Civita Sheriden Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Connecticut.
- Location
- 321 Stonecrest Drive, Bristol, Connecticut 06010
- CMS Provider Number
- 075350
- Inspections on file
- 37
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Civita Sheriden Woods during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, impaired cognition, generalized weakness, poor balance, visual deficits, and a documented fall history was care planned and ordered as an assist of one for ADLs and toilet transfers. A NA assisted the resident to sit on the bedside to use a urinal, then, after the resident requested privacy, pulled the privacy curtain and left the resident sitting at the bedside, out of line of sight, to care for the roommate, despite knowing the resident’s fall risk and inconsistent call-bell use. Within minutes, the NA heard a noise and found the resident on the floor by the bed with active head bleeding and the urinal on the floor, then left the resident unattended again to walk down the hall to notify an RN instead of immediately calling for help. Nursing documentation and staff interviews confirmed that the resident sustained facial lacerations requiring hospital treatment and that the resident should not have been left unsupervised behind the curtain while using the urinal.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a left wrist fracture had an initial care plan and RCC completed at admission, identifying fall risk and related interventions. A subsequent quarterly MDS showed severely impaired cognition and need for substantial assistance with mobility, but no RCC was documented to coincide with that assessment, and the next RCC was not held until more than a month later. The MDS coordinator acknowledged RCCs are required at least quarterly and that one should have been scheduled around the time of the quarterly MDS, but there was no documentation that the planned RCC occurred or that invitations were sent while the coordinator was on vacation. The DON confirmed RCCs must correlate with MDS dates and be documented, and facility policy required quarterly care plan review with resident/representative notification and participation, yet no separate RCC policy was provided.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a prior wrist fracture was initially assessed as not at risk to low fall risk, but the care plan documented fall risk due to cognitive impairment and generalized weakness, with interventions such as call light within reach and assistance with transfers. A subsequent quarterly MDS showed severely impaired cognition (BIMS 3) and need for substantial assistance with mobility, yet no Fall Risk Evaluation was completed for several months, including around the time of the quarterly assessment. The resident later experienced a fall, was found on the floor with a reddened hip and, later, a bump on the head and inability to move the neck, and was transferred to the ED, where an acute displaced type II odontoid fracture was diagnosed. The DON reported that Fall Risk Evaluations were expected on admission, quarterly, and with changes in condition, but no specific policy on Fall Risk Evaluations was available.
Two residents with significant cognitive and mobility impairments experienced falls, and in both cases the assigned RNs failed to document complete post-fall nursing assessments in the medical record as required by facility policy. For one resident with Parkinson’s disease and a history of falls, the RN recorded discovery of the resident on the floor with a facial laceration, EMS transfer, and provider/representative notification, but did not document range of motion (ROM), neurological findings, or a full assessment via SBAR. For another resident with dementia, prior wrist fracture, and severe cognitive impairment, the RN documented the resident on the floor with a reddened hip, vital signs, and provider notification, but did not document ROM, additional injury assessment, new monitoring orders, or an SBAR. Both RNs later stated they had performed full assessments but had not recorded their findings, contrary to the facility’s Falls Protocol and charting policies requiring detailed documentation of post-fall assessments and changes in condition.
The facility failed to consistently provide substantial evening snacks to residents. Surveyors observed that the snack shelf and snack cart often contained only beverages and minimal crackers, with no other substantial snack items available, and the café refrigerator held a limited number of Jello, pudding, or fruit cups despite a resident capacity of 125. The FSD reported that snacks were delivered weekly but routinely ran out early in the week due to a reduced snack budget, and the Administrator was aware of the shortage. The dietician stated that snack availability had significantly declined since a change in ownership, that requests for additional snacks were not approved, and that snacks needed for diabetics or residents who did not eat meals for caloric supplementation were not always available.
A resident with dementia, depression, and mood disorder who used a wheelchair and required limited assistance for care was receiving incontinent care from three NAs when the resident became combative and refused care. Two NAs held the resident’s arms while the third provided care, and one NA slapped the resident’s arm and used profanity, as witnessed by two staff. The witnesses did not immediately report the incident, and all three NAs continued working for additional days before the allegation was brought to an RN and investigated, contrary to facility policy requiring immediate action to prevent abuse.
