Civita Care Center At Salmon Brook
Inspection history, citations, penalties and survey trends for this long-term care facility in Glastonbury, Connecticut.
- Location
- 72 Salmon Brook Drive, Glastonbury, Connecticut 06033
- CMS Provider Number
- 075060
- Inspections on file
- 33
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Civita Care Center At Salmon Brook during CMS and state inspections, most recent first.
The facility did not provide evidence of a completed background check for a Recreation Aide. Interviews and document reviews revealed that the employee's file lacked the required background check, and facility staff were unable to produce the documentation despite multiple attempts.
The facility failed to keep laundry equipment in working order, leading to ongoing shortages of clean washcloths and towels and significant delays in returning personal laundry to residents. Multiple residents and staff reported that only one washing machine was consistently operational for months, with other machines and a dryer out of order for extended periods. Staff described hazardous workarounds and repeated, unaddressed requests for more linens and repairs, while administrative staff did not arrange for alternative laundry solutions or regular linen audits.
The facility failed to maintain laundry equipment and ensure an adequate supply of linens, resulting in residents experiencing delays in receiving clean personal laundry and a shortage of washcloths and towels for care. Staff and residents reported ongoing issues with laundry turnaround and linen availability, with only one washing machine functioning for months and some equipment out of order for years. Despite repeated reports to administration, the facility did not take effective action to address the shortages or utilize alternative solutions.
A resident identified as high fall risk experienced a fall out of bed, and although the care plan called for a floor mat to be placed to the left side of the bed, there was no immediate physician order or documentation on the MAR/TAR to confirm the intervention was implemented. The order for the floor mat was delayed, and staff interviews confirmed that the intervention should have been initiated and documented right after the fall.
A resident admitted with a stage 2 pressure injury and high risk for further skin breakdown did not receive timely or documented interventions such as an air mattress or scheduled turning and repositioning, as required by facility policy. The resident's wounds worsened and new pressure injuries developed, with staff unable to explain the lack of orders or documentation for these preventative measures.
A resident with dementia and other complex needs, who required staff assistance for ADLs, did not have consistent or complete Nurse Aide documentation for care tasks over a two-month period. Observations showed the resident was well cared for, but documentation for essential care activities was missing or inconsistent on most days. The DNS was unaware of these documentation lapses, and no facility policy for Nurse Aide documentation was provided.
A resident with diabetes and neuropathy developed an infection in the left great toe, prompting an APRN to order antibiotics and a priority podiatry consult. Despite these orders and communication attempts, the resident was not added to the podiatrist's priority list and was not seen as scheduled, due to a failure in the facility's scheduling process.
A resident with Alzheimer's and a high risk for wandering was unaccounted for over four hours due to inadequate supervision and security measures. The resident exited through an unalarmed door and was found outside near the kitchen entrance. Despite previous reports of wandering behavior and broken locks, the facility failed to implement effective interventions, resulting in Immediate Jeopardy.
The facility failed to timely obtain physician orders for wander guard bracelets for two residents identified as high wander risks. One resident with Alzheimer's disease did not have a wander guard applied until 12 days after being assessed as high risk. Another resident with Parkinsonism and dementia lacked a current order to check the wander guard's function nightly, contrary to facility policy.
The facility failed to ensure only authorized personnel had access to medication keys and did not maintain proper storage for controlled drugs. An RN left keys in an unlocked drawer, accessible to others, and a medication refrigerator was found unsecured. The DNS was unaware of the proper procedures, and the facility lacked a policy for narcotic storage.
The facility failed to effectively manage resources and provide proper administrative oversight, resulting in multiple deficiencies. There was no Governing Body, and the Medical Director was not appointed by one. The facility did not notify the State Agency of a reportable event timely, and clinical records were incomplete. A resident with a known wander risk accessed an unlocked egress, and medication security was inadequate. Annual in-service training and policy reviews were not completed timely, leading to differing policies. Interviews revealed a lack of oversight processes, compromising resident well-being.
The facility failed to establish a governing body responsible for management and operation, as evidenced by missing documentation and inconsistent Elopement Policies. Interviews confirmed the absence of a governing body and lack of annual policy reviews, despite existing By-Laws outlining these responsibilities.
