Bickford Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor Locks, Connecticut.
- Location
- 14 Main Street, Windsor Locks, Connecticut 06096
- CMS Provider Number
- 075358
- Inspections on file
- 32
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 51 (2 serious)
Citation history
Health deficiencies cited at Bickford Health Care Center during CMS and state inspections, most recent first.
A resident with dementia, anxiety, rheumatoid arthritis, and moderate cognitive impairment required substantial/maximal assistance for transfers and was wheelchair dependent. The care plan contained conflicting directions, listing both one- and two-person assist for transfers, while the physician’s order and NA care card specified one-person assist with a gait belt. In practice, some RNs and an NA believed or used a mechanical (Hoyer) lift for transfers due to the resident’s leg weakness, but there was no corresponding physician order, care plan entry, or NA care card direction for lift use. The DON was unaware that a mechanical lift was being used and acknowledged that any change in transfer status should have been supported by an RN or therapy assessment and updates to orders and the care plan, which had not occurred.
Two residents did not receive care in accordance with physician orders and their care plans. One resident with severe cognitive impairment and multiple comorbidities was ordered to be transferred with a Hoyer lift using two staff into a custom wheelchair, but a NA performed the Hoyer transfer alone, after the resident had reported bilateral leg pain, and the resident was later found to have a hematoma on the leg. Another resident with dementia, osteoporosis, and a history of falls had physician‑ordered motion sensor alarms that were to remain on at the bedside and at the nurses’ station, but staff reported no alarm sounding when the resident was found on a bathroom floor with a non‑displaced clavicle fracture, and the alarm system was later determined to have been in the off position.
The facility failed to ensure clinical records were complete and accurately identified the individual documenting in the EMR. For two residents—one with dementia and severe cognitive impairment requiring ADL assistance, and another with bipolar and psychotic disorders, delusions, and a history of rejecting care—multiple nursing notes describing medication administration, tolerance, pain status, and refusal of care were signed using generic pool nurse identifiers (e.g., "2LPN pool2 LPN," "poolnurse supervisor RN") instead of specific staff names. The DON confirmed that all agency RNs, LPNs, and NAs share common EMR logins, acknowledged this as a long-standing practice, and stated that identifying the actual author of a note would require checking the staffing schedule, despite facility policy requiring documentation to include the name and title of the individual providing and documenting care.
Surveyors found that the facility failed to ensure an active, on-site Medical Director and appropriate physician coverage. The DON reported that the sole Medical Director was only available by phone and did not come into the building, and that a second physician had retired and was never replaced. Weekly Medical Director rounds did not occur as scheduled, with no physician present for recent rounds. The Administrator acknowledged there was no Medical Director available to conduct weekly rounds and that efforts to secure additional physician coverage were limited. The facility lacked a current executed contract defining the Medical Director’s responsibilities and availability, had no documented contingency or alternate coverage plan, and could not produce a policy outlining the Medical Director’s roles and oversight expectations.
The facility failed to ensure its QAA/QAPI group, including medical staff, met at least quarterly and maintained required documentation. The Medical Director had been unavailable to come into the facility for an extended period, and the only other physician had retired and was not replaced. The Administrator could not provide Medical Staff/QAPI meeting minutes or agendas for the previous year and could only recall an undocumented meeting several months earlier. A more recent planned Medical Staff/QAPI meeting did not occur due to lack of quorum, and no related facility policy was produced for surveyor review.
A resident with vascular dementia, severe cognitive impairment, and documented wandering/elopement risk was care planned and ordered to have a wander guard on the ankle with checks each shift, and was known by the DON to wander up and down the hallways. However, the annual MDS coded no pacing or wandering behaviors and indicated no wander/elopement alarm in use, despite existing assessments, care plans, and physician orders documenting wandering risk and wander guard use, resulting in an inaccurate assessment of the resident’s behaviors and alarm status.
Two residents with dementia and severe cognitive impairment experienced deficiencies in elopement risk management when elopement risk assessments were not completed as required, a wander guard was used without a corresponding physician order or clear initiation/discontinuation dates, and a malfunctioning wander guard device was not replaced promptly. One resident’s record lacked quarterly elopement risk evaluations despite documented roaming into other residents’ rooms and later identification of wandering into unsafe areas, while another resident’s care plan called for shift-by-shift wander guard checks, yet a nonfunctioning device remained in place for two days without documented 15‑minute safety checks, contrary to facility policy and the DON’s expectations.
Surveyors found that staff were unable to correctly identify, respond to, or silence multiple door alarms, and that egress doors were not reliably secured. Door alarms sounded for extended periods while staff walked by or incorrectly assumed a different door was alarming, and some staff reported they did not handle doors or did not respond because they believed it was not their door. One door could be opened and remain unarmed after a code was entered, with no way to re‑arm it from the stairwell side, and another door’s alarm continued without staff response despite personnel being nearby. No policy on securing egress doors was available for review.
The facility failed to maintain complete and accurate documentation of wander guard placement and function checks for five cognitively impaired residents assessed as at risk for elopement. Each resident had dementia or Alzheimer’s disease, severe cognitive impairment, and documented behaviors such as wandering, roaming into other rooms, or being near exit doors. Care plans, elopement risk evaluations, and physician orders required wander guard devices and shift-by-shift checks, yet the MAR/TAR contained multiple blank entries where these checks should have been recorded across various day, evening, and night shifts. The DON confirmed that nursing staff were expected to document all care, including wander guard checks, and acknowledged that the required documentation was missing despite a facility policy mandating accurate, timely, and complete nursing documentation.
A resident with dementia and identified elopement risk, including a care plan for a wander guard and redirection near exits, was last documented as sleeping during night rounds and later found missing from their room. Staff conducted internal and external searches and eventually found the resident lying outside on the ground in below-freezing temperatures, unresponsive except to painful stimuli. The facility did not notify police within 15 minutes of failing to locate the resident as required by its elopement policy, and the RN delayed calling 911 while assessing the resident and contacting leadership, despite a policy requiring immediate 911 activation for an unresponsive resident. EMS was eventually called, found the resident pulseless, apneic, extremely cold with lividity, and the resident was pronounced deceased, leading surveyors to cite Immediate Jeopardy for failure to prevent neglect and ensure timely notification of law enforcement and emergency services.
A resident with dementia, moderate cognitive impairment, and known elopement risk, ordered to use a wander guard and ambulate with supervised walker use, was able to leave the building unnoticed through inadequately secured exits. Staff charted the resident as in bed while external video showed the resident outside, walking unassisted and ultimately falling on a snow-lined sidewalk in subfreezing conditions. After a nurse aide discovered the resident missing, staff searched for approximately 30 minutes before notifying an RN, then conducted additional searches before finding the resident unresponsive and extremely cold on the front sidewalk. The resident was brought inside, undressed, and warmed while the RN assessed, reviewed DNR status, and called facility leadership; EMS was not contacted until over an hour after the resident was found. Surveyors also observed multiple exit doors that failed to latch or re-lock, had disabled or inaudible alarms, and in some cases had keypad codes posted, while other cognitively impaired, wandering residents in the facility were also identified as elopement risks with wander guards ordered or care planned.
Two residents experienced failures in timely physician notification. One resident with dementia and known wandering risk was found outside during the night with low temperature and low pulses; the supervising RN notified facility leadership and called 911, but documentation and interviews showed the on-call physician was not contacted at the time of the incident, despite facility policy requiring physician notification for accidents and significant changes in condition. Another resident with hypothyroidism had an elevated TSH level reported by the lab, but there was no evidence that nursing notified a physician or APRN, and the lab report lacked provider acknowledgment, even though the care plan and facility policy required reporting abnormal lab results to the physician.
Two residents with dementia and documented elopement risk did not receive care consistent with facility policy and physician direction. For one resident, elopement risk evaluations were not completed at required quarterly intervals despite documented independent ambulation, poor decision-making, and behaviors suggesting attempts to leave, and the wander guard use order was only reviewed during monthly order reviews. For another resident with severe cognitive impairment and a care plan directing frequent wander guard checks, the admission elopement risk assessment was not followed by a timely quarterly reassessment, and there was no physician order specifying daily function checks of the wander guard, even though the DON stated such orders and quarterly assessments were required by facility policy.
The facility did not maintain or provide a written agreement with a CLIA-certified laboratory to ensure timely access to required lab services when on-site services were not available. During surveyor review of facility documents and policies, no contract or agreement for laboratory services could be found. The Administrator reported being unable to locate the laboratory services contract, stating that important document binders had been moved during a recent facility-wide evacuation, and the facility was unable to produce any documentation showing how lab services were formally arranged.
The facility did not maintain or produce a written agreement for radiology and other diagnostic services that were not provided directly on-site. During surveyor review of facility documents and policies, no contract or agreement could be found to verify how these diagnostic services were arranged. In an interview, the Administrator reported being unable to locate the radiology services contract, noting that important document binders had been relocated after a recent facility-wide evacuation. Consequently, the facility could not demonstrate that it had a formal, documented arrangement to ensure timely access to required radiology and diagnostic services for residents.
Surveyors identified that the facility failed to maintain and provide documentation confirming 24-hour physician coverage for emergencies. During review, no written agreements, contracts, or other records were available to verify that physicians were on call at all times, and the Administrator was unable to produce such documentation, citing relocation of binders after a facility-wide evacuation. The facility also lacked a policy or procedure outlining how continuous physician availability is arranged, maintained, and verified for emergency medical oversight.
Surveyors found that the facility did not have a written transfer agreement policy or documentation of a current transfer agreement with a hospital to guide transfers when residents require acute care. During document review, no policy outlining the process for transferring residents to a hospital could be produced. In an interview, the Administrator stated she was unable to locate the requested policy, noting that important document binders had been moved after a recent facility-wide evacuation, but the transfer agreement materials were not found. The facility also could not provide any evidence of formalized arrangements with a hospital to ensure timely transfer of residents needing acute care services.
Surveyors identified that the facility did not have a written contract or agreement available to verify the designation and ongoing engagement of a physician as Medical Director responsible for resident care policies and coordination of medical care. During record review, no documentation of such an agreement could be produced, and the Administrator reported being unable to locate the contract after a recent evacuation in which key binders were moved. The facility also lacked a policy or procedure describing how the Medical Director contract is to be maintained, retained, or kept accessible.
The facility failed to maintain complete and accurate clinical records for three cognitively impaired residents at risk for wandering and elopement. One resident with dementia and an elopement risk had physician orders and a care plan for a wander guard, but the MDS did not reflect an alarm, and nursing staff left multiple blanks on the MAR/TAR for required function and placement checks. During the same period, a NA documented that this resident was asleep in bed at specific times, while police video showed the resident outside the building much earlier, demonstrating inaccurate rounding documentation. Two other residents with dementia and documented wandering or elopement risk had care plans calling for routine wander guard checks, yet nurses and LPNs failed to consistently document these checks, and one resident lacked corresponding physician orders for the monitoring that was being care-planned. The DON confirmed that the documentation for these residents was incomplete or missing despite a facility policy requiring accurate, timely, and complete nursing documentation.
The facility did not maintain or provide a written transfer agreement policy or documentation of formal arrangements with a Medicare- or Medicaid-certified hospital to ensure timely transfer of residents needing acute care. During surveyor review, no written policy outlining the process for hospital transfers could be produced. The Administrator reported that important document binders had been relocated during a recent facility-wide evacuation and the requested policy and transfer agreement documentation could not be located or verified.
A resident admitted with dementia, severe cognitive impairment, incontinence, limited mobility, and an existing heel pressure ulcer was not given a timely Braden Scale assessment or a prevention care plan on admission. Nursing notes did not show the ordered q2h turning and repositioning, and a new coccyx wound developed, progressing from a DTPI to an unstageable wound and then a stage 4 pressure ulcer. Interviews confirmed staff expected immediate pressure injury prevention measures for high-risk residents, but those measures were not implemented before the coccyx wound appeared.
