Beacon Brook Center For Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Naugatuck, Connecticut.
- Location
- 89 Weid Drive, Naugatuck, Connecticut 06770
- CMS Provider Number
- 075390
- Inspections on file
- 36
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Beacon Brook Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with a history of falls and impaired mobility, who required maximal assistance with transfers, experienced a fall with skin tears while performing a stand-pivot transfer assisted by one staff member. The care plan specified one-person assistance but did not include any direction for gait belt use, and the medical record contained no order or notation that a gait belt was required or used. The primary PT and the Director of Rehabilitation later stated that the resident did require a gait belt for transfers, but this requirement had not been documented in therapy notes or communicated to nursing. The DON confirmed there was no physician order, care plan entry, facility policy, or therapy communication directing gait belt use, contrary to the facility’s own charting and documentation policy requiring a complete record to support the plan of care.
A resident with diagnoses including rhabdomyolysis, epilepsy, and major depressive disorder had a signed advance directive indicating DNR/DNI and no artificial respiration or artificial nutrition, but the chart also contained CPR orders and conflicting APRN progress notes. The MDS and care plan listed code status as Full Code/CPR/DNI/RNP, and staff interviews showed the LPN, APRN, and DNS were aware of the inconsistencies but could not explain why the resident’s wishes were not reflected consistently in the orders and documentation.
Food was not maintained at a palatable, appetizing temperature when served. Resident complaints of cold food were documented in multiple Food Committee meetings, and a test tray showed hot items plated in the basement kitchen, transported on a closed meal cart to the 2nd floor, and served over a 22-minute period before surveyors measured the battered fried fish at 118.9 F, roasted tomatoes at 106.9 F, and potatoes at 104.5 F. The DON stated hot food should be at least 120 F, which differed from facility policy defining proper food temperature as safe and appetizing.
Failure to Use PPE and EBP During Resident Care A resident with dementia, ESBL in the urine, a chronic catheter, and a Stage 3 pressure ulcer received wound care without the wound nurse wearing a gown while assisting with repositioning and taking photos. Another resident with a trach, feeding tube, and EBP orders received trach care and suctioning from an LPN who wore no gown. Two other residents with chronic wounds and MDRO history were not consistently managed under EBP, and one NA provided extensive personal care to a resident on EBP without an isolation gown.
Surveyors found that staff failed to follow physician orders and the care plan for two residents. One resident with hemiplegia, dysphagia, and a history of skin breakdown was repeatedly observed in bed without the ordered bed cradle and without bilateral offloading boots, despite clear orders and care card instructions; staff reported not knowing how to apply the bed cradle and believing only one heel protector was needed. Another resident with dementia, COPD, seizure disorder, missing teeth, and documented need for supervised or full-feed meals was left alone with a lunch tray after a CNA cut up the meat and left to assist another resident, contrary to orders and SLP recommendations for meal supervision and cueing. The resident was later found unresponsive with apparent food in the mouth, EMS and hospital records confirmed a choking episode with a large food bolus obstructing the glottic opening, and the resident subsequently died after cardiac arrest.
A resident with dementia and dysphagia, ordered a mechanical soft diet, waited about 30 minutes for a lunch tray while another resident at the same table was already eating. Staff called the kitchen after the tray was missing, but the resident remained at the table with only beverages and no snack offered until the tray was found on another cart and delivered after most other residents had finished lunch.
Failure to follow a resident’s fall prevention care plan. A resident with a history of falls, a prior lower leg fracture, impaired balance, legal blindness, and high fall risk status was supposed to have a low bed and floor mats. Observations showed the resident in bed without the low bed or mats on multiple occasions, and an NA, an LPN, and the DNS were all unsure why the ordered fall precautions were not in place.
Care plan not revised after a resident’s grievance changed care delivery. A resident with COPD, DM2, anxiety, and depression reported that three NAs were unkind and made him/her uncomfortable; the NAs were removed from the assignment and restricted from the room. The resident’s CPCCP was not updated to reflect the complaint or the staff restriction, despite facility policy requiring review and revision when the plan of care changes.
An LPN gave a resident Tramadol 50 mg without a provider order after confusing it with another resident’s medication. The resident had rhabdomyolysis, pain, and anxiety, was cognitively intact, and was later noted to be at baseline with stable VS; the MAR did not document the dose, and the facility confirmed the medication belonged to a different resident.
Two residents who needed help with personal care had untrimmed, lengthy fingernails despite care plans and routine ADL assistance. One resident with dementia, stroke-related weakness, and total ADL dependence was observed multiple times with jagged nails, and an NA said nail trimming was the CNA’s responsibility but had not been done. Another resident with muscle weakness and assistance needs reported nails had not been trimmed since admission, said staff lacked time and showers were inconsistent, and an NA confirmed she did not trim the nails because she ran out of time and did not have clippers available.
Delayed Pressure-Relief Mattress for Resident With Stage 3 Pressure Ulcers: A resident with dementia, stroke-related weakness, and malnutrition was identified as being at risk for skin breakdown and later developed Stage 3 pressure ulcers to the buttock and sacrum. The care plan included repositioning, incontinent care, and wound treatment, but the resident did not receive a low air loss mattress until 35 days after the ulcers were identified. The wound consultant documented a deteriorating sacral wound requiring debridement, and the RN stated the mattress should have been placed when the pressure ulcers were first identified.
Failure to follow urology catheter change orders. A resident with obstructive/reflux uropathy, urinary retention, ESBL hx, and an indwelling foley developed fever, chills, and UTI-related symptoms, was hospitalized, and later had urology document that the catheter had to be changed every 4 weeks at the facility. Facility documentation and staff interviews showed confusion about whether the catheter was being changed on schedule, and the order was later changed to PRN without clear communication with urology.
A resident with schizoaffective disorder, bipolar disorder, and PTSD was receiving an antipsychotic medication, and the consultant pharmacist repeatedly recommended an AIMS because the last one was outdated. APRN #3 repeatedly declined to act, stating the resident was on hospice, while staff gave conflicting statements about whether hospice residents could have an AIMS. The facility also lacked an AIMS policy, and the pharmacy review policy required monthly review and timely response to recommendations.
A resident with chronic pain and left knee MRI findings of a meniscus tear, ligament sprain, and bone contusion was seen by orthopedics, which recommended PT for the knee pain. The record did not show that nursing initiated the PT referral, and the DNS and OT could not locate any communication or referral to therapy; the resident reported ongoing significant knee pain and no recent therapy.
Failure to Notify Ombudsman of Transfer/Discharge: A resident with COPD, dementia, spinal stenosis, and severe cognitive impairment fell, sustained a head laceration, and was sent to the hospital before returning with sutures in place. The SW and DNS stated that social services were responsible for Ombudsman notification, but the required transfer/discharge notice was not sent because the SW lacked portal access.
Failure to notify the PASRR agency for a Level 2 psychiatric review. A resident admitted with psychotic disorder, hallucinations, Parkinson’s disease, and HTN had a prior Level 1 PASRR showing no psych hx and no need for Level 2 review. Later psych notes identified a psychotic disorder stable on meds, but the SW could not confirm the PASRR agency had been notified for a Level 2 assessment, and the facility only contacted PASRR after surveyor inquiry.
Two residents with severe cognitive impairment and a history of dementia were not supervised according to their care plans, which required staff to monitor them when together. Staff left the residents alone in a room for 15-20 minutes, during which time they were later found unclothed in bed together. Although no injuries were found, the required supervision was not provided as directed in the care plans.
A resident with multiple health issues, including malnutrition and chronic wounds, experienced rapid and significant weight loss. Despite facility policy requiring prompt notification and care plan revision for significant weight changes, there was a delay in dietician evaluation due to missed notifications and prioritization issues. The facility lacked a specific policy on the timing of dietician assessments for significant weight loss.
Two residents at moderate risk for pressure injuries did not receive or have documented weekly Braden scale assessments following re-admission, as required by physician orders and facility policy. This lapse was confirmed by review of clinical records, facility documentation, and staff interviews.
A resident with severe cognitive and physical impairments did not receive incontinence care within the care-planned timeframe due to a new NA's inability to complete care without assistance and failure to notify nursing staff. The resident was found with soiled, drying briefs and a stained drawsheet, indicating care was missed for several hours, constituting neglect as defined by facility policy.
A resident with severe cognitive impairment and total dependence for care did not receive incontinence care for approximately five hours because a newly assigned NA was unable to find a second staff member to assist, did not check for incontinence as required, and failed to notify nursing staff of her inability to provide care. This resulted in a delay in care and failure to follow physician orders and the resident's care plan.
