Civita Care Northbridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, Connecticut.
- Location
- 2875 Main Street, Bridgeport, Connecticut 06606
- CMS Provider Number
- 075413
- Inspections on file
- 30
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Civita Care Northbridge during CMS and state inspections, most recent first.
A resident with a history of behavioral issues and prior altercations was placed on 1:1 monitoring but was left unsupervised when the assigned NA left the room. During this time, the resident entered a common area and physically assaulted another resident with hemiplegia, causing distress and anxiety. Staff interviews and documentation confirmed that required supervision was not maintained, leading to the incident.
A resident who was alert, oriented, and able to communicate was restricted from going outside after a conservator revoked outdoor privileges, despite prior assessments indicating no elopement risk and facility policy supporting resident rights. Staff enforced the restriction, leading to increased agitation and aggressive behavior from the resident, without updating the care plan or conducting a new elopement assessment.
A resident with diabetes, anxiety, depression, and mobility issues, who was cognitively intact and independent, did not have a timely or documented discharge plan despite an active discharge goal and referral to a community program. The care plan lacked discharge planning details, and there was no evidence of follow-up on referrals or alternative discharge options, contrary to facility policy.
Two residents with intact cognition and court-appointed conservators maintained a close relationship, including private visits, but staff failed to document or implement a care plan addressing their interactions. Despite staff awareness and facility policy requiring individualized care plans, no interventions or monitoring guidance were included, resulting in a deficiency.
Two residents with intact cognition and independent mobility, one with a history of trauma and the other with prior inappropriate sexual behavior, were allowed to visit unsupervised in a private room. Staff, including NAs, social workers, and the DON, were aware of these unsupervised visits but did not monitor or intervene, despite the known risk. One resident later reported non-consensual sexual contact during these visits, and documentation confirmed that no preventive measures were in place.
A resident with multiple medical conditions sustained a first-degree burn during a shower and did not immediately inform staff. When the injury was later identified, the RN supervisor was notified only by a vague text message and did not follow up, resulting in no timely RN assessment being completed. The administrator confirmed that an RN assessment should have occurred and documentation was lacking.
A resident with cognitive impairment and multiple diagnoses was subjected to verbal abuse by a NA, who responded to the resident's use of foul language with similar expletives. Although the resident did not report feeling offended, the exchange was overheard and confirmed through interviews and documentation, constituting a failure to protect the resident from verbal abuse as required by facility policy.
A resident with cognitive impairments and a history of elopement risk exited a facility without staff knowledge and was found by law enforcement 0.6 miles away. The facility failed to reapply a wander guard bracelet upon the resident's readmission and did not follow protocols for missing residents. Staff did not communicate the resident's elopement risk effectively, and the equipment to monitor wander guards was not functioning. These lapses resulted in a finding of Immediate Jeopardy.
The facility failed to document competencies for Nurse Aides and Licensed Nurses from 2022 to the present, despite completing mandatory in-service training. The absence of a Staff Development Coordinator since March 2023 contributed to this deficiency, with the Administrator and other staff continuing in-servicing without documented competencies.
The facility failed to consistently document the pH levels of the manual sanitizer in the kitchen's three-bay sink, essential for ensuring proper sanitizing levels. A dietary aide struggled to demonstrate the procedure and interpret test results due to a vision problem. The logs showed missing documentation on several occasions, which the Dietary Director attributed to staff possibly forgetting to record results.
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training. Documentation lacked details on training duration and conductors, and there was no tracking system in place. The absence of a Staff Development Coordinator since March 2023 further contributed to this deficiency.
The facility failed to maintain CPR certification for several staff members and did not complete Code Blue logs for two residents who required CPR. This lack of documentation and certification violates facility policy and potentially compromises emergency care quality.
A resident with pneumonia, COPD, and asthma was found unresponsive, leading to CPR initiation. An NA, uncertified in CPR, took over from an LPN, contrary to facility policy allowing only certified personnel to perform CPR. The facility confirmed the NA was not trained or certified, breaching protocol.