The facility failed to analyze monthly infection surveillance data for trends and include those findings in the quarterly infection control report. RN #4 stated she was responsible for the analysis and that the monthly infection rate, number of infections, and infection types should have been completed, but documentation was not provided. The facility also lacked documentation for its water management plan, including an established flushing log, eyewash station protocol, and annual water management meeting records; the Administrator and DOR stated there was no formal annual review, no eyewash flushing protocol, and no established flushing program for low-flow areas.
Resident rooms were not maintained within the required 71 to 81 degree range. A resident with dementia, psychotic disturbance, mood disturbance, and anxiety reported the room was cold most days and needed extra layers and blankets to stay comfortable. Survey observations found room temperatures in the mid-to-high 60s at resident level, while a thermometer placed near the ceiling read 71 degrees, and the baseboard heater was cold. The DON/maintenance staff acknowledged temperature discrepancies, noted temperatures were only documented when below 70 degrees, and observed multiple rooms on the wing below range with residents using extra blankets and layered clothing.
Care Plans Did Not Reflect Positive PASRR Level II Determinations: The facility failed to include positive level II PASRR findings and related recommendations in the care plans for three residents with psychiatric and cognitive diagnoses. Although each resident had PASRR screening results identifying a positive level II determination, the care plans only addressed general psychotropic use, mood, or behavioral monitoring and did not reflect the PASRR status or recommendations. Interviews with the MDS coordinator, SW, and DNS confirmed the care plans should have included the PASRR information.
Care plans failed to reflect hospice services and recommendations for one resident, a positive level II PASRR and its recommendations for another resident, and hospice documentation for a third resident. Staff interviews confirmed that the care plans should have been updated to include these items, but the records either lacked the required hospice paperwork or did not incorporate the relevant hospice or PASRR details.
A resident with dementia, muscle weakness, COPD, impaired cognition, non-ambulatory status, and fragile skin sustained a skin tear to the lower leg when an NA’s finger slid against the skin while putting on shoes. The record lacked an RN assessment note, a physician treatment order, and wound log documentation for the injury at the time it occurred, and the wound was not added to the wound book until later. Staff interviews indicated the supervisor was aware of the incident and was responsible for the assessment, documentation, and obtaining orders.
The facility failed to maintain an established system for controlled substance audit and reconciliation. The DNS said audits were limited to counting narcotics on the med carts and checking expiration dates, while the yellow/pink CSDR sheets kept in binders were not used for audits. RN#4 said she only matched completed white CSDRs to the binder records and did not perform the facility audits. Surveyors flagged 12 controlled substances; 10 were present, but 2 could not be reconciled because they were not in use and were not found in the destroyed med logs. The facility policy required controlled substances to be regularly reconciled to the MAR and documentation.
Expired medications were found in active circulation in the East med cart, including Methocarbamol, Hycosamine, and liquid Lorazepam. The Lorazepam was supposed to be refrigerated but was not, and it also lacked a corresponding white CSDR for administration documentation. An LPN, RN supervisor, and DNS all confirmed that expired meds should be removed, liquid Lorazepam should be refrigerated, and controlled substances should have a sign-off sheet.
Failure to offer and document the COVID-19 booster vaccine for three residents. One resident with dementia and a POA consent, one cognitively intact resident with POA consent, and one resident with dementia and severely impaired cognition all had records that failed to show the annual booster was administered, refused, or properly offered. The Infection Preventionist stated residents with annual vaccine consents should be approached each year and refusals documented.
Failure to Complete Required Pre-Employment Screening: The facility failed to ensure an employee was properly screened before hire. The employee file lacked documentation of a criminal background check, reference checks, and verification of employment or education, even though the hiring checklist and Abuse Prohibition policy required these items. The Administrator stated references are not usually checked and that a resume is used instead of verifying past employment history; the employee also stated he had not been fingerprinted as part of the hiring process.
Failure to Report Allegation of Neglect: A resident with severe cognitive impairment, immobility, and total incontinence was found saturated with urine and feces after not receiving timely incontinent care. The RP reported the incident to nursing leadership, but no accident/incident report was completed and the allegation was not reported to the State Survey Agency. RN and DON leadership later acknowledged the allegation and that the nurse aide had not changed the resident as expected.
Failure to Investigate Alleged Neglect: A resident with severe cognitive impairment, total incontinence, and dependence for care was found saturated with urine and feces after reportedly not being changed for hours. The responsible party reported the incident to nursing staff and facility leadership, but no incident report, skin assessment, or timely investigation was completed, and no report was found in the state reporting portal.
Failure to develop a baseline care plan for pressure ulcer risk. A resident was admitted with dementia, nutritional deficiency, osteoarthritis, and existing pressure ulcers, and was documented as non-ambulatory, severely cognitively impaired, and incontinent of bowel and bladder. The record did not show an admission Braden Scale assessment, and the baseline care plan did not identify pressure injury concerns, goals, or interventions. Later documentation noted an open coccyx area, wound cleansing and dressing, physician notification, and a wound consult recommendation.
Incomplete Admission Nursing Assessment: A resident admitted with dementia, nutritional deficiency, osteoarthritis, and a pressure ulcer had required admission assessments either not completed or incomplete, including the nursing admission assessment, Braden Scale, fall risk, elopement, and observation assessments. RN documentation noted the resident was stable and adjusting to the room, with a left heel pressure ulcer, while the MDS showed severe cognitive impairment, extensive care needs, incontinence, non-ambulatory status, and pressure wound risk.
Failure to Provide Timely Incontinent Care: A resident with severe cognitive impairment, total dependence for several ADLs, and always incontinent of bowel and bladder was found saturated in urine and feces after spending the afternoon in a wheelchair instead of being returned to bed for the usual nap. The care plan directed incontinent care about every 2 hours and as needed, but staff gave conflicting accounts of when care was last provided, and the POA reported urine and feces leaked through the brief and clothing during transfer. The record did not document a specific time for incontinent care or the incident.
Podiatry Consult Recommendations Not Followed: A resident with DM and diabetic retinopathy, who was non-ambulatory and needed extensive assistance with ADLs, had multiple podiatry consults showing ingrown toenails with tenderness and mild erythema. The podiatrist recommended treatments such as OTC pain relief, Epsom salt soaks, topical bacitracin, and monitoring for infection, but the facility’s treatment and MARs did not show the recommendations were started. Interviews showed the podiatry reports were not being received or reviewed by nursing or the MD, and the resident later required an outside podiatry visit with additional treatment orders.
A resident with COPD, parkinsonism, nicotine dependence, and ordered continuous O2 was observed smoking in the courtyard. The care plan noted smoking and a refused nicotine patch, but the facility had no documented accident/incident report, no signed smoking policy acknowledgement in the chart, and no clear system showing the resident and family were informed of the facility’s nonsmoking status. Staff said the facility was nonsmoking and that residents/families were told verbally on admission, but they could not locate a smoking policy or related incident documentation.
A resident with Parkinson's disease, dementia, muscle weakness, and DM2 required 2-person transfers, frequent incontinent care, and turning/repositioning. Due to call outs and a short-staffed PM shift, only 3 NAs were available on the unit, and the resident remained in a wheelchair for hours without being changed before dinner. When the resident was transferred to bed, the incontinence brief and clothing were fully saturated with urine and feces, and urine leaked onto the floor during the transfer.
Incomplete hospice and podiatry documentation in resident records: A resident receiving hospice care had limited hospice paperwork in the chart, with staff confirming that consents, care plans, and communication should have been filed in the physical record but were missing. Another resident with DM and a podiatry order had multiple podiatry consults that were not in the medical record until surveyor inquiry, and staff stated the reports were not being received or reviewed by nursing or the MD.
A resident receiving hospice care had a physician order for hospice related to terminal protein calorie malnutrition, but the facility did not have the hospice POC in the chart, did not clearly assign responsibility for hospice paperwork, and had incomplete hospice documentation. Staff gave conflicting accounts of how hospice communication was handled, with verbal exchanges and limited chart entries, while an LPN reported an undocumented request for a recliner and the RN supervisor confirmed no hospice information was present in the chart.
Failure to notify the Ombudsman office of resident transfers and discharges. A resident with acute respiratory failure with hypoxia, acute kidney failure, hypertension, and moderate cognitive impairment was discharged home with family, but the SW did not routinely submit required monthly discharge notifications and believed the portal was only for AMA, abuse, or inappropriate situations. The admin stated the SW was responsible for the notifications, while the regional ombudsman confirmed the facility had portal access and should have been aware of the updated reporting requirements.
A resident with CHF, dementia, DM2, CKD stage 3, and significant functional dependence was admitted to hospice after a physician order and POA consent. The MDS record did not show a required SCSA after the hospice admission, and the MDS coordinator stated the assessment should have been completed within 2 weeks but was missed even though the resident remained in the facility for over a month after hospice enrollment.
A facility failed to accurately code the PASRR section of MDS assessments for three residents with positive Level II PASRR screenings. Residents with diagnoses including schizoaffective disorder, Down syndrome, and bipolar disorder had admission, annual, or significant change MDSs that incorrectly answered “no” to the PASRR question that should have been answered “yes.” Interviews showed the SW was responsible for coding section A 1500, but he was not aware the residents had positive Level II PASRRs.
PASRR level 1 screening was not accurately completed for a resident with psychotic disorder, major depression, anxiety, and moderate cognitive impairment. The original screen listed no diagnoses, behaviors, or meds and concluded no level II PASRR was needed, even though the chart later showed delusions, paranoia, accusatory behaviors, and psychotropic orders. Interviews confirmed the screen was not reviewed for accuracy and should have been resubmitted when the resident's condition was known.
A nurse aide’s personnel file lacked documentation of required performance appraisals after hire. The Administrator and DNS confirmed that nursing staff evaluations were to be completed by the nursing supervisor, charge nurse, or ADNS, and the facility’s policy required a first appraisal at 90 days, then at 1 year and annually thereafter.
Missing Required Annual Nurse Aide Training: The facility did not provide evidence that a nurse aide completed the required annual 12 hours of training, including abuse prevention, dementia care, resident rights, body mechanics, fire safety, nursing skills review, and hazard communication. Records reviewed showed only prior-year in-services and a single infection control training entry for the current year, while the Administrator and DNS described how staff education files are monitored and distributed.
The facility did not ensure safe water temperatures in resident-accessible areas, with multiple locations recording temperatures above policy limits and no documented interventions or notifications. The Maintenance Worker failed to recheck or report high temperatures, and several resident room sinks were not tested, creating a hazardous environment.
A resident with multiple health conditions experienced worsening of a pressure ulcer due to failures in timely physician notification, inconsistent wound care in accordance with orders, and delayed provision of an air mattress for pressure relief. Nursing staff did not consistently communicate changes in wound status, alternative treatments were applied without provider approval when prescribed medication was unavailable, and a recommended air mattress was not provided promptly, resulting in further wound deterioration.
A resident with multiple comorbidities experienced a worsening pressure ulcer, but staff failed to notify the practitioner in a timely manner about the decline. Nursing notes documented the wound's deterioration, but there was no evidence of provider notification, and staff interviews revealed confusion about responsibilities. Facility policy required prompt communication of changes, but this was not followed, resulting in a deficiency.
A resident with a worsening pressure ulcer did not receive wound care in accordance with physician's orders when Santyl ointment was unavailable. Instead, an LPN applied calcium alginate without notifying the provider or obtaining an alternative order, and the nursing supervisor was not informed of the medication's unavailability. Facility staff confirmed that substituting wound treatments without provider direction was not appropriate, and no documentation showed provider notification or an alternative order.