A resident with complex medical needs returned from the hospital, but several essential medications were not resumed for eleven days due to incomplete medication reconciliation and lack of communication among nursing staff. Multiple nurses noticed the omission but did not notify supervisory staff or the APRN, resulting in a prolonged lapse in medication administration.
A resident with a history of aggressive and sexual behaviors, who was on 1:1 supervision, was able to inappropriately touch another resident's chest area in a common area. Staff present did not prevent the contact, despite care plan interventions and physician orders for close supervision. The incident was witnessed by staff and later substantiated as abuse.
A resident with multiple chronic conditions returned from the hospital, but due to incomplete medication reconciliation, several essential medications were omitted for eleven days. The error occurred when a nurse failed to resume all pages of the resident's medication orders, and other staff did not question the omission, resulting in a significant medication error.
A resident with a history of nicotine dependence repeatedly violated the no-smoking policy in a facility, posing a significant safety risk due to the presence of oxygen therapy in their shared room. Despite being educated on the policy and offered alternatives, the resident continued to smoke, and the facility failed to implement effective interventions or conduct a new smoking evaluation. This led to a finding of Immediate Jeopardy due to inadequate supervision and intervention.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in the deterioration of existing wounds and the development of new ones. One resident did not receive prescribed daily dressing changes for a left heel pressure ulcer, while another resident did not have weekly skin audits conducted as required, leading to new pressure injuries. Interviews with staff revealed a lack of adherence to physician orders and facility policies.
The facility failed to ensure timely physician visits and the signing of physician orders for multiple residents with various medical conditions, such as respiratory failure and dementia. Orders were not renewed and signed as required, with some not signed on admission or every 30 days for the first 90 days. The DNS acknowledged the facility's responsibility to track and ensure timely signing of orders, but the physician had not been signing orders timely.
The facility failed to ensure timely physician visits and order renewals for several residents with various medical conditions, including respiratory failure, diabetes, and dementia. Physician's orders were not renewed and signed every 60 days as required, and some orders were not signed on admission or renewed every 30 days for the first 90 days. The facility's Quality Improvement review identified this issue, and the DNS acknowledged the responsibility to track and ensure timely signing of orders.
The facility failed to ensure proper labeling and storage of medications, with unlabeled insulin and epinephrine found in medication carts, and inconsistent documentation of refrigerator temperatures storing vaccines. A resident was found with medications in their bathroom without a physician's order, violating facility policy.
A dietary staff member was observed preparing food without a beard guard, despite having a beard, which violated the facility's Uniform Policy. The staff member admitted to forgetting the beard guard, and the Director of Dietary confirmed the requirement for its use.
The facility failed to notify a physician and responsible party of a change in condition for a resident with cerebral infarction, leading to a delayed hospital transfer. Additionally, the facility did not provide timely wound care for a resident with Alzheimer's and paraplegia, resulting in further deterioration of pressure ulcers. Staff interviews revealed communication and documentation lapses.
A resident with neuromuscular dysfunction and diabetes reported grievances about noise during shift changes and delayed call light responses. The DNS addressed the noise issue but failed to provide evidence of follow-up on the call light concern, highlighting a deficiency in the grievance resolution process.
A facility failed to complete a PASRR II or Level of Care re-screen for a resident with mental health concerns upon admission. The resident had diagnoses including dementia, anxiety disorder, and depressive disorder, and was noted to have delusional disorder and suicidal ideations. The Director of Social Services was unaware of these issues and did not submit a new level of care determination, as required by state procedures.
The facility failed to address the use of antipsychotic medications in a resident's care plan and did not develop a comprehensive care plan for another resident with a history of mental disorders, including suicidal ideation. The absence of these care plans was confirmed through interviews with staff, highlighting a lack of adherence to the facility's policies on psychotropic medication management and comprehensive care planning.
A resident with nicotine dependence and cognitive impairment repeatedly violated a no-smoking policy in a non-smoking facility. Despite being found with smoking materials multiple times, the facility failed to update the care plan or implement effective interventions to address the behavior. The resident's care plan was not revised to ensure safety, leading to a deficiency.
A resident with Alzheimer's and paraplegia developed a left heel pressure ulcer that was not treated according to physician's orders. Despite recommendations from a wound specialist, the facility failed to document dressing changes for 22 days, leading to the wound's deterioration. Interviews revealed that staff did not transcribe the orders into the medical records, resulting in a deficiency.
A facility failed to assess a resident's ability to self-manage colostomy care, despite the resident's repeated refusals of staff assistance. The resident, with moderate cognitive impairment and a history of alcohol abuse, independently performed ostomy care multiple times without a proper assessment or care plan in place. The facility did not provide a self-care policy when requested.
A resident with COPD and heart failure did not receive oxygen therapy as prescribed, with the oxygen concentrator set at 3 L/min instead of the ordered 2 L/min. The resident did not adjust the flow, and staff were unaware of the change. The facility's policy required adherence to physician's orders, which was not followed.
A facility failed to conduct a timely AIMS assessment and review pharmacy recommendations for a resident started on Zyprexa for nausea. The resident, with a blood disorder and iron deficiency anemia, did not receive the required AIMS assessment until 34 days after medication initiation. The consulting pharmacist's recommendations for orthostatic blood pressure and AIMS were not fully received by the facility, contrary to policy requirements.
A facility failed to maintain a complete medical record for a resident, as the conservatorship document was missing. The resident, with a history of alcohol abuse and nicotine dependence, was observed smoking on facility grounds, contrary to policy. The conservator was unaware of the resident's smoking, and the facility could not provide a policy on record maintenance.
The facility failed to maintain sanitary conditions for a resident with a Foley catheter, as the urinary drainage bag was found on the floor, contrary to facility policy. Additionally, another resident's equipment, including basins and a bedpan, was improperly stored, with items left unlabeled and on the floor. These actions did not comply with infection prevention protocols, as confirmed by staff.
Incomplete Documentation of Gait Belt Requirement for Resident Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record reflecting physical therapy directions for the use of a gait belt during transfers. Resident #1, who had diagnoses including falls and anemia, was cognitively intact with a BIMS score of 15, was dependent for toileting, and required maximal assistance with transfers per the admission MDS. The resident’s care plan identified deficits in functional mobility and potential for falls, with interventions specifying assistance of one staff for transfers. On the date of the fall, an APRN note documented that the resident sustained a fall resulting in a skin tear on the left knee and right forearm while transferring, but the record did not identify that a gait belt was used or required during the transfer. Interviews and record reviews with the Director of Rehabilitation and the primary Physical Therapist established that, prior to the fall and on the date of the incident, the resident required assistance of one staff and the use of a gait belt for transfers. However, the Physical Therapist had not documented in the therapy notes that a gait belt was required, believing it to be a facility policy, and the Director of Rehabilitation could not provide documentation or evidence of communication to nursing regarding this requirement. The DNS confirmed that at the time of the fall the resident required a one-person stand-pivot transfer, that the resident’s knees buckled leading to the fall, and that there was no physician order, care plan directive, facility policy, or therapy communication specifying the use of a gait belt. This was inconsistent with the facility’s Charting and Documentation Policy, which directed that records provide a complete account of the patient’s stay and information used in developing the plan of care.
Inconsistent code status documentation for a resident with advance directives
Penalty
Summary
The facility failed to ensure that Resident #41’s advance directives were consistent throughout the clinical record. Resident #41 was admitted with diagnoses including rhabdomyolysis, epilepsy, and major depressive disorder, and a signed Advance Directive Consent/Acknowledgement and Release Form in the chart indicated the resident did not want CPR, artificial respiration, or artificial nutrition. However, admission physician orders entered on the same day directed CPR, which conflicted with the signed advance directive form. The record also contained inconsistent documentation from APRN #1. One admission progress note stated the code status was reviewed with the resident and that the resident requested DNR/DNI, with documentation updated to reflect that request. Another progress note identified the code status as RN May Pronounce/Do Not Intubate/CPR/DNR, while a separate note identified the code status as CPR. The quarterly MDS showed intact cognition and partial/moderate assistance needs, and the RCP listed the resident’s advanced directive guidelines as Full Code/CPR/DNI/RNP, which also conflicted with the signed advance directive form and the resident’s stated wishes. During interview and record review, LPN #3 stated that if the resident were found unresponsive, CPR would be administered based on what was listed in the computer and on the face sheet, and she identified that the physician’s order in the computer and on the face sheet was incorrect. The DNS stated that when the resident signed the advance directive form for DNR/DNI, LPN #9 should have contacted the physician and obtained a new order, but she could not explain why that did not occur or why APRN #1’s notes were inconsistent. APRN #1 stated she did not review the resident’s orders when discussing code status and was not aware the order still reflected CPR. LPN #9 stated she signed the advance directive form with the resident and assumed the nursing supervisor would obtain the necessary physician order, but she was unsure why that was not done.
