Autumn Lake Healthcare At Glen Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Danbury, Connecticut.
- Location
- 1 Glen Hill Rd, Danbury, Connecticut 06811
- CMS Provider Number
- 075031
- Inspections on file
- 15
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Glen Hill during CMS and state inspections, most recent first.
An open, overflowing garbage can was observed without a lid and placed near the steam table during meal plating, remaining uncovered for about half an hour. The Dietary Manager acknowledged that the garbage can should have been covered and not in proximity to the food service area, in accordance with facility policy requiring sanitary conditions and covered trash containers.
Two residents with cognitive impairment and special dietary needs were left waiting for lunch while another resident at their table was served and ate, resulting in delays of over an hour before the waiting residents received their meals. Staff confirmed that all residents at a table should be served at the same time, and acknowledged the delay was not standard practice.
A resident with severe cognitive impairment and total dependence on staff was found with a fractured thumb of unknown origin. The facility failed to conduct a thorough investigation, as required by policy, by not identifying or interviewing all staff involved in the resident's care or documenting how care was provided during the relevant period.
A resident who was totally dependent on staff did not receive care according to their care plan, which required two staff members for all care, resulting in care being provided by only one staff member. Another resident with respiratory issues did not have interventions for respiratory care or hearing aid maintenance included in their care plan, despite staff acknowledging these omissions. The facility failed to ensure care plans were comprehensive and followed as required.
A resident with overactive bladder, urge incontinence, and CHF was identified as a good candidate for scheduled toileting by multiple screeners and urology consults, but the care plan was not updated to reflect these findings or specialist recommendations. The care plan continued to state the resident could not participate in retraining, and no toileting program was trialed, despite the resident being cognitively intact and requiring substantial assistance with toileting.
A resident with chronic health conditions who required assistance with toileting and preferred female caregivers experienced a significant delay in receiving incontinence care. Despite the care plan reflecting this preference, the resident waited over an hour for a female aide to become available, as the unit was staffed with two male aides and only one female aide. Staff interviews confirmed the delay and the challenges in accommodating resident preferences during the shift.
A resident with overactive bladder, urge incontinence, CHF, and a history of bladder cancer was identified as a good candidate for bladder retraining and scheduled toileting by multiple quarterly screeners and urology consults. Despite being cognitively intact and able to participate, no toileting program was initiated, and the care plan focused only on perineal care and monitoring. The lack of communication and follow-through on screener results and specialist recommendations led to a failure to provide appropriate continence care.
A resident with a history of acute respiratory failure and pneumonia had a standing order for continuous oxygen, but was observed multiple times without oxygen in use and confirmed not receiving it. The care plan lacked respiratory interventions, and staff interviews revealed the resident had been titrated off oxygen without updating the physician's order. Nursing staff and the DNS acknowledged the lapse in ensuring orders were current and accurately implemented.
A resident with a suprapubic urinary catheter was observed multiple times with their foley catheter drainage bag dragging on or touching the floor while attached to their wheelchair, despite facility policy and care plan directives requiring the bag to be kept off the floor. The deficiency was confirmed by the Infection Control Preventionist, who stated that staff are responsible for ensuring proper positioning of the drainage bag.
A resident with severe cognitive impairment and significant physical limitations was left alone on the toilet by a nurse aide who stepped out to retrieve supplies. During the absence, the resident attempted to stand, fell, and sustained injuries to the forehead and knee, despite care plan interventions specifying the resident should not be left alone.
The facility did not make grievance forms accessible to residents, family members, or visitors, and residents were not informed about how to file grievances. During interviews, multiple residents reported being unaware of the grievance process or the location of forms. Observations confirmed the absence of forms on units and that posted policies were not easily visible or instructive for those in wheelchairs. Staff could not provide evidence that the grievance process had been reviewed with residents.
Uncovered Garbage Can Near Food Service Area
Penalty
Summary
During the noon meal plating service, an open industrial garbage can filled to the top with trash was observed without a lid and positioned approximately 15 feet from the steam table where food was being plated. The garbage can remained open for about half an hour during the food service period. The Dietary Manager confirmed that the garbage can should have been covered and not located near the steam table during meal service, and that all kitchen staff are responsible for ensuring trash containers are covered and removed from the serving area. Facility policy requires all food preparation and service areas to be maintained in safe and sanitary conditions, including keeping all trash containers covered in leak-proof containers to prevent cross-contamination.