A resident with diabetes, arthritis, and depression was not assessed for self-medication administration, despite requesting to have medications left at their bedside. The resident separated the medications into two cups, indicating which they intended to take. An LPN left the medications with the resident without confirming an evaluation for self-administration had been conducted. The DON confirmed no evaluation had been done, contrary to facility policy requiring such an assessment and nurse supervision during medication administration.
A resident with dementia and osteoporosis experienced a fall and subsequent pain, but the LTC facility failed to notify the physician promptly. Despite orders to assess and manage pain, the resident's moderate pain was not communicated to the physician until hours later. Nursing staff did not immediately assess or report the pain, and interviews revealed a lack of recall about the incident.
A resident with a history of depression was verbally abused by an LPN, who called them derogatory names. The incident was reported, and an investigation was initiated, leading to the LPN's removal from the facility. The facility's abuse prohibition policy was not upheld, as residents have the right to be free from abuse.
A facility failed to report a verbal abuse allegation involving a resident to an outside state agency in a timely manner. The resident, with a history of depression and other medical conditions, was verbally abused by an LPN. Although the incident was reported to the police, the facility did not notify the required state agency as per their policy.
A facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with cognitive impairments, eloped due to the lack of a wander guard bracelet after hospital readmission. Another resident's care plan was not updated to reflect a change to Full Code status, despite physician orders and discussions with the responsible party. These oversights highlight the facility's failure to ensure timely care plan revisions.
The facility failed to timely evaluate a resident's significant weight loss, assess another resident's safe food consumption with broken dentures, apply ACE wraps as prescribed, and communicate a change in code status to hospice. These deficiencies highlight lapses in following medical orders and ensuring resident safety.
A resident experienced a significant weight loss, but the facility failed to obtain a re-weight and did not evaluate the resident's nutritional needs promptly. The LPN documented the weight discrepancy but did not recall taking further action, and the dietitian was not informed until nine days later. The facility's policy required immediate re-weight and notification of the dietitian, which did not occur, leading to a delay in addressing the resident's nutritional needs.
The facility failed to change and label oxygen tubing weekly for three residents requiring oxygen therapy, as per its policy. Observations revealed undated tubing for residents with conditions such as congestive heart failure and respiratory failure. Interviews with LPNs confirmed the policy requirement, which was not adhered to.
A resident with severe cognitive impairment and under hospice care was not appropriately medicated for pain despite exhibiting daily indicators of discomfort. Physician orders required hourly pain assessments and medication as needed, but records showed consistent zero pain levels until a day when moderate pain was noted multiple times without adequate intervention. The DNS acknowledged the need for better pain management and investigation following the resident's recent fall and hip fracture.
A resident with dementia and dysphagia had broken dentures, and despite a request from the responsible party for evaluation, the facility failed to provide necessary dental services. Dental consults noted the issue but did not recommend repair or replacement. Interviews revealed a lack of communication and follow-up, with the DNS and Medical Records Associate unaware of the request. The facility's policy required prompt referral for dental services, which was not followed.
A resident with a stage 3 pressure ulcer and ESBL resistance received wound care without proper infection control practices. An LPN and NA failed to wear gowns and did not perform hand hygiene between glove changes, despite facility policies and signage indicating the need for enhanced barrier precautions. The LPN admitted to oversight and lack of awareness regarding hand hygiene requirements.
The facility did not effectively communicate its Compliance and Ethics program to all staff. The Administrator could not find records of initial or annual in-service training for the Corporate Compliance program, and 4 out of 6 employee files lacked the Compliance Certificate Statement, indicating missing documentation of compliance training.