Failure to Clearly Define and Update Resident Transfer Status and Method
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards by not clearly directing staff on a resident’s transfer method and not completing a timely assessment when the resident’s transfer ability changed. The resident had dementia, anxiety, and rheumatoid arthritis, with a BIMS score indicating moderate cognitive impairment, and required substantial/maximal assistance with toilet use and transfers, was dependent with wheelchair use, and was of small stature and low weight. The Resident Care Plan initially directed transfer with assistance of one staff to wheelchair, but was later updated to include two staff for transfers, resulting in conflicting directions that simultaneously called for one and two staff assistance. A physician’s order directed out-of-bed transfers with assistance of one staff using a gait belt, and the NA care card also directed transfer and mobility assistance of one staff. There was no documentation in the physician’s orders, care plan, or NA care card directing the use of a mechanical (Hoyer) lift. Despite the lack of documented orders or care plan direction for a mechanical lift, multiple staff interviews revealed that some nurses and NAs believed the resident required a Hoyer lift for transfers due to leg weakness. The regular NA reported providing one-person assist for transfers but felt it would be safer to use a mechanical lift, while two RNs stated the resident’s transfer status was via Hoyer lift and that NAs were expected to follow the care card for transfer status. The DON stated she was unaware staff were using a mechanical lift and indicated that a change in transfer status should have been supported by an RN assessment or therapy evaluation, with corresponding updates to physician/APRN orders, the care plan, and the NA care card. No facility policy specific to directing staff on transfer status or resident assessments was provided, although a general Hoyer lift procedure and a care plan policy existed, further underscoring that the resident’s actual transfer method in practice was not aligned with the documented plan of care and orders.
Failure to Follow Transfer and Alarm Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and the residents’ plans of care for two residents reviewed for accidents. For one resident with mild cognitive impairment, peripheral vascular disease, diabetes mellitus, and anxiety, the MDS showed severe cognitive impairment and a need for substantial/maximal assistance with transfers. Physician orders and the resident’s care plan required use of a Hoyer (mechanical) lift with two staff for all transfers out of bed to a tilt‑in‑space custom wheelchair. Despite these orders and the facility policy requiring two staff for Hoyer transfers, a nursing assistant performed a Hoyer lift transfer alone after being told by a nurse that assistance would be provided later, and transferred the resident into the custom wheelchair without a second staff member present. Following this solo transfer, the resident, who had reported bilateral lower extremity pain during morning care and was wearing geri‑sleeves for skin protection, again reported bilateral lower extremity pain. The facility’s reportable event documentation identified that during the transfer the resident’s left leg struck the left leg of the custom wheelchair, resulting in a 2 cm open hematoma that later was documented as a 9 cm coagulated hematoma. The resident was subsequently sent to the hospital for evaluation and followed by a wound physician. Interviews with the Director of Therapy and nursing leadership confirmed that the resident’s plan of care and facility policy required two staff for Hoyer lift transfers and that the transfer had been completed by one staff member, contrary to the physician order and care plan. For a second resident with dementia, osteoporosis, repeated falls, and major depressive disorder, the MDS showed severe cognitive impairment and a need for substantial/maximal to dependent assistance with transfers. Physician orders and the care plan required a motion sensor alarm to be in place and on at all times when the resident was in bed, with a bedside sensor and a corresponding alarm box at the nursing station to alert staff to attempts at independent ambulation. On the morning of the incident, the resident was later found sitting on a bathroom floor complaining of right arm pain and was diagnosed with a non‑displaced right clavicle fracture. Facility documentation and interviews indicated that multiple staff did not hear any alarm sound, one nursing assistant was unaware of a sensor alarm in the room, and subsequent investigation determined that the alarm box at the nursing station and the motion sensor alarms were in the off position at the time of the fall, contrary to the physician order and the resident’s care plan.
Shared EMR Logins Lead to Incomplete and Non-Identifiable Nursing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records that identify the individual documenting in the electronic medical record (EMR), contrary to its own Charting and Documentation Policy. For a resident with dementia and severe cognitive impairment who required assistance with ADLs, multiple nursing notes over several days documented pain medication administration, medication tolerance, and absence of pain, but were electronically signed with generic identifiers such as "2LPN pool2 LPN" and "poolnurse supervisor RN" rather than the specific nurse’s name. For a second resident with bipolar disorder, psychotic disorder, anxiety, delusions, and a history of rejecting care, a nursing note describing the resident’s refusal of care and irritable, loud behavior was also signed with a generic “poolnurse supervisor RN” identifier. Additional notes for this resident were similarly signed with “2LPN pool2 LPN,” preventing identification of the specific staff member who provided and documented the care. During interview and record review, the DON confirmed that all agency (pool) RNs, LPNs, and NAs use shared, common logins for EMR access, resulting in documentation that does not display the individual staff member’s name. The DON stated that to determine who wrote a particular nursing note, she would need to cross-reference the facility schedule with the date and shift of the entry. The DON acknowledged that this shared-login practice was long-standing, that notes should include the name of the person writing the note, and that facility policy requires documentation to include the name and title of the individual who provided care and the signature and title of the individual documenting. Despite this, agency staff were not provided with individual EMR logins, leading to incomplete and non-individualized documentation for the residents reviewed for abuse.
Lack of On-Site Medical Director Oversight and Contractual Structure
Penalty
Summary
The deficiency involves the facility’s failure to ensure provision and oversight of a Medical Director in accordance with federal requirements. Interviews and document review with the Administrator and DON showed the facility had no current physicians coming to the facility. The DON reported that the facility had one physician designated as the Medical Director, but this physician was not available to come to the facility and was only available by phone. During the prior year there had been a second physician, but that physician retired on an unknown date and was not replaced. All residents were patients either of the Medical Director, who was not available to come to the facility, or of Optum, which provided APRN coverage. The DON stated that weekly Medical Director rounds were supposed to occur every Thursday, but no physician conducted rounds on the most recent scheduled date and none was scheduled for the following week; the last documented rounds occurred 12 days before the survey interview. The Administrator confirmed there was no Medical Director available to come into the facility for weekly rounds. After the second physician retired, the Administrator contacted two physicians about coverage and then waited for the Medical Director to locate a second physician, without advertising or using a staffing agency to secure coverage. The facility was unable to demonstrate that the designated Medical Director provided routine, ongoing oversight within the facility, including at least weekly on-site presence. Record review did not identify a current, executed contract defining the Medical Director’s responsibilities, availability, and coverage expectations. The facility also lacked documentation of a contingency agreement or alternate coverage plan for Medical Director services if the appointed Medical Director was unavailable or failed to provide required services, and could not provide a policy outlining the Medical Director’s roles, responsibilities, and expectations for facility involvement and oversight.
Failure to Hold and Document Required Quarterly Medical Staff/QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA)/QAPI group, including the medical staff, met at least quarterly as required. During interviews and document review with the Administrator, surveyors learned that the facility’s Medical Director had been unavailable to come into the facility since 2/19/2026, and the only other physician on staff had retired at an unknown time in 2025 and had not been replaced. The Administrator was unable to produce any Medical Staff/QAPI meeting minutes or agendas for the prior 12 months and reported that the last Medical Staff/QAPI meeting occurred in September or October 2025, but she could not provide documentation to verify that it took place. She also stated that a Medical Staff/QAPI meeting had been planned for 2/26/2026 but did not occur because they did not have a quorum. No facility policy related to these meetings was provided for surveyor review despite request. No specific residents or their medical conditions were mentioned in the report, and no additional clinical details were provided regarding individual patient involvement in this deficiency.
Inaccurate MDS Coding for Wandering Behavior and Wander Guard Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s behavioral status and use of a wander/elopement alarm. The resident had diagnoses of vascular dementia with behavior disturbances and depression, was cognitively impaired with poor decision-making skills, and had been identified on an elopement risk evaluation as ambulating independently and displaying behaviors that could indicate attempts to leave the facility. The resident’s care plan, initiated on the same date as the elopement risk evaluation, documented that the resident was at risk for wandering/elopement, had been observed near exterior doors, and required a wander guard device on the ankle with placement and function to be checked every shift. A physician’s order also directed that a wander guard device be applied to the resident’s ankle and checked every shift. Despite these documented behaviors and interventions, the annual MDS assessment coded the resident as having severe cognitive impairment (BIMS score 6/15) but no pacing or wandering behaviors, and indicated the resident ambulated independently with supervision using a walker. In Section E (Behavior), the MDS was coded to show delusions but no wandering behaviors, and in Section P (Restraints and Alarms), it was coded to show that no wander/elopement alarm was used. During interview, the DON stated that the resident’s baseline behavior was to always wander up and down the hallways and that the MDS nurse should use assessments, care plans, and progress notes to ensure accurate MDS coding. The DON acknowledged that the MDS did not accurately reflect the resident’s behaviors, and the facility did not provide a specific policy on MDS accuracy, only a general documentation policy stating that nursing documentation must be accurate, timely, complete, and reflective of the care provided.
Failure to Manage Elopement Risk Assessments and Wander Guard Devices
Penalty
Summary
The deficiency involves the facility’s failure to complete timely elopement risk assessments and obtain a physician order for a wander guard device for one resident, and failure to timely replace and document monitoring for a malfunctioning wander guard device for another resident. One resident had diagnoses including dementia with behavior disturbances and depression, with a significant change MDS showing a BIMS score of 99, indicating severe cognitive impairment and inability to complete the interview. The MDS coded no wandering behaviors and no use of a wander/elopement alarm, while the resident’s care plan dated 12/16/2025 identified that the resident roamed into other residents’ rooms and directed staff to ensure the resident did not roam into rooms. Nursing notes indicated the resident had a wander guard in use during 2024, but the clinical record did not show when the wander guard was initiated or discontinued, and there was no physician order directing its use. Further record review for this resident showed that no elopement risk assessments were completed from admission in 9/2024 through 2/18/2026. An elopement risk evaluation dated 2/19/2026 later identified that the resident ambulated independently, was cognitively impaired with poor decision-making skills, had a history of wandering into unsafe areas, and displayed behaviors that may indicate an attempt to leave the facility. The DON stated that elopement risk evaluations should be completed on admission, quarterly, and upon any readmission, and acknowledged that the assessments for this resident were not done as required. The DON also stated that if a wander guard is in use, there should be physician orders directing its use and documentation on the Medication Administration Record each shift and day it is functioning, which was not present in this case. For the second resident, who had diagnoses including dementia, transient ischemic attacks, and syncope, the quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented daily use of a wander/elopement alarm. An elopement risk evaluation identified that this resident ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave. The care plan dated 1/22/2026 identified the resident as at risk for elopement and directed staff to check wander guard function and placement every shift and daily. A nursing note documented that the resident’s wander guard was in place but not functioning and that every 15‑minute checks were initiated; however, the wander guard was not replaced until two days later. The DON confirmed that the device malfunctioned, that staff did not have access to a replacement device at the time, and that there was no documentation of the every 15‑minute checks on the dates the device was not functioning, despite the facility’s documentation policy requiring accurate, timely, and complete nursing documentation reflective of the care provided.
Failure to Secure Egress Doors and Respond Appropriately to Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to ensure egress doors were properly secured and that staff could effectively respond to and silence door alarms. During an observation with an RN, it was identified that staff were conducting 15‑minute rounds on thirteen egress doors in a rotating pattern that resulted in more than three hours between checks of the same door. While observing Door #8 near the hairdresser, the door alarm sounded and the RN did not know how to silence it. Multiple staff walked past the alarming door without intervening. The RN asked a NA and a housekeeper for assistance, but they reported they did not handle doors or had no information. The Housekeeping Director incorrectly stated the alarm was coming from Door #10, and another housekeeper attempted to silence the alarm at the keypad without success, also believing it was the back door. The alarm at Door #8 continued to sound for an extended period while staff attempted to identify and silence the source. Further observations showed similar issues at Door #10, the back door to the parking lot. After the DON and another staff member initially believed Door #10 was the source of the alarm and then determined it was not, they returned to Door #8 and silenced that alarm with a key. Subsequent observation of Door #10 showed it was secure and alarmed when opened, but entering a code into the keypad did not silence the alarm, and the alarm continued to sound without staff response, even though staff were present in the adjacent kitchen area. The Food Service Director and another staff member later stated they did not respond because they thought it was not the back door alarming, despite acknowledging staff should always respond to an alarming door. Additional observation of Door #12 near the nursing station revealed that entering a code on the keypad turned the indicator light green and allowed the door to open without an alarm, and once opened and closed, the door remained unarmed with no way to re‑arm it from the stairwell side. When the light was red, the door could still be opened without difficulty and no alarm sounded. No facility policy regarding securing egress doors was provided for review.