A resident with Alzheimer's and delusional disorders, identified as an elopement risk, was found outside the facility after being reported missing. Despite the facility's interventions, there was no documented RN assessment following the incident, violating the facility's documentation policy.
The facility did not ensure that two nurse aides hired in 2023 received the required 12 hours of annual in-service training. One aide only received education on IV therapy, while the other had training on resident rights, abuse/retaliation, and dementia, but neither met the 12-hour requirement. The DNS confirmed the training shortfall but could not explain the deficiency.
A staff member recorded and posted videos of a resident with Alzheimer's and other residents on social media, capturing unprofessional interactions and personal care without consent. This violated facility policies on privacy and abuse, as the residents' rights to confidentiality and dignity were not protected.
A resident with severe cognitive impairment and behavioral issues was found to have a right wrist fracture of unknown origin. The facility did not complete a thorough investigation, as required by policy, by failing to conduct a 72-hour look back and limiting staff interviews to only one shift.
The facility did not complete or document required neurological assessments after unwitnessed falls for two residents, and failed to document wrist stabilization as recommended by an APRN for another resident with a fracture. Despite facility policies mandating neurological checks and adherence to treatment recommendations, these protocols were not followed or documented in the cited cases.
Annual performance evaluations were not conducted for two nurse aides, as required, with the last documented evaluations occurring nearly a year prior. Administrative changes and lack of communication contributed to the oversight, and no evaluation policy was provided when requested.
A resident with significant mobility impairments and a care plan requiring frequent repositioning and assistance out of bed did not receive timely care after using the call bell for an extended period. The facility failed to conduct a thorough investigation into the resident's allegation of neglect, did not collect statements from all involved staff, and lacked documentation of care provided during the shift.
A resident with significant mobility and continence needs was not provided with required turning, repositioning, or incontinent care for over three hours, despite activating the call bell and having care needs documented in the care plan and physician orders. Staffing shortages contributed to the delay, and care was not documented or provided as required during the morning shift.
A resident with spina bifida and neurogenic bladder did not receive required turning, repositioning, or incontinence care for several hours due to insufficient staffing. The resident's call bell went unanswered for an extended period, and only one NA was present for 22 residents until additional staff arrived later in the morning. As a result, the resident had to move themselves to the bathroom and developed a stage 3 pressure ulcer. Staff interviews and documentation confirmed that the facility was understaffed and unable to meet the resident's care needs as outlined in the care plan and physician orders.
Failure to Provide Background Check Documentation for Employee
Penalty
Summary
The facility failed to provide evidence that a background check had been conducted for one employee, specifically a Recreation Aide. During interviews and a review of facility documents, it was determined that no background check information was found in the employee's file. The current Human Resource Manager, who had recently started, noted that several files were missing background checks and explained that the previous Human Resource Manager worked remotely and did not print or file the necessary forms. Despite attempts by the Administrator and Assistant Director of Nursing Services to locate or obtain the background check, no documentation was produced for the Recreation Aide.
Failure to Maintain Laundry Equipment Results in Linen Shortages and Delayed Personal Laundry
Penalty
Summary
The facility failed to maintain laundry equipment in proper working order, resulting in significant shortages of clean linens and delays in returning personal laundry to residents. Multiple residents reported not receiving their personal laundry for extended periods, with some having to wear dirty clothing due to the lack of clean items. Residents and nursing assistants consistently described a shortage of washcloths and towels, with some staff resorting to using sheets as towels and having to rush to secure available linens at the start of their shifts. Observations confirmed that linen carts and closets were frequently empty or inadequately stocked during care times. Interviews with staff revealed that only one washing machine was consistently operational for several months, while other machines and a dryer remained out of order for extended periods—up to two years for one washer and four years for a dryer. Laundry aides reported that the turnaround time for personal laundry far exceeded the expected 24 hours, often taking up to 72 hours or more, and that they were unable to keep up with the facility's laundry needs due to equipment limitations. Staff also described hazardous workarounds, such as using a pen to operate a broken washing machine latch, and reported that repeated requests for additional linens and equipment repairs were not addressed in a timely manner. Administrative staff acknowledged the ongoing equipment issues and linen shortages, citing delays in obtaining parts and a lack of alternative arrangements, such as sending laundry to outside facilities or borrowing linens from sister facilities. There was no evidence of regular audits of linen levels prior to the survey, and maintenance staff were unclear about the status of equipment repairs and linen inventory. The facility's own infection control policy required the maintenance supervisor to ensure the safe status of equipment, which was not upheld in this instance.