Failure to Provide Adequate Supervision During 1:1 Monitoring Results in Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from mistreatment and did not ensure adequate supervision of a resident who was on one-to-one (1:1) observation, resulting in a resident-to-resident physical altercation. One resident with a history of anxiety, combative behaviors, and prior incidents of resident-to-resident abuse was placed on 1:1 monitoring following multiple behavioral incidents, including altercations and attempts to remove safety devices. Despite these interventions, the resident was left unattended by the assigned staff member, who left the room to obtain coffee, leaving the resident unsupervised. During this period of unsupervised time, the resident left their room and entered the dining area, where another resident with hemiplegia and hemiparesis was present. The unsupervised resident approached and struck the other resident in the face, knocking off their glasses and using derogatory language. The incident was witnessed by staff and reported by the affected resident, who expressed feeling unsafe and anxious following the event. Facility documentation and interviews confirmed that the staff member responsible for 1:1 monitoring was not present with the resident at the time of the incident, contrary to facility policy and the intended purpose of continuous observation. The affected resident, who was dependent on assistance for activities of daily living due to stroke-related impairments, reported increased anxiety and distress as a result of the altercation. Facility records and staff interviews corroborated that the assigned staff member failed to maintain constant visual supervision, which directly led to the opportunity for the physical assault to occur. The facility's policies on 1:1 monitoring and abuse prevention were not followed, resulting in a failure to protect the resident from mistreatment.
Failure to Honor Resident's Right to Self-Determination and Outdoor Access
Penalty
Summary
The facility failed to honor a resident's right to self-determination and a dignified existence by not allowing an alert and oriented resident to leave the facility at will. The resident, who had diagnoses including dementia, sensorineural hearing loss, anxiety, and depression, was assessed as alert and oriented with a BIMS score of 15/15 and was able to communicate daily needs using a communication board. The care plan and physician orders permitted the resident to go on leave of absence with medications and a responsible party, and the resident was not considered at risk for elopement. Despite this, after an incident where the resident attempted to board a city bus, the court-appointed conservator revoked outdoor privileges, and facility staff subsequently restricted the resident from going outside, even though the resident had previously been allowed to do so to feed birds and had not attempted to leave the premises before. Facility documentation and interviews confirmed that staff, including the DON and social worker, enforced the conservator's directive to restrict the resident from going outside, despite acknowledging the resident's rights and alert status. The restriction led to increased agitation and aggressive behaviors from the resident, culminating in a physical altercation and transfer to the hospital. The facility did not update the resident's care plan or conduct a new elopement and wandering assessment after the change in outdoor privileges. The facility's own policy states that residents have the right to make choices about their activities and participate in community life both inside and outside the facility, but this was not upheld in this case.
Failure to Develop and Implement Timely Discharge Plan
Penalty
Summary
A deficiency was identified regarding the facility's failure to develop and implement a timely discharge plan for a resident with diagnoses including diabetes mellitus, anxiety, depression, and difficulty walking. The resident was cognitively intact and independent with personal care, transfers, and ambulation. Although the Minimum Data Set (MDS) indicated an active discharge plan and a referral to the local contact agency, the resident's care plan did not include a discharge plan, and there was no documentation of referrals for potential discharge to another level of care. The interdisciplinary care plan meeting marked discharge planning as not applicable, with only a handwritten note referencing Money Follows the Person (MFP). Interviews revealed that a referral to MFP was made approximately 20 months prior, but the resident remained in the facility without further discharge planning or follow-up contacts regarding MFP or alternative settings. When the resident later requested a transfer to another nursing home, a referral was made and the resident was placed on a waiting list, but no additional follow-up was documented. The facility's discharge planning policy requires that discharge planning be addressed upon admission and throughout the resident's stay, particularly for those expressing a desire to return to the community, which was not consistently followed in this case.
Failure to Develop and Implement Care Plan for Resident Relationship
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the relationship between two residents, both of whom had intact cognition and court-appointed Conservators of Person (COP). One resident had a history of trauma and the other had a prior incident of allegedly inappropriate touching of a peer. Despite staff awareness of the ongoing friendship and frequent private visits between the two residents, there was no documentation in either resident's care plan addressing their relationship or providing guidance for staff on monitoring or managing their interactions. Multiple staff members, including nursing assistants, social workers, LPNs, and the administrator, confirmed knowledge of the residents' friendship and private visits, often with the door closed and without staff monitoring. Both residents' COPs were aware of the relationship, and one resident reported feeling uncomfortable after previously consenting to intimate contact. Facility policy required care plans to reflect resident preferences and needs, but no care plan interventions were documented to address the relationship, resulting in a deficiency.