A resident with dementia and mood disorders, who required limited assistance with ADLs and used a wheelchair, became combative and refused incontinent care while three NAs attempted to change a soaked brief and bedding. During this care, one NA allegedly slapped the resident’s arm while using profanity, and two other NAs reported witnessing the slapping but did not immediately report the incident, each assuming the other would do so. The event was not brought to an RN supervisor until days later, and only then was the DNS notified and an investigation initiated, resulting in a substantiated abuse finding. This sequence of delayed reporting and notification failed to meet requirements for timely reporting of alleged abuse to the state survey agency.
A resident with osteoarthritis, rheumatoid arthritis, and non-ambulatory status, who required a two-person stand-pivot transfer with a walker per care card and provider order, was transferred by a single NA who did not use a gait belt or walker. The NA assisted the resident to stand from a wheelchair using the bed rail and instructed the resident to pivot toward the bed, during which a pop/grinding sound was heard from the left knee and the resident experienced immediate pain. Initial nursing assessment noted pain with movement but no visible swelling or redness, and the provider was not notified until hours later when swelling and continued pain were reported by an LPN. A STAT X-ray subsequently revealed an acute comminuted fracture of the distal left femoral shaft, and the resident required hospital transfer and surgical repair.
A resident with osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder had a current physician order for bed mobility assist of two and transfer assist of two with a rolling walker, and therapy discharge documentation showed the resident performing stand-pivot transfers with assist of two. Despite this, the resident’s care plan, last reviewed by the IDT and MDS nurse, continued to list the resident as a total lift for transfers and was not revised to reflect the updated mobility status and orders, contrary to the facility’s comprehensive care planning policy requiring ongoing review and revision with condition changes.
A resident with osteoarthritis and rheumatoid arthritis, who had a PRN order for acetaminophen every six hours for pain, sustained a left distal femur fracture during a transfer and experienced significant pain with movement. Initial PRN acetaminophen given in the late afternoon was documented as effective, but when the resident later yelled out in pain and swelling was observed, an LPN did not administer another PRN dose despite the order parameters. During the night, another LPN observed ongoing discomfort but delayed giving acetaminophen until early morning, assuming it had already been given and not checking the MAR. The early-morning dose was documented as ineffective for 10/10 pain, and although this unrelieved pain was reported to a supervisor, the provider was not notified and no additional pain medication was obtained before the resident was sent to the hospital. The facility’s pain policy requiring frequent reassessment of acute pain, MAR review, and reporting of prolonged unrelieved pain was not followed.
The facility did not complete required annual performance evaluations for a nurse aide working the 3–11 PM shift. Review of the aide’s personnel file showed a hire date more than a decade earlier and a last documented evaluation several years ago, with no evidence of subsequent yearly evaluations. The Administrator reported that all employees must receive annual evaluations based on their hire-date anniversary and that HR was responsible for notifying when evaluations were due, routing them to nursing supervisors, and ensuring they were filed. Facility policy specified that evaluations should summarize counseling sessions to identify trends, review job description performance ratings with the employee, and be filed per policy, but this process was not followed for the identified aide.
A resident in hospice care with Alzheimer's and other conditions did not receive prescribed medications due to facility errors. Lorazepam and Atropine were not administered as ordered because of pharmacy delivery issues and miscommunication. Nurses documented medication administration without actually giving it, and oral Acetaminophen was improperly continued despite swallowing difficulties. These failures led to inadequate symptom management during the resident's end-of-life care.
A resident in hospice care did not receive prescribed Lorazepam due to unavailability, yet two LPNs inaccurately documented its administration in the e-MAR. The nurses failed to correct the documentation or notify the supervisor, leading to a deficiency in accurate clinical record-keeping.
A resident with COPD and nicotine dependence experienced multiple documented smoking incidents, including possessing cigarettes and smoking on facility grounds, despite having a care plan addressing smoking cessation. The care plan was not updated to reflect these incidents or to include new interventions, and facility leadership confirmed the lack of timely care plan revision.
A resident with COPD and nicotine dependence was repeatedly found in possession of or using smoking materials independently, despite facility policies prohibiting this. Staff documented the incidents but did not complete required accident/incident reports or investigations, nor did they report the events to the State Agency as mandated by policy.
Two residents experienced misappropriation of their controlled medications, including Morphine and Lacosamide, along with missing controlled substance records. In both cases, medications were removed from secure storage without authorization, and the facility was unable to account for the missing drugs or identify the responsible party, violating policies against misappropriation of resident property.
