Cheshire House Health Care Facility & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterbury, Connecticut.
- Location
- 3396 E Main Street, Waterbury, Connecticut 06705
- CMS Provider Number
- 075373
- Inspections on file
- 32
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Cheshire House Health Care Facility & Rehab Center during CMS and state inspections, most recent first.
A resident admitted after a right total hip replacement with diagnoses including type 2 DM, HTN, and hyperlipidemia was discharged from the hospital with a recommendation for Atorvastatin for hyperlipidemia, but the facility entered an order for Atogepant, a migraine medication, with the indication of hyperlipidemia. The admission evaluation documented that all active medication orders were accurate based on the referral form, and subsequent provider notes listed Atogepant and stated that medications had been reviewed in the EMR. During the initial drug regimen review, the pharmacist identified that Atogepant was ordered with an incorrect clinical indication, but there was no documentation that an APRN or physician reviewed or addressed this concern, contrary to facility policies requiring complete admission medication verification and documented follow‑up on identified irregularities.
A resident with dementia and behavioral disturbances was involved in an incident where a nurse aide witnessed another aide continue care after the resident refused, which was perceived as abusive. The witnessing aide did not report the allegation until the following day, exceeding the facility's required two-hour reporting timeframe, in violation of policy.
Surveyors found that several residents requiring oxygen and nebulizer therapy had unlabeled and undated tubing, and nebulizer masks were stored improperly. In addition, a resident with chronic respiratory conditions did not have oxygen saturation documented every shift as ordered. Nursing staff and the DNS were unable to explain the lapses or confirm when equipment was last changed, and there was a lack of clear documentation and staff education regarding respiratory care procedures.
The consultant pharmacist did not ensure that required behavior monitoring was implemented and documented for two residents receiving antipsychotic medications. Despite care plans and physician orders directing monitoring of specific target behaviors, the pharmacist failed to identify or address the lack of behavior monitoring during monthly drug regimen reviews.
Two residents prescribed antipsychotic medications did not have their target behaviors identified and monitored as required by facility policy. One resident with dementia and mood disorders had no documentation of behavior monitoring for yelling out, despite care plan interventions and physician orders. Another resident with psychiatric diagnoses continued to receive Quetiapine without the required behavior monitoring after re-admission, as the order was missed and not completed.
Multiple residents with dysphagia and cognitive impairment did not receive the required supervision during meals, as staff left them unsupervised or failed to provide necessary assistance such as cutting food or monitoring for aspiration. Communication lapses and incomplete documentation led to dietary and nursing staff being unaware of specific supervision and feeding guidelines, resulting in residents being served meals without appropriate precautions.
A resident with chronic venous and thrombotic conditions was not informed prior to a physician-ordered ultrasound or updated on the test results. The resident, who is cognitively intact, reported this lack of communication occurs frequently. An LPN failed to relay the resident's request for results to the APRN, resulting in a delay of seven days before the resident was updated, contrary to facility policy requiring residents to be informed and involved in their care.
The facility failed to notify the APRN of a significant weight gain in a resident with CHF and did not inform the family of another resident's substantial weight loss. In both cases, staff interviews and documentation review revealed confusion about responsibilities and a lack of communication, despite clear physician orders and facility policies requiring such notifications.
A resident with multiple chronic conditions reported missing money from their room. Although the facility conducted an internal investigation, reimbursed the resident, and implemented changes to secure resident funds, the incident was not reported to the State Agency as required by policy. Staff interviews revealed uncertainty about the nature of the loss, leading to the failure to report the suspected misappropriation.
A resident with multiple chronic conditions reported missing money from their room. The facility did not conduct or document a thorough investigation as required by policy, failing to record which staff were interviewed, the last time the resident saw the money, and which staff had access to the room. Key details were not documented or recalled by the Director of Social Services or the Administrator.
The facility did not ensure that care plans were accurately developed and implemented for two residents: one with a history of falls whose fall risk was not reflected in the care plan until after another incident, and another who required two staff for direct care but was often assisted by only one staff member. Staff were unaware of or unable to follow the care plan directives, resulting in deficiencies in care planning and delivery.
Two residents experienced deficiencies in care: one performed wound care without proper supervision, assessment, or infection control, and another was not weighed daily as ordered for nutritional monitoring. Staff were unaware or did not document these lapses, and facility policies for wound care and weight assessment were not followed.
A resident with a pressure ulcer did not receive recommended therapy and dietary consultations after a wound consultant's assessment, as staff were unaware of the recommendations and no follow-up occurred. The resident remained bedfast and was not evaluated for support surfaces or repositioning, despite facility policy requiring such actions after significant changes in condition.