Failure to Supervise Residents with Known Risk Leading to Sexual Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident sexual incident involving two residents, both of whom had intact cognition and were independently mobile. One resident had a history of trauma and the other had a documented prior incident of inappropriate touching of another resident. Despite this history, both residents were allowed to visit each other unsupervised in a private room with the door closed, and staff were aware of these visits but did not monitor or check on them during these times. Multiple staff members, including nursing assistants, social workers, and the Director of Nursing, acknowledged awareness of the friendly relationship and unsupervised visits between the two residents. Staff interviews revealed that no interventions were implemented to prevent inappropriate contact during these visits, even though one resident had a known history of inappropriate sexual behavior. The facility's abuse prohibition policy defined sexual abuse as non-consensual sexual contact of any type with a resident, yet there was a lack of preventive measures in place. The incident came to light when one resident reported feeling uncomfortable and stated that the other resident had touched them in a manner they did not consent to, despite having previously had a consensual relationship. The resident reported telling the other to stop, but the inappropriate touching continued. Documentation and interviews confirmed that staff were aware of the risk factors and the unsupervised nature of the visits but failed to implement or explain any interventions to ensure resident safety during these interactions.
Failure to Ensure Timely RN Assessment After Resident Burn
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the RN supervisor and completion of an RN assessment after a resident experienced a change in condition. The resident, who had diagnoses including type 2 diabetes, anemia, and Charcot's joint, independently showered and sustained a first-degree burn to the right lower extremity after using a hot washcloth during a shower. The resident did not immediately report the injury to staff and later requested lotion for the affected area. Upon identification of the burn by staff, the RN supervisor was notified only via a non-urgent text message, which did not specify the nature of the incident. The RN supervisor did not follow up, and no RN assessment was completed at the time the burn was discovered. The administrator confirmed that an RN assessment should have been performed and that there was no documentation of such an assessment when the injury was first identified. The facility was unable to provide an assessment policy for review.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with Parkinson's disease, unspecified dementia, and generalized anxiety disorder, who was moderately cognitively impaired and required assistance with activities of daily living, was subjected to verbal abuse by a nursing assistant (NA). The incident occurred when the resident, who was incontinent and dependent on staff for transfers, repeatedly requested to get out of bed. The NA responded to the resident's requests with foul language after the resident used similar language towards the NA. Facility documentation and interviews confirmed that the NA replied to the resident with the same expletive the resident had used, and this exchange was overheard by staff. Interviews with the resident, the NA, and other staff revealed that such exchanges were not uncommon between the resident and the NA, and the resident did not express feeling offended or fearful. However, the facility's investigation substantiated that verbal abuse had occurred, as the NA engaged in inappropriate language with the resident, contrary to facility policy prohibiting abuse, neglect, and exploitation. The incident was documented in the nurse's notes and corroborated by multiple interviews and facility records.
Failure to Implement Elopement Interventions Leads to Resident's Unauthorized Exit
Penalty
Summary
The facility failed to implement necessary interventions for a resident identified at risk for elopement, resulting in the resident exiting the facility without staff knowledge and being found 0.6 miles away by law enforcement. The resident, who had diagnoses including paranoid schizophrenia, dementia, depression, anxiety disorder, and psychosis, was moderately cognitively impaired according to a recent assessment. Despite being identified as at risk for elopement, the resident's care plan interventions, such as the application of a wander guard bracelet, were not effectively implemented. On the day of the incident, the resident's wander guard was removed prior to a hospital transfer, and upon readmission, the facility failed to reapply the wander guard or implement other measures to monitor the resident's location. The facility's investigation revealed multiple lapses in protocol and communication. Staff did not follow the facility's policy to page a Dr. Hunt when the resident was identified as missing. The wander guard bracelet was not reapplied upon the resident's readmission, and there was no evidence of physician orders for its reapplication. Additionally, the receptionist, who was responsible for monitoring exits, did not notice the resident leaving the building, and the dietary aide who accompanied the resident on the elevator did not recognize the resident as being at risk for elopement. Interviews with staff indicated a lack of awareness and adherence to the facility's elopement policies. The charge nurse and RN supervisor failed to communicate the resident's elopement risk and need for a wander guard to the appropriate parties. The facility's transmitter used to check the function of wander guard bracelets had been broken for several months, and there was a delay in obtaining a replacement. These failures in communication, policy adherence, and equipment maintenance contributed to the resident's elopement and the subsequent finding of Immediate Jeopardy.