Food Served at Inadequate Temperature
Penalty
Summary
Food items were not maintained at a palatable and appetizing temperature at the time of serving. Food Committee Meeting Minutes from 1/13/25, 2/24/25, 4/21/25, 5/19/25, 6/16/25, and 7/23/25 documented resident complaints of cold food. On 1/2/25 at 12:20 PM, a test/temperature tray was conducted with the Director of Dietary. The test meal was plated in the basement kitchen at 12:26 PM on a heated dish, placed in a plastic base, covered with a plastic dome, and loaded onto a meal tray in a closed meal delivery truck with other resident trays. The meal delivery truck left the kitchen at 12:27 PM and arrived at the second-floor hallway 1 at 12:29 PM, where staff were observed distributing trays to residents. At 12:39 PM, the cart proceeded to second-floor hallway 2, where staff continued passing trays to residents, and the last resident tray was passed at 12:48 PM. Surveyors then took temperatures of the test tray with a calibrated thermometer in the presence of the Dietary Manager, who did not bring a thermometer. The battered fried fish measured 118.9 F, the roasted tomatoes measured 106.9 F, and the oven potatoes measured 104.5 F. On 1/5/25 at 10:21 AM, the Dietary Manager stated hot food should be served at a minimum of 120 F to ensure palatability, which differed from the facility policy. The facility's Culinary Services: Food Temperature Measurement policy, revised March 2022, states that food held between 41 F and 135 F is in the danger zone and defines proper food temperature as both safe and appetizing to the resident.
Failure to Use PPE and EBP During Wound, Trach, and Personal Care
Penalty
Summary
The facility failed to use PPE during wound care and tracheostomy care, and failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds and indwelling medical devices. Resident #13 had dementia, ESBL in the urine, a chronic urinary catheter, and a Stage 3 sacral pressure ulcer. The resident’s care plan and physician orders identified EBP for the urinary catheter, history of ESBL, and the Stage 3 pressure ulcer, with wound treatment ordered for the sacrum. During a dressing change, the wound care nurse assisted with repositioning the resident and took photographs while wearing only gloves and not a gown, despite the resident being on EBP and other staff in the room wearing full PPE. The nurse did not wash hands or change gloves during the process, and later stated she should have worn full PPE because she provided hands-on assistance. Resident #15 had chronic respiratory failure, a history of stroke, diabetes, a feeding tube, and required tracheostomy care and suctioning. The resident’s care plan identified EBP due to the tracheostomy, feeding tube, and indwelling medical device, and the room had EBP signage posted. During tracheostomy care, an LPN suctioned the trach and changed the gauze around the area without wearing a gown. The LPN acknowledged the resident was on EBP and stated she should have worn a gown but could not explain why she did not. The DON also stated that a gown and gloves should have been worn for the trach care. Resident #29 had type 2 diabetes with a foot ulcer, a chronic left ankle ulcer, and MRSA infection. The resident’s care plan addressed the wound and MDRO history, but did not identify EBP, and the room initially lacked EBP signage. Staff stated the resident was not on EBP because they believed only residents with draining wounds and an MDRO needed it. During wound care, the wound care nurse wore gloves but did not wear a gown. After surveyor inquiry, EBP signage was later posted, and the IP nurse stated the resident should have been on EBP for the wound and MDRO history. Resident #60 had ESRD, ESBL in the urine, severe cognitive impairment, dependence for care, and hemodialysis. The care plan identified EBP for the AV shunt and MDRO history, and signage was posted. During personal care, an NA provided incontinent care, a bed bath, dressing, and transfer to a wheelchair without wearing an isolation gown, stating she did not realize the resident was on EBP and had not checked her assignment.
Failure to Follow Skin Protection Orders and Meal Supervision Requirements Resulting in Harm
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and the care plan for skin protection and positioning for one resident, and failure to provide required supervision and feeding assistance during meals for another resident. Resident #14 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left side, dysphagia, diabetes, and was identified on the MDS as cognitively intact but dependent on staff for eating, showering, toileting, dressing, and transfers. The MDS and care plan documented that the resident was at risk for pressure ulcer development and required a pressure-reducing device for the bed and chair, a bed cradle at the bottom of the bed at all times, offloading boots to both feet at all times, and skin integrity checks every shift. Physician orders dated 12/2/25 mirrored these interventions, directing use of a bed cradle at all times and bilateral offloading boots with skin checks each shift. Surveyor observations on multiple occasions showed that these orders and care plan interventions were not consistently implemented for Resident #14. On 12/30/25 in the morning, the resident was observed in bed with only one heel protector on the left leg, no bed cradle in place, and the sheets resting on the resident’s toes while the lower extremities were elevated on a pillow. Later that afternoon, the resident again was observed in bed without a bed cradle, which was instead on the floor by the dresser, and still only one heel protector on the left leg with sheets contacting the toes. On 12/31/25, the resident was again observed in bed without the bed cradle in place, the cradle remaining on the floor, and the right heel protector not in place while the sheets hit the resident’s toes. A nurse aide reported believing the resident was to wear only one heel protector with the other foot elevated on a pillow and stated she did not know how to place the bed cradle on the bed and had never asked for instruction. She also reported never having seen a second heel protector in the room, despite the care card specifying bilateral offloading boots and a bed cradle at all times. Interviews with licensed nursing staff and leadership confirmed awareness of the physician orders and the responsibility for oversight, but also confirmed that the orders were not followed. An LPN acknowledged that the orders required a bed cradle at the bottom of the bed and offloading boots to both feet at all times and that she was responsible for following physician orders and providing oversight, but she could not identify why this was not done. She also stated that the resident had a past history of skin breakdown and that the bed cradle and offloading boots were ordered for protection and prevention of skin breakdown. The DNS confirmed that the resident had orders for bilateral offloading boots and a bed cradle at all times and that the nurse on the unit was responsible for oversight. The DNS also indicated that the facility did not have a policy for heel protectors or bed cradles when one was requested. The deficiency also includes the facility’s failure to ensure that meal supervision and feeding assistance were provided in accordance with physician orders and the care plan for Resident #125, resulting in a choking incident. Resident #125 had diagnoses including dementia, COPD, and seizure disorder, and the care plan identified a potential for aspiration and weight loss due to missing teeth and unintentional weight loss. Interventions included encouraging dining room meals, providing a full feed to promote intake, giving verbal encouragement and attention to the meal task, ensuring the resident ate while upright and remained upright after meals, and promoting slow eating with small bites and thorough chewing. The MDS showed mild cognitive impairment and a need for substantial assistance with eating. Physician orders included a consistent carbohydrate regular diet with regular texture and thin liquids, and an order dated 12/6/25 directed assistance with all meals and a speech therapy consult for difficulties swallowing related to weight loss. Speech therapy documentation indicated that Resident #125 had mildly extended mastication due to missing teeth but good oral clearance and no signs of aspiration, and required maximum verbal cues and supervision to improve oral intake due to frequent distraction. The SLP recommended supervision with meals to enhance intake and keep the resident on task and documented that staff had been educated on strategies to promote oral intake. The facility’s reportable event form and nursing notes described that on 12/6/25, staff observed the resident with sudden drooling of fluid and seizure-like activity while seated in a wheelchair in the room, with a piece of chicken falling from the resident’s mouth. Staff assessed the airway, noted the resident was breathing with some coughing, and initiated back blows and abdominal thrusts per facility policy. The resident remained breathing but unresponsive and was transferred to the hospital by EMS. Further interviews and documentation clarified that Resident #125 was supposed to have meals supervised or be a full feed, with a staff member staying with the resident to assist feeding and provide cues, consistent with the care plan and SLP recommendations. Due to a respiratory outbreak, communal dining was suspended, and a nurse aide brought the lunch tray to the resident’s room, placed it on the bedside table, cut up the chicken, replaced the lid, and left the room to feed another resident, leaving the tray accessible while the resident was alone. Another nurse aide later observed the resident in the wheelchair with jerking motions and found the tray on the bedside table with the plate cover removed and small cut-up pieces of chicken on the plate. LPNs responding to the call for help observed the resident slumped forward, drooling with apparent food particles in the mouth, unresponsive but attempting to cough or breathe, and they performed abdominal thrusts and finger sweeps without dislodging visible food. EMS and hospital records documented that the resident was believed to have choked, lost pulses en route, and was found to have a large food bolus within the glottic opening that was removed during laryngoscopy, with subsequent cardiac arrest and death on 12/8/25. The DNS and regional nurse confirmed that the resident required supervised or full feed meals and that the nurse aide who delivered the tray had not reviewed the care card before the shift and left the tray despite the resident’s need for supervision.
