Autumn Lake Healthcare At Norwalk
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, Connecticut.
- Location
- 34 Midrocks Drive, Norwalk, Connecticut 06851
- CMS Provider Number
- 075387
- Inspections on file
- 24
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Norwalk during CMS and state inspections, most recent first.
A facility-wide rule restricted residents from going to the front patio without staff or family accompaniment, even for residents who were cognitively intact, independent, and low risk for elopement. Two residents who enjoyed the outdoors reported they had previously gone outside on their own and were only told about the new requirement when they tried to go out. Staff confirmed the change was newly implemented, residents were not informed in advance, and the facility could not provide a written policy for outdoor access.
Missed Scheduled Showers for a Resident: A resident who was cognitively intact and dependent for bathing was scheduled for showers twice weekly based on preference, but the facility record showed repeated missed showers, especially on Mondays, with baths given instead. An NA stated the resident did not refuse showers but often wanted them later in the morning, and dining room duties prevented accommodating the requested time; an LPN was not aware the resident had been missing the scheduled showers.
Incomplete Nurse Aide Resident Care Competencies: The facility failed to ensure all Nurse Aide Resident Care competencies were completed for 2025. The Facility Assessment identified the need for staff training, education, and skill checks to support the resident population, but the ADNS stated that only IV care competencies had been completed after taking over staff development late in the year and that work on the remaining competencies had just begun.
Improper storage and labeling of IV supplies were observed in multiple medication rooms and in a resident’s room. A resident receiving IV meds had pharmacy-labeled normal saline flushes hanging from the IV pole in the room, while other saline syringes were stored as house stock in medication room drawers, and additional IV meds and unlabeled IV tubing and caps were found in a first-floor medication room. Staff stated resident supplies were being placed together and used for other residents, and saline flushes were also used for wound care.
PPE was not readily available at the point of care for a resident on EBP with diverticulitis with perforation and an ileostomy, and disposal bins were not placed inside the rooms of five residents on EBP, including residents with wounds, a history of VRE, and a wound with an ostomy. Surveyors observed staff would need to leave the immediate care area to retrieve gowns and gloves, and hallway bins required staff to exit rooms while still wearing contaminated PPE.
The deficiency centers on multiple residents for whom staff did not follow physician orders or facility protocols related to falls, acute changes in condition, and vascular access management. One resident with prior toe fractures and multiple psychoactive and pain medications reported slipping in an elevator, but staff did not classify it as a fall, did not notify the RN supervisor, and did not complete required assessments or accident/incident documentation. Another resident with dementia and cardiovascular issues was found pale and unresponsive, sent to the ER, yet there was no RN assessment or detailed documentation of the event, EMS involvement, or condition at transfer as required by policy. A third resident with sepsis was admitted with a midline catheter, but staff obtained and followed central line orders instead, failed to enter appropriate midline orders on the MAR/TAR, and did not document dressing changes, flushes, or routine site assessments per midline policy. Additionally, a cognitively intact resident with ESRD left the facility alone using a ride-share despite an active order requiring a responsible party for leave of absence, meaning the resident departed without adherence to the existing LOA order.
A resident with dementia and prior cerebral infarction experienced an acute change in condition, becoming pale and unresponsive in a wheelchair. Staff notified a physician, obtained an order to send the resident to the ER, called 911, and documented some vital signs and notifications, but there was no RN assessment documented before transfer. The DON later confirmed the record lacked key details such as the exact time of the incident, EMS arrival and departure times, the resident’s level of alertness at transfer, and evidence that a face sheet and report were provided to the hospital. An LPN reported checking blood sugar, performing a sternal rub, and moving the resident to bed as the resident began to recover, but none of this care was recorded, contrary to facility policy requiring documentation of changes in condition and related events.
Failure to Provide Written Notice Before Room Change: A resident with PTSD, panic disorder, and severe morbid obesity was moved from a private room to a double room for infection control needs. Staff said the resident was verbally notified and the family agreed, but the chart contained no written notice before the room change, despite facility policy requiring written notice with the reason for the move.
A resident with metabolic encephalopathy and documented hearing impairment was not accurately assessed in the admission MDS, which stated the resident had adequate hearing and was cognitively intact. Clinical notes, room signage, and staff interviews showed the resident could not hear and used a communication device to communicate effectively, but the MDS nurse acknowledged the assessment did not reflect the resident’s actual status.
A resident with metabolic encephalopathy and hearing impairment did not have hearing loss and communication interventions added to the baseline care plan within 48 hours of admission. Although the resident was described as hard of hearing and later used a communication device, the MDS nurse confirmed the care plan did not identify the hearing deficit, and the charge nurse could not explain why the baseline care plan was not developed to address it.
Incomplete Care Planning for Hearing Loss and Dementia: The facility failed to develop comprehensive care plans for two residents with communication and cognitive needs. One resident with metabolic encephalopathy and hearing impairment had later notes showing cognitive deficit, use of a communication device, and a room sign directing staff to use writing supplies, but the care plan lacked documented goals, timetables, and interventions. Another resident with dementia had admission documentation showing severe cognitive impairment and MDS findings indicating care planning was needed, yet staff could not locate a dementia care plan.
A resident with multiple chronic conditions, recent toe fractures, and psychoactive, opioid, and antipsychotic medications was observed ambulating in socks/gripper socks instead of appropriate footwear, with clutter narrowing the walking path in the room. After repeated slip/fall-related events, the record lacked evidence of nursing assessment, change-in-condition documentation, provider notification, or care plan updates addressing the ongoing fall risk. In a separate finding, multiple cigarette butts were found in the patio/common area of a non-smoking facility.
A resident with ESRD receiving specialized treatment three times weekly had no physician orders documenting the type, location, assessment, or care of the venous access site, even though staff identified a chest port and referenced access-site checks. The facility policy required orders for the access route and AV access precautions, but staff could not locate the needed orders. The resident also had PRN orders for Milk of Magnesia and a Fleet enema, and Milk of Magnesia was administered despite the facility’s specialized treatment policy listing it as a medication to be avoided.
A resident with multiple chronic diagnoses, including cognitive and behavioral concerns, had a pharmacy recommendation for behavior monitoring related to PRN trazodone, but the EMR showed no physician response and no behavioral monitoring was documented. The resident was observed in activity, groomed appropriately, and agitated but easily redirected; the DNS confirmed nursing was responsible for following up on the pharmacy recommendation.
Unnecessary Medication: Missing Stop Date for Pain Medication. A resident with multiple diagnoses, including chronic pain and acute respiratory failure with hypoxia, was ordered Oxycontin ER 50 mg for pain with no stop date or revaluation on the physician order and MAR. During observation, the resident was alert and oriented and receiving morning care. The DNS and ADNS stated they could not see a stop date for the narcotic order and noted unit management was responsible for auditing narcotics for stop dates.
A resident with severe cognitive impairment and multiple medical conditions had conflicting code status documentation in their records, with a DNR form signed by an unauthorized contact and a full code order in the electronic record. When the resident was found unresponsive, staff initiated CPR after confirming code status with the legal representative, but the inconsistency in documentation was confirmed by staff and administration.