Deficiency in Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that competencies were conducted for Nurse Aides and Licensed Nurses to confirm that staff was competent to provide care for and meet the needs of all residents. During interviews and reviews of facility documentation, it was revealed that while mandatory in-service training was completed for all staff in 2022 and 2023, the facility was unable to provide any competencies for Nurse Aides or Licensed Nurses from 2022 to the present. The Administrator acknowledged the absence of a Staff Development Coordinator since March 2023, despite ongoing efforts to fill the position. The Administrator, along with the nursing supervisor and the Infection Preventionist, continued monthly and annual in-servicing. However, the lack of documented competencies persisted, indicating a deficiency in ensuring staff competency as required by the facility's assessment.
Inconsistent Documentation of Sanitizer pH Levels in Kitchen
Penalty
Summary
The facility failed to consistently document the pH levels of the manual sanitizer used in the kitchen's three-bay sink, which is essential for ensuring that sanitizing levels are adequate to effectively remove harmful bacteria on food contact surfaces. During a kitchen tour, it was observed that a dietary aide was unable to explain or demonstrate the procedure for checking the sanitizer concentration without prompting. The dietary aide also had difficulty interpreting the results of the pH test strip due to a vision problem, which was noted by the Dietary Director. A review of the daily temperature logs revealed that pH testing of the manual sanitizer was not documented on several occasions, including specific meals on multiple days. The Dietary Director acknowledged that there would have been pots to sanitize on those days and suggested that staff might be forgetting to record their results. The facility's policy requires staff to perform pH tests and record the results to ensure proper sanitizing levels, but this was not consistently followed, leading to the deficiency.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that all nurse aides received at least 12 hours of annual in-service training, as required. During an interview and review of facility documentation with the Administrator, it was identified that while in-service training sessions were conducted, many of the in-service sheets lacked details such as the duration of the training and the identity of the person who conducted it. Furthermore, the facility did not have a system in place to track or monitor whether each nurse aide completed the required annual training hours. Additionally, the facility had been unable to fill the Staff Development Coordinator position since March 2023, despite ongoing efforts to advertise the vacancy. This lack of a dedicated staff development coordinator contributed to the failure in monitoring and ensuring compliance with the training requirements for nurse aides.
Deficiencies in CPR Certification and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and certification for CPR among its staff, which is a critical component of emergency response in a healthcare setting. Specifically, the facility did not have a copy of the CPR certification card for several licensed staff members, including LPN #4 and NA #1, as required by facility policy. LPN #4's CPR certification had expired, and there was no evidence of renewal, while NA #1 could not confirm their certification status. Additionally, LPN #13 was not certified at the time of the incident but was scheduled to attend a CPR class. The facility's practice of discarding CPR certifications upon employee termination further complicated the issue, as it hindered the ability to verify staff qualifications. The report also highlights the facility's failure to complete the Code Blue transcription log for residents who required CPR, which is a breach of their own policy. For Resident #286, who was a full code and required CPR after being found unresponsive, the facility did not maintain a Code Blue log in the resident's file. Similarly, for Resident #288, who was also a full code and required CPR, the Code Blue log was missing from the clinical documentation. This lack of documentation is contrary to the facility's CPR policy, which mandates that a Code Blue log be completed and included in the resident's clinical record. These deficiencies were identified through clinical record reviews, facility documentation, policy review, and staff interviews. The absence of proper documentation and certification not only violates the facility's policies but also potentially compromises the quality of care provided to residents in emergency situations. The facility's failure to adhere to its own policies regarding CPR certification and documentation reflects a significant oversight in maintaining professional standards of quality care.