Incomplete Documentation of Wander Guard Checks for Multiple Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records regarding the placement and function checks of wander guard devices for five residents with dementia and elopement risk. For one resident with severe cognitive impairment and documented room-roaming behavior, the care plan and elopement risk evaluation identified a need for a wander guard and shift-by-shift checks. A physician order directed staff to check the wander guard every shift, yet the MAR/TAR for February showed missing documentation of wander guard placement checks on specified evening and night shifts. A second resident with severe cognitive impairment, elopement risk, and a documented daily wander/elopement alarm had a care plan and physician order requiring wander guard function and placement checks every shift. However, the MAR/TAR from mid to late February contained multiple blank entries where staff failed to document these checks across several day, evening, and night shifts. A third resident with dementia and behavioral disturbances, identified as an elopement risk and care planned to use an alarm device with checks for proper functioning, also had a physician order for wander guard placement checks every shift. The February MAR/TAR showed missing documentation of these checks on two separate day shifts. A fourth resident with vascular dementia, Alzheimer’s disease, and severe cognitive impairment was assessed as an elopement risk and care planned to have a wander guard on the ankle with placement and function checks every shift, supported by a physician order. The February MAR/TAR showed blank entries for required wander guard checks on multiple shifts. A fifth resident with Alzheimer’s disease, severe cognitive impairment, daily wandering behaviors, and a history of wandering into unsafe areas had a care plan and physician order requiring wander guard checks every shift. The MAR/TAR from mid to late February showed missing documentation of wander guard placement checks on identified day and evening shifts. In an interview, the DON confirmed that it was the expectation that nursing staff document all provided care, including wander guard checks, acknowledged the missing documentation for all five residents, and referenced the facility’s documentation policy requiring accurate, timely, and complete nursing documentation of treatments.
Failure to Follow Elopement and Emergency Response Policies for Missing, Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident at risk for elopement by not following its elopement and change in condition policies. The resident had dementia, an elopement evaluation identifying them as at risk for elopement, and a care plan including a wander guard on the right ankle with interventions to redirect the resident near doors and check the wander guard per protocol. A quarterly MDS showed moderate cognitive impairment, independent ambulation with supervision, and no wander/elopement alarm. Nurse aide documentation showed the resident was observed sleeping in bed at approximately 1:00 AM and 3:00 AM. According to staff statements, around 4:30 AM a nurse aide noted the resident was no longer in bed and began searching other rooms and another wing, informing a coworker who also searched while the aide went outside. The coworker then notified the nurse. The two aides searched outside and found the resident lying on the ground by the walkway. The nurse was notified, and the resident was brought back inside. RN documentation and interviews indicated the RN was informed at approximately 5:00 AM that the resident was missing, initiated another room search, then an outside search, and the resident was found on the sidewalk outside, only responding to painful stimuli and blinking. The facility’s elopement policy required that when a resident is discovered missing, the supervisor or DNS be informed, an overhead page be made, staff conduct repeated searches including outside, and the police be notified within 15 minutes if the resident was not located; staff interviews indicated the police should have been notified within 15 minutes of not locating the resident. After the resident was found outside in below-freezing temperatures and brought back inside, staff applied warm clothing and blankets. The RN reviewed the resident’s code status, assessed the resident, and contacted the DNS and Administrator before calling 911. The thermometer used to assess the resident read “LO,” consistent with a temperature below 89.6°F. EMS records showed 911 was called at 6:23 AM, EMS arrived to find the resident unresponsive, pulseless, apneic, extremely cold to the touch, with lividity noted on the left side and fixed, non-reactive pupils, and the resident was pronounced deceased at 6:46 AM. The facility’s change in condition policy directed that 911 should be called immediately if a resident is unresponsive. The facility failed to notify police within 15 minutes of the resident being identified as missing and failed to call 911 immediately when the resident was found unresponsive outside in severe cold, resulting in a finding of Immediate Jeopardy.
Elopement of Dementia Resident Due to Inadequate Supervision and Exit Door Security
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a cognitively impaired resident with known wandering and elopement risk, who was able to leave the building without staff knowledge in subfreezing temperatures. The resident had dementia, a BIMS score indicating moderate cognitive impairment, poor decision-making skills, and documented behaviors and statements about leaving. An elopement risk evaluation identified the resident as ambulatory and at risk for elopement, and the care plan and physician orders specified use of a wander guard bracelet and supervision with a four-wheeled walker. Despite this, the quarterly MDS noted no wander/elopement alarm, and the resident’s care plan interventions were limited to redirection near doors and checking wander guard function per protocol. On the night of the incident, nurse aide documentation recorded that the resident was observed sleeping in bed at approximately 1:00 AM and 3:00 AM. However, police-obtained video showed a person believed to be the resident outside at the back of the building at 1:50 AM, walking along the side of the building past the main entrance toward the road without a walker and with no apparent gait difficulty. A second video showed the same person at the driveway apron at 1:55 AM, then walking along the front sidewalk, slowing, bending down, and then falling face forward at approximately 1:58 AM, after which no further movement was observed. This timeline directly conflicted with the staff documentation that the resident was in bed at 3:00 AM. Staff statements indicated that around 4:30–4:45 AM, a nurse aide discovered the resident was not in bed and began searching the unit with another aide. They searched rooms and another wing before notifying the RN supervisor at about 5:00 AM, approximately 30 minutes after the resident was first identified as missing. After the RN was notified, staff conducted another internal search and then began searching outside. Around 5:11–5:12 AM, staff found the resident lying on the sidewalk in front of the building, unresponsive or minimally responsive, cold to the touch, with clothing described as cold and icy. The resident was brought inside in a wheelchair, undressed, given dry clothing and warm blankets and towels, and assessed. Vital signs were severely abnormal, including a pulse in the 20s–30s and a thermometer reading "LO," indicating a temperature below 89.6°F. The RN reviewed the DNR status, contacted the Administrator and DON by conference call at approximately 6:08 AM, and 911 was not called until 6:23 AM, about 1 hour and 11 minutes after the resident was found outside. The deficiency also includes multiple environmental and systems failures related to exit door security and elopement prevention. The facility had only one wander guard–equipped door (double fire doors near the nurse’s station leading to the lobby). Other exits near the resident’s unit and dietary area had no alarms to alert staff if residents passed through, and an outside door with a keypad had the access code posted above it. The alarm on that outside door was not audible in the adjacent hallway or at the nurse’s station. Observations showed that several exit doors (rear exit to back parking lot, kitchen exit near the hairdresser, and a T-wing exit to a courtyard) failed to latch or re-lock after being opened with the keypad code, and in some cases did not alarm or only briefly alarmed, allowing unrestricted entry and exit. A courtyard door from the dining room could be set with a code that left it unlocked for multiple entries/exits, and courtyard gates opened easily to the parking lot. The Director of Maintenance and Administrator acknowledged that keypad alarms had been turned off, that the code was improperly posted, and that doors were in "winter mode" with no functioning alarm notification to staff, and the facility lacked a policy to ensure proper functioning of emergency exit doors. Additional residents were also identified as elopement risks, with dementia, cognitive impairment, and wandering behaviors, and had orders or care plans for wander guards and checks of device function and placement. One resident’s MDS showed no wander/elopement alarm despite elopement risk, and another had a care plan for elopement risk with interventions to check wander guard function and placement every shift. These findings, combined with the malfunctioning and non-alarming exit doors, the posted keypad code, and the lack of audible alarms to the nurse’s station, demonstrate that residents at risk for elopement could exit the building or enclosed areas without staff awareness. The facility’s own leadership acknowledged that the resident should not have been able to exit without staff knowledge, that nurse aides should have notified the nurse immediately when the resident was found missing, and that 911 should have been called immediately after the resident was found outside.
Failure to Notify Physician of Significant Change in Condition and Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician notification following a significant change in condition for one resident and abnormal laboratory results for another resident, as required by facility policy. One resident with dementia, poor decision-making skills, and a history of wandering was assessed as an elopement risk and care planned to wear a wander guard on the right ankle, with interventions to redirect if near exit doors and to check the device per protocol. On the date of the incident, this resident was discovered missing from their room during overnight rounds, and a search revealed the resident lying outside on the sidewalk with the upper body in the snow, blinking and responding to painful stimuli but nonverbal. The supervising RN brought the resident back inside, performed an assessment that showed low temperature and low pulses, provided warm blankets and care, and called emergency services, but the facility’s reportable event documentation and investigation did not identify that the physician was notified at the time of the incident. Interviews and documentation further clarified the lack of timely physician notification for this event. The supervising RN reported notifying the Administrator, DON, and Infection Control Nurse before calling 911, but did not identify that he called the physician. The attending physician/Medical Director later stated he was not notified of the incident, and the facility’s on-call service confirmed that this physician was covering his own office during the relevant overnight hours with no other providers on call. The DON reported that the facility’s investigation could not determine whether the RN had notified the physician at the time of the incident. Facility policy on change in condition directed that the attending or on-call physician be notified when there is an accident or incident involving the resident, a significant change in condition, or a need to transfer the resident to a hospital or treatment center. A second deficiency involved failure to notify a provider of abnormal laboratory results for another resident. This resident had diagnoses including influenza A, UTI, and hypothyroidism, and was care planned as being at risk for nutritional issues related to vitamin deficiency and hypomagnesemia, with interventions to obtain lab work as ordered and report abnormal findings to the physician. Laboratory results showed an elevated TSH of 9.73 u/mL, above the normal range of 0.34–5.60 u/mL, but the lab report lacked a physician signature of acknowledgment, and record review did not show that the physician was notified of these results. A later progress note by an APRN referenced a TSH result of 9 from the same time period and documented a plan to increase levothyroxine and recheck TSH, but the DON was unable to verify that nursing had notified a physician or APRN about the elevated TSH, and the attending physician stated he was on-site on two subsequent dates and was not notified of the lab results, contrary to the facility’s policy requiring notification of abnormal laboratory reports.
Failure to Complete Timely Elopement Risk Assessments and Obtain Wander Guard Function Orders
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement appropriate physician orders for wander guard function checks and to complete elopement risk assessments according to policy for residents with dementia and identified elopement risk. For one resident with dementia and moderate cognitive impairment, an elopement risk evaluation documented independent ambulation, poor decision-making, statements about leaving, and behaviors suggesting attempts to leave. The care plan identified a wander guard on the right ankle with interventions to redirect near exits and check device functioning per protocol, and physician orders directed staff to check wander guard placement every shift and function daily. However, review of elopement risk evaluations showed they were not completed at quarterly intervals as required, with gaps of 124 and 174 days between assessments, and the physician order for wander guard use was only reviewed during monthly order reviews. For another resident with dementia and severe cognitive impairment, the MDS and elopement risk evaluation identified cognitive impairment, behaviors suggesting attempts to leave, and use of a wander/elopement alarm. The care plan documented elopement risk with interventions to check wander guard placement and function every shift and daily. Record review showed that the admission elopement risk evaluation was followed by the next evaluation 179 days later, exceeding the quarterly requirement. Additionally, although there was a physician order to check wander guard placement every shift, there was no physician order directing staff to perform daily function checks of the wander guard. The DON confirmed that elopement risk evaluations are required on admission, quarterly, and at readmission, and that physician orders should direct daily function checks of wander guards, but acknowledged that the assessments were not completed timely and that an order for function checks was not obtained for this resident, contrary to facility policies on wandering risk assessment and wander-guard security system use.