A nurse failed to follow infection control protocols during a dressing change for a resident on Enhanced Barrier Precautions, including not wearing required PPE, not performing hand hygiene at key steps, and using unsanitized scissors to cut dressing material. These actions were not in accordance with facility policy and standard infection control practices.
Surveyors found that wheelchairs, both standard and electric, were being stored in the dining room and a resident lounge during meal times and while residents were present. Staff confirmed this was due to lack of space in resident rooms, and the DNS acknowledged the practice was inappropriate. The facility did not have a policy for wheelchair storage, resulting in a failure to provide a homelike environment.
A resident with severe cognitive impairment and multiple chronic conditions developed pneumonia and was started on antibiotics after assessment and diagnostic testing. The facility did not document in the clinical record that the family was notified of the change in condition, diagnostic results, or new treatment, despite facility policy requiring such documentation.
The facility did not complete required annual performance evaluations for two nurse aides, as shown by the absence of evaluations in their personnel files despite ongoing employment and work activity. The DON confirmed the evaluations were not done and no written policy was provided when requested.
A resident with diabetes and other serious conditions experienced a change in mental status and became unresponsive. Although the care plan and facility policy required blood glucose monitoring when symptoms of hypo- or hyperglycemia were present, staff did not perform a fingerstick blood glucose check at the time of the incident. The omission was confirmed by both the DON and an LPN, and the resident was later found to have a critically low blood glucose level in the emergency department.
A resident with severe cognitive impairment and agitation, whose family held power of attorney, requested a room change due to a disruptive roommate causing anxiety and sleep issues. Despite the request being communicated to staff, there was no evidence that the facility addressed or acted on the request before the resident was discharged, and key staff were unaware of the request until much later.
Residents voiced ongoing concerns about delayed call bell responses during multiple council meetings, particularly on the second shift. The DNS was aware of these grievances but could not provide documentation that the facility addressed or acted upon them, nor evidence of staff education or completed audits prior to surveyor inquiry. The facility also could not provide a resident council policy when requested.
A resident with multiple health conditions experienced symptoms including malaise, body aches, chills, loss of appetite, and a raspy voice, along with signs of oral thrush. An LPN observed these changes but did not notify the physician or APRN as required, instead leaving a note in the APRN book. The resident was not assessed by the APRN until three days later, after the family requested it, at which point oral thrush was diagnosed and treated. Facility policy required immediate notification of such changes, which did not occur.
Two residents with dementia and cognitive impairment, who had a family-approved friendly relationship with specific boundaries, were involved in an incident where one was found touching the other's genital area in their room. Despite care plan interventions and staff monitoring, the supervision provided was inadequate to prevent this sexual contact, which exceeded the consent given by the family and violated facility policy.
Controlled medications and their disposition records for multiple residents, all of whom were alert, oriented, and receiving pain management for various conditions, were wrongfully removed from the facility by an LPN. The issue was discovered during a routine narcotic count, leading to an audit that confirmed the loss of several residents' medications and records. The DON was unable to locate the missing items, and the incident was reported to regulatory authorities for investigation.
A resident admitted with a left knee replacement, pain, and osteoarthritis did not receive a prescribed cryocuff (cold compress) treatment as ordered in the hospital discharge summary. The order was not transcribed into the facility's admission orders, and the resident reported never receiving ice to the affected knee. Nursing staff indicated there was no order for ice, and the DON could not explain the omission.
Surveyors found that many residents did not have identification bracelets or any visible form of identification, with most residents lacking name bands according to a facility audit. The DON confirmed that all residents were expected to have identification for medication administration, but this was not consistently implemented, and no policy for resident identification was available.
