policy requiring the removal of staff members named in abuse allegations from the schedule pending investigation, LPN #6 continued to work during the investigation period. The interim Director of Nursing Services (DNS) acknowledged the oversight but could not explain why the policy was not followed. In another incident, Resident #214 expressed concerns about the behavior of Resident #1, who had a history of dementia with behavioral disturbances and was known to exhibit aggression and combative behavior towards staff. Despite these concerns, the facility did not adequately monitor Resident #1's behavior to ensure they were not a danger to themselves or others. The facility's documentation failed to show that Resident #1 was evaluated by psychiatry until several days after the concerns were raised, leaving Resident #214 feeling threatened and requesting a room change. The facility's documentation and interviews revealed a lack of timely follow-up and monitoring of the residents involved, particularly in ensuring the safety and well-being of Resident #214. The facility did not provide evidence of consistent monitoring or psychiatric evaluation of Resident #1 to address the concerns raised by Resident #214, resulting in a deficiency in the facility's handling of abuse allegations and resident safety concerns.
Deficiencies in Care Planning for Dialysis and Sensory Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #111, who has end-stage renal disease and is dependent on dialysis. The care plan dated 12/20/2024 did not include specific interventions related to the resident's dialysis access site, which is crucial for their treatment. This oversight was identified during an interview and record review with a nursing supervisor, who acknowledged the absence of a specific care plan addressing the resident's dialysis needs. The facility's policy requires a comprehensive, person-centered care plan that meets the resident's physical, psychosocial, and functional needs, which was not adhered to in this case. Additionally, the facility did not address the sensory needs of Resident #109, who requires corrective lenses. The care plan dated 11/28/2024 failed to include interventions for the resident's eyeglasses, despite the resident being identified as needing them. Observations revealed that the resident had broken glasses, and despite informing the facility staff and the Ombudsman Office, no action was taken to address the issue. Interviews with social workers and nursing staff indicated a lack of communication and oversight, as the broken glasses were not documented or addressed in the resident's care plan.
Failure to Revise Care Plans for Urinary Retention and Incontinence
Penalty
Summary
The facility failed to revise the care plan for a resident with urinary retention after returning from an inpatient stay. The resident, who was cognitively intact, had a physician's order to begin voiding trials and perform bladder scans with intermittent catheterization if necessary. However, the care plan was not updated to include these interventions, and the nursing supervisor confirmed that all physician's orders and nursing interventions should be documented in the care plan. Another resident, who was cognitively intact and had diagnoses including diabetes mellitus and sepsis, was frequently incontinent of bowel and bladder. Despite being noted as frequently incontinent on assessments, there was no evidence of an evaluation for participation in a bowel and bladder retraining program. The resident expressed a preference for independence and did not use the bathroom or commode, instead using an adult incontinent brief. The care plan did not reflect the resident's preferences or include an evaluation for a retraining program. Interviews with staff revealed a lack of awareness and documentation regarding the residents' care needs and preferences. The facility's policy required a comprehensive, person-centered care plan to meet each resident's needs, but this was not adhered to in these cases. The nursing supervisor acknowledged the deficiencies and the need to revise the care plans to reflect the residents' current conditions and preferences.
Failure to Provide Required ADL Care for Resident
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care to a resident who required assistance with toileting. The resident, who was cognitively intact and frequently incontinent of urine, was not offered incontinent care during the 11:00 PM to 7:00 AM shift. The resident reported that they were last provided care at 9:00 PM and were not checked on until 6:00 AM the following morning, resulting in the resident being soaked with urine. The Point of Care History confirmed that incontinent care did not occur during the night shift. The nursing assistant (NA #3) assigned to the resident during the night shift stated that they did not wake the resident for care unless the resident was awake and calling. This practice was contrary to the resident's care plan, which required assistance with transfers and toileting. The facility's policy directed that residents should be provided care to maintain their ability to carry out ADLs, including elimination and toileting needs. The interim Director of Nursing Services (DNS) confirmed that the resident was not offered toileting as required and provided education to the staff member involved.