A resident with mobility and incontinence issues was not treated with dignity and respect by a nurse aide, who yelled at the resident after an incontinence episode, threw items around the room, and failed to assist the resident back to bed. The incident was witnessed by a roommate and confirmed by staff interviews, in violation of the facility's policy on resident rights.
The facility failed to ensure congruence between physician's orders and advanced directive forms for several residents, leading to discrepancies in code status documentation. For instance, a resident's advanced directive indicated DNR, but the care plan and physician's orders showed full code. Another resident's code status was changed by a Probate Decree, but this was not updated in the clinical record until later. Additionally, a resident's desire for CPR was not reflected in the physician's orders, and the facility did not verify the authority of the POA to make medical decisions.
A resident with dementia and other conditions was prescribed Gabapentin 300 mg, but the intent was 100 mg twice daily. The pharmacy consultant failed to identify this discrepancy during monthly reviews. An LPN administered the incorrect dosage, and the pharmacy provider did not follow protocol to clarify the order, leading to a deficiency in medication management.
A resident with severe cognitive impairment and physical limitations was found with excessively long and thick fingernails, indicating a deficiency in personal hygiene care. Despite care plans and physician's orders for regular nail maintenance, staff failed to adequately address the resident's nail condition. Interviews revealed a lack of awareness and communication among staff, leading to neglect in nail care.
A resident with multiple health issues had a wound on the right great toe that was not assessed by an RN upon initial observation, nor monitored weekly as required. Interviews with staff revealed that the wound nurse was not informed, leading to a lack of proper monitoring, contrary to facility policy and state regulations.
A facility failed to ensure that a resident's pressure ulcer was assessed by an RN as required by policy. The resident, at risk for pressure ulcers, had a new deep tissue injury on the right heel initially assessed by an LPN. The wound was not assessed by an RN until much later, despite policy requirements for initial and weekly RN assessments.
A facility failed to discuss and provide a written summary of a baseline care plan to a resident admitted with Covid-19, atrial fibrillation, hypertension, and polyarthritis. Despite the policy to develop a care plan within 48 hours, there was no documentation of the interdisciplinary team meeting with the resident or their representative to discuss the plan. Interviews with staff confirmed the oversight.
The facility failed to maintain complete and accessible medical records for laboratory results for three residents. Despite having multiple blood tests conducted, the results were not present in the residents' records. Staff interviews revealed a lack of clarity and accountability in handling and filing these results, leading to incomplete medical documentation.
A facility failed to maintain complete hospice documentation for a resident with dementia and other conditions. Despite being admitted to hospice care, the resident's clinical record lacked necessary documentation, including interdisciplinary team notes and care plans. Interviews with staff revealed confusion about the location and organization of hospice records, exacerbated by changes in the hospice company's filing system.
Failure to Supervise High Fall-Risk Resident During Bedside Urinal Use
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an accident for a cognitively impaired, fall‑risk resident during bedside urinal use. The resident had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition (BIMS 11), impaired balance, unsteady gait, visual difficulty, and a documented history of falls including a prior fall with injury since admission. The care plan and physician orders identified the resident as an assist of one for ADLs and toilet transfers, with interventions including assistance for toileting at wheelchair level using a grab bar, use of simple language, reorientation as needed, and instruction to ask for assistance before transferring or ambulating. On the day of the incident, a nursing assistant (NA) entered the resident’s room when the resident requested to use a urinal. The NA assisted the resident to sit on the bedside to use the urinal. When the resident was unable to urinate, the resident requested privacy. Despite knowing the resident required assist of one for ADLs and toileting, had a history of falls, was sometimes confused, and had a history of not using the call bell, the NA pulled the privacy curtain around the bed, left the resident sitting on the bedside behind the curtain and out of her line of sight, and went to provide care to the roommate. Approximately two minutes later, the NA heard a bang, opened the curtain, and found the resident on the floor beside the bed with active bleeding from the head and the urinal on the floor. After discovering the resident on the floor, the NA briefly asked if the resident was okay and then left the resident unattended again while she walked down the hallway to notify the RN, without calling out for help or using the call bell. Subsequent nursing notes documented that the resident was found seated on the floor with a laceration to the face and active bleeding from the forehead, and that EMS was notified and the resident was transferred to the hospital, where multiple forehead lacerations were repaired with absorbable sutures. Interviews with the LPN, RN, and DON confirmed that, based on the resident’s plan of care and known fall risk, the resident should not have been left out of sight behind a privacy curtain while sitting on the bedside to use the urinal, and that the NA did not maintain appropriate supervision or immediately seek assistance while the resident was actively bleeding on the floor.