Failure to Maintain Written Agreement for Laboratory Services
Penalty
Summary
The facility failed to maintain and provide a written agreement with a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory to ensure timely availability of required laboratory services when such services are not provided on-site. During document and policy review, surveyors were unable to identify any written agreement or contract verifying arrangements for laboratory services. In an interview, the Administrator reported being unable to locate the requested laboratory services contract at the time of survey, explaining that binders containing important documents had been relocated following a recent facility-wide evacuation. The facility ultimately could not produce documentation verifying how laboratory services are formally arranged and maintained in compliance with regulatory requirements. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Failure to Maintain Written Agreement for Radiology and Diagnostic Services
Penalty
Summary
The facility failed to maintain and provide a written agreement for radiology and other diagnostic services when such services were not provided directly by the facility. During document and policy review, surveyors were unable to obtain any written agreement or contract verifying how radiology and other diagnostic services were arranged. An interview with the Administrator revealed that she could not locate the requested radiology services contract at the time of the survey. She explained that, following a recent facility-wide evacuation, binders containing important documents had been relocated, and the specific agreement for radiology and diagnostic services could not be produced. As a result, the facility was unable to provide documentation demonstrating that required diagnostic services were available in a timely manner to meet resident needs. No specific residents or their medical conditions were identified in the report.
Lack of Documentation and Policy for 24-Hour Physician Coverage
Penalty
Summary
The deficiency involves the facility’s failure to maintain and provide evidence of 24-hour physician coverage for emergency care. During document and policy review, surveyors were unable to obtain any written agreement, contract, or other documentation verifying that physician services were available around the clock to respond to resident medical emergencies. An interview with the Administrator revealed that she could not produce documentation demonstrating how 24-hour physician services are ensured, explaining that important binders had been relocated during a recent facility-wide evacuation and the requested documents could not be located at the time of survey. Additionally, the facility was unable to provide any policy or procedure describing how 24-hour physician availability is arranged, maintained, and verified to ensure timely medical oversight during emergencies. No resident-specific information, medical histories, or conditions at the time of the deficiency were documented in the report.
Failure to Maintain Written Hospital Transfer Agreement Policy and Documentation
Penalty
Summary
The facility failed to maintain and provide a written transfer agreement policy and documentation of a current transfer agreement with a hospital, as required for managing resident transfers when medically necessary. During document and policy review, surveyors were unable to obtain any written policy outlining the process for transferring residents to a hospital for acute care services. An interview with the Administrator revealed that she could not provide the requested transfer agreement policy at the time of survey, explaining that binders containing important documents had been relocated following a recent facility-wide evacuation, but the specific documentation could not be produced. Additionally, the facility was unable to provide any evidence of a current written transfer agreement or documentation verifying formalized arrangements with a hospital to ensure timely transfer of residents requiring acute care services. No specific residents or clinical situations were identified in the report; the deficiency centered on the absence of required written policies and formalized transfer arrangements at the facility level.
Lack of Written Medical Director Agreement and Contract Management Process
Penalty
Summary
The facility failed to maintain and provide evidence of a written agreement designating a physician as Medical Director responsible for implementation of resident care policies and coordination of medical care. During document and policy review, surveyors were unable to obtain any written contract or agreement verifying the appointment and ongoing contractual relationship between the facility and a Medical Director. An interview with the Administrator revealed that she could not locate the Medical Director contract at the time of survey, explaining that a recent facility-wide evacuation had led to relocation of important binders, but the requested contract still could not be produced. The facility also could not provide any policy or procedure describing how the Medical Director contract is to be maintained, retained, or made accessible. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Incomplete and Inaccurate Documentation of Wander Guard Use and Resident Rounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records related to resident wandering risks, care checks, and wander guard devices. For one resident with dementia and identified elopement risk, the MDS documented no wander/elopement alarm despite physician orders and a care plan indicating use of a wander guard and the need to check its placement every shift and function daily. MAR/TAR review for this resident showed missing documentation by nursing staff on multiple dates for both wander guard function and placement checks. A reportable event documented that this resident, who had dementia and a history of wandering, was found outside the building early in the morning and was brought back inside, assessed, and later pronounced deceased by EMTs. Nurse aide care check rounds documentation and the aide’s written statement indicated that this resident was observed asleep in bed at approximately 1:00 AM and again around 3:00–3:30 AM, with the aide also documenting care to the roommate at 3:30 AM. However, video obtained by local police showed a person believed to be this resident outside at the back of the building at 1:50 AM, walking along the side of the building and appearing at the driveway apron at 1:55 AM, which conflicted with the aide’s documentation that the resident was in bed at 3:00 AM. The video also showed staff locating the resident on the sidewalk in front of the building at 5:11 AM. The discrepancy between the video evidence and the aide’s charted observations demonstrated that the resident location rounds documentation was not accurate. Two additional residents with dementia and significant cognitive impairment, both assessed as having wandering or elopement risk, also had incomplete documentation related to their wander guard devices. For one resident with daily wandering behaviors and a care plan directing wander guard checks every shift and as needed, MAR/TAR review showed missing nurse documentation on several dates for both function and placement checks. For another resident with severe cognitive impairment and a care plan directing wander guard function and placement checks every shift and daily, the MAR/TAR showed missed documentation of placement checks by two LPNs, and there was no physician order on file to monitor wander guard placement every shift and function daily. The DON stated it was her expectation that nursing staff document all care provided, acknowledged that the documentation for these residents was incomplete or missing, and that orders should be obtained for all residents to check wander guard placement every shift and function daily. A facility documentation policy stated that nursing documentation will be accurate, timely, complete, and reflective of the care provided.
Failure to Maintain Written Hospital Transfer Agreement Policy and Documentation
Penalty
Summary
The facility failed to maintain and provide a written transfer agreement policy and documentation of formalized arrangements with a Medicare- or Medicaid-certified hospital to ensure residents could be transferred when medically necessary. During document and policy review, surveyors were unable to obtain a written transfer agreement policy outlining the process for transferring residents to a hospital for acute care. In an interview, the Administrator stated she could not provide the requested transfer agreement policy at the time of survey, explaining that binders containing important documents had been relocated during a recent facility-wide evacuation and the documentation could not be produced. The facility also could not provide evidence of a current written transfer agreement or other documentation verifying formal transfer arrangements with a hospital for timely resident transfers. No specific residents, medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Assess and Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to assess and manage pressure ulcer risk for a resident admitted with dementia, nutritional deficiency, osteoarthritis, severe cognitive impairment, non-ambulatory status, incontinence, and an existing stage 3 pressure ulcer to the left heel. On admission, the record did not reflect a Braden Scale assessment, and the resident’s chart from 8/1/24 through 8/13/24 did not show that a pressure ulcer prevention care plan had been developed and implemented despite the resident’s high-risk condition and known wound history. The resident’s wound physician evaluated the left heel wound on 8/8/24 and identified it as an unstageable pressure wound, with orders that included a pressure redistribution mattress, wheelchair pressure redistribution cushion, heel offloading, and turning and repositioning every two hours. Review of nurses’ notes from 8/1/24 to 8/15/24 failed to identify that the resident was turned and repositioned every two hours as directed. On 8/14/24, nursing documented a new open area to the coccyx, which was cleansed and covered with a border dressing, and the physician was notified. The resident’s care plan dated 8/14/24 identified an unstageable coccyx wound and included interventions for wound treatment, incontinent care every two hours and as needed, turning and repositioning every two hours, and an air mattress. The wound physician’s notes on 8/15/24 identified the coccyx wound as a new deep tissue pressure injury related to pressure. The coccyx wound then worsened, becoming unstageable and later a stage 4 pressure ulcer, while the left heel wound eventually resolved. Facility staff interviews confirmed that residents at high risk for pressure ulcer development were expected to have immediate assessment and preventive interventions, but the nursing supervisor and DNS could not explain why the resident did not have a prevention care plan in place before the coccyx wound developed.
Infection Surveillance and Water Management Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that infection control surveillance data collected monthly was analyzed for trends and included in the quarterly infection control report. Review of the infection control program for April 2024 through January 2026 with the Infection Preventionist (RN #4) showed no documentation reflecting analysis of trends from the monthly infection surveillance data. Review of the quarterly infection control reports for the same period also failed to show analyzed monthly infection trends obtained from the surveillance data collection. RN #4 stated she was responsible for analyzing the monthly infection surveillance data, including the monthly infection control rate, the number of infections, and the types of infections identified during the month, and that this information was to be included in the quarterly infection control report presented at the quarterly Medical Staff Meeting. She acknowledged the monthly infection rate or resolution rate should have been completed and stated she had done it in the past but not in recent years. The facility also failed to provide documentation that the water management plan was implemented as described. Review of the Water Management Plan/Program with the Administrator and Director of Maintenance showed no established flushing log, eyewash station protocol, or annual water management meeting documentation. RN #4 stated she was only responsible for checking the ice machine filter and that maintenance was responsible for testing, and she identified there was no formal water management meeting. The Administrator and Director of Maintenance stated the water management plan was handled by the Director of Maintenance and Infection Preventionist, that an outside contracted company developed the plan and handled annual Legionella testing, and that daily water temperature checks were completed at different faucets. They also stated the water management binder may have been destroyed during a leak and that they had not held a formal annual meeting to review the plan. The Administrator described an eyewash station practice of running the water until it cleared if it appeared brown, but there was no documentation of this, and the Director of Maintenance stated there was no eyewash protocol for flushing and no established flushing program for low-flow areas.
Resident Rooms Maintained Below Required Temperature Range
Penalty
Summary
The facility failed to ensure resident rooms were kept at comfortable and safe temperature levels within the regulatory recommended range of 71 degrees to 81 degrees. Resident #24, admitted in January 2024 with diagnoses including dementia, psychotic disturbance, mood disturbance, and anxiety, had moderately impaired cognition on the annual MDS, was independent with self-care, and used a rolling walker with supervision. The care plan dated 1/8/26 did not identify any concerns related to the room being cold, although the resident reported that the room was cold most days and not comfortable without multiple layers of clothing and extra blankets. Observations in Resident #24's room showed temperatures below the required range at multiple points in the room. On 1/7/26, the temperature near the window was 65.8 degrees F, at the foot of the bed was 67.8 degrees F, and at the doorway with the door closed was 69 degrees F, while a thermometer placed high on the wardrobe near the ceiling read 71 degrees F. The baseboard heater was cold to the touch, and the resident was observed dressed in a turtleneck sweater and covered with a blanket. On 1/8/26, the room thermometer read 69 degrees F, and the resident stated he/she was moving slowly because it was too cold to change clothes. The Director of Maintenance stated he was aware of heat discrepancies in resident rooms and that temperatures were being checked, but he did not document temperatures unless they were below 70 degrees and had no documentation because none were below 70 degrees. He also stated there was one thermostat for the building's boiler hot water baseboard system, a secondary forced hot air source for the hallway, and that resident room doors were required to remain open for safety so hallway heat would enter the rooms. On 1/13/26, temperatures in six resident rooms on the west nursing wing were observed below 70 degrees when thermometers were placed at waist level where residents were located, including Resident #24's room at 66 degrees F, and residents in those rooms were observed with additional blankets and layered clothing.