Failure to Reconcile Admission Medications and Address Pharmacy-Identified Irregularity
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate medication reconciliation and appropriate follow‑up to a pharmacist’s drug regimen review for a newly admitted resident. The resident had diagnoses including aftercare following joint replacement, type 2 diabetes, hypertension, and hyperlipidemia, and was discharged from the hospital after a right total hip replacement with a recommendation for Atorvastatin 10 mg nightly for hyperlipidemia. The hospital discharge summary did not list migraine headaches as a diagnosis. Upon admission, a physician’s order was entered for Atogepant 10 mg by mouth once daily for hyperlipidemia, even though Atogepant is a medication used to treat migraine headaches. The admission evaluation signed the day after admission stated that all active medication orders had been reviewed and were accurate based on the Inter‑Agency Referral Form/W‑10. During the initial pharmacy medication regimen review conducted shortly after admission, the pharmacist identified a concern that Atogepant had been ordered with an incorrect clinical indication of elevated lipids. However, review of interim physician orders and provider progress notes over the following days showed no documentation that this pharmacy concern was reviewed or addressed by an APRN or physician. Provider progress notes during this period documented a full medication list including Atogepant and indicated that medications had been reviewed in the EMR, but did not address the pharmacist’s identified irregularity. Interviews with the DON, the attending physician, and the pharmacist confirmed that nursing staff were responsible for entering and reconciling admission orders, that the physician relied on pharmacy to notify the facility of inappropriate medications, and that the pharmacist recognized Atogepant’s indication as migraine headaches and not hyperlipidemia. The facility’s own Medication Verification and Medication Regimen Review policies required complete review of admission medications and documentation by the attending physician of any identified irregularities and actions taken, which was not done in this case.
Failure to Timely Report Alleged Abuse
Penalty
Summary
A deficiency occurred when an allegation of abuse involving a resident with dementia, anxiety, and repeated falls was not reported to the facility Administrator or designee within the required two-hour timeframe. The resident, who had impaired cognition and required assistance with daily activities, was the subject of an incident witnessed by a nurse aide (NA #1). NA #1 observed another nurse aide (NA #2) continue to attempt care after the resident refused, which NA #1 perceived as abusive. NA #1 intervened by directing NA #2 to leave the room and redirected the resident. Despite facility policy requiring immediate reporting of abuse allegations, NA #1 did not report the incident until the following day. The Director of Nursing confirmed that the policy mandates reporting within two hours of the incident, and that NA #1 failed to comply with this requirement. Facility documentation and interviews corroborated that the delay in reporting constituted a failure to follow established abuse reporting protocols.
Failure to Maintain and Document Safe Respiratory Care Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents requiring oxygen therapy and nebulizer treatments. For four residents, oxygen and nebulizer tubing were found to be unlabeled and undated, contrary to facility policy which requires weekly changing, labeling, and dating of such equipment. In addition, nebulizer masks were observed to be stored improperly, either uncovered in bedside drawers or on top of bedside tables, rather than in a manner that would maintain cleanliness and prevent contamination. These deficiencies were observed during direct inspection and confirmed through interviews with nursing staff, who were unable to provide reasons for the lapses or confirm when the equipment was last changed. For one resident with chronic obstructive pulmonary disease, asthma, and congestive heart failure, the facility failed to document oxygen saturation levels every shift as required by physician order. Review of the electronic medical record revealed that oxygen saturation was not consistently recorded for every shift, and the documentation system lacked a prompt to ensure compliance with the order. The Director of Nursing Services (DNS) acknowledged that the absence of documentation made it impossible to verify that the resident's oxygen saturation remained above the physician-ordered threshold on every shift. Interviews with nursing staff and the DNS revealed a lack of clarity regarding responsibility for changing, labeling, and dating respiratory equipment, as well as uncertainty about whether staff had received adequate education on these procedures. Facility documentation and physician orders were also found to be lacking in directives for the maintenance of respiratory equipment. The facility's own policy requires oxygen tubing to be dated and changed weekly, but this was not consistently implemented or documented for the residents reviewed.
Pharmacist Failed to Ensure Required Behavior Monitoring for Residents on Antipsychotics
Penalty
Summary
A deficiency was identified in the facility's process for monthly drug regimen reviews by the consultant pharmacist, specifically regarding residents prescribed antipsychotic medications. For two residents with significant psychiatric and cognitive diagnoses, the pharmacist failed to ensure that behavior monitoring was implemented and documented as required by facility policy and physician orders. In both cases, the residents were prescribed antipsychotic medications, and orders or care plans directed that specific target behaviors be identified and monitored every shift. For one resident with vascular dementia, major depressive disorder, and anxiety, the care plan and physician orders required monitoring of target behaviors related to antipsychotic use. Although the pharmacist initially recommended the inclusion of specific, objectively documented target behaviors, subsequent monthly reviews did not follow up on whether these recommendations were implemented. There was no documentation that behavior monitoring was being completed as required, and the pharmacist did not identify or address this ongoing lack of compliance in later reviews. For another resident with bipolar disorder and other psychiatric diagnoses, physician orders and the care plan required behavior monitoring for antipsychotic use. After a change in orders, behavior monitoring was not completed or documented, and the pharmacist's monthly review did not identify or recommend correction of this omission. Interviews with facility staff and the pharmacist confirmed that the required monitoring was not in place, and the pharmacist did not detect or address the deficiency during the medication regimen review.