A resident with severe cognitive impairment and a court-appointed conservator was found unresponsive and later pronounced deceased after CPR efforts. Although nursing staff notified the conservator of the resident's death by phone, they failed to document this notification in the medical record as required by facility policy.
A resident reported missing personal clothing items, which were not returned despite inquiries and reports to staff. The facility also failed to maintain a clean and homelike environment, with numerous issues such as soiled furniture and unclean bathrooms observed. The facility was undergoing renovations, but many issues remained unaddressed, and there was a lack of awareness among staff about the deficiencies.
A facility failed to maintain sanitary conditions during food preparation. A staff member was observed thawing chicken in a three-compartment sink filled with dirty pots and soap suds, without wearing gloves. The Dining Services Director and Dietitian were unaware of the issue, and the staff member used the sink due to the designated meat preparation sink being occupied. This practice violated the facility's policy and FDA guidelines.
A resident's request for a specific hospice provider was not honored due to miscommunication about contract availability. Despite the resident's representative requesting Hospice Agency #1, the facility admitted the resident to Hospice Agency #2, citing a lack of contract. Interviews revealed the facility could have arranged a one-time contract with the preferred provider, highlighting a failure to respect the resident's rights.
A resident experienced restricted access to personal funds managed by the facility, despite having intact cognition and being entitled to monthly disbursements. The Business Office Manager was on leave, and the administrator was temporarily covering fund access, but the process was unclear outside of designated hours. The resident also faced delays in receiving social security checks, and the facility failed to provide a policy on fund access during posted banking hours.
A resident's personal funds were mismanaged by the facility, with missing quarterly statements and discrepancies in financial records. The facility's Business Office Manager was on leave, and the Administrator was covering the position. An outside accounting firm was involved, but there were inconsistencies in the accounting documents, and the resident's name was missing from the Funds Balance Report. The facility failed to follow its policy on resident rights and personal needs allowance, leading to a lack of transparency in financial reporting.
The facility failed to document advance directives for two residents shortly after admission. One resident, with impaired cognition, had blank forms over two months post-admission, while another resident's form lacked specific treatment options despite a verbal request for full code status. The facility's policy requires these forms to be completed upon admission, but this was not adhered to, leading to the deficiency.
A resident returned from the hospital with a potential shoulder dislocation, but the facility failed to notify the physician as required. The resident had a history of falls and required assistance for transfers. Despite the facility's policy to notify physicians of significant changes, there was no documentation of such notification.
A facility failed to complete a timely PASARR rescreen for a resident with mental health diagnoses, including schizoaffective disorder and schizophrenia. The resident was admitted with a 30-day hospital discharge exemption, requiring a rescreen if the stay extended beyond this period. The rescreen was conducted 10 days after the exemption expired, contrary to the facility's policy and federal regulations.
The facility failed to notify the state mental health authority of significant changes in the mental health diagnoses of two residents. One resident, initially diagnosed with anxiety and bipolar disorder, later received a dementia diagnosis, which was not updated in the PASARR. Another resident's diagnosis changed from major depression to situational depression episodes, but the state was not informed. The social worker was unaware of the requirement to update the PASARR, leading to a deficiency.
A facility failed to develop a comprehensive care plan for a resident with dementia, despite the resident receiving anti-psychotic medication and having a documented diagnosis of non-Alzheimer's dementia. Interviews with the DNS and social services indicated an expectation for a dementia care plan, but it was not included in the comprehensive care plan. The MDS coordinator, who typically initiates such plans, was unavailable for interview.
A resident with intact cognition and multiple diagnoses was not invited to care conferences, and no conferences were documented for over six months. Interviews with staff revealed issues with scheduling and executing these conferences, despite facility policies mandating resident participation.
The facility failed to ensure RN assessments were conducted after falls for two residents, leading to improper handling and documentation of injuries. Resident #6, with multiple fractures, was moved without an RN assessment, and a bruise was not properly evaluated. Resident #112 experienced falls without RN assessments, contrary to facility policy.
The facility failed to maintain correct air mattress settings for a resident with dementia and COPD, and did not ensure a helmet was consistently worn by another resident with a history of stroke. The air mattress was set incorrectly multiple times, and the helmet was not documented as worn when the resident was out of bed, with no physician's order obtained for its use.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in deficiencies. One resident was admitted with a history of pressure ulcers and did not receive consistent skin assessments or Braden Scale evaluations, leading to the development of a new ulcer. Another resident, admitted with an unstageable pressure ulcer, also did not receive required assessments, resulting in new pressure ulcers on the heels. Staff interviews revealed a lack of adherence to facility policies and documentation requirements.
The facility failed to provide adequate supervision and intervention for residents, leading to deficiencies in fall prevention, smoking policy enforcement, and elopement risk management. A nurse aide was found asleep while supervising residents in a fall prevention program, a resident repeatedly violated the non-smoking policy, and another resident at risk of elopement was able to leave the facility unattended. These incidents highlight lapses in adherence to facility policies and procedures.
A resident with multiple diagnoses, including phantom limb syndrome, did not receive a PRN dose of Hydromorphone for severe pain as requested. Despite multiple requests during a shift, the LPN failed to administer the medication, citing being busy. The resident suffered from pain throughout the night, and staff interviews revealed a lack of adherence to physician's orders for PRN medication administration.
The facility failed to ensure consistent completion of shift-to-shift controlled drugs counts for two medication carts. On the first floor, the 1B unit's controlled drugs count record for July 2024 was missing 11 signatures across all shifts. Similarly, on the third floor, the 3 AB unit's record was missing 8 signatures. The DNS and ADNS were unaware of these issues until they were highlighted during observations. The facility's policy requires nurses to count controlled drugs at each shift change and sign the record, which was not adhered to.
The facility failed to store PPE in a sanitary manner for a resident on transmission-based precautions. An LPN identified an isolation cart with PPE stored on the floor in a missing drawer slot. The LPN could not explain the missing drawer or the floor storage. Facility policy requires PPE to be stored according to guidelines and instructions.
Restriction of Outdoor Access Without Individualized Assessment and Delayed Notice of Rule Change
Penalty
Summary
The facility failed to ensure residents were not restricted from an outdoor common area without an individualized assessment and failed to notify residents of rule changes. Resident #62 had diagnoses including polyneuropathy and insomnia, was cognitively intact, and was assessed as independent with transfers and walking at least 150 feet using a two-wheeled walker. Records also showed low elopement risk, low fall risk, and that the resident enjoyed outdoor activities, walking, and people watching. The care plan noted the resident enjoyed walking and included encouragement to walk following facility guidelines, with ambulation on/off the unit and in the community for leave of absence listed as independent. Resident #62 stated that the resident had previously been able to go outside without a problem and was first told on 3/10/2026 that a staff member now had to accompany them outside. The resident said this was a new requirement and that the front area was preferred because it had more activity and people to watch. In a later interview, the resident stated the facility told residents they could use the back courtyard/garden or the smaller side patio, but those areas were less desirable because they were behind the building and did not provide the same opportunity for people watching. Resident #80 had diagnoses including brain injury and mild cognitive impairment, was assessed as cognitively intact, had no wandering behaviors, and identified going outside for fresh air when the weather was good as very important. The resident enjoyed the outdoors and was observed self-propelling in a wheelchair in the main lobby while stating the requirement to have staff accompany residents outside did not make sense. The resident reported the rule was new and that prior to 3/9/2026 the resident had gone outside independently. Staff interviews confirmed the rule was newly implemented, applied facility-wide to all residents including those considered independent or oriented, and residents were not informed until they began asking to go outside. The Recreation Director, reception staff, and Administrator all described the new restriction, and the facility was unable to provide a written policy addressing residents' access to the outdoors.