Care Plans Did Not Reflect Positive PASRR Level II Determinations
Penalty
Summary
The facility failed to ensure that the recommendations from positive level II PASRR determinations were included in the care plans for three sampled residents. Resident #11 was admitted with diagnoses including Down syndrome, adjustment disorder with anxiety, and nontraumatic intracerebral hemorrhage. The PASRR level II screening identified a positive level II determination with recommendations for the facility to address, but the resident’s care plan only addressed psychotropic drug use related to anxiety and did not reflect the positive PASRR status or the PASRR recommendations. Resident #39 had diagnoses including schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. The PASRR level II screening identified a positive level II PASRR approved without specialized services and included recommendations for the facility to address. The resident’s care plan addressed psychosocial well-being related to dementia and included interventions related to psychiatry and monitoring for mood or behavior changes, but it did not reflect the positive PASRR determination or include the PASRR recommendations. Resident #42 was admitted with diagnoses including bipolar disorder, psychotic disorder, and generalized anxiety disorder. The PASRR level II screening identified a positive level II short-term approval without specialized services and included recommendations for the facility to address. The resident’s care plan addressed psychotropic drug use related to bipolar disorder, anxiety, and ADD, but it did not reflect the positive PASRR determination or the PASRR recommendations. Interviews with the MDS coordinator, social worker, and DNS confirmed that the care plans should have reflected the positive level II PASRR determinations and the recommendations provided.
Care plans did not reflect hospice, PASRR, and hospice documentation requirements
Penalty
Summary
The facility failed to ensure resident care plans were revised to reflect hospice services and recommendations for one resident, and failed to ensure a positive level II PASRR determination and its recommendations were included in another resident’s care plan. The report also identified a third resident whose care plan noted hospice services and directed staff to follow the hospice care plan, but the facility record did not contain hospice paperwork or a hospice care plan, and staff were unsure whether hospice recommendations had been incorporated into the facility care plan. Resident #48 was admitted with diagnoses including chronic systolic congestive heart failure, dementia, type 2 diabetes mellitus, and chronic kidney disease stage 3. The admission MDS identified moderately impaired cognition, maximal assistance needs for toileting hygiene, personal hygiene, and bed mobility, and that the resident was non-ambulatory. The care plan addressed advance directives, and a physician order later directed hospice evaluation and treatment. Nursing documentation then identified that the resident was admitted to hospice effective the same day, but the MDS Coordinator stated the care plan would typically be updated when the significant change MDS was completed and acknowledged that this had not been done after hospice admission. Resident #3 had diagnoses including schizoaffective disorder, depression, and insomnia. The PASRR level II screening identified a positive level II PASRR approved without specialized services, and the quarterly MDS showed severely impaired cognition, hallucinations and delusions, total dependence for multiple activities of daily living, and non-ambulatory status. The care plan addressed psychotropic drug use and related behaviors, but it did not reflect the positive level II PASRR or the recommendations from that determination. Staff interviews confirmed that the care plan should have been completed to reflect the positive level II PASRR and its recommendations. Resident #38 was admitted with protein calorie malnutrition and later had physician orders for hospice care related to terminal protein calorie malnutrition. The significant change MDS identified severely impaired cognition, substantial to maximal assistance needs, incontinence, scheduled and as-needed pain medication, and hospice care. The care plan stated the resident was receiving hospice services and directed staff to follow the hospice care plan for care and pain management, but the clinical record contained only one hospice communication page and no hospice paperwork or hospice care plan. Interviews with nursing and hospice staff confirmed that hospice documentation and the hospice plan of care were expected to be present in the record, and the DNS stated that hospice recommendations should be included in the care plan and specify what those recommendations were for the resident.
Missing assessment and treatment orders after skin tear
Penalty
Summary
Resident #2, who had dementia, muscle weakness, COPD, moderately impaired cognition, non-ambulatory status, and a history of skin tears, sustained a 3.0 cm by 1.0 cm skin tear to the left lower leg when NA #5 reported her finger slid against the resident’s skin while putting on the resident’s shoes. The resident’s care plan identified fragile skin, a history of skin tears, and bumping arms as risks, with interventions to check skin weekly and provide daily moisturizing lotion to the extremities. After the skin tear occurred, the record did not contain a physician’s treatment order for the wound for the period reviewed, and there was no RN assessment note documented after the incident. The Weekly Wound Documentation for December 2025 did not identify the skin tear, and the wound was not added to the wound log until January 2026, when the wound nurse stated the resident was first seen because that was when the resident was added to the wound book. The charge nurse stated the supervisor was made aware of the skin tear, and the nursing supervisor stated that when an accident or incident occurs, the supervisor is responsible for completing an RN assessment, writing a note, notifying the physician and family, and obtaining orders. The wound nurse later noted the resident had an old dressing hanging off the leg and the area appeared infected and smelly, and the physician was notified.
Controlled Substance Audit and Reconciliation Failure
Penalty
Summary
The facility failed to ensure it had an established system of audit and reconciliation for controlled substances. The DNS stated that the narcotic audit process consisted of counting narcotics on the two medication carts and checking expiration dates, and that when a narcotic medication came into the facility, the white controlled substance disposition record was placed on the cart while the yellow/pink CSDR sheets were kept in binders in the IP nurse's office. The DNS also stated that the audits were signed off for November and December 2025 when she first came to work at the facility, but she could not identify any audit paperwork from November 2025 back to September 2024, and she said the yellow/pink CSDR sheets in the binders were not used to complete the audits. When asked how she ensured that all controlled substances brought into the facility were accounted for, she did not answer. RN#4, who was responsible for keeping track of the controlled substance records in two binders, stated that she only matched completed white CSDRs to the yellow/pink CSDRs in the binders and did not do the facility audits. Surveyors flagged 12 controlled substances for audit; 10 were in the facility, while 2 were not in use and were not in the destroyed medication logs, so they could not be reconciled. The DNS later stated that the 2 missing medications had been brought into the facility before she took the DNS position. The facility policy stated that the DON, in collaboration with the consultant pharmacist, maintains compliance with laws and regulations in handling controlled substances and that controlled substance inventory is regularly reconciled to the MAR and documentation.
Expired Medications and Controlled Substance Storage Issues
Penalty
Summary
The facility failed to ensure expired medications were removed from active circulation and failed to ensure medications were stored according to manufacturer guidelines. During observation of the East medication cart, expired medications were found in active use, including Methocarbamol 750 mg tablets with 10 pills remaining, Hycosamine 1.25 mg tablets with 1 pill remaining, and Lorazepam 2 mg/ml with 10 ml remaining in the bottle. The Lorazepam liquid was identified as a medication that should be refrigerated, but it was not stored that way at the time of observation. The facility also failed to ensure controlled substances were monitored correctly and had corresponding administration sign-off sheets. The observed Lorazepam liquid did not have a corresponding white controlled substance disposition record to document administrations. During interviews, the LPN, RN supervisor, and DNS each stated that expired medications should be removed or discarded, that liquid Lorazepam should be refrigerated, and that controlled substances should have a corresponding sign-off sheet for inventory control. The medication storage policy stated that controlled substances requiring refrigeration are stored within a box attached to the inside of the refrigerator.
Failure to Offer and Document COVID-19 Booster Vaccination
Penalty
Summary
The facility failed to ensure that the COVID-19 2025-2026 booster vaccine was offered and administered when requested for three residents reviewed for immunizations. Resident #20 had diagnoses including dementia, a history of TIA, and hypertension, and the quarterly MDS identified severely impaired cognition. The resident’s POA signed vaccine consent forms on 7/3/25 for the annual COVID-19 booster, but review of the clinical record, immunization consents, and Preventative Health Care Report with the Infection Preventionist failed to show that the booster was administered or that the resident refused it. Resident #39 had diagnoses including schizoaffective disorder, bipolar disorder, COPD, and generalized anxiety disorder, and the quarterly MDS identified the resident as cognitively intact. The resident’s POA signed vaccine consent forms on 8/15/24 for the COVID-19 booster, but the record review failed to show administration of the 2025-2026 booster or a refusal. Resident #41 had diagnoses including dementia, type 2 diabetes mellitus, and depression, and the annual MDS identified severely impaired cognition and that the resident was not up to date with COVID-19 vaccination. Review of immunization consent records and the Preventative Health Care Report failed to show that the booster was offered, and the Infection Preventionist stated the family had previously not wanted the vaccine but a refusal consent should have been obtained for the 2025-2026 booster.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
The facility failed to ensure that an employee was appropriately screened prior to employment. Review of the Social Worker designee’s employment records showed that SW#1 was hired in July 2020, but the file did not contain documentation of a criminal background check, reference checks, or verification of employment or education. The facility’s general orientation/hiring checklist identified that background checks and license/certification verification were to be completed before orientation, but those documents were not present in SW#1’s record. During interview, the Administrator stated that the employee records did not contain a background check and that references are not usually checked, with the resume used in place of past employment history verification. The Administrator also stated that the facility does not normally call to verify references or past employment history and that she and the DNS are responsible for reviewing applicants and hiring. SW#1 stated that he had not been fingerprinted as part of the hiring process, although he had fingerprints done long before this employment. The facility’s Abuse Prohibition policy stated that personnel would be screened for a history of abuse, that a criminal background check and a minimum of two reference checks were required, and that the information would be documented and kept in a separate HR file.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency for a resident with Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus who had severely impaired cognition, was non-ambulatory, and was dependent for bed mobility, toileting, bathing, and lower body dressing. The resident was also always incontinent of bowel and bladder and had a care plan directing incontinent care approximately every 2 hours and turning and repositioning every 2 hours. A complaint from the resident's responsible party stated that the resident was found in a wheelchair saturated with urine and feces, with urine and feces leaking through the brief and clothing onto the floor. The responsible party reported that the resident had remained in the wheelchair during a recreational program and had not been changed for a prolonged period. The responsible party said the incident was reported to the nursing supervisor and emailed to the DNS and Administrator, but no accident and incident report was provided for the event and no report was found in the State Agency's online reporting portal. The DNS and Administrator later acknowledged they had not initially seen the email, and the DNS stated she would have initiated an investigation and reported the incident to the State Survey Agency if she had seen it. RN #3 stated the responsible party told her the resident was very wet and filled with feces and that the nurse aide admitted she had not changed the resident at 4:00 PM because she had come to work late. RN #3 also stated she did not report the allegation to the DNS, did not assess the resident's skin, and did not complete an accident and incident report. The facility later submitted a reportable event identifying an alleged neglect related to the resident not receiving incontinent care on a timely basis.
Failure to Investigate Alleged Neglect
Penalty
Summary
The facility failed to initiate an investigation of an alleged neglect involving a resident with Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus. The resident's quarterly MDS identified severely impaired cognition, dependence for bed mobility, wheelchair use, non-ambulatory status, and total incontinence of bladder and bowel. The care plan identified the resident was at risk for pressure injury related to a history of a healed stage 3 coccyx wound and directed incontinent care approximately every 2 hours and turning and repositioning every 2 hours and as needed. A complaint from the resident's responsible party reported that the resident had remained in a wheelchair during a recreational program and was found saturated with urine and feces, with urine and feces leaking during transfer to bed. The responsible party stated the incident was reported to nursing staff and emailed to the DNS and Administrator, but no accident and incident report was provided and no report was found in the State Agency reporting portal for the alleged neglect. The RN stated the responsible party told her the resident was very wet and filled with feces, that the assigned nurse aide admitted she had not changed the resident because she came to work late, and that she did not report the allegation to the DNS, assess the resident's skin, or document the event. The DNS and Administrator stated that when neglect is alleged, the supervisor should initiate an accident and incident report and notify the DNS, but this was not done at the time of the allegation.
Failure to Develop Baseline Care Plan for Pressure Ulcer Risk
Penalty
Summary
The facility failed to develop a baseline care plan to prevent pressure ulcer/injury on admission for Resident #7. Resident #7 was admitted with diagnoses including dementia, nutritional deficiency, a stage 4 pressure ulcer wound, and osteoarthritis. On admission, RN #1 documented that the resident was in stable condition and adjusting to the room, but also noted dry, peeling lower extremities and a stage 3 pressure ulcer to the left heel measuring 1.0 cm by 1.0 cm with good granulation tissue in the wound bed. The clinical record did not show that a Braden Scale assessment had been completed on admission, and the baseline care plan dated 8/1/24 did not identify areas of concern, goals of care, or interventions related to pressure ulcer prevention. The admission MDS identified severe cognitive impairment, extensive assistance needs for bed mobility, personal hygiene, toileting, dressing, and transfers, non-ambulatory status, and that the resident was always incontinent of bladder and bowel and at risk for pressure ulcers with one unstageable pressure wound. Later, RN #1 documented an open area to the coccyx, cleansed it, applied a border dressing, and notified the physician, who recommended a wound consultation. The care plan dated 8/14/24 then identified an unstageable coccyx wound and included interventions such as observing for worsening, providing treatment as ordered, incontinent care every 2 hours and as needed, turning and repositioning every 2 hours, and use of an air mattress. The DNS stated licensed staff are responsible for developing and implementing a care plan for care issues identified on admission and that the care plan should have been implemented immediately on admission.