Untrained Staff Administered CPR Against Facility Policy
Penalty
Summary
The facility failed to ensure that an employee who administered CPR was appropriately trained according to facility practice and policy. This deficiency was observed in the case of a resident with diagnoses including pneumonia, COPD, and asthma, who was identified as a full code. The resident was found unresponsive with no pulse, heartbeat, or respiration, prompting the initiation of CPR and a call to 911. However, the nurse aide who took over CPR from the LPN was not certified to perform CPR, as per facility policy, which only allows RNs, LPNs, or any personnel with valid CPR certification to perform such procedures. The nurse aide admitted to not knowing how to call a code and took over CPR from the LPN, despite being aware that nurse aides are not supposed to perform CPR according to facility policy. The facility's administration confirmed that the nurse aide was not trained or certified to perform CPR at the time of the incident. The facility's CPR policy mandates that CPR should be performed by trained registered or licensed practical nurses or any other personnel who have completed CPR training, highlighting a breach in protocol during the incident with the resident.
Failure to Assess Resident for Self-Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-medication administration, which is a requirement when a resident desires to self-administer medications. Resident #99, who has diagnoses including diabetes mellitus, arthritis, and depression, was observed with medication cups containing pills next to their breakfast tray. The resident had requested the medications to be left in their room while eating breakfast and had separated the medications into two cups, one for the medications they intended to take and another for those they did not want to take that morning. An interview with an LPN revealed that the resident had requested the medications be left at the bedside, and the LPN complied with this request without knowing if the resident had been evaluated for self-administration. The Director of Nursing Services confirmed that Resident #99 had not been evaluated for self-administration of medication, which is a necessary step if a resident wants to have their pills at the bedside. The facility's policy requires the nurse to stay with the resident until the medication is swallowed, which was not adhered to in this instance.
Failure to Notify Physician of Resident's Pain Post-Fall
Penalty
Summary
The facility failed to notify the physician of a resident's new and ongoing pain following a fall. Resident #100, who was severely cognitively impaired and receiving hospice care, experienced a fall and subsequent pain that was not promptly communicated to the physician. Despite a physician's order to assess and manage pain, the resident's pain was not adequately addressed, and the physician was not notified until several hours after the resident first exhibited signs of moderate pain. The resident had a history of dementia, repeated falls, and osteoporosis, and was unable to verbalize pain, relying on vocal complaints and protective body movements as indicators. The nursing progress notes revealed that the resident exhibited moderate pain shortly after an unwitnessed fall, but there was no immediate assessment or notification to the physician. The resident's pain was documented at a level of 5 on multiple occasions, yet the nursing staff did not contact the physician or APRN until hours later. Interviews with staff indicated a lack of recall regarding the incident, and attempts to contact certain staff members were unsuccessful. The DNS acknowledged that there should have been an intervention to address the resident's ongoing pain, especially given the recent fall.
Resident Subjected to Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Licensed Practical Nurse (LPN). The resident, who was cognitively intact and had a history of depression, was verbally abused by being called derogatory names by the LPN. This incident was reported in a nursing progress note, and an investigation was initiated, with the police being notified. The facility's abuse prohibition policy mandates that residents have the right to be free from abuse, but this was not upheld in this case. Interviews conducted during the investigation revealed that the psychiatric consultant agency no longer had records of the incident, and the staff who witnessed it were no longer employed there. The Director of Nursing Services, who was not in the position at the time of the incident, confirmed that the facility's procedures were to remove the staff from the resident's care and start an investigation. The Administrator confirmed that the incident was reported by psychiatric consultant staff, and the LPN involved was removed from the resident's care and is no longer employed at the facility due to the substantiated verbal abuse.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to an outside state agency in a timely manner. Resident #189, who was diagnosed with adjustment disorder, type 2 diabetes mellitus, and hypotension, was identified as cognitively intact and required supervision for eating and limited assistance with bed mobility and transfers. The resident's care plan noted a history of depression, with interventions to encourage verbalization of feelings and provide emotional support. On a specific date, a nursing progress note documented that a report was received about verbal abuse by a charge nurse, and an investigation was initiated with the police being notified. The reportable event indicated that an LPN called the resident derogatory names. However, the facility administrator later indicated that the incident was not reported to an outside state agency, as required by the facility's Abuse Prohibition policy, which mandates reporting to the Connecticut Department of Social Service if abuse is confirmed.