Missed Scheduled Showers for a Resident
Penalty
Summary
The facility failed to ensure that Resident #57 received scheduled showers according to the resident’s preferences. Resident #57 had diagnoses of muscle weakness and difficulty walking, and the annual MDS identified the resident as cognitively intact, dependent for showering and bathing, and requiring partial to moderate assistance for tub and shower transfers. The MDS also indicated the resident had not exhibited behaviors of rejection of care. During interview, Resident #57 stated a preference for two showers weekly, on Mondays and Thursdays, but reported usually missing the Monday shower. The facility shower schedule showed Resident #57 was assigned showers on Mondays and Thursdays during the 7:00 AM to 3:00 PM shift. The nurse aide care card did not identify shower frequency or any refusal of showers, though it did indicate the resident required assistance with bathing. The bathing flowsheet from 2/1/2026 through 3/10/2026 showed missed Monday showers on 2/9, 2/16, 2/23, 3/2, and 3/9, and a missed Thursday shower on 2/26; on those days, the resident received a bath instead of a shower. NA#8 stated the resident did not refuse showers, but often preferred to sleep in on Mondays and sometimes requested a shower as late as 11:45 A.M.; because the aide had dining room responsibilities and could not accommodate that time, a bed bath was provided instead. The Unit Manager/LPN stated she was not aware the resident had been missing Monday showers and would have worked with the resident on finding a time for showers.
Incomplete Nurse Aide Resident Care Competencies
Penalty
Summary
The facility failed to ensure that all Nurse Aide Resident Care competencies were completed for 2025. The Facility Assessment Tool reviewed on 1/13/2026 indicated that staff training, education, and competency skill checks were necessary to provide the level and types of support and care needed for the resident population. During an interview and document review on 3/13/2026 at 11:23 AM, the ADNS, who was responsible for staff development, stated that the Nurse Aide Resident Care competencies had been completed in 2024. The ADNS further stated that after being given the responsibility late in 2025, only the IV Care competencies for nurse aides had been completed and that work was just beginning toward completion of all competencies.
Improper Storage and Labeling of IV Supplies
Penalty
Summary
Drugs and biologicals used in the facility were not stored and labeled in accordance with accepted professional principles. For Resident #38, who had sepsis, was cognitively intact, had an IV device, and was receiving IV medication, an observation and interview found a large bag of normal saline IV flushes labeled from the pharmacy for that resident hanging from the IV pole in the resident’s room. RN #1 stated the flushes should have been in the medication room and did not know why they were in the room. Additional observations of the medication rooms found saline solution syringes stored in drawers on the 3rd floor and 2nd floor medication rooms, with LPN #7 stating the flushes in the drawers were from discharged residents and were being used as house stock for other residents. In the first-floor medication room, a large three-drawer clear plastic chest was filled with IV flushes, and a box contained two dark brown plastic bags, one with a pharmacy label for Resident #38 containing multiple IV medications. Another box contained unlabeled IV supplies, including IV tubing and tubing caps. RN #1 stated all residents’ supplies were placed in one bin and used, and that saline flushes were also used for wound care. Administrative staff, including the DON, ADON, Administrator, and regional RNs, stated the current IV supply storage would be corrected immediately and that the current practice was not how it should be.
PPE Access and Disposal Deficiencies for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility did not ensure that PPE was readily accessible for a resident on Enhanced Barrier Precautions who had diverticulitis with perforation and an ileostomy. During multiple observations, a sign indicating EBP was posted outside the resident’s room, but gowns and gloves were not available at or immediately outside the point of care. Surveyors observed that staff would have to leave the immediate resident care area and go to a hallway storage location more than three rooms away to obtain PPE before providing care. The facility also did not ensure that trash receptacles were available inside the rooms of five residents on EBP. For residents with wounds, a resident with a history of VRE, and a resident with a wound and an ostomy, disposal bins were observed in the hallway outside the rooms rather than inside the rooms. This required staff to exit resident rooms while wearing contaminated PPE in order to dispose of used equipment.
Failure to Follow Physician Orders and Assessment Protocols for Falls, Acute Changes, and Vascular Access
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and facility policies for documentation, assessment, and vascular access management. One resident with multiple orthopedic, neurologic, cardiac, respiratory, and psychiatric diagnoses, who was cognitively intact and on psychoactive medications, opioids, and an antipsychotic, experienced a slip while exiting an elevator after having previously sustained toe fractures from a fall. Staff did not classify the elevator event as a fall, did not report it to the nursing supervisor on the day it occurred, and did not complete a nursing assessment or documentation at that time. The Assistant Director of Nursing Services later learned of the event directly from the resident the following morning and documented the resident’s report of slipping and having pain in the same previously injured foot. Staff reported that they did not complete an Accident and Incident report because the resident described the event as a slip rather than a fall, and the then-Director of Nursing Services had advised that no report was necessary. This was inconsistent with the MDS definition of a fall and with facility policies requiring documentation of changes in condition, evaluation of falls, and reporting of accidents and incidents. Another resident with dementia and a history of cerebral infarction had a documented care plan for altered cardiovascular status, including assessment of chest pain, shortness of breath, and cyanosis and reporting changes to the physician. On one occasion, this resident was found pale and unresponsive in a wheelchair, and the physician was notified with an order to send the resident to the emergency room. An LPN documented vital signs and notification of the physician and responsible party, and another LPN recalled checking the resident’s blood sugar and obtaining a minimal response to a sternal rub before transferring the resident to bed. The resident became more alert and was transferred to the hospital. However, there was no documented RN assessment in the clinical record prior to the transfer, no documentation of the exact time of the incident, no times for EMS arrival and departure, no description of the resident’s state of alertness at transfer, and no documentation of sending a face sheet or calling the hospital emergency room with report. This lack of RN assessment and incomplete documentation did not meet the facility’s Acute Condition Changes/RN Assessment Protocol, which required RN involvement and documentation when residents experienced acute changes in condition. A third resident with sepsis had been discharged from the hospital with a midline catheter placed in the upper arm for IV antibiotic therapy. The hospital discharge summary and intra-agency report identified the device as a midline catheter, and an outside IV company’s documentation described placement of a 12 cm midline catheter in a vein in the inner left arm, with instructions for midline care per protocol. However, the admitting nurse obtained physician orders for a central line catheter rather than a midline, including orders for central line observation, dressing changes, and flushing with normal saline followed by heparin. The facility did not use heparin in IVs, and the prepopulated heparin orders should have been removed. There were no appropriate midline-specific orders entered on the MAR/TAR for dressing changes, flushing, or routine site assessments, and there was no documentation that dressing changes or flushes had been completed since admission. The midline site was observed with a clear dressing and a manufacturer label stating "MIDLINE," but the clinical record lacked consistent documentation of care per the facility’s midline catheter policies, which required specific physician orders and detailed documentation of flushing, dressing changes, and site assessments. A fourth resident with type 2 diabetes, chronic kidney disease, ESRD on hemodialysis, psychiatric diagnoses, and mild cognitive impairment had a physician’s order allowing leave of absence only with a responsible party and medications. This resident was cognitively intact and psychiatrically stable at the time. On one occasion, the resident told staff they were going to the lobby but instead left the facility alone via a ride-share without notifying staff or signing out on LOA, contrary to the active physician order requiring accompaniment by a responsible party. Staff discovered the resident was no longer in the lobby and then determined the resident had gone to a local hospital to see a nephrologist. At the time of this event, the physician’s order had not yet been updated to allow independent LOA, and the resident’s departure without a responsible party was inconsistent with the existing order. This failure to follow the physician’s LOA order contributed to the overall deficiency in ensuring care and services were provided in accordance with physician directives and facility policies.