Failure to Monitor Target Behaviors for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to identify and monitor target behaviors for two residents who were prescribed antipsychotic medications. For one resident with vascular dementia, major depressive disorder, and anxiety, the care plan included monitoring target behaviors and gradual dose reduction as ordered. Despite multiple physician orders for antipsychotic medications and care plan interventions, there was no documentation that the specific target behavior of yelling out was monitored every shift as required by facility policy. The Director of Nursing Services (DNS) confirmed that behavior monitoring should have been documented electronically but was unable to provide evidence that this was done. For another resident with bipolar disorder, anxiety disorder, and mood disorder, physician orders required behavior monitoring every shift for specific target behaviors while receiving Quetiapine. Although behavior monitoring was completed prior to a certain date, after the resident was re-admitted and continued on Quetiapine, the order for behavior monitoring was missed and not completed as required. The DNS acknowledged that the responsibility for ensuring behavior monitoring fell to the admitting nurse and that the monitoring had not been done. Facility policies directed that residents on antipsychotic medications must have specific target behaviors identified and monitored every shift, but this was not followed for these residents.
Failure to Provide Adequate Mealtime Supervision for Residents at Aspiration Risk
Penalty
Summary
Surveyors identified that the facility failed to provide adequate supervision during mealtimes for multiple residents with a history of aspiration and dysphagia. For one resident with diagnoses including dysphagia, blindness, and Alzheimer's dementia, physician orders and care plans required direct supervision during meals, including verbal cues and alternating solids with liquids. However, the resident was observed eating alone in their room without staff present, and the assigned nurse aide left the resident unsupervised. Interviews revealed inconsistencies in staff understanding and communication regarding the required level of supervision, and the dietary report did not include the necessary supervision and feeding guidelines as required. Another resident with severe cognitive impairment and dysphagia was observed eating alone in their room without assistance or supervision, despite orders for intermittent distant supervision and assistance with cutting food into bite-sized pieces. The dietary aide delivered the meal without knowledge of the resident's specific needs, and the tray ticket failed to indicate the required precautions and assistance. Nursing and dietary staff were unclear about their responsibilities, and the resident's care needs were not communicated effectively through the facility's documentation systems. A third resident, admitted with dementia and malnutrition, was also not provided the required supervision during meals. The resident was observed with a meal tray in front of them and no staff in eyesight, despite orders for distant supervision and aspiration precautions. Staff interviews confirmed a lack of awareness of the resident's supervision requirements, and the tray ticket did not reflect the necessary precautions. Facility documentation and communication breakdowns contributed to the failure to ensure appropriate supervision and adherence to aspiration precautions for residents at risk.
Failure to Inform Resident of Diagnostic Testing and Results
Penalty
Summary
Resident #34, who has diagnoses including chronic venous hypertension, chronic embolism, thrombosis of the lower extremities, and anxiety, was not fully informed about physician-ordered testing or the results of those tests. The resident, who is cognitively intact and dependent on staff for most activities of daily living, was not notified prior to a venous and arterial ultrasound being performed on their lower extremities, nor was the resident informed of the reason for the test. The resident reported that this lack of communication regarding tests and results occurs frequently, including with blood work and other diagnostic procedures. After the ultrasound was completed, the resident requested to speak with the APRN about the results, informing an LPN of this request. The LPN did not communicate the resident's request to the APRN or document it, stating she forgot. The APRN was unaware of the resident's request and only provided the results seven days after the report was available. Facility policy states that residents have the right to be informed of changes in their medical condition and to participate in care planning, but these procedures were not followed in this instance.