Delayed Meal Service and Lack of Dignified Dining Experience
Penalty
Summary
Resident #42, who was admitted with diagnoses including dementia, anxiety, and dysphagia, was identified by the annual MDS as severely cognitively impaired and needing set up assistance for meals and moderate assistance with ADLs. The care plan directed staff to provide adequate time to consume meals, assist as needed, honor food preferences, monitor for signs of swallowing difficulty, and document intake. Physician orders directed an easy-to-chew mechanical soft diet with regular liquids. During lunch observation in the 2nd floor main dining room, Resident #42 was seated with another resident but did not receive a meal tray until 1:05 PM, while the other resident received a tray at 12:35 PM and was already eating. At 12:47 PM, a nurse aide called the kitchen because the resident still had no tray, but the resident remained at the table with only beverages and no snack offered while waiting. The tray was later found on another cart from the Brookview unit, and dietary staff delivered a lunch tray at the same time. By then, all other residents in the dining room except two had finished lunch and were eating dessert, and the resident began eating about 30 minutes after the others were served.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to follow the plan of care for a resident with a history of falls. Resident #29 had diagnoses including a displaced fracture of the left lower leg, repeated falls, and a history of falls. A fall evaluation dated 2/15/25 identified the resident as a high fall risk with unsteady and unsafe behaviors, intermittent confusion and disorientation, and visual impairment. The quarterly MDS identified the resident as cognitively intact and requiring substantial/maximal assistance with bed mobility, toileting, and transfers, and also noted a lower extremity impairment on one side. The resident care plan dated 10/29/25 identified impaired mobility, muscle weakness, and fall risk related to impaired balance, an unsteady gait, and legal blindness, with interventions to provide a low bed and floor mats and keep the bed at an acceptable height. The nurse aide care card/kardex also identified the resident as a high fall risk requiring a low bed and floor mats. However, observations on 12/29/25, 1/2/26, and 1/5/26 showed the resident in bed without a low bed and without floor mats in place. During the 1/5/26 observation, the resident was awake, and the floor mats could not be located in the room. The NA stated the resident was supposed to have floor mats and a low bed, but was unsure what happened to the mats and said she would need to ask the nurse. The LPN also stated the resident was a high fall risk and should have been in a low bed with floor mats, but was unsure why the bed was not low and the mats were not in the room. The DNS confirmed the resident should have had a low bed and fall mats in place and was unsure why the resident was in a regular bed without mats.
Care Plan Not Revised After Staff-Related Grievance
Penalty
Summary
The facility failed to revise Resident #109’s care plan after a staff-related grievance changed how care was delivered. Resident #109 had diagnoses including COPD, type 2 DM, generalized anxiety disorder, and major depressive disorder, and was documented as cognitively intact, independent with eating, requiring set-up assistance for oral hygiene, and dependent for toileting, bathing, dressing, and transfers. The resident’s care plan already addressed anxiety with reassurance and supportive psychiatric and social services, and accusatory behavior with redirection, two staff for care, a supportive approach, and trigger monitoring. After Resident #109 filed a grievance stating that three named NAs were at times unkind and made him/her uncomfortable, the grievance record documented that the NAs were educated, removed from the resident’s assignment, and restricted from entering the resident’s room. The grievance also stated that the resident agreed to the plan, which changed the assigned staff and how daily care was provided. Review of the care plan showed it was not revised to include the complaint about the NAs being unkind or the intervention prohibiting those three NAs from providing care, even though the facility policy required the comprehensive person-centered care plan to be reviewed and revised when the plan of care or resident status changed or when new problems, goals, or interventions were identified.
Incorrect Medication Administered Without Order
Penalty
Summary
The facility failed to ensure the correct medication was administered according to professional standards of practice for Resident #41, who had diagnoses including rhabdomyolysis, left hip pain, and anxiety. The resident’s MDS identified the resident as cognitively intact and dependent on staff for oral/personal hygiene, toilet use, and bathing, and the care plan identified pain-related needs with interventions to administer medications per orders and monitor pain medication effects. On 12/1/25, LPN #10 administered Tramadol 50 mg to the resident without a physician order, and the medication was later identified as belonging to a different resident. The medication error was documented in a reportable event form and an APRN note, which stated the resident had been asleep most of the night, was easily awakened, and was at baseline physical and cognitive status with stable vital signs. The MAR did not document Tramadol administration for the resident, and the investigation statement from LPN #10 indicated the medication was added to the resident’s other medications due to a name mix-up. Facility interviews confirmed the Tramadol had been taken from the cart and given because the nurse thought it was the resident’s medication, even though it was ordered for another resident.
Failure to Provide Nail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to provide nail care for residents who required assistance with personal care. Resident #13 was admitted with dementia, cerebral infarction with left-sided weakness, and malnutrition, and the MDS identified the resident as dependent on staff for all ADLs. The care plan identified a deficit in ADLs/self-care related to weakness, left hemiparesis, and the need for assistance with personal care, with interventions for assistance with all personal hygiene. Physician orders included use of a left-hand splint and therapy as needed. Observations on 12/30/25 and 12/31/25 showed Resident #13 out of bed in a wheelchair with fingernails on both hands jagged, lengthy, and in need of trimming. On 1/2/26, after AM care had been provided, the nails were still lengthy and needed trimming. The nurse aide stated the resident should have nails trimmed on shower day and that nurse aides were responsible for trimming fingernails, but she had not attempted to trim them during care. After surveyor inquiry, the nurse aide trimmed the resident’s fingernails. The DNS stated the facility had audited fingernails, but Resident #13 was not on the list, and indicated the assigned NA was responsible to ensure fingernails were trimmed on shower days or as needed. Resident #41 was admitted with rhabdomyolysis, muscle weakness, and need for assistance with personal care. The quarterly MDS identified the resident as cognitively intact and requiring partial/moderate assistance with toileting, bed mobility, and transfers, and the care plan identified a need for substantial/maximal assistance with personal hygiene. Observations on 10/29/25 and again on 12/30/25 showed both hands’ fingernails untrimmed and very lengthy. The resident stated the nails had not been trimmed since admission, that staff had said they did not have time, and that weekly showers were not consistently provided, so nail care was never done. The nurse aide stated she was responsible for trimming the nails but did not do so because she ran out of time, and also said nail clippers were not available when the resident asked for nail care during a shower. The DNS later stated fingernails should be trimmed when needed and checked and trimmed with weekly showers, and that the assigned NA was responsible for nail care.
Delayed Pressure-Relief Mattress for Resident With Stage 3 Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with dementia, a prior cerebral infarction with left-sided weakness, and malnutrition. The resident’s readmission MDS identified severe cognitive impairment, maximum assistance with bed mobility, and risk for pressure ulcer development. Physician orders included skin prep to both heels, weekly skin checks, and nutritional supplementation, and the care plan identified risk for skin breakdown with interventions for repositioning, incontinent care, and nutritional support. After pressure ulcers developed, the care plan was revised to include a Stage 3 sacral pressure ulcer with more frequent repositioning, wound treatment, and wound evaluations. The wound consultant’s initial evaluation identified Stage 3 pressure ulcers to the left buttock and sacrum, with the sacral wound measuring 3.6 cm by 2.5 cm by 0.1 cm and containing moderate serosanguinous drainage, granulation tissue, and slough requiring debridement. The wound consultant later documented that the left buttock wound had healed, but the sacral wound was deteriorating and debridement was performed. RN #3 stated that the resident did not have a low air loss mattress placed on the bed until 35 days after the pressure ulcers were identified, and that the mattress should have been placed when the pressure ulcers were identified. The facility policy stated that one Stage 3 pressure ulcer indicates the use of an alternating pressure mattress, and the admission/readmission policy required Braden/[NAME] evaluations upon admission/readmission and weekly for 4 weeks; however, no further Braden Scale assessments were completed after 10/14/25.