Failure to Update Care Plans for Elopement and Code Status
Penalty
Summary
The facility failed to revise the care plan for Resident #8 in a timely manner, which contributed to an elopement incident. Resident #8, diagnosed with paranoid schizophrenia, dementia, depression, anxiety disorder, and psychosis, was identified as moderately cognitively impaired with no wandering behaviors noted during a quarterly assessment. However, the resident's care plan indicated a risk of leaving the facility and a tendency to remove the wander guard bracelet. After being transferred to the hospital for a psychiatric evaluation, the resident was readmitted without the necessary elopement precautions being implemented. This oversight led to Resident #8 being found outside the facility by EMS, indicating a failure to update the care plan and apply a wander guard bracelet as required. In another case, the facility did not update the care plan for Resident #88 to reflect a change in code status. Resident #88, diagnosed with dementia and failure to thrive, was initially under hospice care with a DNR/DNI status. However, after discussions with the responsible party, the code status was changed to Full Code, but this change was not reflected in the resident's care plan. The social worker involved did not follow up on the code status change, and the care plan remained outdated, not matching the physician's orders or the resident's current wishes. These deficiencies highlight the facility's failure to ensure timely updates and revisions to residents' care plans, which are crucial for addressing their current medical and safety needs. The lack of communication and follow-up among staff members contributed to these oversights, resulting in inadequate care planning for both residents.
Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to timely evaluate the medical needs of Resident #6, who experienced significant weight loss. Despite a documented weight loss of 23.7 lbs, or 17.34%, from the previous month, there was no immediate re-weight or medical evaluation. The Advanced Practice Registered Nurse (APRN) noted the weight discrepancy eight days later, identifying moderate protein-calorie malnutrition. The facility's policy required notification of the interdisciplinary team and implementation of interventions for significant weight loss, which was not promptly followed. Resident #82, who had dementia and dysphagia, was not assessed for safe food consumption while awaiting dental services for broken dentures. Despite a request for a dental evaluation, there was no documented assessment of the resident's ability to eat safely. Interviews revealed that nursing staff could assess chewing and swallowing difficulties, but no such assessment was documented. The facility's policy required prompt referral for dental services and documentation of measures to ensure adequate eating and drinking if the referral was delayed. The facility also failed to apply ACE wraps as prescribed for Resident #126, who had lower extremity edema. Despite a physician's order to apply ACE wraps daily, observations showed the resident without them. An LPN was unaware of the order and could not explain the omission. Additionally, Resident #88's change in code status to Full Code was not communicated to hospice services, as required by facility policy. The Director of Nursing acknowledged the oversight, and the social worker did not follow up on the code status change, leading to a lack of communication with hospice.
Failure to Address Significant Weight Loss in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's weight was obtained according to policy and did not evaluate the resident's nutritional needs following significant weight loss in a timely manner. Resident #6, who had diagnoses including dementia, anemia, and hypertension, experienced a significant weight loss of 23.7 pounds or 17.34% from the previous month, as documented on 4/16/24. Despite this significant weight discrepancy, there was no documented re-weight, and the issue was not promptly addressed or communicated to the dietitian. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for documenting the weight discrepancy was unable to recall the actions taken to address the issue. The Director of Nursing Services (DNS) and the facility's policy indicated that a re-weight should have been conducted immediately, and the dietitian should have been notified. However, the dietitian was not informed of the weight discrepancy until nine days later, and there was no documented re-weight or immediate dietary intervention. The facility's policy required that any significant weight loss be reviewed by the dietary team, with the interdisciplinary team, dietitian, physician, and family notified. However, the dietitian, who provided services only one day a week, was not informed of the weight discrepancy in a timely manner, and Resident #6's nutritional needs were not addressed promptly. The delay in addressing the weight loss was attributed to the lack of immediate communication and the limited availability of the dietitian.