Incomplete and Inaccurate Documentation During Resident Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident with dementia and a history of cerebral infarction who experienced an acute change in condition. The resident’s quarterly MDS showed moderate cognitive decline, and the care plan directed staff to assess for chest pain, shortness of breath, cyanosis, and to report changes to the physician. On the date of the incident, a progress note labeled as a change in condition documented that the resident was observed sitting in a wheelchair, pale and unresponsive, that the physician was notified, an order was obtained to send the resident to the emergency room, and that 911 was called. The note further stated that while awaiting EMS, the resident became alert and returned to baseline but was still sent to the emergency room. A concurrent review assessment by an LPN recorded vital signs and notification of the physician and responsible party regarding the transfer. During interviews and record review, the DNS confirmed there was no RN assessment documented prior to the transfer, despite an expectation that an RN assessment would be written in the progress notes and, if an LPN documented the assessment, the RN would sign it. The DNS also reported that the record lacked documentation of the exact time of the incident, EMS arrival and departure times, the resident’s state of alertness at the time of transfer, and any indication that a face sheet with diagnoses, medications, and pertinent data was sent with the resident or that the hospital emergency room was called with report. An LPN working the 3–11 shift stated that upon being notified the resident was unresponsive in a wheelchair, blood sugar was checked (within normal range), a sternal rub was performed with minimal response, and the resident was moved to bed and began to “come around,” while the RN supervisor remained at the nurses’ station making calls and preparing transfer paperwork. None of this LPN’s described evaluation and care was documented in the clinical record. Another RN recalled seeing the resident in the wheelchair starting to come to but could not remember details. These omissions occurred despite a facility policy requiring documentation of changes in condition, events, incidents, or accidents involving the resident.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice before changing a resident’s room. Resident #9, who had diagnoses including severe morbid obesity, PTSD, and panic disorder, was moved from a private room to a double room on 1/23/2026. Social services documentation indicated the room change was related to infection control needs, and the resident’s family member agreed to the move. However, review of the electronic medical record and paper chart found no evidence that written notice was given to the resident before the room change. During interviews, the resident stated the move occurred without prior notice and believed the change may have been related to personal belongings or interactions with other residents. Social workers stated the facility learned a private isolation room was needed a couple of days in advance and verbally notified the resident, but also acknowledged that written notice was not provided for room changes. The facility policy for change of room or roommate stated that notice would be provided in writing and include the reason for the move or change.
MDS Assessment Did Not Reflect Resident’s Hearing Impairment
Penalty
Summary
The facility failed to comprehensively assess a resident with hearing loss in the comprehensive MDS assessment. Resident #38 had a diagnosis of metabolic encephalopathy, and the care plan conference summary dated 2/24/2026 described the resident as alert, oriented, hard of hearing, and able to make needs known. However, the admission MDS assessment indicated the resident was cognitively intact and had adequate hearing, which did not match later documentation in the clinical record. Provider encounter notes dated 2/27/2026 and 3/08/2026 documented that the resident had a cognitive deficit, hearing impairment, and was using a communication device. An observation in the resident’s room on 3/9/2026 found a sign stating the resident could not hear and that staff should use the communication device with writing supplies. The MDS nurse stated the assessment was most likely completed by nursing staff and acknowledged the hearing status was not accurately reflected. The SLP stated the resident could not hear and communicated effectively using the communication device, and the regular charge nurse stated staff used the communication device to ensure the resident understood questions being asked.
Baseline Care Plan Missing Hearing Loss Interventions
Penalty
Summary
The facility failed to add hearing loss and related interventions to the baseline care plan to meet Resident #38’s immediate needs within 48 hours of admission. Resident #38 had a diagnosis of metabolic encephalopathy, and the care plan conference summary dated 2/24/2026 indicated the 72-hour care plan meeting was held with a family member and caregiver present by phone, along with the RN supervisor, social worker, and therapy representatives. That summary stated Resident #38 was alert, oriented, hard of hearing, and able to make needs known. However, the admission MDS assessment indicated the resident was cognitively intact and had adequate hearing, while a provider encounter note dated 2/27/2026 documented a cognitive deficit and hearing impairment. A provider encounter note dated 3/8/2026 indicated Resident #38 was using a communication device. During an observation in the resident’s private room on 3/9/2026, a sign posted on the wall stated the resident could not hear and to use a communication device with writing supplies. The MDS nurse stated at that time that the resident’s care plan initiated on 2/23/2026 did not indicate the resident could not hear. The SLP stated the resident was on service for dysphagia, could not hear, and communicated effectively by using the communication device and then verbalizing answers or questions. The regular charge nurse stated the sign and communication device were brought in by the resident’s caregiver from home and could not explain why a baseline care plan had not been developed with an intervention for the resident’s hearing loss within 48 hours of admission.
Incomplete Care Planning for Hearing Loss and Dementia
Penalty
Summary
The facility failed to develop a comprehensive care plan with goals, timetables, and interventions for a resident with hearing loss and cognitive changes. Resident #38 had a diagnosis of metabolic encephalopathy. The care plan conference summary from the 72-hour care plan meeting documented that the resident was alert, oriented, hard of hearing, and able to make needs known, with a family member and caregiver participating by phone and facility staff present. However, the admission MDS assessment indicated the resident was cognitively intact and had adequate hearing, while later provider encounter notes documented a cognitive deficit, hearing impairment, and use of a communication device. An observation in the resident’s room showed a posted sign stating the resident could not hear and that a communication device with writing supplies should be used. During interview, the Regional MDS nurse stated it was up to the MDS nurse and nursing department to ensure the resident had a care plan and that the information was placed on the Nurse Aide Assignment Card. The facility also failed to ensure staff identified cognitive deficits and developed a plan of care for a resident with dementia. Resident #2 had a diagnosis of dementia. The nursing admission assessment documented the resident was rarely or never understood and had severe cognitive impairment. The admission MDS assessment documented moderate cognitive loss and indicated the facility was to proceed with care planning for dementia. During record review and interview, the MDS nurse could not find a dementia care plan even though the MDS indicated one with interventions to meet the resident’s cognitive needs. The Regional MDS nurse stated the social worker was responsible for the cognitive assessment and adding the care plan, and that the facility MDS nurse who completed the admission assessment should have added the care plan if it had not already been added by the social worker.