Incomplete Admission Nursing Assessment
Penalty
Summary
The facility failed to ensure the RN completed the required admission assessments for a newly admitted resident with dementia, nutritional deficiency, a stage 4 pressure ulcer wound, and osteoarthritis. The admission/readmission checklist required a complete nursing assessment within 24 to 48 hours, including admission observations, a nursing assessment, Braden Scale assessment, fall risk assessment, elopement assessment, and wound measurements with wound care. Review of the clinical record showed that the observation assessment, admission nursing assessment, Braden Scale assessment, fall risk assessment, and elopement risk assessment were either not done or were incomplete. RN documentation noted the resident was admitted in stable condition and adjusting to the room, and also described a left heel stage 3 pressure ulcer measuring 1.0 cm by 1.0 cm with good granulation tissue. The admission MDS identified severe cognitive impairment, extensive assistance needs for personal hygiene, toileting, dressing, and transfers, non-ambulatory status, bowel and bladder incontinence, risk for pressure ulcers, and one unstageable pressure wound. RN #1 stated she was responsible for completing the comprehensive admission assessment, including the head-to-toe assessment, fall risk assessment, Braden Scale assessment, and elopement assessment, but could not recall whether she comprehensively assessed the resident. The DNS stated licensed staff were responsible for completing these assessments and expected them to be completed and available in the EHR.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to ensure that a resident who was always incontinent of bowel and bladder received incontinent care in a timely manner as outlined in the care plan. The resident had diagnoses including Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus, and the quarterly MDS identified severely impaired cognition, dependence for multiple ADLs, and risk for pressure ulcers. The care plan directed incontinent care approximately every 2 hours and as needed, along with turning and repositioning approximately every 2 hours and as needed. On 1/2/26, the resident attended an entertainment program in the afternoon and remained in a wheelchair instead of taking the usual afternoon nap in bed. A complaint reported that when the resident's POA assisted with a transfer from the wheelchair to the bed, the resident's incontinence product was fully saturated and urine and feces leaked through clothing and onto the floor. The POA later reported the resident was saturated in urine and feces up to the belly, and that urine was squirting out during the transfer. The complaint was emailed to the DNS, Administrator, and Regional Ombudsman the same evening. Staff interviews showed conflicting accounts of the timing and completion of incontinent care. NA #1 stated the resident was checked at about 10:30 AM and again at about 2:00 PM, and that care was provided around 2:00 PM before the resident went to entertainment. NA #4 stated two aides were present for the 2:00 PM care and that the resident was transferred back to the wheelchair afterward. In contrast, NA #3 stated she arrived late, found the resident already up and wet, and did not get back to change the resident before dinner because of short staffing and other residents needing care. The evening supervisor and the POA reported the resident was not changed in time, and the clinical record and point-of-care history did not document a specific time that incontinent care was provided or any incident related to the saturated brief and leakage.
Podiatry Consult Recommendations Not Followed
Penalty
Summary
The facility failed to ensure that podiatry consultation findings were reviewed and that the podiatrist’s treatment recommendations were carried out for Resident #39, who had diabetes mellitus with diabetic retinopathy without macular edema and was non-ambulatory with extensive assistance needs for personal hygiene, toileting, dressing, and transfers. The resident had physician orders for podiatry consultation as needed and had consented to podiatry services. The record identified multiple podiatry consultation reports, including findings of ingrown toenails with tenderness and mild erythema, but the clinical record initially did not contain the consults until after surveyor inquiry. The podiatry consultation report dated 6/16/25 identified a right great toe ingrown nail that was tender to palpation with mild redness and no swelling. The podiatrist recommended post-procedure care for the right ingrown toenail, OTC medication for pain, warm Epsom salt soaks if swelling persisted, monitoring for signs and symptoms of infection, and consideration of antibiotic medication if infection occurred. The report dated 8/18/25 identified bilateral ingrown toenails with similar findings and recommended OTC medication for pain, warm soaks if swelling persisted, monitoring for infection, topical bacitracin once daily for two weeks, and routine follow-up. Review of the treatment and medication administration records for June 2025 through September 2025 did not reflect that the house podiatrist’s recommendations were initiated. The resident later had an outpatient podiatry consult for the ingrown toenail, which recommended Epsom salt soaks, silver sulfadiazine cream, dry clean dressing, and cephalexin, and a physician order was written to match those recommendations. Interviews with the DNS, RN supervisor, and Medical Director identified that the podiatry reports were not being received or reviewed by nursing staff or the physician, and that the RN supervisor was unaware the resident had been seen by the in-house podiatrist. The facility ancillary physician policy stated that podiatry services were available and that services provided were recorded in the resident’s medical record.
Failure to Supervise Resident Smoking and Maintain Smoking Policy Documentation
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from smoking in the courtyard, failed to develop a comprehensive smoking policy and procedures, and failed to develop a system to ensure the resident and family were aware of the facility’s non-smoking status. Resident #5 had diagnoses including COPD, parkinsonism, chronic back pain, and nicotine dependence. The physician ordered continuous oxygen at 2 liters per minute to keep pulse oximetry above 90 percent. The quarterly MDS identified the resident as cognitively intact, independent with dressing, hygiene, and transfers, ambulatory with a cane, and receiving oxygen therapy. The resident care plan noted that Resident #5 was observed smoking cigarettes outside in the courtyard and directed staff to educate the resident on smoking; it also noted that a nicotine patch had been offered and refused. A physician order directed that the resident be independent with a straight cane in the courtyard and be checked every 15 minutes. However, when an accident and incident report related to the smoking incident was requested, the facility did not have one documented. The smoking policy education and acknowledgement form provided by the facility was unsigned, undated, and not found in the resident’s clinical record. The resident’s representative stated the facility had not provided education about the risks of smoking while using oxygen and was unaware the resident had been observed smoking in the courtyard. Facility staff stated the facility was nonsmoking, that admission staff verbally informed residents and families of that status, and that they could not locate a smoking policy or any accident and incident reports related to the incident.
Inadequate Staffing and Delayed Incontinence Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet resident needs and to have sufficient nursing staff available on each shift. Resident #16 had Parkinson's disease, dementia, muscle weakness, and type 2 diabetes mellitus, with severely impaired cognition, dependence for multiple activities of daily living, and a history of a healed stage 3 coccyx pressure injury. The resident's care plan required incontinent care and turning/repositioning approximately every 2 hours, and physician orders required a stand-pivot transfer to a custom wheelchair with assistance of two staff and two nurse aides in the room at all times for care. On the afternoon of the incident, a complaint reported that Resident #16 did not receive the customary afternoon nap in bed and remained in a wheelchair during musical entertainment for approximately 2 hours. When the resident was transferred from the wheelchair to bed, the resident's incontinence product and clothing were fully saturated, and urine and feces leaked onto the floor. During interview, the resident's POA stated the resident was saturated in urine and feces up to the belly and urine was squirting out over the chair during the transfer, after which the POA cleaned the resident. The complaint was reported to the evening supervisor and emailed to the DNS and Administrator. Staff interviews and schedule review showed the 3:00 PM to 11:00 PM shift was short staffed on the day of the incident. The schedule for a census of 43 showed 3 licensed staff and 5 nurse aides planned for the shift, but 2 nurse aides called out, leaving only 3 nurse aides. One aide was expected to arrive later, another was late, and the evening supervisor stated she had to cover the dining room because of the shortage and no other staff came. An aide stated the unit had only 3 nurse aides working with the supervisor and two other nurses, and another aide stated residents who required mechanical lift transfers were being changed first, so Resident #16 was not changed before dinner. The scheduler stated the facility typically scheduled 4 to 5 aides on that shift depending on census and that the facility needed a minimum of 4 aides to meet staffing requirements.
Incomplete hospice and podiatry documentation in resident records
Penalty
Summary
The facility failed to ensure Resident #38’s medical record was complete and readily accessible for hospice services. Resident #38 had diagnoses including protein calorie malnutrition and senile degeneration of the brain, was receiving hospice care related to terminal protein calorie malnutrition, and had a significant change MDS showing severely impaired cognition, substantial/maximal assistance needs, incontinence, pain medication use, and hospice services. The care plan identified that the resident was receiving hospice services and directed staff to follow the hospice care plan for care and pain management. Review of the resident’s electronic progress notes showed only one note indicating a hospice representative visit, while review of the physical clinical record found only limited hospice paperwork containing medication changes. Interviews with RN #2, the MDS Coordinator, the Director of Hospice Operations, LPN #1, and the DNS confirmed that hospice paperwork, including consents, care plans, and communication, should have been in the resident’s physical chart, but it was not found there. Staff also described that hospice communication occurred through the physical chart and verbal exchanges, and that recommendations from hospice were used to write orders, yet the chart did not contain the expected hospice documentation. The facility also failed to ensure podiatry consultations were included in Resident #39’s medical record. Resident #39 had diabetes mellitus due to underlying condition with diabetic retinopathy, a physician order for podiatry consultation as needed, and podiatry consent to treat. The clinical record did not contain the podiatry consults until they were provided after surveyor inquiry, even though reports dated 2/14/25, 4/16/25, 6/16/25, 8/18/25, and 10/27/25 showed the resident received podiatry services. Interviews with the DNS, RN #2, and the Medical Director showed the reports were not being received or reviewed by nursing staff or the physician, and the DNS stated the reports should be filed in the resident’s clinical record after review.
Hospice Communication and Documentation Gaps
Penalty
Summary
The facility failed to arrange for hospice services or assist the resident in transferring to a facility that would arrange hospice services, as evidenced by deficiencies in the communication process between the facility and the hospice provider, the lack of a designated staff member responsible for coordinating hospice care, the absence of a hospice care plan in the resident record, and missing hospice-related documentation. The resident had diagnoses of protein calorie malnutrition and senile degeneration of the brain, and the physician ordered hospice care for the terminal diagnosis of protein calorie malnutrition. The resident’s significant change MDS identified severely impaired cognition, substantial/maximal assistance needs for self-care and rolling, total incontinence, pain medication use, and receipt of hospice care. The resident’s care plan stated that hospice services were being received and that staff were to follow the hospice care plan for care and pain management, but the hospice plan of care was not available in the chart. Review of the physical clinical record found only one communication page in the hospice section, containing medication change documentation, and nurses’ progress notes showed only one note indicating the resident was seen by a hospice representative. Facility staff gave conflicting statements about who handled hospice paperwork and who was responsible for ensuring the chart was complete, and the RN supervisor confirmed that there was no hospice information in the chart at the time of review. Interviews with facility and hospice staff showed that communication was occurring verbally and through the resident’s physical chart, but documentation was incomplete and inconsistent. The hospice director stated that all visits should be documented on recommendation sheets in the resident chart and that consents and care plans should be present for continuity of care. An LPN reported requesting a recliner chair through hospice but did not document the interaction or know the hospice nurse’s name. The facility contract required regular communication between the facility and hospice and required each party to document communications in its own records, while also requiring hospice to provide the plan of care, medications and orders, election form, certifications, contact information, and on-call system.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to ensure that the Ombudsman’s office was provided with required notification of resident transfers and discharges for a sampled resident who was discharged home with medications and left the facility with family. The resident had diagnoses of acute respiratory failure with hypoxia, acute kidney failure, and hypertension, and the admission MDS identified moderate cognitive impairment along with dependence on staff for personal hygiene, toileting hygiene, upper body dressing, bed mobility, transfers, and ambulation using a walker. The nurse’s note documented that the resident was stable, denied pain or discomfort, and had no shortness of breath at the time of discharge. During interviews, the social worker stated he was not routinely sending transfer and discharge notifications to the state Ombudsman’s office and had not sent any notifications for the last three months. He said he knew about the online reporting portal but had not used it because he had no need, and he believed it was only for AMA discharges, suspected abuse, or inappropriate situations. The administrator stated the social worker was responsible for sending notification of transfers and discharges and that hospitalization and discharge notifications should be sent every 30 days, with unplanned discharges sent immediately. The regional ombudsman stated the facility had access to the online portal and should have received notice of the reporting changes earlier in 2025. The facility did not provide a transfer/discharge notification policy, and the DNS stated the facility’s practice was to send monthly notifications of discharges, hospitalizations, and admissions to the Ombudsman office.