Failure to Notify APRN and Family of Significant Weight Changes
Penalty
Summary
The facility failed to notify the Advanced Practice Registered Nurse (APRN) of a significant weight gain in a resident with congestive heart failure (CHF). The resident, who had diagnoses including COPD, chronic kidney disease, and CHF, was to be weighed weekly with instructions to notify the physician or APRN if there was a weight gain of 2 pounds or more in a day or 5 pounds or more in a week. Despite a documented weight gain of 7.7 pounds in one week, there was no evidence in the nursing notes or clinical record that the APRN was informed of this change. The APRN confirmed she was not notified and would have investigated the cause if she had been made aware. Nursing staff described inconsistent practices regarding weight monitoring and communication, with some confusion about shift responsibilities and documentation in the APRN communication book. Additionally, the facility failed to notify the family or responsible party of a significant weight loss in another resident who was admitted with diagnoses including failure to thrive, protein-calorie malnutrition, and dementia. This resident experienced a weight loss of 9.9 pounds in one week and a total of 22.7 pounds over two weeks. The care plan included monitoring for nutritional status and weighing per physician orders. Despite documentation of the weight loss by the dietician, there was no evidence that the family was notified. Interviews revealed confusion among staff regarding who was responsible for family notification, with the dietician believing it was nursing's responsibility and the Director of Nursing stating it was the dietician's role. The facility policy indicated the dietician should discuss undesired weight loss with the family, but this did not occur. Both deficiencies were identified through review of clinical records, facility documentation, and staff interviews. The failures were contrary to physician orders and facility policies, which required timely notification of significant changes in resident condition to the appropriate medical provider and family members.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the State Agency after a resident reported $14.00 missing from an envelope on their nightstand. The resident, who had diagnoses including chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure, was cognitively intact and required assistance with personal hygiene and mobility. Upon the resident's report, a room search was conducted, nursing staff were questioned, and the money was not found. The incident was documented, and the resident was reimbursed for the missing amount. The Director of Social Services completed the investigation and discussed the resolution with the resident, while the Administrator signed off on the documentation. Despite the facility's internal investigation and reimbursement, the incident was not reported to the State Agency as required by facility policy and state regulations. Interviews with facility staff revealed that the Director of Social Services did not consider the missing money as misappropriation due to the resident's uncertainty about losing it, and the Administrator cited too many unknowns to confirm the loss. The Director of Nursing Services was unaware of the incident. Facility policy directs that all reports of theft or misappropriation of resident property must be promptly investigated and reported to the State Agency within two hours, which was not followed in this case.
Failure to Thoroughly Investigate Allegation of Misappropriation of Resident Money
Penalty
Summary
The facility failed to identify and thoroughly investigate an allegation of misappropriation of money for one resident. The resident, who had diagnoses including chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure, reported missing $14.00 from an envelope on the nightstand. The facility's documentation did not include a comprehensive investigation, as required by policy. Specifically, there was no documentation of which nursing staff were interviewed, the date and time the resident last saw the money, the varying amounts reported missing, the amount of money in the resident's possession during the investigation, or which staff had access to the resident's room across all shifts. Interviews with the Director of Social Services and the Administrator revealed that neither could recall or had documented key details of the investigation, such as the names of staff interviewed or the specifics of the resident's last appointment. The Administrator acknowledged not interviewing all relevant staff, including the nurse aide who accompanied the resident to an appointment, and could not provide a reason for the lack of documentation. The facility's abuse prohibition policy required a prompt and thorough investigation, including interviews with all relevant parties and a room search, but these steps were not fully documented or completed.
Failure to Develop and Implement Comprehensive Care Plans for Fall Risk and ADL Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to fall risk management and adherence to required assistance for activities of daily living. One resident with chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure had a history of falls and was identified as having impairments in strength and mobility. Despite a fall and subsequent risk assessment indicating the resident was at risk for falls, the care plan did not reflect this risk or include appropriate interventions until after another fall occurred. Documentation revealed that the fall risk care plan had previously been marked as resolved without clear justification, and staff responsible for care planning were unaware of the absence of an active fall risk plan prior to the incident. Another resident with adjustment disorder, anxiety, and psychotic disorder was care planned to require two staff members for all direct care due to behavioral concerns. Observations showed that this intervention was not consistently followed, with nurse aides providing care alone on multiple occasions. Interviews with staff indicated a lack of awareness regarding the continued need for two-person assistance, and staffing patterns made it difficult to comply with the care plan directive. The care card for the resident continued to specify the need for two staff members, but this was not adhered to in practice. Facility policy required the development and ongoing updating of individualized care plans, with staff expected to follow the most current plan of care. In both cases, the facility did not ensure that care plans accurately reflected residents' needs or that staff consistently implemented the specified interventions, leading to deficiencies in resident care.