Failure to Complete and Document Quarterly Resident Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure Resident Care Conferences (RCCs) were completed at least quarterly and in conjunction with the required quarterly MDS assessment for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction, and the care plan dated 11/19/25 identified the resident as being at risk for falls due to new admission status, cognitive impairment, and generalized weakness. An RCC and interdisciplinary care plan meeting were documented on 11/19/25, and the quarterly MDS dated 2/3/26 showed severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. However, review of the clinical record from 11/20/25 through 3/8/26 did not show that an RCC was scheduled or held to correspond with the 2/3/26 MDS. The Interdisciplinary Care Plan Meeting Documentation showed the next RCC for this resident occurred on 3/9/26, more than one month after the quarterly MDS. The MDS Coordinator (RN #3) stated that RCCs are to be completed at least quarterly with review of the resident care plan and acknowledged that the resident should have had an RCC scheduled around the time of the 2/3/26 MDS. RN #3 reported an RCC was initially scheduled for 2/19/26 but could not provide documentation that the meeting occurred or that invitations were sent to the resident or representative, noting she had been on vacation when invitations should have been sent. The DON confirmed that all residents are to have quarterly RCCs that correlate with the MDS date and be documented in the clinical record, and that if an RCC is rescheduled, there should be documentation explaining the reason and new date. Review of the Comprehensive Care Planning policy showed requirements for informing residents of their right to participate in care planning, providing advance notice of conferences, documenting when participation is not practicable, and reviewing and updating the care plan at least quarterly with the MDS; no separate RCC policy was provided despite request.
Failure to Complete Quarterly Fall Risk Evaluation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not completing a required Fall Risk Evaluation at least quarterly for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction. A Fall Risk Evaluation dated 10/30/25 identified the resident as not at risk to low fall risk, while the Resident Care Plan dated 11/19/25 documented that the resident was at risk for falls due to new admission status, cognitive impairment, and generalized weakness, with interventions such as keeping the call light within reach, orienting to surroundings, and instructing the resident to ask for assistance before transfers or ambulation. A quarterly MDS assessment later identified severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. Despite these findings, review of the clinical record showed no Fall Risk Evaluation was completed between 10/31/25 and 2/9/26, including around the time of the quarterly MDS. On 2/10/26 at 1:31 AM, an RN documented that the resident had fallen and was found on the floor on the right side, with a reddened right hip but denying pain; vital signs were obtained and the provider was notified, but there were no documented orders for monitoring the reddened hip. Later that day, the DON documented that the resident had sustained a fall and was later noted to have a bump on the right side of the head and inability to move the neck, though still denying pain or discomfort, and the resident was evaluated by an APRN and transferred to the ED. Hospital records showed an admission from 2/10/26 through 2/16/26 for an acute displaced type II odontoid fracture following the fall. The DON stated that all residents should have a Fall Risk Evaluation on admission, quarterly, and with a change in condition, and acknowledged that this resident should have had a Fall Risk Evaluation completed around the time of the quarterly MDS. The facility’s Falls Protocol policy referenced review and documentation of fall risk factors and evaluation of falls, but a specific policy on Fall Risk Evaluations was not available.