Unsafe Ambulatory Path, Inadequate Fall-Related Monitoring, and Cigarette Butts in Non-Smoking Area
Penalty
Summary
The facility failed to ensure that Resident #17’s environment was free of potential hazards and failed to provide adequate interventions to reduce fall risk during a period of increased vulnerability related to recent lower extremity injury. Resident #17 had diagnoses including orthopedic conditions, phantom limb syndrome with pain, cervical disc degeneration, chronic pain syndrome, cervical radiculopathy, heart failure, asthma, bipolar disorder, depression, anxiety, and schizoaffective disorder. The resident’s care plan noted a preference for gripper socks and declining shoes, with interventions to encourage shoes as tolerated and provide gripper socks as needed. The resident was cognitively intact, used no assistive device, required varying levels of ADL assistance, and was prescribed psychoactive medications, opioids, and an antipsychotic medication. After a witnessed fall with non-displaced fractures of several toes on the left foot, the resident was placed in a walking orthopedic shoe, later had a slip exiting an elevator without descending to the ground, and the record lacked evidence of nursing assessment, change-in-condition documentation, or provider notification after that event. The clinical record also lacked evidence that the care plan was updated to address environmental or safety risks after the repeated fall-related events. A physiatry note documented the reported slip and observed the resident ambulating in the hallway wearing socks, and an orthopedic follow-up documented the resident’s report of slipping on an unmarked wet floor with an ankle injury, after which a short orthopedic boot was fitted. Subsequent observations found clutter and multiple items obstructing or narrowing the resident’s walking path in the room, and the resident was observed ambulating in the room and hallways wearing gripper socks instead of appropriate footwear. The facility’s Falls Clinical Protocol directed staff and the physician to re-evaluate the situation and reconsider reasons for falling and current interventions when falls or fall-related events continue. In a separate finding, a tour of the front outdoor common area/patio identified multiple cigarette butts on the concrete patio and at least 33 cigarette butts on the grass near the patio, while the Administrator stated the building was non-smoking and staff and visitors were not allowed to smoke in the building or common areas.
Missing Dialysis Access Orders and Use of Prohibited Constipation Medications
Penalty
Summary
The facility failed to ensure physician orders were obtained for Resident #5’s specialized venous access site, including the type and location of the access and the assessment and care required for that site. Resident #5 had a diagnosis of End Stage Renal Failure and was ordered to attend a specialized service facility three times per week for treatment. During interview and observation, the charge nurse identified that the resident used a port in the upper chest for treatment, and that the access site would be checked for a dry and intact dressing. However, the charge nurse could not locate physician orders identifying the access site type, its location, or the ordered assessment and care for the site. The nursing supervisor also could not locate such orders and stated nurses would know not to take blood pressure on an arm with specialized venous access by looking at the physician’s orders, although no such orders were found. The facility policy for dialysis treatment indicated that physician orders should be carried to the treatment kardex and should include the type and location of the catheter or graft, as well as the days and times for appointments at the specialized service location. The policy also addressed care of AV access sites, including not using the arm for blood pressure or laboratory work and monitoring for bruit and thrill. In addition, the facility failed to avoid medications listed in its specialized treatment policy as medications to be avoided. Resident #5 had physician orders for Milk of Magnesia and a Fleet enema as needed for constipation, and the MAR showed Milk of Magnesia was administered twice. The nursing supervisor stated she did not know why the orders were present, and the MD later stated specialized treatment patients should not receive Milk of Magnesia.
Failure to Act on Pharmacy Recommendation for Behavioral Monitoring
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review was acted upon in a timely manner for a resident with diagnoses including adjustment disorder, atherosclerotic heart disease, cerebral infarction, hypertension, anemia, cystic disease of the liver and kidney, polyneuropathy, bradycardia, and osteoarthritis. A pharmacy recommendation report dated 11/9/25 identified that behavior monitoring was required for trazodone when necessary, but review of the electronic medical record from 11/10/25 through 3/17/26 did not show any physician response to that recommendation. The resident’s care plan dated 3/10/26 addressed impaired cognitive function/thought process and included monitoring and reporting changes in decision making, memory, recall, general awareness, difficulty understanding others, and level of consciousness. During observation on 3/17/26 at 11:15 AM, the resident was seen in a recreational activity, appropriately groomed, and noted to be agitated, though easily redirected by recreational staff. Review of the electronic medical record and interview with the DNS on 3/17/26 at 11:48 AM showed no behavioral monitoring had been conducted from 11/9/25 through 3/17/26 and no physician response to the pharmacy recommendation. The DNS stated that nursing was responsible for following up on pharmacy recommendations with the physician and indicated she could explain why this was not done.
Unnecessary Medication: Missing Stop Date for Pain Medication
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was cited after the facility failed to ensure a pain medication had a stop date for one resident. The resident had diagnoses including acute respiratory failure with hypoxia, right shoulder pain, chronic pain, acute ischemic heart disease, hypotension, gastro-esophageal reflux, diabetes mellitus type 2, obstructive sleep apnea, and anxiety. Physician orders dated 3/5/26 directed Oxycontin ER 50 mg, one tablet for pain, with no stop date, and the March 2026 MAR also directed the medication with no stop date or revaluation. During observation on 3/17/26 at 11:20 AM, the resident was alert and oriented, answering questions appropriately, and receiving morning care from a nurse aide while discussing care. During record review and interview on 3/17/26 at 11:31 AM, the DNS and ADNS stated they could not see a stop date for the Oxycontin ER order and said it was the responsibility of unit management during auditing to check narcotics for stop dates.
Failure to Ensure Accurate and Legally Authorized Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately obtained from the legal representative and that the medical record reflected the correct advance directives. The resident, who had diagnoses including dementia, hypertension, and cirrhosis of the liver, had a court-appointed Conservator of Person (COP) listed as the emergency contact. However, the advanced directive form in the record was signed by a different emergency contact who was not the legal representative, and the required signature from the COP and the physician was missing. Additionally, there was a discrepancy between the paper medical record, which indicated Do Not Resuscitate (DNR), and the electronic medical record, which indicated full code status (administer CPR). Physician orders and care plans also reflected conflicting code statuses. When the resident was found unresponsive, staff reviewed the chart and found both a DNR directive and a full code physician order. The COP was contacted and confirmed the resident was a full code, leading staff to initiate CPR. Emergency Medical Services (EMS) continued resuscitation efforts upon arrival, but the resident was ultimately pronounced deceased. Interviews with staff and facility leadership confirmed the inconsistency between the paper and electronic records and acknowledged that the advanced directive should have been signed by the COP. The facility's policy required that advance directives be signed by the appropriate legal representative and physician, which was not followed in this case.