Failure to Supervise Wound Care and Adhere to Physician Orders for Nutrition
Penalty
Summary
The facility failed to ensure proper supervision and adherence to physician orders for two residents, resulting in deficiencies related to wound care and nutritional monitoring. One resident with a history of cellulitis, chronic respiratory failure, and lymphedema was observed self-performing wound care on the left plantar foot without the use of gloves or clean technique. The resident removed a soiled dressing, applied Lidocaine cream, and changed the dressing without hand hygiene or infection control measures. Staff interviews revealed that the nursing team was not aware the resident was self-administering wound care, and no assessment or education had been provided for self-administration. Additionally, there was no physician order permitting self-administration, and documentation of refusals or observations of poor technique was lacking. Facility documentation showed that previous self-administration evaluations for this resident did not include the current wound care or Lidocaine jelly application. The facility's policy required dressings to be applied by licensed nursing personnel using proper hand hygiene, which was not followed in this case. Staff members, including the LPN and RN, acknowledged that they had not communicated or documented the resident's self-care activities or refusals, and the Director of Nursing was unaware of the situation until the surveyor's inquiry. In a separate incident, another resident with diagnoses of failure to thrive, protein-calorie malnutrition, and congestive heart failure was not weighed daily as ordered by the physician. The care plan required daily weights at a specific time, but review of records showed that weights were only recorded on 7 out of 15 required days. Staff interviews confirmed that daily weights were not completed or documented as ordered, and the facility's policy emphasized the importance of regular weight monitoring to prevent and intervene in cases of undesirable weight loss.
Failure to Follow Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to follow up on wound consultant recommendations for a resident with an unstageable pressure ulcer on the coccyx. The resident, who was bedfast most of the time and required maximum assistance for personal hygiene and bed mobility, had a care plan that included interventions such as a low air loss mattress, skin care protocols, and therapy consultations. However, the care plan did not address the resident's refusals to get out of bed or reposition, and there was no evidence that therapy or dietary consultations recommended by the wound consultant were initiated. The wound consultant had recommended ongoing treatments, optimization of nutrition, and a PT evaluation for support surfaces, but these recommendations were not communicated or acted upon by the therapy, dietary, or nursing staff. Observations showed the resident remained lying flat on their back throughout the day, and interviews with staff revealed that neither therapy nor the DNS were aware of the wound consultant's recommendations. The wound consultant confirmed that she expected therapy and dietary evaluations to have occurred, but was unaware that these had not been completed. Facility policy required rehabilitation screens for residents with significant changes in functional ability, but no such screen or evaluation was found for this resident following the new wound development.
Failure to Follow Infection Control Practices During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency was identified when a nurse failed to follow infection control practices during a dressing change for a resident with a pressure ulcer who was on Enhanced Barrier Precautions (EBP). The resident, who had diagnoses including a sacral pressure ulcer, dementia, and was bedfast, required maximum assistance for personal hygiene and was at risk for developing pressure ulcers. During the observed dressing change, the nurse did not apply the required personal protective equipment (PPE) such as gown and gloves, as mandated by the facility's EBP policy. The nurse prepared a clean field, applied gloves, removed the soiled dressing, and cleansed the wound, but did not perform hand hygiene after removing gloves or before handling clean dressings. Additionally, the nurse used scissors from her scrub pocket to cut dressing material without sanitizing them, and did not perform hand hygiene before donning new gloves to apply the clean dressing. Interviews with the facility's Infection Preventionist and the nurse confirmed that these actions were not in accordance with facility policy and standard infection control practices. The facility's policies required hand hygiene at multiple steps and the use of sanitized equipment, which were not followed during this dressing change.
Wheelchairs Improperly Stored in Resident Common Areas
Penalty
Summary
Surveyors observed that standard and electric wheelchairs were being stored in resident common areas, specifically the dining room and a resident lounge, during meal times and while residents were present. On multiple occasions, up to nine standard wheelchairs were stored in the dining room while residents were eating lunch, and several wheelchairs, including an electric one that was plugged in and charging, were stored in the Hampshire Unit Lounge while a resident was eating breakfast and watching television. Staff interviews confirmed that wheelchairs were routinely stored in these areas due to insufficient space in resident rooms. The Director of Nursing Services (DNS) acknowledged that the wheelchairs should not be stored in the dining room or lounge and indicated that alternative storage solutions would be sought. The facility was unable to provide a policy regarding the storage of durable medical equipment, specifically wheelchairs, when requested by surveyors. These actions and inactions resulted in a failure to maintain a safe, clean, and homelike environment for residents, as required.