Failure to Follow Urology Catheter Change Orders
Penalty
Summary
The facility failed to ensure that urology orders were implemented for changing an indwelling urinary catheter for Resident #13, who was admitted with obstructive and reflux uropathy, urinary retention, and a history of ESBL bacteria in the urine. The resident’s discharge MDS identified severe cognitive impairment, need for moderate assistance with ADLs, and an indwelling urinary catheter. Physician orders on 4/8/25 directed catheter replacement if removed, leaking, or plugged, and the care plan identified the resident’s foley catheter/stents and included monitoring for UTI signs and symptoms, but it did not reflect how often the catheter needed to be changed or the catheter size. Resident #13 developed fever, shivering, concentrated urine, and decreased urine output, and APRN #1 documented that the resident was at high risk for urinary infection related to dislodged stents and was scheduled to see urology. The resident continued to have elevated temperature, chills, nausea, and vomiting and was sent to the hospital for evaluation. After hospitalization for UTI treatment and stent removal, APRN #4 contacted urology regarding catheter management, and urology directed that the catheter remain in place until follow-up. At the urology follow-up, APRN #2 documented that the urinary catheter must be changed every 4 weeks at the facility. However, later facility documentation and interviews showed confusion about the catheter change schedule: a nursing note reflected a call to urology about whether the catheter had been changed, an order was obtained to change it every 4 weeks, and then a later physician order discontinued the scheduled change and changed the catheter only if removed, dislodged, or plugged. Staff interviews indicated nursing was unsure whether the catheter had been changed at the facility or at urology, and the DNS stated the facility policy was not to change catheters on a regular schedule. APRN #2 stated she was not aware the facility was not changing the catheter every 4 weeks and expected the facility to contact the office before changing the order to as needed.
Failure to Timely Respond to Pharmacy AIMS Recommendations
Penalty
Summary
The facility failed to review and respond in a timely manner to pharmacy medication regimen review recommendations for a resident with schizoaffective disorder, bipolar disorder, and post-traumatic stress disorder who was receiving lurasidone 40 mg daily. The resident’s quarterly MDS identified cognitive intactness, dependence on staff for all activities of daily living, and use of antipsychotic, antianxiety, and antidepressant medications. The resident care plan identified a potential for behavior problems related to the psychiatric diagnoses and included psychiatric evaluation and mental health counseling interventions. The consultant pharmacist repeatedly identified that the resident’s last AIMS assessment had been completed on 9/6/24 and recommended that it be completed every 6 months, with multiple monthly medication regimen review forms from 9/5/24 through 7/1/25 repeating the recommendation. APRN #3 repeatedly responded that she could not reevaluate the resident because the resident was receiving hospice services. Interviews showed conflicting understanding among staff about whether hospice residents could have an AIMS completed, and the facility identified that it had no policy on AIMS evaluations. The facility’s Pharmacy Medication Review policy stated that each resident’s medication regimen should be reviewed monthly, recommendations communicated to those responsible, and responses provided in a timely fashion, with the consultant pharmacist following up to verify appropriate action or response within a reasonable time frame.
Failure to Initiate PT After Orthopedic Recommendation
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for Resident #116 after an orthopedic physician recommended physical therapy for left knee pain. Resident #116 was admitted with diagnoses including lower back pain, right shoulder pain, left thigh pain, left knee effusion, and cervical spondylosis, and the annual MDS identified intact cognition and independence with all ADLs. The care plan addressed chronic pain conditions and included interventions such as pain medication administration, monitoring pain causes, splinting and bracing the left knee, and physical/occupational referrals as ordered. The clinical record showed that an orthopedic consult was ordered for left knee pain after MRI results identified a complex meniscus tear, lateral ligament sprain, and a small bone marrow contusion of the lateral proximal tibia. The orthopedic physician recommended on 11/4/25 that Resident #116 start physical therapy and, if there was no positive outcome, then be referred to orthopedics. The record lacked documentation that a physical therapy referral was initiated in November 2025. The resident stated he/she had significant left knee pain and had not recently received therapy for the knee. The DNS stated she was not aware of the orthopedic recommendation and could not locate communication to therapy, and OT #1 confirmed no PT was received in November or December and no referral or nursing-to-therapy communication sheet could be found.
Failure to Notify Ombudsman of Resident Transfer/Discharge
Penalty
Summary
The facility failed to provide required notification to the state Ombudsman’s office related to Resident #107’s transfer/discharge to the hospital. Resident #107 had diagnoses including chronic obstructive pulmonary disease, dementia, and spinal stenosis. The resident’s care plan identified a risk for falls, need for assistance with transfers and ambulation, use of a mechanical lift with 2 staff, and positioning while out of bed. The quarterly MDS showed severe cognitive impairment and dependence with bed mobility, transfers, dressing, toileting, eating, and personal hygiene. After Resident #107 fell and sustained a laceration above the right eyebrow, the resident was sent to the hospital and later admitted. The resident returned to the facility 2 days later with a laceration to the left side of the forehead and 5 sutures in place. Interviews with the SW and DNS identified that social workers were responsible for notifying the Ombudsman of all transfers/discharges, but the notification was not sent because the SW did not have access to the electronic portal. The facility’s admission/discharge policy stated that the Ombudsman’s office was to be notified of discharges per state and federal regulations.
Failure to Notify PASRR Agency for Level 2 Psychiatric Review
Penalty
Summary
The facility failed to notify the PASRR agency to complete a Level 2 screen for a resident with a psychiatric diagnosis. Resident #2 was admitted from another long-term care facility with diagnoses that included psychotic disorder with hallucinations related to physiological conditions, Parkinson’s disease, and hypertension. A Level 1 PASRR screen transferred with the resident dated 2/1/19 identified no psychiatric history and stated that a Level 2 evaluation was not required. Psychiatric progress notes written by an APRN dated 10/20/25 identified the resident had a psychotic disorder that was stable on current psychiatric medications, while also noting the resident denied psychiatric history despite previous psychiatric diagnoses. During an interview and record review on 1/5/26, the Social Worker was unable to identify that the PASRR agency had been notified to complete a Level 2 assessment for the resident’s psychiatric diagnosis. The Social Worker stated the psychiatric group verbally notifies her when residents develop a new psychiatric diagnosis and that she would be responsible for notifying the PASRR agency, but she was not employed at the facility during that time frame.
Failure to Provide Required Supervision for Residents with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide supervision in accordance with the care plan for a resident with severe cognitive impairment, resulting in two incidents involving another resident with similar cognitive deficits. Both residents had diagnoses including dementia, major depressive disorder, anxiety, and cognitive communication deficits, and were assessed as having severely impaired cognition based on their BIMS scores. The care plans for both residents specifically directed staff to supervise them when together, with interventions including every 15-minute checks and, at times, 1:1 observation. On one occasion, a staff member observed the two residents together in a room, left to provide care for another resident, and returned approximately 15-20 minutes later to find both residents in bed without clothing. Although the care plan required supervision when the residents were together, staff did not provide the required level of supervision, and the residents were left alone for an extended period. Assessments following the incident found no injuries, and both residents denied discomfort or harm. Staff interviews confirmed awareness of the supervision requirements but revealed a lack of adherence to the care plan directives. Documentation and interviews indicated that staff failed to implement the care plan interventions as written, specifically the need for constant or frequent supervision when the two residents were together. The facility's policy required all clinical department heads to ensure implementation of resident care plans, but the supervision outlined in the care plans was not provided, leading to the incident where the residents were found unsupervised and unclothed in a private room.
Failure to Provide Timely Dietician Evaluation for Significant Weight Loss
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes mellitus, dysphagia, anemia, heart failure, and chronic kidney disease, experienced a significant and rapid weight loss over a short period. The resident's care plan identified high nutritional risk factors, such as malnutrition, increased nutrient needs, and the presence of chronic wounds. Despite documented weight losses of 5% in one month, 7.6% in two weeks, and 13% in three weeks, there was a delay in obtaining a timely dietician evaluation to address these changes. The dietician last evaluated the resident on 5/6/2025 and did not reassess until 6/3/2025, despite the weight loss being evident in the facility's records and weight reports. Facility policy required that significant weight changes be verified, reported to the interdisciplinary team, and the care plan revised as appropriate. The dietician relied on weight reports and notifications from nursing staff to identify residents needing evaluation but did not recall noticing the resident's significant weight loss in the reports. The DON confirmed that a weight change of 5% or more should have triggered immediate notification and evaluation by the dietician, which did not occur. The facility did not have a specific policy addressing the timing of dietician evaluations for significant weight loss.