Failure to Maintain Laundry Equipment and Provide Adequate Linens
Penalty
Summary
The facility failed to maintain building equipment and provide adequate linens, resulting in a lack of a clean, comfortable, and homelike environment for residents. Multiple residents reported significant delays in receiving their personal laundry, with some waiting over a week and being forced to wear dirty clothing due to the unavailability of clean items. Residents and nursing assistants consistently described a shortage of washcloths and towels, with staff sometimes resorting to using sheets for bathing and being unable to provide proper care due to insufficient linens. Observations confirmed that linen carts and closets were frequently empty or severely understocked during care shifts. Staff interviews revealed that the facility had only one consistently functioning washing machine for several months, making it impossible to keep up with both facility linens and residents' personal laundry. Laundry aides reported that the turnaround time for personal laundry was significantly delayed, often taking up to 72 hours instead of the expected 24 hours. Despite repeated reports of linen shortages and equipment failures to the Administrator and Director of Housekeeping, no effective action was taken to resolve the issues, and the facility did not utilize available options such as sending laundry to outside facilities or borrowing linens from sister facilities. Further investigation found that some laundry equipment had been out of order for extended periods, with one washing machine nonfunctional for almost two years and a dryer for nearly four years. The Director of Housekeeping was unaware of the full extent of the equipment failures and did not have authority over repairs or purchasing. The facility also lacked policies addressing residents' rights to a clean, homelike environment and did not provide requested policies on laundry or environmental standards.
Failure to Timely Implement and Document Fall Prevention Intervention
Penalty
Summary
A resident with diagnoses including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure was identified as a high fall risk and experienced a fall out of bed. The resident's care plan specified interventions such as ensuring the call bell was within reach, encouraging its use, and placing a floor mat to the left side of the bed. Despite these interventions being documented in the care plan and accident investigation, there was no evidence that a physician's order for the floor mat was obtained or transcribed immediately after the fall. The order for the floor mat was not entered until six days after the incident, and there was no documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to confirm that nursing staff ensured the mat was in place as required. Interviews with facility staff, including the Director of Nursing Services (DNS) and a regional nurse, confirmed that the expected protocol was to obtain and transcribe a physician's order for the intervention immediately after the fall and to ensure it was reflected on the TAR for staff accountability. The facility's Accident and Incident Investigation policy also required that interventions to prevent further incidents be identified and implemented promptly. The failure to timely implement and document the fall intervention according to the care plan and physician order constituted the deficiency.
Failure to Implement and Document Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
A resident with multiple diagnoses, including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure, was admitted to the facility with a stage 2 pressure injury to the coccyx. Upon admission, the resident was assessed as high risk for pressure injuries using the Braden Scale and required substantial assistance for bed mobility, personal hygiene, and transfers. Despite these findings, there was no evidence that preventative interventions, such as an air mattress or a scheduled turning and repositioning regimen, were initiated or documented in the days following admission, as required by facility policy. The resident's care plan, initiated five days after admission, included interventions for pressure injury prevention and treatment, but physician orders and nursing documentation did not reflect the implementation of these interventions. The pressure injury progressed to an unstageable wound, and a new facility-acquired unstageable pressure injury developed on the resident's left heel. Throughout the resident's stay, there was a lack of documentation indicating that an air mattress was provided or that a turning and repositioning schedule was followed, even after the wounds worsened and new wounds developed. Additionally, weekly skin observation tools were either not completed or not documented as required by facility policy. Interviews with facility staff, including the DNS, wound physician, and wound nurse, confirmed that interventions such as air mattress placement and frequent turning and repositioning should have been implemented immediately upon admission and after wound deterioration. Staff were unable to explain why these interventions were not ordered or documented. The facility's policy clearly directed these interventions for residents with stage 2 or greater pressure injuries, but the required actions were not taken or recorded, leading to the identified deficiency.