Failure to Document Family Notification of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to document family notification regarding a significant change in condition for a resident with multiple diagnoses, including diabetes, Parkinson's disease, and Alzheimer's disease. The resident was assessed by an APRN for a congested cough with thick secretions, and a chest x-ray revealed modest left basilar pneumonia. Following this, an antibiotic was ordered and initiated. However, there was no documentation in the clinical record that the family or responsible party was notified about the change in condition, the diagnostic testing, the results, or the new treatment. Interviews with the Director of Nursing Services (DNS) and a Registered Nurse (RN) confirmed that it was the nurse or nurse supervisor's responsibility to notify the family and document this in the clinical record. Although the daily nursing supervisor report indicated that a message was left for the family, this report was not part of the resident's clinical record. The RN involved stated she was unaware of the requirement to document family notification in the clinical record. Facility policy required that such notifications and changes be documented in the electronic record, but this was not done in this instance.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete required annual performance evaluations for two nurse aides, as evidenced by the absence of any such evaluations in their personnel files. Both nurse aides had been employed at the facility for multiple years and had worked several shifts during the review period. Despite requests, the facility was unable to provide documentation of completed annual evaluations for either employee. The Director of Nurses confirmed that performance evaluations should have been present in the personnel files and acknowledged that they had not been completed, attributing the oversight to a lapse in tracking and scheduling by human resources. No written facility policy on performance evaluations was provided when requested. This deficiency was identified through interviews and review of employee files, as well as time punch records confirming the ongoing employment and work activity of the nurse aides in question.
Failure to Assess Blood Glucose During Change in Mental Status
Penalty
Summary
A resident with diagnoses including bacteremia, liver carcinoma, and diabetes mellitus experienced a change in mental status and became unresponsive. The resident's care plan and physician's orders required fingerstick blood glucose monitoring twice daily and as needed if symptoms of hypo- or hyperglycemia were present. On the day of the incident, the resident was noted to be drowsy and later had a significant drop in oxygen saturation, prompting staff to apply supplemental oxygen and notify the primary care provider. Although a blood glucose check had been performed earlier in the day, no additional fingerstick blood glucose was obtained at the time of the mental status change, despite facility policy and care plan interventions directing staff to do so when symptoms of hypo- or hyperglycemia occurred. The Director of Nursing and the LPN involved both confirmed that a blood glucose check was not performed at the time of the resident's acute change in condition. The resident was subsequently sent to the emergency department, where a critically low blood glucose level was identified. Facility documentation and interviews revealed that the required assessment for blood glucose was omitted during the episode of altered mental status, which was inconsistent with both physician orders and facility policy.
Failure to Address Resident Room Change Request
Penalty
Summary
A deficiency occurred when the facility failed to act on a resident and family request for a room change in a timely manner. The resident, who had diagnoses including surgical aftercare and Parkinson's disease, was assessed as alert but with severe cognitive impairment and agitation. On admission, the resident required assistance with activities of daily living and transfers. Documentation shows that the family, who held power of attorney, requested a room change due to the roommate's disruptive nighttime behavior, which caused the resident anxiety and sleep disturbance. The request was noted by nursing staff and the supervisor was made aware, but there was no evidence in the record that the request was addressed or that a room change was made prior to the resident's discharge. Interviews with social work and the director of nursing revealed a lack of awareness and follow-up regarding the room change request. The social worker was not informed of the initial request and only became aware during a care conference focused on discharge planning, while the director of nursing only learned of the request on the day of discharge. Facility policy requires reasonable accommodation of resident needs and preferences, but the documentation and interviews failed to show that the facility took action to address the resident's or family's concerns about the room assignment.
Failure to Address Resident Grievances Regarding Call Light Response
Penalty
Summary
Residents repeatedly expressed concerns during multiple resident council meetings about call bells not being answered in a timely manner, particularly during the second shift. These concerns were documented in the meeting minutes over several months, with residents noting that the issue was ongoing. The Director of Nursing Services (DNS) was aware of these grievances, as they were discussed during the meetings, and acknowledged the residents' dissatisfaction with call light response times. Despite being aware of the issue, the facility failed to provide documentation showing that the residents' grievances regarding lengthy call bell wait times were addressed or acted upon. Although the DNS indicated that audits were being conducted to monitor call light response and that staff education was being considered, there was no evidence that these actions had been implemented prior to the surveyor's inquiry. Additionally, the facility was unable to provide a resident council policy when requested.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes mellitus and thrombocytopenia experienced a change in condition that was not promptly reported to the physician or advanced practice registered nurse (APRN). The resident, who required assistance with activities of daily living and had intact cognition, reported symptoms such as malaise, body aches, chills, no appetite, and a low raspy voice. An LPN documented these symptoms and noted a white coating on the resident's tongue, suggestive of the onset of oral thrush. However, the LPN did not notify the physician or APRN at the time of the change in condition, instead placing a note in the APRN's book and assuming the APRN would see the resident the following day. Three days later, the APRN assessed the resident at the family's request and diagnosed oral thrush, subsequently initiating antifungal treatment. Interviews with facility staff confirmed that the LPN did not make a direct notification to the physician or APRN regarding the resident's change in condition, and the observed symptoms were not fully documented in the APRN book. The facility's policy required that any change in a resident's condition be reported to the physician, which was not followed in this instance.