Failure to Document Complete Post-Fall Nursing Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete and document nursing assessments in the medical records at the time of residents’ falls, as required by facility policy and professional standards. For Resident #1, who had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition, and a history of falls, the care plan identified multiple fall risks and required assistance with ADLs and toileting. After a fall on 2/7/26, RN #1 documented that the resident was found seated on the floor attempting to get up, with a facial laceration and bleeding, that EMS was notified, the resident remained on the floor until EMS arrival, and that the resident was transferred to the hospital. The note also documented notification of the on-call provider and the resident’s representative. However, the clinical record for Resident #1 did not include documentation that range of motion (ROM) was assessed for additional injuries or pain following the fall, and there was no completed Situation, Background, Assessment, Recommendation (SBAR) form to show that a full assessment had been performed. In interview, RN #1 stated she had performed a full assessment, including ROM and neurological signs, but acknowledged she did not document her findings and that the assessment should have been documented before the end of her shift. This lack of documentation conflicted with the facility’s Falls Protocol policy, which directed nurses to assess and document vital signs, recent injury, musculoskeletal function including changes in ROM or weight bearing, cognition and neurological status, pain, and details of the fall. For Resident #2, who had a scaphoid fracture of the left wrist, weakness, Alzheimer’s disease, aphasia following cerebral infarction, severe cognitive impairment, and required substantial assistance with mobility, the care plan identified fall risk related to new admission, cognitive impairment, and generalized weakness. After a fall on 2/10/26, RN #2 documented that the resident was found on the right side on the floor, with the right hip reddened from lying on it, and that the resident denied pain; vital signs were obtained and the provider was notified. The record did not show any new orders for monitoring the reddened hip, did not document that ROM was assessed for further injuries, and did not contain an SBAR documenting a full assessment. Later documentation by the DON noted that the resident was subsequently found with a bump on the right side of the head and inability to move the neck, and hospital records showed admission for an acute displaced type II odontoid fracture. In interview, RN #2 stated she had performed a full assessment including movement and ROM but did not document it, and the DON confirmed that both RNs should have documented full post-fall assessments in the nurse’s notes or SBARs in accordance with the facility’s Falls Protocol and Charting Documentation policies.
Failure to Provide Substantial and Consistent Evening Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a substantial evening snack on a daily basis, as required by regulation and facility policy. Surveyor observations of the dietary department’s dry storage room on multiple dates showed that the designated snack shelf contained only a small quantity of items, such as one box of crackers and several 1-liter bottles of cola, with no chips, cookies, crackers, or other substantial snacks available. On another observation, there were no snacks available to residents at all. Review of the snack cart revealed it typically contained only a coffee carafe, a bottle of ginger ale, and at most a single or partial package of crackers, with no other food items present for residents. Further observations of the café refrigerator showed fewer than 20 containers of Jello, pudding, or fruit cups available for a facility with a capacity of 125 residents. In interviews, the Food Service Director (FSD) reported that snacks were delivered weekly on Thursdays but routinely ran out by Mondays due to a reduced snack budget of $315 per week. The Administrator acknowledged awareness of the lack of snacks and that the FSD had raised concerns. The dietician reported that snack availability had significantly declined since a change in ownership, that requests to purchase more snacks were not approved, and that snacks needed for residents who are diabetic or who did not eat meals were not always available, despite their importance for caloric supplementation.
Failure to Protect Resident From Physical Abuse and Delay in Reporting Incident
Penalty
Summary
The deficiency involves a resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder who was moderately cognitively impaired, used a wheelchair, and required limited assistance with mobility and personal care. The resident’s care plan identified a risk for refusing care and not waiting for assistance with transfers, with interventions including use of two staff for care and transfers, calm and gentle approach, and clear explanations. During an evening episode of incontinent care, three NAs entered the resident’s room when the resident did not want to be changed and became combative, swinging arms and feet. Two NAs held the resident’s arms while a third NA provided care. During this care, one NA slapped the resident hard on the arm and used an expletive, according to two staff witness statements, while the resident continued to resist by kicking and slapping. The deficiency also includes the failure of two staff members to immediately report the witnessed physical abuse. Both NAs who observed the slapping did not report the incident at the time it occurred, despite one believing the other would report it, and there was no discussion between them about reporting. As a result, the alleged abuser and the two witnesses continued to work in the facility for two additional days before the allegation was reported to the Nursing Supervisor near the end of a later shift. The facility’s policy required protections for residents through written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and called for an immediate investigation when suspicion or reports of abuse occur, but the delay in reporting and the occurrence of the slapping incident demonstrate a failure to ensure the resident was free from mistreatment.
Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse to the state survey agency. A resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder was moderately cognitively impaired, required limited assistance with ADLs, and used a wheelchair. The resident’s care plan identified risk for refusing care and not waiting for assistance with transfers, with interventions including assistance of two staff for care and transfers and use of a calm, gentle approach. During provision of incontinent care, the resident became combative and refused care while staff attempted to change a soaked brief and bedding. According to written statements, three NAs entered the resident’s room to provide care. One NA held the resident’s arms so another NA could change the brief, and a third NA assisted in holding the resident’s arms. One NA was alleged to have slapped the resident hard on the arm while using an expletive, and two NAs reported witnessing the slapping. One NA stated she should have reported the incident when it happened, and another NA stated she did not report the incident because she thought the other NA would report it, although they had not discussed reporting. The involved NAs continued to work in the facility on subsequent days because the allegation was not reported at the time of occurrence. The incident was alleged to have occurred several days before it was brought to the attention of the RN Nursing Supervisor, who was notified toward the end of a later shift that an NA had slapped the resident during care. The Nursing Supervisor documented that two NAs confirmed the allegation and that the incident had occurred days earlier, with no noted signs or symptoms of injury. The DNS was later notified via text message and began an investigation, during which statements were obtained and the allegation was ultimately substantiated based on two staff witnesses. The facility’s policy required immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation, but the delay in reporting by staff and the delayed notification to the state survey agency constituted a failure to ensure timely reporting of the abuse allegation.