Failure to Ensure Complete and Accurate Nurse Aide Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation by Nurse Aides for a resident with multiple diagnoses, including dementia, altered mental status, anxiety disorder, and malnutrition. The resident was assessed as having moderately impaired cognition and required staff assistance for activities of daily living (ADLs), including eating, personal care, bed mobility, and transfers. Observations confirmed that the resident appeared clean, well-dressed, and had access to water and reading material. However, a review of Nurse Aide documentation for April and May revealed significant inconsistencies in recording care tasks such as behavior symptoms, transferring, bed mobility, bowel movements, toileting hygiene, intake and output, toilet use, oral hygiene, personal hygiene, showering/bathing, snacks, eating, and amount eaten. Documentation was incomplete for the majority of days reviewed in both months. During an interview, the Director of Nursing Services (DNS) was unaware of the inconsistent documentation and acknowledged that Nurse Aides should be documenting all tasks every shift. The facility was unable to provide a policy for Nurse Aide documentation when requested. The deficiency centers on the lack of consistent and complete documentation of care provided to a dependent resident, as required by accepted professional standards.
Failure to Ensure Timely Podiatry Care for Resident with Toe Infection
Penalty
Summary
A resident with diabetes and polyneuropathy, who was dependent on staff for personal care and had a history of memory recall deficits, developed redness, swelling, and pain in the left great toe. The care plan required daily foot checks and prompt reporting of any abnormalities. After a family member reported the toe issue, an Advanced Practice Registered Nurse (APRN) evaluated the resident, diagnosed an infection, and ordered antibiotics, warm soaks, and a podiatry consult. The APRN also directed that the resident be placed on the podiatrist's priority schedule for an upcoming visit. Despite these orders, the facility failed to ensure the resident was added to the podiatrist's priority list. Although the scheduling secretary reported emailing the podiatry office to include the resident, the facility's podiatry list for the scheduled visit did not reflect the resident's name. As a result, the resident was not seen by the podiatrist as intended. Interviews with facility staff and the podiatrist confirmed that the resident should have been prioritized and that Medicare coverage was not a barrier to timely care.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified as high risk for wandering, resulting in the resident being unaccounted for over four hours. The resident, diagnosed with Alzheimer's disease and delusional disorders, was known to have exit-seeking behaviors and had previously been found wandering in unauthorized areas. Despite being identified as a high wander risk, the resident's care plan interventions, such as using a wander guard bracelet and offering diversions, were insufficient to prevent the resident from leaving the facility unnoticed. On the day of the incident, the resident was last seen by a nursing assistant at 3:15 AM, and it was discovered that the resident was missing at 4:00 AM. The facility's search efforts were delayed, and the police were not notified until 6:00 AM, contrary to the facility's policy of notifying authorities within 5 to 7 minutes if a resident is not located. The resident was eventually found outside near the rear kitchen entrance, having exited through an unalarmed and unlocked door, and was believed to have been in a dryer service room that was also unlocked. Interviews and observations revealed that several doors within the facility, including those leading to the kitchen and laundry areas, had broken locks or were unalarmed, allowing the resident to exit the building. Staff had previously reported the resident's wandering behavior and the broken locks, but no room change or additional monitoring orders were implemented. The facility's failure to maintain secure exits and promptly address the resident's wandering risk resulted in a finding of Immediate Jeopardy.