Failure to Document Notification of Responsible Party After Resident Death
Penalty
Summary
The facility failed to ensure that the medical record for a resident with dementia, hypertension, and cirrhosis of the liver was complete and accurate regarding notification of the responsible party after a change in condition. The resident, who had a court-appointed Conservator of Person (COP) and was identified as having severely impaired cognition, was found unresponsive and subsequently pronounced deceased after CPR was administered by staff and EMS. Although the COP was listed as the emergency contact and was contacted to confirm advance directives when the resident was found unresponsive, there was no documentation in the medical record that the COP was notified after the resident was pronounced deceased. Interviews with two RNs revealed that both believed they had notified the COP of the resident's death via telephone, but neither documented this notification in the medical record, each assuming the other would do so or forgetting to write the note. The Director of Nursing Services (DNS) and Administrator confirmed that the COP was notified, but acknowledged that the nurse failed to document the notification as required. Review of the facility's Charting and Documentation policy indicated that such notifications should be documented, but this was not done in this instance.
Deficiencies in Resident Property Security and Facility Maintenance
Penalty
Summary
The facility failed to ensure the safety and security of a resident's personal property, as evidenced by the case of a resident who reported missing clothing items. The resident, who was cognitively intact and required assistance with dressing, had sent several personal clothing items to the laundry, which were not returned. Despite making inquiries and reporting the missing items to various staff members, the resident only received replacement items from donations, which did not include all the missing items, some of which held sentimental value. Interviews with the Director of Laundry and a Laundry Aide revealed a lack of awareness about the missing items, and the facility's social worker and Director of Nursing Services were also unaware of the resident's reports. Additionally, the facility was found to have failed in maintaining a safe, clean, comfortable, and homelike environment. Observations during a tour of the facility revealed numerous issues, including soiled and damaged furniture, unclean bathrooms, and disrepair in various rooms and common areas. The facility was undergoing renovations, but the maintenance director, who was newly hired, was not aware of many of the issues identified. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unclean and poorly maintained conditions observed. The facility's failure to address these issues was further compounded by the lack of a personal property policy and the absence of a signed agreement for the intended repairs. The facility's staff, including the nursing staff, were expected to report maintenance concerns, but the issues persisted, indicating a breakdown in communication and follow-through. The facility's corporate management was reportedly addressing the concerns, but the deficiencies remained uncorrected at the time of the survey.
Unsanitary Food Preparation Practices
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions in accordance with professional standards. During an observation, a staff member was seen thawing frozen chicken in a deep pot under running cold water in the third compartment of a three-compartment sink. The first sink was filled with dirty pots and bowls soaking in soapy water, while the second sink contained soap suds and food debris. The staff member was preparing the chicken without gloves, which is against the facility's food preparation policy. Interviews with the Dining Services Director, Dietitian, and the staff member involved revealed that the staff member was not supposed to use the three-compartment sinks for thawing chicken, especially when they were dirty. The Dining Services Director and Dietitian were unaware of the issue, and the staff member explained that the designated meat preparation sink was occupied, and the other preparation sink was reserved for fruits and vegetables. The facility's policy requires that all foods be prepared in accordance with the FDA food code, and the FDA guidelines for three-compartment sinks state that each sink must be emptied, washed, and sanitized before and after each use if food products are to be washed or thawed in them.
Failure to Honor Resident's Hospice Provider Choice
Penalty
Summary
The facility failed to honor the request of a resident's representative for a specific hospice provider, leading to a deficiency in resident rights and care planning. Resident #23, who had diagnoses including dementia and chronic obstructive pulmonary disease, was admitted to the facility and required hospice care. The resident's representative, Person #1, requested Hospice Agency #1, which had previously provided satisfactory services to the resident at home. Despite this request, the facility did not accommodate the choice, citing a lack of contract with Hospice Agency #1. The facility's social worker, SW #2, informed Person #1 that the facility did not have a contract with Hospice Agency #1 and offered alternatives from the facility's contracted providers. SW #2 did not explore the possibility of a one-time contract with Hospice Agency #1, nor did she consult with the Director of Social Services or the Administrator about the request. Consequently, Resident #23 was admitted to Hospice Agency #2, contrary to the expressed wishes of Person #1. Interviews with the Director of Social Services and the Administrator revealed that the facility could have arranged a one-time contract with Hospice Agency #1 to honor the resident's choice. The Administrator confirmed that the facility indeed had a contract with Hospice Agency #1, contradicting the information given to Person #1. This oversight resulted in a failure to respect the resident's right to participate in their care planning and choose their hospice provider, as outlined in the facility's policies on hospice services and resident rights.
Resident's Access to Personal Funds Restricted
Penalty
Summary
The facility failed to ensure that a resident had ready and reasonable access to their personal funds, which were managed by the facility. The resident, who was admitted for short-term rehabilitation and had intact cognition, reported difficulties in accessing their funds since admission. The resident was supposed to receive $75 monthly but experienced restricted access to their money. The resident also did not receive any quarterly statements and mentioned that the previous social worker, who attempted to assist with fund access, was no longer employed at the facility. The resident expressed frustration over the situation, noting that the facility administrator had given them $20 from his wallet due to the resident's distress, despite the resident having their own funds. The administrator acknowledged that the Business Office Manager, responsible for disbursing residents' funds, was on leave, and he was temporarily covering the position. He stated that he was available during specific hours for residents to access their funds and that residents could contact a nursing supervisor outside of these hours. However, the administrator could not explain how funds would be accessed if he or the Director of Nursing Services (DNS) were unavailable by phone. Additionally, the administrator mentioned delays in the resident's social security checks, which were being mailed instead of direct deposit, but could not recall specific discussions with the resident about this issue. An observation noted a sign indicating banking hours, but the facility failed to provide a policy on accessing personal funds during these hours.