Failure to Prevent Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse between two residents, both of whom had diagnoses of dementia and other cognitive impairments. The care plans for both residents acknowledged a consensual, friendly relationship that was approved by family members, with specific interventions in place such as allowing hand-holding, hugging, and kissing, but not sexual acts. There were also environmental cues, such as yellow tape at the room threshold, to remind one resident not to enter the other's room unaccompanied, and social services were tasked with monitoring the relationship to ensure compliance with family guidelines. Despite these interventions, an incident occurred in which one resident was found by a staff member touching the genital area of the other resident in the latter's room. At the time, the resident whose room it was had their pants and brief pulled down, while the other resident was fully dressed and seated in a wheelchair. Both residents were assessed as having significant cognitive impairment, with one scoring a 4 and the other a 15 on the Brief Cognitive Assessment Tool, and both had dementia diagnoses. Staff interviews confirmed that prior to this event, there had been no previous sexual contact between the two residents, and both were aware of the boundaries set by family and staff. The incident was reported to supervisory staff and documented in the facility's accident and incident report. The family member with power of attorney for one resident had previously approved only non-sexual physical contact and did not consent to sexual acts. The facility's policy required staff to monitor residents for inappropriate behaviors, but the supervision and interventions in place were insufficient to prevent the sexual contact that occurred, resulting in a failure to protect the resident from abuse as required.
Controlled Medications and Disposition Records Wrongfully Removed by Nurse
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings, specifically controlled medications and their corresponding disposition records. For five of seven sampled residents, it was found that their controlled medications, including Oxycodone and Dilaudid, as well as the controlled substance disposition sheets, were removed from the facility by a licensed nurse without authorization. These residents had various diagnoses such as fractures, muscle weakness, anxiety, peripheral vascular disease, and multiple myeloma, and all were alert, oriented, and receiving pain medications as ordered by their physicians. The deficiency was identified when a charge nurse reported that a resident's Oxycodone and the associated disposition record were missing during a shift-to-shift narcotic count. Subsequent audits revealed that controlled medications and disposition records for four additional residents were also missing. The Director of Nursing conducted a search of medication carts and storage areas for expired or discontinued medications but was unable to locate the missing items. The investigation determined that a licensed nurse had removed the controlled medications and disposition records from the facility. The incident was reported to the Department of Consumer Protection, Drug Enforcement Division, which took over the investigation. Facility policy defines misappropriation of resident property as the wrongful, temporary, or permanent use of a resident's belongings without consent, which was substantiated in this case.
Failure to Implement Hospital Discharge Order for Cryocuff Therapy
Penalty
Summary
A deficiency occurred when the facility failed to implement a hospital discharge order for a cryocuff (cold compress) treatment for a resident admitted with a left knee replacement, pain, and osteoarthritis. The hospital discharge summary included a specific order for cryocuff application to the affected knee every four hours and as needed, but this order was not transcribed into the facility's admission orders. The resident's care plan identified a risk for pain and included interventions for pain management, but did not address the cryocuff treatment. The resident reported never receiving ice to the left knee and stated that nursing staff indicated there was no order for ice when asked. The DON confirmed that the hospital discharge summary is reviewed and orders are placed by the attending physician or APRN, but could not explain why the cryocuff order was omitted. The facility was unable to provide a policy for transcribing orders when requested. This failure to address and implement the hospital's discharge recommendation for a specific treatment order resulted in the resident not receiving the prescribed cryocuff therapy upon admission.
Failure to Provide Resident Identification Bracelets
Penalty
Summary
The facility failed to ensure that residents had identification bracelets or another form of visible identification, as observed during a survey. On the date of observation, three out of five residents seated in wheelchairs in the common area did not have any visible identification, and two residents confirmed they had never worn an identification bracelet. Further observations across three facility units and the recreation area revealed multiple residents without identification bracelets. The DON stated that the expectation was for each resident to have a name band for identification, particularly for medication administration, and that charge nurses were instructed to audit and ensure compliance. A review of the facility's audit showed that 52 out of 75 residents did not have an identification bracelet or other visible identification. The facility did not have a policy for resident identification when requested.
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.