Failure to Timely Obtain and Implement Wander Guard Orders for High-Risk Residents
Penalty
Summary
The facility failed to obtain timely physician orders for wander guard bracelets for two residents identified as high wander risks. Resident #1, diagnosed with Alzheimer's disease and delusional disorders, was assessed on 1/10/2025 as a high wander risk with a score of 12. Despite this assessment, a physician order for a wander guard bracelet was not obtained until 1/22/2025, 12 days later. The Director of Nursing Services (DNS) believed a wander guard was applied earlier, but no documentation supported this. The facility's wander guard tracking book also lacked evidence of a bracelet being signed out for Resident #1 before 1/22/2025. Similarly, Resident #2, with diagnoses including Parkinsonism and dementia, was also identified as a high wander risk with a score of 12 on 1/13/2025. Although a physician order was eventually obtained on 1/22/2025 to verify the placement and function of the wander guard bracelet, there was no current order directing staff to check the bracelet's function nightly. The DNS acknowledged the absence of such an order, which contradicted the facility's policy requiring nightly checks by the 11 PM to 7 AM supervisor.
Unauthorized Access to Medication Keys and Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to keys for medication storage, including medication rooms and carts, and did not maintain separately locked, permanently affixed compartments for controlled drugs. During an observation, a registered nurse (RN) was found to not carry the nursing supervisor keys on her person due to their weight, instead keeping them in an unlocked drawer in the supervisor's office. This office was located on a different wing and was accessible to others, including a resident who was present in the office at the time of the observation. The RN demonstrated that the keys provided access to all areas of the facility, including medication storage areas. Further observations revealed that the medication room on the B-unit was unattended, and the refrigerator meant for storing controlled emergency medications was not properly secured. The keypad lock intended for the refrigerator was found sitting on top of it, leaving the refrigerator unlocked. Inside, a locked box containing controlled substances like liquid Morphine and Ativan was chained to the refrigerator. The Director of Nursing Services (DNS) was unable to explain why the RN did not have control of the keys and incorrectly believed that the lock's placement on top of the refrigerator was acceptable. The facility's policy on controlled pharmaceuticals required that keys to controlled substance containers be maintained separately, but there was no policy for the storage of narcotic/controlled medications.
Deficiencies in Administrative Oversight and Resource Management
Penalty
Summary
The facility failed to administer its resources effectively and ensure proper administrative oversight, leading to several deficiencies. There was no Governing Body in place, and the Medical Director was not appointed by such a body. The facility did not notify the State Agency in a timely manner about a reportable event. Clinical records were incomplete and lacked documentation or an RN assessment. A resident with a known wander risk had access to an unlocked egress, and the orders for a wander guard bracelet were neither accurate nor timely. Medications were not secured properly, and unauthorized staff had access to keys. Additionally, annual in-service training was not completed on time, and facility policies were not reviewed or approved annually, resulting in differing and duplicate policies. The facility had three different Elopement Policies in effect, none of which matched, and it was unclear which policy staff had been educated on prior to an elopement incident. Interviews with the DNS, Administrator, and Regional Nurse revealed a lack of process for administrative oversight regarding the Governing Body, Medical Director appointment, medication storage, notification of reportable events, annual training, policy review, physician orders, and resident access to unlocked egress. The facility's failure to utilize resources effectively compromised the residents' well-being, and no facility policy was provided for review.
Lack of Governing Body and Policy Oversight
Penalty
Summary
The facility failed to establish a governing body or designate individuals to function as a governing body responsible for the management and operation of the facility. This deficiency was identified through a review of facility documentation, which did not reveal the existence of a governing body. Additionally, the Administrator's employee file lacked evidence of appointment by a governing body. The facility's policy and procedure manual also failed to show that an annual review of policies was conducted, which is a requirement for maintaining effective management and operation. Further investigation revealed inconsistencies in the facility's Elopement Policies, with three different versions in effect, each from different sources, and no clear indication of which policy staff had been educated on. Interviews with the Director of Nursing Services (DNS), Administrator, and Regional Nurse confirmed the absence of a governing body and the lack of annual policy reviews. Despite the presence of Governing Body By-Laws, which outline the responsibilities of the governing board, the facility did not adhere to these guidelines, leading to a lack of oversight and management of the facility's operations.