Improper One-Person Transfer Without Gait Belt Leads to Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for transfers was transferred per protocol, resulting in a preventable accident and an acute comminuted fracture of the left distal femoral shaft. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and was non-ambulatory at baseline. An annual MDS showed a BIMS score of 12/15 with some memory deficits, partial assistance needed for bed mobility and transfers, and wheelchair use for mobility. Therapy staff and the DON confirmed that, at the time of the incident, the resident required an assist of two for stand-pivot transfers with a walker per the care card and physician’s order. On the day of the incident, the resident reported feeling very tired and falling asleep in the wheelchair, with left foot discomfort. A nurse aide observed the resident leaning forward in the wheelchair with hands on the side rail and believed the resident was trying to stand. Although the aide knew the resident required two-person assistance and a walker for stand-pivot transfers, she did not call for help, did not use the call bell, did not apply a gait belt, and did not use the walker. Instead, she assisted the resident to stand while the resident held the side rail and instructed the resident to pivot toward the bed. As the resident attempted to pivot on the left leg, both the resident and the aide heard a pop or grinding sound from the left knee, and the resident experienced immediate pain. The aide then maneuvered the resident onto the edge of the bed and into bed without a fall occurring. Following the incident, the resident complained of pain with movement of the left leg and knee. The 3–11 PM RN supervisor assessed the resident around 4:15 PM but did not observe redness or swelling and did not immediately notify the provider. Later that evening, after the charge LPN reported swelling and continued pain, the RN supervisor reassessed the resident and contacted the provider, who ordered a STAT left knee X-ray, ice, and continued PRN Tylenol. The X-ray obtained early the next morning showed an acute comminuted fracture of the distal shaft of the left femur, and the resident was subsequently transferred to the hospital, where surgical intervention with open reduction internal fixation was performed. The incident was documented on the facility’s reportable incident form as occurring during a transfer performed by the 3–11 PM nurse aide, with a pop sound heard and increased left knee pain, and was identified as a preventable accident reflecting a breakdown in supervision and adherence to established protocols.
Failure to Update Mobility Care Plan to Match Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s mobility care plan to reflect a current physician’s order. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and had a BIMS score of 12/15 indicating some memory recall deficits. A physician’s order dated 3/2/25, and still current, directed that the resident receive bed mobility assistance of two and transfer assistance of two with a rolling walker. The annual MDS identified that the resident required partial assistance with bed mobility and transfers and used a wheelchair for mobility. However, the Resident Care Plan initiated on 1/6/24 and last reviewed on 1/16/26 identified the resident as requiring assistance with mobility due to decreased strength and listed interventions indicating the resident was a total lift for transfers, which did not match the physician’s order. Interviews and record reviews confirmed that the care plan had not been updated despite changes in the resident’s mobility status and existing orders. The PT and OT reported that the resident had been on therapy services until 12/18/25 and was discharged at that time as an assist of two for stand-pivot transfers between bed and wheelchair, consistent with the 3/2/25 activity orders. They stated they would have notified the charge nurse of the resident’s transfer status and that therapy staff do not update care plans, leaving that responsibility to nursing. They acknowledged the mobility care plan last reviewed on 1/16/26 was incorrect and that the resident had not required a total lift for transfers since 3/2025. The DON confirmed that the mobility care plan should have matched the 3/2/25 physician’s order and that both the IDT and the MDS nurse were responsible for reviewing and revising care plans, including during care plan meetings. The facility’s Comprehensive Care Planning policy directed that care plans be revised as residents’ conditions change and be reviewed and updated at significant changes and at least quarterly, but this was not done for this resident’s mobility care plan.