Deficiencies in Pain Management and Appointment Coordination
Penalty
Summary
The facility failed to adequately address the pain management needs of a resident with a history of dysuria and bipolar disorder. The resident, who was cognitively intact, reported increasing pain and refused the offered acetaminophen, stating it would not alleviate the pain. Despite the resident's complaints of significant pain and refusal of the medication, the nursing staff did not conduct a thorough assessment or notify the appropriate medical personnel for further evaluation and potential adjustment of the pain management plan. The lack of communication and assessment led to the resident being told that the only alternative was to go to the hospital. In another incident, the facility failed to ensure a resident with cardiac issues attended a scheduled cardiologist appointment. The resident, who was dependent on staff for wheelchair mobility, missed the appointment due to the absence of a staff escort. Although the transport van arrived, the resident was unable to attend the appointment because the assigned escort was not present, and no alternative arrangements were made. The facility's policy did not provide a clear process for handling situations where an escort was unavailable, leading to the resident missing a critical medical appointment. These deficiencies highlight a lack of proper communication and coordination among the facility's staff, resulting in inadequate care and support for the residents. The failure to assess and address the resident's pain and the oversight in ensuring the resident's attendance at a medical appointment demonstrate significant lapses in the facility's operational procedures.
Failure to Follow Physician Orders and Assess Incontinence
Penalty
Summary
The facility failed to follow the discharge summary physician's order for a resident diagnosed with urinary retention. The resident, who was cognitively intact and required maximum assistance with personal hygiene, returned from the hospital with a diagnosis of urinary retention. The physician's order required bladder scans every six hours while awake and intermittent catheterization for post-void residual urine greater than 600. However, the facility did not have a bladder scanner, and there was no documentation of voiding trials, bladder scans, or intermittent catheterizations in the Treatment Administration Record. The nursing supervisor and unit secretary were unaware of the order, and the care plan did not include revised interventions for urinary retention. Another resident, who was frequently incontinent of bowel and bladder, was not assessed for participation in a bowel and bladder retraining program. The resident was cognitively intact, required substantial assistance for toileting, and was frequently incontinent. Despite being noted as frequently incontinent on the Minimum Data Set assessments, there was no evidence of an evaluation for a bowel and bladder program. The care plan included interventions for incontinence care but did not address retraining. Interviews with staff revealed a lack of documentation and awareness of the resident's incontinence management needs. The facility's policies for managing urinary retention and bowel and bladder programs were not followed. The policy for urinary retention included catheterization as appropriate, but this was not implemented due to the lack of a bladder scanner. The bowel and bladder program policy required assessment for participation in a program for residents with frequent incontinence, but this was not conducted for the resident in question. The deficiencies highlight a failure to adhere to physician orders and facility policies, resulting in inadequate care for residents with urinary and bowel incontinence issues.
Failure to Monitor Resident's Weight Accurately
Penalty
Summary
The facility failed to ensure timely and accurate weight monitoring for a resident at nutritional risk, leading to a deficiency in maintaining the resident's health. Resident #105, who had diagnoses including diabetes mellitus and abnormal weight loss, was readmitted to the facility on 9/11/2024. However, the facility did not obtain a readmission weight within the required 24 hours, as per their policy. Subsequent weights were not consistently recorded or verified, with invalid entries noted in November 2024, leaving no accurate monthly weight for that month. This lack of timely and accurate weight monitoring was critical for Resident #105, who was identified as being at nutritional risk. The facility's policy required reweights for any resident displaying a significant weight change, but this was not consistently followed. Despite the dietician's requests for reweights and discussions during at-risk meetings, the nursing staff did not obtain the necessary reweights promptly. The weight book lacked documentation for November 2024, and the computer system showed invalid weights that were not reverified. This failure to adhere to the facility's weight policy and ensure accurate weight monitoring contributed to the deficiency, as Resident #105 experienced significant weight fluctuations without appropriate intervention or documentation.
Failure to Maintain Respiratory Equipment Due to Power Outage
Penalty
Summary
The facility failed to ensure that respiratory equipment was in working condition for a resident with significant respiratory needs. Resident #78, who had a history of malignant neoplasm of the larynx, acute respiratory failure with hypoxia, and pulmonary hypertension, was left without power in their room, rendering their suction machine inoperable. The resident reported the power outage to staff on Friday, but the issue was not addressed until Monday. The resident's care plan required regular suctioning of the laryngectomy tube, which was compromised due to the lack of power. Interviews with various staff members revealed a lack of awareness and communication regarding the power outage. The maintenance staff identified the issue as a tripped breaker but did not ensure immediate resolution or communicate effectively with nursing staff. The Director of Maintenance and the DNS were unaware of the outage until it was brought to their attention by the surveyor. The facility lacked a policy on power outages, and there were no battery-powered suction machines available, leaving the resident at risk without a backup plan in place.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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