Failure to Complete and Document Weekly Skin Risk Assessments Post Re-Admission
Penalty
Summary
The facility failed to complete and document weekly skin risk assessments, specifically Braden scale evaluations, for two residents following re-admission, as required by both physician orders and facility policy. One resident, with diagnoses including dementia, peripheral vascular disease, and sepsis, was identified as being at risk for pressure injuries and required extensive assistance with activities of daily living. After returning from a hospital stay, this resident had a physician's order for weekly Braden scale assessments for four weeks, but the medical record did not show that these assessments were completed as ordered. Another resident, admitted with metabolic encephalopathy and heart failure, was also identified as a moderate risk for pressure injuries. Following a hospital stay and re-admission, there was no documentation of a Braden scale assessment upon re-admission or weekly thereafter for four weeks, as required. The facility's policy and the Clinical Director confirmed that these assessments should have been completed on admission/re-admission and weekly for four weeks, but this was not done for the residents reviewed.
Failure to Provide Timely Incontinence Care Resulting in Neglect
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, aphasia, hemiplegia, and total dependence for care did not receive timely incontinence care as required by their care plan. The resident was care planned to receive incontinence care every two to three hours and required two staff for bed mobility and transfers. On the day of the incident, the assigned nursing assistant (NA) provided care at 11 AM but did not provide further incontinence care for the next four hours, despite the resident being dependent for all activities of daily living and unable to communicate needs. The NA, who was new to the facility and to long-term care, attempted to reposition the resident but was unable to provide full care due to lack of assistance and did not notify the nurse or other staff about her inability to complete the assignment. The NA also placed two briefs on the resident and did not check for incontinence with each attempted repositioning. The charge nurse was not made aware of the missed care, and other available NAs were not approached for help. The nursing supervisor discovered the issue after a visitor raised concern, finding the resident with a soiled and drying brief, a stained drawsheet, and two briefs in place, indicating care had not been provided within the care-planned timeframe. Facility documentation and staff interviews confirmed that the resident did not receive incontinence care for a period exceeding the care plan's requirements, and the staff member responsible did not seek assistance or report the issue. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm or distress, and the incident was documented as an event of neglect. No negative effects on the resident's skin were observed at the time of discovery.
Failure to Provide Timely Incontinence Care and Adhere to Physician Orders
Penalty
Summary
A resident with a history of stroke, severe cognitive impairment, aphasia, and high risk for pressure ulcers was dependent on staff for all activities of daily living (ADLs), including incontinence care, and required assistance from two staff members for bed mobility and transfers. Physician orders and the resident's care plan specified that incontinence care should be provided every two to three hours and that two staff members were required for all ADL care. On the day of the incident, the assigned nursing assistant (NA) provided care at 11 AM but was unable to find a second staff member to assist with subsequent care, resulting in the resident not receiving incontinence care for approximately five hours. The NA attempted to reposition the resident alone, which was not in accordance with the care plan, and did not check for incontinence each time. The NA did not notify the nurse or other staff that she was unable to provide care as required, despite being aware of the resident's needs and the facility's expectations. The NA was newly off orientation, unfamiliar with the residents on the unit, and reported struggling to complete her assignment. The charge nurse was not informed that the resident had not received timely care, and other available NAs were not approached for assistance. The deficiency was identified when a visitor alerted the nursing supervisor to the resident's condition, leading to the discovery of soiled and drying briefs, a stained drawsheet, and a delay in care. Facility policy required staff to provide ADL assistance per the care plan and to report when care could not be provided. However, the NA did not follow these protocols, resulting in a delay in incontinence care and failure to provide care according to physician orders and the resident's plan of care.
Failure to Resume Medications After Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, cardiac infarction, atrial fibrillation, and neuromuscular bladder dysfunction, was transferred to the Emergency Department due to hallucinations, pallor, hematuria, and low blood pressure. Upon return to the facility, the resident's medication orders were not fully resumed, resulting in the omission of several critical medications for eleven days. The hospital discharge summary indicated no changes to pre-hospital medications except for the addition of an antibiotic, and the discharge instructions listed all medications to be continued. The failure to resume all medications was due to a breakdown in the medication reconciliation process. Nursing staff did not recognize that the second page of the medication orders had not been activated, and some assumed the medications were held for a pending surgical procedure. Multiple nurses noticed the medications were still on hold but did not notify the Nursing Supervisor or the Advanced Practice Registered Nurse (APRN) to clarify or obtain new orders. The APRN and Assistant Director of Nursing (ADON) confirmed that the process for resuming medications after a short hospital stay was not followed, and the omission was not identified until eleven days later. Facility policy required that a licensed nurse complete medication reconciliation in the electronic health record and resolve orders with the attending healthcare provider upon admission or re-admission. However, this process was not properly executed, leading to the prolonged omission of essential medications for the resident. The deficiency was identified through clinical record review, facility documentation, and staff interviews.
Failure to Prevent Inappropriate Contact Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide appropriate supervision for a resident who was on one-to-one (1:1) supervision due to a history of aggressive and sexual behaviors. Despite a physician's order and care plan interventions requiring 1:1 supervision when the resident was out of bed, the resident was able to approach another resident in the reception area without effective staff intervention. The resident initiated inappropriate physical contact by touching another resident's private chest area over clothing, an act witnessed by staff and the facility's administrative assistant. The resident who committed the inappropriate contact had diagnoses including dementia with behavioral disturbances, frontotemporal neurocognitive disorder, and antisocial personality disorder, and was known to have poor decision-making and behavioral symptoms. The other resident involved also had dementia with behavioral disturbances and was independent in mobility. Both residents' care plans included interventions to address their behavioral and mood issues, but the supervision in place was not sufficient to prevent the incident. Staff present at the time, including a nurse aide and the administrative assistant, observed the event as it occurred. The nurse aide was walking behind the resident but did not prevent the inappropriate contact. The administrative assistant confirmed that the resident moved closer to the other resident and grabbed their chest area after repeated verbal interaction. The incident was later substantiated as abuse by the facility after investigation.
Failure to Accurately Reconcile Medications After Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, cardiac infarction, atrial fibrillation, and neuromuscular bladder dysfunction, was transferred to the hospital and subsequently returned to the facility. Upon return, the resident's medication regimen was not accurately reconciled, resulting in the omission of several prescribed medications for eleven days. The hospital discharge summary indicated that only one new medication, Keflex, was added, and all other pre-hospital medications were to be continued. However, only some of the medications were resumed upon the resident's return, as the nurse on duty failed to recognize that there were two pages of medication orders, leading to incomplete transcription and activation of the resident's full medication regimen. The omitted medications included Baclofen, Lactulose, Eliquis, Atorvastatin, Amiodarone, and Oxybutynin, all of which were part of the resident's ongoing treatment for their complex medical conditions. The error was not identified until eleven days later, when it was discovered that the second page of medication orders had not been resumed. During this period, the resident did not receive these essential medications as prescribed. Interviews with facility staff revealed that the process for resuming medications after a hospital transfer involved placing all medications on hold and then resuming them upon the resident's return, provided there were no changes. The nurse responsible for resuming the medications was unaware of the need to activate each page of orders individually, and other staff members who noticed the omission did not question or report it, contributing to the prolonged medication error.
Failure to Supervise Smoking Resident Poses Immediate Jeopardy
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accident hazards related to smoking for Resident #101, who was moderately cognitively impaired and had a history of nicotine dependence. Despite an initial smoking evaluation indicating no desire to smoke, Resident #101 was repeatedly found smoking on facility grounds and in their room, which was shared with another resident dependent on supplemental oxygen. This posed a significant safety risk, especially given the presence of oxygen, which could lead to a fire hazard. The facility's documentation and staff interviews revealed multiple incidents where Resident #101 was found with smoking materials, including cigarettes and lighters, despite being educated on the facility's no-smoking policy. The facility failed to conduct a new smoking evaluation assessment after these incidents and did not implement effective interventions to prevent further non-compliance. The resident was offered nicotine patches and transfers to a smoking-permitted facility, but these were declined. The facility's care plan included every fifteen-minute checks, but there were gaps in documentation, and no additional interventions were put in place to monitor the resident's non-compliance. Interviews with the Director of Nursing Services (DNS) and the Administrator indicated a lack of documentation and effective strategies to address the resident's non-compliance with the smoking policy. The facility was concerned about balancing the resident's rights with safety but failed to provide evidence of any additional measures taken to ensure the safety of all residents. The repeated incidents of smoking in the presence of oxygen therapy led to a finding of Immediate Jeopardy, highlighting the facility's failure to supervise and implement necessary interventions.
Removal Plan
- Any resident has the potential to be affected by this alleged deficient practice.