Failure to Provide Timely and Effective PRN Pain Management After Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely pain management to a resident following an injury that resulted in a left distal femur fracture. The resident had diagnoses of osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder, and had a standing PRN order for acetaminophen 325 mg, three tablets by mouth every six hours as needed for pain. The care plan identified the resident as having potential for pain related to arthritis, with interventions including administering medications as prescribed and monitoring effectiveness. On the date of the incident, during a transfer by a nurse aide, a popping sound was heard and the resident reported increased left knee pain. The nurse supervisor directed the charge nurse to obtain vital signs and administer acetaminophen around 4:15 PM, which was documented as effective at that time. Later that evening, around 10:40 PM, the charge nurse noted the resident yelled out in pain when the left leg was lifted and observed swelling of the left knee. Despite recognizing the resident’s pain at that time, the charge nurse did not administer another dose of acetaminophen, even though more than six hours had elapsed since the prior dose and the medication was ordered every six hours as needed. The provider was notified and ordered a STAT x-ray, continuation of PRN Tylenol, and application of ice. During the overnight shift, the oncoming LPN was informed that the resident had been in pain at the end of the prior shift and observed that the resident appeared uncomfortable throughout the night. However, this nurse did not administer acetaminophen until 5:12 AM, assuming the prior nurse had already given it and failing to verify the last administration time on the MAR. After the 5:12 AM dose, the resident continued to appear restless and uncomfortable during care, and the acetaminophen was documented as ineffective for a pain level of 10/10. Although the nurse reported the unrelieved pain to the nursing supervisor, there was no documentation that the provider was notified of the ineffective pain control or that any additional or alternative pain medication was obtained prior to the resident’s transfer to the hospital later that morning. The facility’s pain policy required acute pain to be assessed every 30–60 minutes until relief was obtained, review of the MAR to determine PRN use and effectiveness, and reporting of significant changes in pain level and prolonged, unrelieved pain to the practitioner. These steps were not followed, resulting in prolonged unrelieved pain for the resident after the injury and prior to hospital transfer.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete required annual performance evaluations for at least one nurse aide. Review of the personnel file for a 3–11 PM nurse aide (NA #1) showed a hire date of 11/26/12 and documented that the last performance evaluation was completed on 12/18/22, with no evidence that yearly evaluations were completed in 2023, 2024, or 2025. The Administrator stated that each employee was required to have an annual performance evaluation based on their hire-date anniversary and explained that, although the facility currently had no Human Resources (HR) staff member, HR had been expected to notify when evaluations were due, distribute them to nursing supervisors for completion, and ensure they were filed in the employee record. Facility policy titled “How to Complete the Performance Evaluation” indicated that the facility reviews and summarizes employee counseling sessions to identify trends and patterns, reviews job description performance ratings with the employee to ensure understanding of performance expectations, and files the performance evaluation per facility policy, but this process was not carried out for NA #1 for multiple consecutive years. No resident medical history or condition was described in relation to this deficiency.
Failure to Administer Prescribed Medications for Hospice Resident
Penalty
Summary
The facility failed to administer medications as prescribed for a resident receiving palliative care, leading to a deficiency in care. The resident, who had Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive, was admitted to hospice care and required specific medications for comfort during the end-of-life process. Despite physician orders for Lorazepam and Atropine to manage anxiety and secretions, these medications were not administered as prescribed due to a lack of delivery from the pharmacy and miscommunication regarding the medication orders. The report highlights several instances where the facility's staff did not follow proper procedures. On two occasions, nurses documented the administration of Lorazepam without actually administering it, failing to correct their records or notify supervisors. Additionally, the facility did not ensure that the necessary prescriptions were sent to the pharmacy, resulting in the unavailability of Lorazepam and Atropine. The pharmacy's requests for clarification on the Atropine order went unanswered, and the medication was not delivered to the resident. Furthermore, the facility continued to administer oral Acetaminophen despite hospice recommendations to discontinue all oral medications due to the resident's inability to swallow. This oversight was compounded by the discontinuation of a rectal Tylenol order, which was intended for pain management. The lack of communication and failure to adhere to medication orders contributed to the resident not receiving the necessary care to manage symptoms effectively during the end-of-life stage.