Failure to Serve Meals Simultaneously Compromises Resident Dignity
Penalty
Summary
Two residents with cognitive impairment and dysphagia were observed waiting for lunch in the lounge area while another resident at their table received their meal significantly earlier. One resident received their meal 1 hour and 50 minutes after the other, while the second resident waited 1 hour and 5 minutes. Both residents were care planned for nutritional risk and required specific dietary accommodations, but were left to watch another resident eat while they waited for their own meals. Staff interviews confirmed that all residents at a table should be served at the same time, and that it was not normal practice for residents to wait such a long period while others ate. The delay in meal service was attributed to the kitchen staff delivering one resident's tray at the time meals were served in the main dining room, while the other two residents' trays were not brought until much later. The nurse aide acknowledged that she should have either provided snacks or obtained the trays for the waiting residents, and reported the delay to the kitchen staff. Facility policy on resident rights emphasized dignity and respect, but a specific dining policy was not provided upon request.
Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an injury of unknown origin sustained by a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis. The resident was totally dependent on staff for all activities of daily living and required two-person assistance for bed mobility and transfers, as documented in the care plan. The resident was found with a swollen, red left thumb, which was later diagnosed as a fracture. The incident was reported as a reportable event, and the responsible party and physician were notified. The investigation initiated by the Director of Nursing Services (DNS) was incomplete. Statements from nurse aides and licensed staff did not identify which staff provided care to the resident during the relevant shifts, nor did they provide details about how care was delivered or whether any unusual occurrences took place. The DNS was unable to determine who provided care to the resident on the day prior to the injury, and some staff could not recall their involvement. Additionally, the DNS did not directly interview all relevant staff, and the investigation lacked documentation and clarity regarding the circumstances of the injury. Medical review revealed conflicting diagnoses regarding the nature of the fracture, with initial suggestions of a pathological fracture due to osteoporosis, but later clarification indicated it was not pathological. The facility's abuse policy requires immediate and thorough investigation of injuries of unknown origin, including identification and interviews of all involved individuals, but this was not followed in this case, resulting in an incomplete investigation.
Failure to Follow and Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis, who was totally dependent on staff for personal hygiene, transfers, toileting, and bed mobility, did not receive care according to their individualized care plan. The care plan and care card specified that two staff members were required to assist with all care, including bed mobility. However, a nursing assistant was observed providing care alone, despite being aware of the two-person assistance requirement. This deviation from the care plan was identified during an investigation into an injury of unknown origin, specifically a fractured left thumb, which may have resulted from care being provided by only one staff member. Another deficiency was identified for a resident with acute respiratory failure, hypoxia, pneumonia, and insomnia. The resident was cognitively intact and required oxygen therapy. The care plan for this resident did not include any interventions to address respiratory care needs, nor did it document any behaviors related to refusal of care. Nursing staff acknowledged that the omission of respiratory interventions was an oversight and that all residents on oxygen should have a care plan addressing this need. Additionally, the same resident was observed using hearing aids, but the care plan did not include interventions for the care or maintenance of the hearing aids. Staff interviews confirmed that the facility is responsible for the care and maintenance of hearing aids and that this should have been included in the care plan. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents in question.
Failure to Revise Care Plan for Incontinence Management
Penalty
Summary
The facility failed to revise the care plan for a resident with overactive bladder, urge incontinence, and congestive heart failure to reflect the resident's current status and needs. Despite multiple quarterly Bowel and Bladder Program Screeners and urology consults indicating the resident was a good candidate for scheduled toileting (timed voiding), the care plan continued to state the resident was unable to cognitively or physically participate in a retraining program due to impaired mobility. The resident was cognitively intact and required substantial assistance with toileting, but no trial of a toileting program was initiated, and the care plan was not updated to reflect recommendations from the urologist or the results of the screeners. Physician orders and specialist recommendations advised interventions such as timed toileting, limiting nighttime fluids, and avoiding irritants, but these were not incorporated into the care plan. The Director of Nursing Services confirmed that the care plan had not been updated to reflect the resident's candidacy for retraining or the recommendations from the urologist, and that the resident had not been interviewed regarding their wishes for a toileting program. Facility policy required ongoing revision of care plans as resident conditions changed, but this was not followed in this case.
Delay in Incontinence Care Due to Staffing and Resident Preference
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and heart disease, who was cognitively intact and required partial to moderate assistance for toileting hygiene, did not receive prompt incontinence care. The resident, who was frequently incontinent of the bladder and had a documented preference for female caregivers, reported having to wait approximately two hours for incontinence care after an episode. Staff interviews confirmed that on a specific evening, the resident requested assistance from a male aide but declined care, expressing a preference for a female aide. The male aide informed the resident that they would need to wait for the female aide to become available, and the resident ultimately waited about one hour to one hour and fifteen minutes before receiving care from a female aide. Further interviews with nursing staff revealed that the unit was staffed with two male aides and one female aide at the time, and the challenge of accommodating multiple female residents' preferences for female caregivers was noted. The LPN on duty was unable to assist due to other responsibilities, and the nursing supervisor was notified of the staffing issue. The care plan for the resident had been updated to reflect the preference for female caregivers, but the resident still experienced a significant delay in receiving incontinence care.