Failure to Complete Significant Change Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for Resident #48 after the resident was admitted to hospice care. Resident #48 was admitted to the facility in August 2025 with diagnoses including chronic systolic congestive heart failure, dementia, type 2 diabetes mellitus, and chronic kidney disease stage 3. The admission MDS identified moderately impaired cognition, maximal assistance needs for toileting hygiene, personal hygiene, and bed mobility, and that the resident was non-ambulatory. A physician order on 9/11/25 directed hospice evaluation and treatment. A nurse's note dated 9/13/25 documented that Resident #48 was admitted to hospice effective that day, the physician was notified, orders were reinstated per the resident's POA request to hospice, and hospice informed consent was obtained and signed by the POA. Review of the MDS record from admission through November 2025 did not show that a SCSA was completed after hospice admission. The MDS coordinator stated that significant change MDS assessments are completed within 2 weeks of admission to or discharge from hospice and that this resident's assessment should have been scheduled and completed by 9/28/25, but it was missed even though the resident remained in the facility for more than a month after hospice admission. The DNS stated she was responsible for signing off MDS assessments and that her signature indicated the sections were completed, not that they were accurately completed.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to ensure comprehensive assessments were accurately coded for residents with positive Level II PASRR screenings. For Resident #3, whose diagnoses included schizoaffective disorder, depression, and insomnia, the PASRR Level II screening dated 12/9/2022 identified a positive Level II PASRR approved without specialized services. However, the annual MDS assessment identified severe impaired cognition and answered “no” to the PASRR question asking whether the resident was currently considered by the Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition; the response should have been “yes.” For Resident #11, who was admitted in December 2025 with diagnoses including Down syndrome, adjustment disorder with anxiety, and nontraumatic intracerebral hemorrhage, the PASRR Level II screening dated 12/17/2025 identified a positive Level II PASRR. The admission MDS assessment identified moderately impaired cognition and also answered “no” to the PASRR question regarding whether the resident was currently considered by the Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition, when the response should have been “yes.” For Resident #39, whose diagnoses included schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, the PASRR Level II screening dated 9/26/2024 identified a positive Level II PASRR approved without specialized services. The admission MDS assessment identified moderately impaired cognition and the significant change MDS assessment identified cognitively intact, but both assessments answered “no” to the PASRR question that should have been answered “yes.” Interviews with the MDS coordinator and the Social Worker identified that the Social Worker was responsible for coding section A 1500 on admission, annual, and significant change MDS assessments, and that the PASRR section was not completed accurately for these residents because they all had positive Level II screenings. The Social Worker stated he was not aware the residents had positive Level II PASRRs because he received PASRR information from the business office and from admission. A policy for accuracy of MDS coding was requested but not provided.
PASRR Screening Not Accurately Completed
Penalty
Summary
The facility failed to ensure the PASRR level 1 screening for one resident was accurately completed to determine whether a level II PASRR screening was needed. The level 1 screen submitted on 2/26/24 stated that no medical diagnoses, behaviors, or medications were identified and concluded that no level II screening was required because the resident had no intellectual/developmental disability or serious behavioral health issues. The screening also stated that if changes occurred or new information refuted those findings, a new screening must be submitted. The resident was later documented as having psychotic disorder with delusions due to a known physiological condition, major depressive disorder recurrent with severe psychotic symptoms, and anxiety. Physician orders included sertraline, trazodone, and quetiapine. The care plan identified behavioral symptoms, wild stories, delusions, increased paranoia, and accusatory behaviors, and the admission MDS identified moderate cognitive impairment and a depression diagnosis. A psychiatrist note documented anxiety, depression, delusional statements, and distress, restlessness, and anxiety related to reports that the resident's spouse was hurting him/her. Interviews with the SW and businessperson showed that the PASRR screen was not reviewed for accuracy and that a new PASRR screen should have been submitted because the original screen did not include the resident's diagnoses, behaviors, or medications.
Missing Performance Appraisals for Newly Hired NA
Penalty
Summary
The facility failed to ensure that a performance appraisal was completed for one of four nurse aides, NA #7, in accordance with its policy. Review of NA #7’s personnel file showed she was hired on 10/25/24, but there was no documentation that a performance evaluation was completed 90 days after hire, at one year, or annually thereafter in 2024 and 2025. Interviews with the Administrator and DNS on 1/12/26 at 1:50 PM identified that department heads were responsible for completing staff performance evaluations, and that nursing staff evaluations were completed by the nursing supervisor, charge nurse, or ADNS. The Administrator stated performance evaluations were to be completed 3 months after hire, then at 6 months and one year after hire, and confirmed NA #7 should have had a performance evaluation completed. On 1/13/25 at 9:00 AM, the Administrator stated she was unable to locate performance evaluations for NA #7 after conducting a search. The facility’s Employee Performance Appraisal policy stated newly hired employees should be appraised first at 90 days, then at 1 year, and annually thereafter.
Missing Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to provide evidence that nurse aide #7 received the required 12 hours of annual training in 2025, including education on resident rights, dementia, proper body mechanics, the facility abuse policy and procedure, fire safety, nursing skills review, and hazard communication. Review of the staff training records for 2024 and 2025 with the Administrator on 1/12/26 showed that the training folder only contained in-services from 2024, and the records provided for 2025 reflected only infection control training. During an interview on 1/13/26 at 9:00 AM, the Administrator stated she monitors staff education files kept in a shared office space and that education materials are dispersed to department heads depending on the education, then given to the Infection Control Nurse. The DNS stated the facility has a policy to provide mandatory annual education and other in-services as needed, but a requested policy regarding mandatory education for nurse aides/nursing staff was not provided.
Failure to Maintain Safe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain safe water temperatures in resident care areas, resulting in a hazardous environment that could have led to burn injuries. Observations by Building and Fire Inspection Safety identified water temperatures in multiple resident-accessible areas, including the East Shower Room, [NAME] Shower Room, and T Wing Hall bathroom, that exceeded the facility's policy limit of 120 degrees Fahrenheit, with some readings as high as 142 degrees Fahrenheit. Review of the Water Temperature Log over a three-month period showed that 40% of recorded temperatures in these areas were above the acceptable range, yet there was no evidence of intervention, notification to the Administrator, or re-evaluation of the temperatures to ensure resident safety. The facility's Domestic Hot Water Temperature Policy required immediate reporting of temperatures above 120 degrees Fahrenheit, but this was not followed. Interviews revealed that the Maintenance Worker, who was responsible for daily water temperature checks, did not consistently recheck or document corrective actions when high temperatures were found, nor did he inform the Administrator or educate staff about the hazard. The facility President acknowledged that he had not recently monitored the water temperatures, despite being aware of issues with one of the boilers. Additionally, only certain areas were being checked for water temperature, leaving several resident room bathroom sinks untested during the reviewed period. Staff interviews confirmed that water temperatures in some areas could become hot, but no systematic approach was in place to address or communicate these hazards.
Failure to Report Wound Deterioration and Implement Timely Pressure Ulcer Interventions
Penalty
Summary
A resident with multiple comorbidities, including Parkinson's disease, dementia, diabetes, and muscle weakness, was identified as being at moderate risk for developing pressure ulcers. The resident had a stage 2 pressure ulcer on the coccyx, which was present on admission, and required significant assistance with mobility and activities of daily living. The care plan included regular turning and repositioning, maintaining dry linens, therapy for wheelchair positioning, wound physician visits, and adherence to skin care protocols. Despite these interventions, the resident's wound deteriorated over time. Nursing documentation indicated that the wound worsened, with tunneling and increased drainage, but there was no evidence that the nursing supervisor or physician was notified of these changes as required. Interviews revealed conflicting accounts between nursing staff regarding whether the change in wound status was communicated. Additionally, when a new treatment (Santyl ointment) was ordered for the wound, it was not administered as prescribed due to unavailability, and an alternative treatment was applied without provider notification or a new order. The clinical record also failed to show timely notification to the physician when the wound appeared infected. Furthermore, a wound care physician recommended the use of an air mattress for pressure offloading, but this recommendation was not implemented in a timely manner. Staff interviews confirmed that the recommendation was missed, and an order for the air mattress was not entered, resulting in a delay in providing this essential intervention. The wound continued to deteriorate, with subsequent assessments documenting increased size and worsening tissue condition. Facility policies required timely assessment, reporting, and adherence to physician orders, but these were not followed in this case.
Failure to Timely Notify Practitioner of Pressure Ulcer Deterioration
Penalty
Summary
A deficiency occurred when facility staff failed to notify the practitioner in a timely manner regarding the deterioration of a resident's pressure ulcer. The resident, who had significant medical conditions including Parkinson's disease, dementia with behavioral disturbances, type 2 diabetes mellitus, and muscle weakness, was identified as having a stage 2 pressure ulcer on the coccyx. The care plan included regular turning, therapy, wound physician visits, and specific wound treatments. Despite these interventions, documentation showed that the wound worsened over several days, with increased tunneling and changes in wound measurements, but there was no evidence that the nursing supervisor or provider was notified of these changes during that period. Nursing notes indicated that the wound had worsened on multiple occasions, and staff interviews revealed confusion and lack of follow-up regarding provider notification. One LPN stated she informed the nursing supervisor about the wound's decline but did not confirm if the provider was notified, while the nursing supervisor denied receiving such notification. Additionally, when a prescribed wound treatment (Santyl) was unavailable, there was no clear documentation or confirmation that the provider was contacted for alternative orders, and staff instead used a previous treatment without provider approval. Further review of progress notes and interviews with medical staff confirmed that the wound physician was not contacted between scheduled visits despite the wound's deterioration. Facility policies required timely communication of changes in condition and collaboration with the healthcare team, but these procedures were not followed. The lack of timely notification and documentation of provider contact regarding the resident's declining wound condition constituted the deficiency.
Failure to Follow Physician's Orders for Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's disease, dementia, diabetes, and muscle weakness, developed a worsening unstageable pressure ulcer to the coccyx. The resident's care plan included specific interventions for pressure ulcer management, and a physician's order was in place to cleanse the wound and apply Santyl ointment daily. However, on one occasion, the Santyl ointment was unavailable, and the wound was instead treated with calcium alginate without a corresponding physician's order or provider notification. The LPN responsible for the resident's care documented that the Santyl was not available and applied alginate to the wound, referencing a previous treatment order. The LPN reported notifying the nursing supervisor but did not follow up to confirm whether the provider was contacted or if an alternative order was obtained. The nursing supervisor later stated she was not notified about the medication's unavailability and would have taken steps to secure an alternative treatment if she had been informed. Further interviews with facility staff, including the infection control nurse and an APRN, confirmed that it was not appropriate to substitute the wound treatment without provider direction. Review of facility policies indicated that staff are required to follow physician's orders and communicate changes or concerns regarding wound care to the healthcare team. No documentation was found to show that the provider was notified or that an alternative order was obtained for the use of alginate in place of Santyl.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