Failure to Manage Resident's Personal Funds
Penalty
Summary
The facility failed to properly manage the personal funds of a resident, identified as Resident #44, who was admitted for short-term rehabilitation with diagnoses including cardiomyopathy, insulin-dependent diabetes, and anxiety disorder. The resident, who had intact cognition, did not receive quarterly statements or an accounting of their funds managed by the facility. The facility's policy required that residents receive quarterly banking statements and that funds be kept in an interest-bearing account, but these requirements were not met. The facility's Business Office Manager, responsible for dispersing residents' funds, was on leave, and the Administrator was temporarily covering the position. An outside accounting firm was used for managing the residents' funds, but discrepancies were found in the accounting documents for Resident #44. The resident's name was missing from the Funds Balance Report, and there were inconsistencies in the statements provided, including missing vouchers and unexplained debits. The facility and the accounting firm failed to provide a clear and accurate accounting of the resident's funds. Interviews with the Administrator and a representative from the accounting firm revealed confusion and lack of clarity regarding the responsibility for disbursing quarterly statements to residents. The facility's policy on resident rights and personal needs allowance was not followed, as the resident was not given access to their financial records, and the funds were not managed according to generally accepted accounting principles. The facility's failure to ensure proper management of the resident's funds led to multiple discrepancies and a lack of transparency in financial reporting.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to obtain and document the code status for two residents, Resident #45 and Resident #93, shortly after their admission, as required by their policy. Resident #45, who was admitted with acute kidney failure and dementia, had severely impaired cognition, making it necessary for the facility to discuss code status with the resident's representative. However, over two months after admission, the Advance Directives Level of Treatment Options forms remained blank. The Nurse Manager acknowledged that the code status should have been determined and documented within 72 hours of admission. Resident #93, who was cognitively intact and admitted with conditions including hypertension and chronic kidney disease, had a physician's order indicating full code status. However, the Advance Directives Level of Treatment Options form in the resident's clinical record was incomplete, lacking specific treatment options. The Nurse Supervisor confirmed that the form was not filled out with the resident's choices, despite the resident verbally requesting full code status upon admission. The facility's policy mandates that the Advance Directives Level of Treatment Options form be reviewed and completed upon admission. The Director of Nursing (DNS) stated that it is the responsibility of the charge nurse and admitting supervisor to ensure the form is completed. The policy also requires that if a resident is incapacitated, the information should be provided to the legal representative. The failure to adhere to these procedures resulted in the deficiency noted by the surveyors.
Failure to Notify Physician of Resident's Shoulder Displacement
Penalty
Summary
The facility failed to notify the physician when a resident returned from the hospital with a new mild anterior displacement of the right humerus, which could represent an anterior glenohumeral dislocation. The resident, who had a history of congestive heart failure, pulmonary embolism, rheumatoid arthritis, and repeated falls, was admitted to the facility and required extensive assistance for transfers. Upon returning from the hospital, the resident's discharge summary indicated a potential shoulder dislocation, but there was no documentation that the physician or APRN was notified of this condition. Interviews revealed that the facility's DNS stated that the receiving supervisor, unit manager, and ADNS were responsible for reviewing hospital paperwork and notifying the physician of any significant findings. However, the physician was not informed of the shoulder displacement, and there was no documentation of such notification in the progress notes. The facility's Change in Condition Policy mandates prompt notification of the physician for significant changes in a resident's condition, which was not adhered to in this case.
Failure to Timely Complete PASARR Rescreen
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) rescreen for a resident with mental health diagnoses, including schizoaffective disorder, schizophrenia, bipolar disorder, and depressive episodes. The resident was admitted with a 30-day hospital discharge exemption, which required a rescreen if the stay extended beyond this period. The initial PASARR Level I Screen Outcome indicated that a rescreen was necessary by the 30th day if the resident remained in the facility. However, the facility did not conduct the required rescreen until 10 days after the exemption expired. The resident's admission Minimum Data Set (MDS) noted intact cognition and a lack of Level II PASARR evaluation, despite the presence of serious mental illness. The care plan included the use of psychotropic medications and monitoring for side effects. The Director of Social Services acknowledged the oversight, stating that the rescreen should have been completed before or on the expiration date. The facility's policy mandates compliance with state and federal regulations for PASARR, which was not adhered to in this instance.
Failure to Notify State Mental Health Authority of Diagnosis Changes
Penalty
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health diagnoses of two residents, leading to a deficiency. Resident #2, who was initially diagnosed with anxiety and bipolar disorder, was admitted with these diagnoses and later received a new diagnosis of dementia on 10/1/22. Despite this significant change, the PASARR was not updated, and the state mental health authority was not informed, as required. The social worker (SW #1) was unaware of the need to update the PASARR with the new diagnosis, resulting in a lack of reevaluation by the state mental health authority. Similarly, Resident #39 was admitted with major depressive disorder, bipolar disorder, and PTSD. The PASARR identified these diagnoses but did not include dementia. Over time, the resident's diagnosis changed from major depression to situational depression episodes, as noted in psychiatric evaluations on 9/22/22 and 7/9/24. However, the state mental health authority was not notified of this change in diagnosis, as SW #1 was unsure of the requirement to update them. This oversight resulted in the failure to conduct a necessary PASARR reevaluation for Resident #39.
Failure to Develop Comprehensive Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of dementia, which was identified during a review of the clinical record, facility policy, and interviews. The resident, who was admitted with diagnoses including moderate dementia with behavioral disturbances and delirium, was receiving anti-psychotic medication routinely. However, the care plan dated 6/19/24 did not include goals and interventions for the resident's dementia diagnosis, despite the quarterly MDS indicating moderately impaired cognition and non-Alzheimer's dementia. Interviews with the Director of Nursing Services (DNS) and the Director of Social Services (SW #1) revealed an expectation for a dementia care plan to be in place. The DNS noted that the resident's dementia diagnosis was documented in the baseline care plan, and expressed uncertainty as to why it was not included in the comprehensive care plan. SW #1 indicated that typically the MDS coordinator initiates the dementia care plan, although the social worker could also do so. The MDS coordinator was unavailable for interview. The facility's policy mandates the development of an individualized comprehensive care plan based on thorough assessments, including MDS assessments, and requires revisions as the resident's condition changes.
Failure to Conduct Timely Resident Care Conferences
Penalty
Summary
The facility failed to invite a resident and their representative to care conferences and did not hold these conferences in a timely manner. The resident, who was admitted for short-term rehabilitation with diagnoses including cardiomyopathy, insulin-dependent diabetes, and anxiety disorder, had intact cognition as per the quarterly MDS. Despite this, the resident could not recall participating in a care conference, and the clinical record showed no documentation of care conferences for over six months in 2024, with the last noted conference occurring in January 2024. Interviews with facility staff, including the Social Services Director and the DNS, revealed awareness of issues related to the scheduling and execution of resident care conferences. The Social Services Director, who assumed the role in April 2024, was unable to explain the lapse in care conferences for the resident. The DNS acknowledged problems with the social services staff, including the previous Social Services Director, in ensuring timely care conferences. Facility policy mandates resident participation in care planning, with the Social Services Director responsible for scheduling these conferences, highlighting a failure to adhere to these guidelines.
Failure to Conduct RN Assessments After Falls
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed an assessment after falls and prior to moving residents off the floor, as well as conducting neurological assessments after falls or when new bruising was found. For Resident #6, who had diagnoses including drug-induced parkinsonism and osteoporosis, the facility did not perform an RN assessment after an unwitnessed fall on 5/12/23. The resident was found on the floor with pain, and despite the presence of multiple fractures diagnosed later at the hospital, the assessment was conducted by an LPN instead of an RN. The resident was moved off the floor without an RN assessment, contrary to facility policy. Additionally, on 9/26/23, Resident #6 was observed with a bruise on the forehead, and the resident claimed to have fallen. However, there was no RN assessment or neurological assessment conducted, and no measurements of the bruise were taken. The facility's policy requires an RN to perform a head-to-toe assessment and document any findings, which was not done in this case. The lack of proper documentation and assessment highlights a failure to adhere to the facility's protocols for handling falls and potential injuries. For Resident #112, who had a history of end-stage renal disease and stroke, the facility also failed to conduct RN assessments after falls on 2/14/24 and 3/13/24. Both incidents were assessed by LPNs, and the residents were moved without an RN evaluation. The facility's policy mandates that an RN must assess residents after a fall before they are moved, which was not followed. This repeated failure to ensure RN assessments after falls indicates a systemic issue in adhering to the facility's protocols for managing resident safety and care.