- The facility policy titled Smoking Policy was reviewed and remains current.
- All licensed staff were provided education on the facility smoking policy, the use of oxygen present with a smoking resident, significant harm that could occur, at risk factors involved in active smoking resident in the facility, and supervision needed to be provided with cognitively impaired residents who wish to smoke.
- All residents will be educated on the facility smoking policy and that the facility is a non-smoking facility. Residents will be educated on risk factors involved with smoking materials and contraband usage in the facility. Current residents in the facility will be educated, and all new admissions will be educated upon admission.
- Smoking evaluations audits will be performed on all residents currently in the facility, and any resident who chooses to smoke in the facility will be offered a transfer to a smoking facility. The resident will be assessed to determine if a nicotine patch is appropriate. An audit will be conducted to ensure all assessments have been done for all residents, and concerns for any resident will be addressed immediately. The physician and family will be notified of any concerns.
- Random audits will be completed. The results of the audit will be presented at Quality Assurance and Improvement Program as required.
- The DNS or designee is responsible for the completion of this Plan of Correction.
Failure in Pressure Ulcer Care and Skin Audits
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for Resident #418, who was admitted with diagnoses including Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia. The care plan for this resident included interventions such as skin inspections, use of a low air loss mattress, and regular repositioning. Despite these measures, a new wound on the resident's left heel was identified as a Deep Tissue Injury (DTI) and later reclassified as a stage 2 pressure ulcer. The facility did not perform the prescribed daily dressing changes from 8/2/22 to 8/23/22, as documented in the nurse's notes and Treatment Administration Record (TAR). Interviews with nursing staff revealed a lack of awareness and documentation of the necessary wound care treatments. Resident #90, with diagnoses including type 2 diabetes mellitus and quadriplegia, was also affected by the facility's failure to conduct weekly skin audits as per the physician's order. The resident was identified as being at very high risk for pressure ulcers, with a Norton Plus skin assessment score of 8. Despite this, the facility did not perform weekly skin audits on 12 occasions, as required by the facility's policy. This oversight contributed to the development of a new stage 2 pressure injury to the coccyx and a suspected deep tissue injury to the ball of the left foot. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed the lack of adherence to the weekly skin audit policy. The facility's policy for the prevention and management of pressure injuries was not followed, leading to deficiencies in the care of both residents. The wound specialist and medical director highlighted the importance of following physician orders and facility policies to prevent further skin breakdown. The failure to perform prescribed treatments and audits resulted in the deterioration of existing pressure ulcers and the development of new ones, indicating a significant lapse in the facility's wound care management.
Failure to Ensure Timely Physician Visits and Order Signatures
Penalty
Summary
The facility failed to ensure timely physician visits and the signing of physician orders for 11 out of 12 sampled residents. Residents with various medical conditions, including respiratory failure, diabetes, dementia, and heart failure, did not have their physician orders renewed and signed as required. For instance, Resident #20's physician orders were not renewed every 60 days, with the last signature dated 7/23/23. Similarly, Resident #21's orders were not signed every 60 days, and Resident #44's orders were not signed on admission and not renewed every 30 days for the first 90 days. The deficiency was further highlighted by the facility's failure to provide a policy on the timely signing of physician orders. The Director of Nursing Services (DNS) acknowledged the responsibility of the facility to track and ensure timely signing of orders, noting that the physician was aware of the requirement to sign orders on admission and subsequently every 30 and 60 days. Despite this, the physician had not been signing orders timely, and the facility had identified this issue in their Quality Assurance and Performance Improvement (QAPI) process.
Failure to Ensure Timely Physician Visits and Order Renewals
Penalty
Summary
The facility failed to ensure timely physician visits and order renewals for 11 out of 12 sampled residents. Residents had various medical conditions, including respiratory failure, diabetes, dementia, and heart failure, and required extensive assistance with daily activities. The physician's orders for these residents were not renewed and signed every 60 days as required. Additionally, for some residents, the orders were not signed on admission and not renewed every 30 days for the first 90 days. The facility's Quality Improvement and Performance Improvement review identified an issue with the timely signing of physician's orders. The Director of Nursing Services acknowledged the facility's responsibility to track and ensure timely signing of orders, which should occur on admission, every 30 days for the first 60 days, and every 60 days thereafter. Despite this acknowledgment, the facility policy was not provided upon request.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications across four nursing units. During observations, a medication cart was found to contain a bottle of Humalog insulin and an auto-injector of epinephrine without prescription labels or identification of ownership. Additionally, a clear bag of unlabeled medications was discovered, and the LPN present was unaware of their ownership. Another medication cart contained Cyclosporin ophthalmic eye drops without a prescription label, which were believed to belong to a specific resident but were not stored correctly. The facility's policy requires medications to be labeled and stored according to professional standards, which was not adhered to in these instances. The facility also failed to consistently document refrigerator temperatures that store vaccines, as required by their policy. Temperature logs for multiple refrigerators were missing entries for several days, and vaccines such as Prevnar and flu/RSV were stored in these refrigerators. Furthermore, a resident with a diagnosis of cellulitis, falls, and seizure disorder was found to have medications such as antifungal powder and medicated chest rub in their bathroom without a physician's order, contrary to the facility's policy that requires medications to be stored in locked compartments accessible only to licensed personnel.
Dietary Staff Failed to Wear Beard Guard
Penalty
Summary
The facility failed to ensure a sanitary environment in the dietary department due to a staff member not wearing a beard guard while preparing food. During an observation of the tray line, a dietary staff member was seen stirring a tray of beef stew at a steam table without a beard guard, despite having a beard. The staff member acknowledged that he had been instructed to wear a beard guard in the past but had forgotten to do so on this occasion, as he usually does not have a long beard. The Director of Dietary confirmed that the staff member should have been wearing a beard guard, as per the facility's Uniform Policy, which requires chefs or cooks to wear a beard guard along with other specified attire.
Failure to Notify Physician and Provide Timely Wound Care
Penalty
Summary
The facility failed to notify the physician and responsible party of a change in condition for a resident diagnosed with cerebral infarction, aphasia, dysphagia, and atrial fibrillation. On a particular day, the resident reported feeling 'funny' and had difficulty with speech, but the nursing staff did not immediately recognize these as significant changes. Despite the resident's reluctance to go to the hospital, the symptoms progressed to a left-sided mouth droop and slurred speech, prompting a delayed transfer to the emergency room. The hospital later diagnosed the resident with a right frontal lobe acute lacunar infarct. In another case, the facility failed to provide timely wound care for a resident with Alzheimer's disease and paraplegia, who had stage 3 pressure ulcers. The resident's care plan included specific interventions, but the facility did not consistently perform dressing changes as ordered. A new wound on the resident's left heel was identified, but there was a significant delay in implementing the recommended treatment, leading to further deterioration of the wound. Interviews with staff revealed a lack of communication and documentation regarding the residents' conditions and treatments. The facility's policies required timely communication with physicians and families about changes in residents' conditions, but these were not followed, contributing to the deficiencies observed during the survey.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, specifically regarding the noise level during shift changes and the delayed response to call lights. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder and diabetes mellitus, reported these issues. The resident's care plan included interventions to keep the call bell and needed items within reach and to provide assistance to maximize their level of function. Despite these measures, the resident experienced issues with noise and delayed call light responses. The Director of Nursing Services (DNS) was informed of the grievances, and while the noise level issue was addressed, there was no evidence of follow-up regarding the timely response to call lights. The DNS acknowledged discussing the noise concern with the resident and planned staff in-service training. However, the DNS could not provide documentation of follow-up actions taken to address the call light issue, indicating a lapse in the facility's grievance resolution process.
Failure to Complete PASRR II for Resident with Mental Health Concerns
Penalty
Summary
The facility failed to ensure that a resident had a PASRR II or Level of Care re-screen completed upon admission. The resident, who was admitted with diagnoses including cerebral infarction, dementia, anxiety disorder, and depressive disorder, was identified in a Notice of Care Determination as approved for long-term care. However, the Inter-Agency Patient Referral report noted additional mental health concerns such as delusional disorder and suicidal ideations, which were not addressed in the PASRR process. The admission Minimum Data Set indicated the resident had severely impaired cognition and active diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and suicidal ideations, and was on psychotropic medications. The Director of Social Services (SW #1) was unaware of the resident's history of suicidal ideation or delusional disorder upon their transfer from another LTC facility. SW #1 indicated that a new level of care determination should have been submitted upon the resident's admission, given the mental and behavioral health diagnoses. The state PASRR and Level of Care Screening Procedures require that any changes affecting a resident's placement or service decisions be reported, which was not done in this case.