Failure to Change and Label Oxygen Tubing Weekly
Penalty
Summary
The facility failed to adhere to its policy of changing and labeling oxygen tubing weekly for three residents who required oxygen therapy. Resident #69, diagnosed with acute on chronic congestive heart failure, pneumonia, and acute and chronic respiratory failure, had a physician's order for oxygen administration via nasal cannula. Observations on June 12, 2024, revealed that the oxygen tubing was not dated, and the Treatment Administration Record indicated that the tubing should be changed every Sunday night shift starting June 23, 2024, after surveyor inquiry. Similarly, Resident #84, with diagnoses including congestive heart failure, cardiomyopathy, and end-stage renal disease, was observed on June 12, 2024, with undated oxygen tubing. Resident #126, diagnosed with heart failure, hypertension, and edema, also had undated oxygen tubing, with no evidence of tubing change on June 9, 2024, as per the Treatment Administration Record. Interviews with LPNs confirmed the requirement to change and document the oxygen tubing weekly, as per the facility's policy updated in 2024, which was not followed in these cases.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was severely cognitively impaired and unable to verbalize pain. The resident, who had a history of dementia, repeated falls, and osteoporosis, was under hospice care and exhibited daily indicators of pain. Despite physician orders to assess the resident's pain every hour and medicate as needed, the Medication Administration Record (MAR) showed that the resident's pain was consistently recorded as zero from the beginning of the month until mid-month. However, on the day of the incident, the resident was evaluated as having moderate pain multiple times during the early morning hours, yet only received a scheduled dose of Morphine at 4:00 AM. The nursing progress notes indicated that the resident exhibited symptoms of pain, such as holding their left leg and facial expressions of pain, but there was a lack of timely intervention. An LPN noted difficulty in contacting hospice services for further guidance. The Director of Nursing Services (DNS) acknowledged that there should have been an intervention to address the resident's ongoing pain, especially considering the recent fall and subsequent hip fracture identified by an x-ray. The failure to adequately manage the resident's pain and investigate the cause of increased pain led to the deficiency identified in the report.
Failure to Provide Dental Services for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident with broken dentures, despite a request from the responsible party. The resident, who had diagnoses including dementia, anorexia, and dysphagia, was identified as severely cognitively impaired and independent with activities of daily living. The resident's care plan noted the use of partial dentures and required monitoring for dental issues. On a specific date, the responsible party requested an evaluation for the resident's broken dentures, but the facility did not act on this request. Dental consults conducted on various dates noted broken or missing dentures but did not include recommendations for repair or replacement. Interviews with facility staff revealed a lack of communication and follow-up regarding the dental service request. The social worker confirmed that the issue was discussed in a care plan meeting and an email was sent to the Director of Nursing Services (DNS), but no response was received. The DNS acknowledged that requests for specialty services should be acted upon, and the Medical Records Associate, responsible for scheduling specialty services, stated she had not received any requests for dental evaluation or replacement for the resident. The facility's policy required prompt referral for dental services within three days for lost or damaged dentures, which was not adhered to in this case.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a dressing change for a resident with a stage 3 pressure ulcer and a history of ESBL resistance. The resident, who had severe cognitive impairment and required extensive assistance with mobility and toileting, was observed receiving wound care without the staff adhering to enhanced barrier precautions. Specifically, LPN #5 and NA #2 did not wear gowns as required, despite signage indicating the need for gloves and gowns when providing care. Additionally, LPN #5 did not perform hand hygiene between glove changes, which is a part of the facility's hand hygiene compliance policy. During interviews, LPN #5 acknowledged awareness of the enhanced barrier precautions but admitted to not wearing the gown due to oversight and was unaware of the necessity for hand hygiene between glove changes. The DNS confirmed the expectation for staff to follow posted instructions regarding personal protective equipment and emphasized the requirement for gown use during wound care. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, contributing to the deficiency in infection control practices.
Failure to Communicate Compliance and Ethics Program
Penalty
Summary
The facility failed to ensure effective communication of its Compliance and Ethics program standards, policies, and procedures to all staff members. During an extended survey, it was found that the Administrator could not locate records of initial or annual in-service training that included communication of the Corporate Compliance program for all staff. The Administrator acknowledged that annual in-service training was scheduled to begin in 2024 and confirmed that the facility's governing body operates five or more buildings. Additionally, a review of employee files with the Human Resources Director revealed that 4 out of 6 employee files were missing the Compliance Certificate Statement. This statement, which should be kept in the employee's personnel file at the time of hire, indicates that the employee received Corporate Compliance training. This deficiency highlights a lack of documentation and communication regarding compliance training within the facility.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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