Failure to Ensure Proper Equipment Settings and Usage
Penalty
Summary
The facility failed to ensure proper settings for an air mattress for Resident #23, who was admitted with diagnoses including dementia and chronic obstructive pulmonary disease. The physician's order specified that the air mattress should be set between 160lbs. and 200lbs., with checks every shift. However, observations revealed that the air mattress was incorrectly set at 260lbs. and later at 120lbs., despite the resident's weight being 158.8lbs. Interviews with staff indicated confusion and inconsistency in adhering to the physician's order, with the air mattress settings being adjusted incorrectly multiple times. For Resident #94, who had a history of stroke and required a helmet when out of bed due to a decompressive hemicraniectomy, the facility failed to ensure the helmet was consistently worn. The discharge summary and care plan indicated the necessity of the helmet, but the clinical records over several months did not reflect its use when the resident was out of bed. Additionally, there was no physician's order obtained for the helmet upon admission, and the DNS was unaware of this oversight. The deficiencies highlight lapses in following physician orders and ensuring proper care for residents with specific medical needs. The facility's staff, including charge nurses and unit managers, were responsible for checking and maintaining the correct settings and equipment usage, but failed to do so consistently, leading to potential risks for the residents involved.
Failure to Ensure Proper Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident #94 was admitted with a history of pressure ulcers and other medical conditions that increased the risk of skin breakdown. Despite a physician's order for regular skin assessments and the use of the Braden Scale to assess pressure ulcer risk, these assessments were not consistently documented. Weekly skin evaluations were missing for several weeks, and a new pressure ulcer was identified without proper documentation of the assessment, including measurements and descriptions. Resident #111 was admitted with an unstageable pressure ulcer and required regular skin assessments and Braden Scale evaluations as per physician orders. However, the facility failed to document the Braden Scale assessment upon admission and did not consistently perform weekly skin assessments. After the resolution of the initial pressure ulcer, new pressure ulcers developed on the resident's heels, which were not identified until a later date. The facility's failure to adhere to physician orders and document assessments contributed to the development of these new pressure ulcers. Interviews with facility staff revealed a lack of adherence to policies and procedures regarding pressure ulcer care and documentation. The Director of Nursing Services (DNS) and other nursing staff acknowledged the deficiencies in completing and documenting skin assessments and Braden Scale evaluations. The facility's policies required these assessments to be completed and documented, but the staff failed to follow through, leading to the deficiencies identified in the report.
Inadequate Supervision and Intervention in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and intervention for several residents, leading to multiple deficiencies. For residents participating in the fall prevention program, a nurse aide was observed with her eyes closed while supervising residents, which was against the facility's expectations. This lapse in supervision was acknowledged by the Assistant Director of Nursing Services (ADNS) and resulted in the nurse aide being removed from her duties. The facility's policy emphasized the importance of active supervision to prevent falls, yet this was not adhered to, compromising resident safety. Another deficiency involved a resident with a history of smoking who repeatedly violated the facility's non-smoking policy. Despite being educated on the policy and having smoking materials confiscated on multiple occasions, the resident continued to possess contraband. The facility's documentation lacked detailed records of room searches and the disposition of contraband, indicating a failure to implement effective measures to prevent smoking and ensure safety. The facility's contraband policy required immediate action upon detection of contraband, which was not consistently followed. Additionally, the facility failed to revise interventions for residents at risk of falls and elopement. One resident experienced multiple falls without any new interventions being implemented, and another resident, identified as an elopement risk, was able to leave the facility unattended despite wearing a wander guard. The facility's policies on fall prevention and elopement required systematic monitoring and intervention, which were not adequately executed, leading to these deficiencies.
Failure to Administer PRN Pain Medication
Penalty
Summary
The facility failed to administer a PRN pain medication to Resident #42, who was admitted with multiple diagnoses including an infection following a procedure, deep incisional surgical site, infective bursitis, cellulitis, and phantom limb syndrome with pain. The physician's order included a PRN dose of 4mg Hydromorphone for severe pain, which was not administered when requested by the resident. The resident reported experiencing breakthrough pain and indicated that some nurses did not take his reports of pain seriously, leading to delays in receiving pain medication. On the evening of 7/14/24, Resident #42 requested the PRN dose of Hydromorphone from LPN #7 multiple times between 8:00 PM and 10:00 PM, but it was not administered. LPN #7 admitted to forgetting to administer the PRN dose due to being busy, despite having administered the scheduled medications. The resident later approached another nurse during the 11:00 PM - 7:00 AM shift, but the request was ignored, resulting in the resident suffering from pain throughout the night. Interviews with staff revealed a lack of awareness and adherence to the physician's orders for PRN medication administration. LPN #7 acknowledged the oversight, and RN #2 expressed the expectation that PRN medications should be given when requested within the appropriate timeframe. The facility's Pain-Clinical Protocol emphasizes the importance of evaluating and reporting the frequency of PRN medication requests, which was not followed in this case.
Failure to Complete Controlled Drugs Count
Penalty
Summary
The facility failed to ensure that shift-to-shift controlled drugs counts were consistently completed for two of the seven medication carts. On the first floor, the controlled drugs count record for July 2024 was missing signatures on multiple dates across all shifts on the 1B unit, totaling 11 missing signatures. The Director of Nursing Services (DNS) was unaware of these missing signatures until they were pointed out during an observation. It was noted that it is the responsibility of all nurses to sign the controlled drugs count record at the beginning and end of each shift. Similarly, on the third floor, the controlled drugs count record for July 2024 was also missing signatures on multiple dates across all shifts on the 3 AB unit, with 8 signatures missing. Interviews with the DNS and the Assistant Director of Nursing Services (ADNS) revealed that they became aware of the issue on the previous day. Both the DNS and ADNS confirmed that the facility's expectation is for the on-coming and off-going nurses to count the controlled drugs together during each shift change and sign the record afterward. The facility's controlled substances policy mandates compliance with all laws and regulations related to the handling and documentation of controlled substances, requiring nurses to count controlled drugs at the end of each shift and report any discrepancies.
Improper Storage of PPE for Resident on Precautions
Penalty
Summary
The facility failed to store personal protective equipment (PPE) in a sanitary manner for a resident on transmission-based precautions. During an observation, an LPN identified an isolation cart containing PPE, where the PPE was improperly stored on the floor in a slot meant for a third drawer, which was missing. The LPN was unable to explain the absence of the drawer or why the PPE was stored on the floor. The facility's policy for PPE storage requires that infection prevention and control equipment and supplies be obtained, stored, and used according to current guidelines and manufacturer instructions.
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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