Deficiencies in Care Planning for Antipsychotic Use and Mental Health
Penalty
Summary
The facility failed to ensure that Resident #74's care plan addressed the use of antipsychotic medications. Despite a physician's order for Zyprexa to be administered daily for nausea, the care plans from late February to the present did not include a plan for the antipsychotic medication. An interview with RN #3 confirmed the absence of a care plan reflecting the antipsychotic use, which was contrary to the facility's policy on Psychotropic Medication Management that requires care planning for psychoactive medications and regular reviews with the interdisciplinary team. Additionally, the facility did not develop a comprehensive care plan for Resident #92, who had a history of mental disorders, including suicidal ideation. The admission MDS identified several active diagnoses, but the care plan failed to address goals and interventions for suicidal ideation. The Director of Social Services was unaware of the resident's history due to a transition in staff and acknowledged the lack of a care plan for suicidal ideation. The Director of Nursing Services also noted the absence of a focus on suicidal ideation in the care plan, which was expected to be included. The Corporate RN identified that the comprehensive care plan should be developed through an interdisciplinary approach, with the MDS Coordinator responsible for ensuring all diagnoses are reviewed and included in the care plan.
Failure to Revise Care Plan for Non-Compliant Smoking Resident
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was non-compliant with the facility's no-smoking policy. The resident, who was moderately cognitively impaired and had a history of nicotine dependence, was observed smoking in a visitor's car on the facility's grounds. Despite being informed of the no-smoking policy, the resident continued to attempt to smoke on the premises and was found with smoking materials multiple times. The facility did not conduct a new Smoking Evaluation Assessment after the resident was found smoking, nor did it implement effective interventions to prevent further non-compliance. The resident's care plan was not updated to address the ongoing smoking behavior, and there was a lack of documentation supporting the facility's actions to manage the situation. The resident was repeatedly found with cigarettes and lighters, and on one occasion, was intoxicated with alcohol found in their room. Interviews with facility staff revealed that the resident's non-compliance with smoking was a known issue, yet there were no additional interventions or updates to the care plan to ensure the safety of the resident and others. The facility's Comprehensive Care Plan policy requires the care plan to be developed and reviewed by an interdisciplinary team, but this was not adequately done in this case, leading to the deficiency.
Failure to Transcribe and Perform Wound Treatments
Penalty
Summary
The facility failed to ensure that wound treatments for a resident with pressure ulcers were transcribed and performed according to the physician's orders. The resident, who had Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia, was admitted with two stage 3 pressure ulcers. A new wound on the left heel was identified as a Deep Tissue Injury (DTI) and later reclassified as a stage 2 pressure ulcer. Despite the wound specialist's recommendations for treatment, the facility did not document any dressing changes for the left heel pressure ulcer from the time it was discovered until 22 days later. Interviews and record reviews revealed that the wound nurse and other staff members failed to transcribe the physician's orders into the electronic medical records. The Director of Nursing Services and other nursing staff were unable to identify dressing change orders for the left heel pressure ulcer during the specified period. The wound specialist confirmed that the facility was responsible for accepting and transcribing the recommendations into the medical records. The facility's policy for the prevention and management of pressure injuries indicated that wound treatments should be performed per physician's orders. However, the lack of documentation and failure to perform the prescribed treatments for the resident's left heel pressure ulcer led to the deficiency. The wound was noted to have deteriorated, with increased drainage and maceration, indicating a lack of proper care and attention to the resident's condition.
Failure to Assess Resident's Self-Care Ability for Colostomy
Penalty
Summary
The facility failed to assess a resident's ability for self-care of a colostomy, despite the resident's repeated refusals to allow staff to provide the care. The resident, who was moderately cognitively impaired and had a history of alcohol abuse and nicotine dependence, was admitted with diagnoses including cellulitis of the abdominal wall. The physician's orders required colostomy care every shift, but the resident independently provided ostomy care on multiple occasions, refusing staff assistance. The facility did not conduct an assessment of the resident's ability to manage their colostomy care or develop a care plan to support the resident's desire for self-care. The clinical record review showed that the resident refused staff assistance with colostomy care 22 times, opting to perform the care independently. Despite the resident's cognitive impairment and the presence of abdominal cellulitis, the facility did not provide an assessment or a care plan to address the resident's self-care preferences. Interviews with the Director of Nursing Services (DNS) confirmed the lack of assessment and care planning for the resident's colostomy care. Additionally, the facility was unable to provide a policy for self-care when requested.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to ensure that a resident with chronic obstructive pulmonary disease (COPD) and heart failure received oxygen therapy as prescribed. The resident was supposed to be on 2 liters of oxygen per minute (L/min) via nasal cannula to maintain oxygen saturations greater than 92%. However, during an observation, the oxygen concentrator was set at 3 L/min, which was not in accordance with the physician's order at that time. The resident indicated that they did not adjust the oxygen flow themselves, and it was the facility staff who made the adjustments. A Licensed Practical Nurse (LPN) confirmed that the resident was on 2 L/min but was unaware of why the oxygen was set at 3 L/min, suggesting that the night shift might have increased it. The nursing supervisor later indicated that the resident was not meeting the oxygen saturation threshold on 2 L/min, which led to a change in the oxygen order. However, the Advanced Practice Registered Nurse (APRN) was not informed of any decreased oxygen saturations on the day of the observation and expected staff to notify her if there were no physician's orders for a specific situation. The facility's policy required oxygen to be delivered per the physician's order, and the oxygen liter flow should be set to the prescribed rate, which was not adhered to in this instance.
Failure to Conduct Timely AIMS Assessment and Review Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were obtained and reviewed, and did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner for a resident who was started on an antipsychotic medication, Zyprexa. The resident, who was cognitively intact, had a diagnosis of a blood disorder not yet in remission and iron deficiency anemia. A physician's order was given to administer Zyprexa for secondary prophylaxis for nausea. However, the Director of Nursing Services (DNS) was unable to locate an AIMS assessment completed at the start of the medication, which was later completed 34 days after initiation, only after surveyor inquiry. Additionally, the consulting pharmacist indicated that recommendations for orthostatic blood pressure and an AIMS assessment were made, but the facility only received recommendations related to insulin. The DNS confirmed only receiving one page of recommendations and was unable to provide the second page that was reportedly faxed by the pharmacist. The facility's policy on psychotropic medication management requires a baseline AIMS assessment upon initiation of any antipsychotic medication, which was not adhered to in this case.
Failure to Maintain Complete Medical Records for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for Resident #101, as required by accepted professional standards. Resident #101, who was admitted with diagnoses including cellulitis of the abdominal wall, alcohol abuse, and nicotine dependence, was identified as having a conservator of both estate and person. Despite this, the clinical record did not contain a copy of the conservatorship document. This omission was discovered during a survey when the Director of Nursing Services (DNS) confirmed the absence of the conservatorship document upon request. Additionally, the facility's social service notes documented an incident where Resident #101 was observed smoking in a visitor's car on the facility's grounds, despite the facility's no-smoking policy. The social worker informed both the resident and the visitor of the policy and later met with the resident's conservator, who was unaware of the resident's smoking activities. The facility was unable to provide a policy on clinical record maintenance or conservatorship when requested, further highlighting the deficiency in maintaining complete and accurate records.
Infection Control Deficiencies in Resident Equipment Storage
Penalty
Summary
The facility failed to maintain sanitary conditions for Resident #74, who had a diagnosis of neuromuscular dysfunction of the bladder and diabetes mellitus. The resident's care plan indicated the use of a Foley catheter due to neurogenic bladder, with specific interventions to prevent infection, including changing the catheter and bag per physician's order and providing catheter care every shift. However, an observation on April 11, 2024, noted that Resident #74's urinary drainage bag was lying on the floor, which was confirmed by charge nurse LPN #3 as inappropriate. The facility's policy required urinary drainage bags to be hung in a privacy bag, not placed on the floor. Additionally, the facility did not ensure sanitary storage of resident equipment for Resident #101, who had diagnoses including cellulitis of the abdominal wall, falls, and seizure disorder. Observations on April 11 and April 15, 2024, identified unlabeled basins and personal care items left on the floor in Resident #101's bathroom, as well as a bedpan on the bedside table. RN #1 confirmed that bedpans and basins should be bagged, labeled, and not placed on the floor, according to the facility's policy. These observations indicate a failure to adhere to infection prevention and control protocols, potentially increasing the risk of infection spread within the facility.
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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