Failure to Document RN Assessment After Resident Elopement
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident following an elopement incident. The resident, diagnosed with Alzheimer's disease and delusional disorders, was identified as an elopement risk and had interventions in place, such as a wander guard bracelet. Despite these measures, the resident was reported missing from their room early in the morning. The facility staff, along with local police, conducted a search and eventually found the resident outside near the rear kitchen entrance, with dryer lint on their clothes, indicating they had been in the laundry area. The deficiency arose because there was no documented RN assessment following the resident's elopement, as required by the facility's Charting and Documentation policy. Although the Director of Nursing Services (DNS) stated that an RN assessment was completed, they could not provide documentation to support this claim. The absence of this documentation in the resident's medical record constitutes a failure to maintain complete and accurate records, as per accepted professional standards.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides, hired in 2023, received the required 12 hours of annual in-service training. The review of the employee file for one nurse aide, hired on August 10, 2023, showed that the only education provided was on Intravenous (IV) therapy, with no additional or general orientation education documented for 2023, 2024, and up to February 27, 2025. Another nurse aide, hired on July 20, 2023, had annual education that included resident rights, abuse/retaliation, and dementia, but still did not meet the 12-hour requirement. An interview with the Director of Nursing Services (DNS) confirmed that all nurse aides should have a minimum of 12 hours of annual in-service training, but the DNS could not explain why the required training was not completed for these two aides. The facility's assessment tool from August 2024 outlined topics for annual education, including abuse, resident rights, confidentiality, and infection control, among others, which were not fully addressed in the training provided to these aides.
Staff Recorded and Posted Inappropriate Resident Videos on Social Media
Penalty
Summary
A staff member at the facility recorded videos of residents, including one resident with Alzheimer's disease, depression, and agitation, who was dependent on staff for transfers, personal hygiene, and dressing. The videos captured the staff member interacting with residents in an unprofessional manner, such as speaking inappropriately to a resident while they were rummaging through bins in the recreation room and referring to the resident as 'thieving.' Other videos included footage of a resident's legs during personal care and a resident being told they were banned from the dining area and recreational activities. These videos were posted on social media without the residents' consent. The facility's policies on resident privacy and abuse explicitly prohibit such actions, stating that residents have a right to privacy and confidentiality and that abuse includes actions facilitated through technology. The incident was brought to the attention of the DON by another staff member, who reported the existence of the videos. The DON reviewed the videos and confirmed the inappropriate conduct and unauthorized recording and posting of residents, which constituted a failure to protect residents from abuse and to uphold their rights to privacy and dignity.
Failure to Conduct Thorough Investigation for Injury of Unknown Origin
Penalty
Summary
A resident with dementia, behavioral issues, and severe cognitive impairment was admitted to the facility and required significant assistance with daily activities. The resident was noted to have a history of physical aggression and attempts to get up unassisted. On a specified date, the resident was found to have increased pain, swelling, and decreased range of motion in the right wrist, which was later diagnosed as a fracture of the right ulnar styloid process. The injury was of unknown origin, and there was no documentation of negative behaviors or incidents in the days leading up to the discovery of the injury. The facility failed to conduct a thorough investigation into the cause of the resident's injury as required by its policy. Specifically, a 72-hour look back was not completed, and staff interviews were limited to only those working one shift on the day before the injury was identified. No staff from other shifts were interviewed, and the investigation did not include a comprehensive review of possible causes. The Director of Nursing acknowledged that the required 72-hour look back was not performed.
Failure to Complete Neurological Assessments and Follow Treatment Recommendations After Accidents
Penalty
Summary
The facility failed to complete required neurological assessments following unwitnessed falls for two residents and did not document wrist stabilization as recommended by an APRN for another resident with a fracture. For one resident with dementia and a history of falls, there was no documentation of neurological checks after an unwitnessed fall, despite facility policy requiring such assessments. The Director of Nursing Services (DNS) confirmed the absence of documentation and could not explain why the assessments were not completed. Another resident with severe cognitive impairment and a right wrist fracture did not have documentation showing that the APRN's recommendation to stabilize the wrist was followed. Although the APRN directed wrist stabilization and pain management, there was no evidence in the nursing notes, physician orders, or treatment records that the wrist was immobilized or how it was stabilized prior to the resident being sent to the emergency room for further evaluation. A third resident with Parkinson's disease and a history of falls experienced multiple unwitnessed falls. Neurological assessments were either incomplete or missing for several shifts following these incidents, contrary to facility policy. The DNS acknowledged that neurological checks were not consistently documented or performed as required after unwitnessed falls. Facility policies clearly directed staff to perform and document neurological checks after any unwitnessed fall, but these protocols were not followed in the cited cases.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance evaluations for two out of four nurse aides reviewed. Personnel files showed that the last performance evaluations for both nurse aides were completed nearly a year prior to the review. Interviews with the Regional Clinical Nurse and the Administrator confirmed that annual evaluations were expected but had not been completed due to administrative changes and lack of awareness by the current leadership. Additionally, the facility was unable to provide an employee performance evaluation policy when requested.
Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an allegation of neglect for a resident with spina bifida, neurogenic bladder, and spinal stenosis. The resident was care planned to be turned and repositioned every two hours and to be assisted out of bed before breakfast. On the date in question, the resident reported using the call bell for one and a half hours without receiving assistance, ultimately moving themselves from bed to wheelchair despite having no feeling from the waist down. The grievance form documented the resident's complaint but did not include a resolution or a comprehensive investigation, such as obtaining statements from all relevant staff or reviewing care provided during the shift. Documentation for the shift lacked evidence of care provided, and interviews revealed confusion regarding staff assignments and care responsibilities. The only NA on the floor was not assigned to the resident and was not interviewed about the incident. The LPN and administrator acknowledged the resident's concerns but did not ensure a thorough investigation or confirm that care was provided as required by the care plan. The facility's abuse reporting policy requires all alleged violations to be reported and investigated, but this process was not followed in this case.
Failure to Provide Timely Incontinent Care and Repositioning
Penalty
Summary
A resident with spina bifida, neurogenic bladder, and spinal stenosis, who was non-ambulatory and incontinent, required extensive assistance with activities of daily living, including turning and repositioning every two hours and timely incontinent care, as documented in the care plan and physician orders. On the morning in question, the resident activated the call bell at 8:33 AM to request incontinent care, but did not receive assistance until between 10:30 and 11:00 AM, resulting in a delay of approximately two hours. During this period, the resident was not turned, repositioned, or provided with incontinent care from the start of the shift at 7:00 AM until care was finally given, totaling a lapse of 3.5 hours. Documentation for the shift did not reflect care provided, and the resident was not assisted out of bed for breakfast as per their care plan. Staff interviews revealed that only one NA was present for 22 residents on the unit until 9:00 AM, and the assigned NA did not provide care to the resident during the relevant period. The resident reported having to move themselves to their wheelchair, despite being assessed as unable to do so due to lack of sensation from the waist down. The facility was also found to be understaffed on the day in question, with a deficit of 23 nursing and NA hours for the census. The failure to provide timely care and assistance was confirmed by staff and resident interviews, review of care documentation, and facility records.
Failure to Provide Adequate Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of a resident with significant medical conditions, including spina bifida, neurogenic bladder, and spinal stenosis. Physician orders and the resident's care plan required turning and repositioning every two hours, early morning care before breakfast, and prompt incontinence care to prevent pressure ulcers. On the day in question, the resident activated the call bell for assistance at 8:33 AM but did not receive care until after 10:30 AM, despite repeated requests. Documentation showed no care was provided from the start of the shift at 7:00 AM until 10:30 AM, and the resident had to move themselves to the bathroom due to lack of assistance. Staffing records revealed only one nursing assistant was present for 22 residents on the resident's unit until 9:00 AM, and overall facility staffing was below the required hours per state regulations. Interviews with staff confirmed that the assigned nursing assistant was not available for the resident, and the replacement did not arrive until later in the morning. The resident was not turned, repositioned, or provided incontinence care for at least 3.5 hours, contrary to the care plan and physician orders. The resident subsequently developed a stage 3 pressure ulcer. The facility's documentation and staff interviews corroborated that the lack of sufficient staffing directly resulted in unmet care needs for the resident, including delayed response to call bells and failure to provide timely incontinence and mobility assistance.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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