Failure to Implement Scheduled Toileting for Incontinent Resident
Penalty
Summary
The facility failed to implement appropriate interventions to restore or manage bladder and bowel continence for a resident with a history of overactive bladder, urge incontinence, congestive heart failure, and prior bladder cancer. Despite multiple quarterly Bowel and Bladder Program Screeners indicating the resident was a good candidate for retraining or scheduled toileting, and urology consults recommending timed toileting and other interventions, there was no evidence that a toileting program or bladder retraining was trialed. The resident was cognitively intact, required substantial assistance with toileting, and had functional limitations, but the care plan and clinical record did not reflect any attempt to initiate a toileting program as recommended by both the screeners and the urologist. The care plan interventions focused on perineal care, monitoring for infection, and use of disposable briefs, but did not address the recommendations for scheduled toileting or retraining. Physician orders for medications related to bowel and bladder management were present, but the lack of communication and follow-through on the results of the continence screeners and urology recommendations led to a failure in providing appropriate care aimed at restoring or improving continence. The Director of Nursing confirmed that the nursing staff did not inform the care team of the screener results, resulting in missed opportunities to trial a toileting program.
Failure to Maintain Current Physician's Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including acute respiratory failure with hypoxia and pneumonia had a physician's order for continuous oxygen at 1 liter per minute via nasal cannula. Despite this order, multiple observations over several days showed the resident was not receiving oxygen, and the oxygen machine in the room was not in use. The resident confirmed not having received oxygen, and there was no documentation of refusal of treatment in the nurse's notes. The care plan did not include interventions for respiratory care, nor did it document any refusal behaviors. Interviews with staff revealed that the resident had been titrated off oxygen the previous week, but the physician's orders had not been updated to reflect this change. Nursing staff acknowledged responsibility for ensuring orders are accurate and implemented as written. The Director of Nursing Services (DNS) stated that orders should be updated immediately when changes occur but could not explain why the resident was not receiving oxygen as ordered or why the orders were not current. The physician's order was only updated after inquiry to reflect as-needed oxygen administration.
Foley Catheter Drainage Bag Found Touching Floor During Resident Transport
Penalty
Summary
A deficiency was identified when a resident with a suprapubic urinary catheter was observed multiple times with their foley catheter drainage bag attached to the back of their wheelchair, dragging on or touching the floor as the wheelchair was moved. The resident had diagnoses including congenital stricture of the urethra, obstructive and reflex uropathy, and urinary retention, and required moderate assistance for personal hygiene, dressing, and transfers. The resident's care plan and physician orders specified interventions for catheter care, including keeping the drainage bag below the level of the bladder and off the floor, but these were not followed during the observed periods. The facility's policy on urinary catheter care directed that catheter tubing and drainage bags be kept off the floor and handled with clean technique. Despite these requirements, the drainage bag was repeatedly seen touching the floor during several observations. The Infection Control Preventionist confirmed that the drainage bag should not be dragging or touching the floor and that staff responsible for the resident's care should ensure proper positioning of the drainage bag throughout the shift.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, stroke with right-sided hemiplegia and hemiparesis, and vascular dementia was left unsupervised in the bathroom. The resident was severely cognitively impaired and required maximal assistance with toileting hygiene, personal hygiene, and toilet transfers, as documented in the Minimum Data Set assessment. The resident's care plan specifically identified falls as a concern and included interventions such as not leaving the resident alone and gathering all necessary items before providing care. Despite these interventions, a nurse aide left the resident alone on the toilet to retrieve an incontinent brief from the hallway. During this time, the resident stood up without assistance, fell forward, and sustained injuries including an abrasion and large bump to the forehead and an abrasion to the left knee. The incident was confirmed through clinical record review, staff interviews, and direct observation of the resident's injuries. The facility's policy required staff to implement interventions tailored to the resident's fall risk, which was not followed in this instance.
Failure to Ensure Grievance Process Accessibility and Resident Awareness
Penalty
Summary
The facility failed to ensure that grievance forms were readily available to residents, family members, and visitors, and did not adequately inform residents about the process for filing grievances. During a meeting with twelve residents who regularly attend resident council meetings, all participants stated they were unaware of the grievance process and did not know where the forms were located. Further interviews and observations revealed that no grievance forms were present on the units, and only an empty folder was found in a file drawer. The posted grievance policy was placed high above the State Ombudsman contact form, making it difficult for individuals in wheelchairs to see or read, and the policy did not provide instructions on how to obtain a form or who to contact. Although a social worker stated that the grievance process had been reviewed with residents, no evidence of this could be provided. The facility's policy supported the right to voice grievances but lacked a date and did not ensure accessibility or awareness of the grievance process.
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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