Inaccurate Medication Documentation for Palliative Care Resident
Penalty
Summary
The facility failed to ensure accurate clinical record documentation for a resident receiving palliative care, leading to a deficiency. The resident, diagnosed with Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive, was admitted to hospice care and required specific medications for comfort. On a particular day, the hospice recommended discontinuing all scheduled medications and starting Morphine, Lorazepam, and Atropine for comfort care. However, the electronic Medication Administration Record (e-MAR) inaccurately reflected that Lorazepam was administered twice when it was not available, and the nurses involved did not correct the documentation or notify the appropriate personnel. The deficiency was further compounded by the lack of communication and proper documentation procedures. One LPN signed the e-MAR before realizing the medication was unavailable and failed to strike off her signature or notify the supervisor. Another LPN also signed for the administration of Lorazepam without it being available and did not follow up with the necessary steps to rectify the situation. The Assistant Director of Nursing Services (ADNS) confirmed that the nurses should have corrected the e-MAR and informed the nursing supervisor to ensure the resident received the prescribed medications. The facility did not provide a policy to guide the staff on handling such situations, contributing to the deficiency.
Failure to Update Care Plan After Repeated Smoking Incidents
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was updated to address known smoking incidents for a resident with chronic obstructive pulmonary disease and nicotine dependence. The resident was cognitively intact and independent in mobility, with a care plan that initially included interventions such as instruction on the facility smoking policy, securing smoking materials, offering a nicotine patch, and addressing smoking cessation. However, clinical record reviews revealed multiple incidents where the resident possessed smoking materials, was observed smoking on facility grounds, and smoked while using a nicotine patch. Despite these documented incidents on three separate occasions, the care plan was not revised to reflect the new behaviors or to include additional interventions to prevent recurrence. An interview with the Assistant Director of Nursing confirmed that the care plan had not been updated following these events, and the facility was unable to provide a policy regarding the review and revision of comprehensive care plans.
Failure to Investigate and Report Resident Smoking Incidents
Penalty
Summary
The facility failed to ensure timely investigation of known smoking incidents involving a resident with chronic obstructive pulmonary disease and nicotine dependence. The resident, who was cognitively intact and independent in mobility, had a care plan that included instructions about the facility smoking policy, securing smoking materials, and offering nicotine patches. Despite this, nursing progress notes documented three separate occasions where the resident was found in possession of smoking materials or observed smoking independently on facility property. On each occasion, staff either removed the items or educated the resident, but no formal accident/incident reports or investigations were completed as required by facility policy. Additionally, the facility did not submit reportable events to the State Agency for any of these incidents. Interviews with facility leadership confirmed that no investigations were conducted to determine how the resident obtained smoking paraphernalia or to implement interventions to prevent recurrence. Facility policies clearly stated that residents were not permitted to possess smoking materials or smoke independently, and that all accidents and incidents must be documented and reported. However, these procedures were not followed in response to the documented smoking incidents.
Failure to Safeguard Residents' Controlled Medications and Records
Penalty
Summary
The facility failed to protect residents from the wrongful use or removal of their controlled medications and associated documentation. For one resident with Alzheimer's disease and colon cancer, an unopened bottle of Morphine Sulfate prescribed for pain and shortness of breath was discovered missing from the controlled medication box when the resident required a dose for comfort. The investigation revealed that the previous Director of Nursing had removed the controlled medications, including Morphine and Oxycodone from the emergency and drug destruction boxes, without authorization. The incident was not reported immediately upon discovery, and the missing medication was only reported to the current Director of Nursing the following day. In a separate incident, another resident with epilepsy and dementia was found to be missing a significant quantity of Lacosamide tablets, along with the controlled substance disposition record. The missing medication was identified during a routine narcotics count, and the investigation confirmed that a total of eighty-eight tablets were unaccounted for, but could not determine who was responsible for their removal. Both incidents were reported to the Department of Consumer Protection, Drug Enforcement Division, and were in violation of the facility's policy prohibiting misappropriation of resident property.
Failure to Treat Resident with Dignity and Respect During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of knee replacement, mobility difficulties, and incontinence was not treated with dignity and respect by a staff member. The resident, who was alert and oriented, required substantial assistance with personal hygiene and toileting. According to facility documentation and interviews, the resident reported that a nurse aide became upset and yelled at the resident after an episode of incontinence. The aide was also described as throwing items around the resident's side of the room and failing to assist the resident back to bed after providing care. The incident was witnessed by the resident's roommate. Interviews with facility staff confirmed that the resident alleged verbal abuse and disrespectful behavior from the nurse aide, including being yelled at for soiling themselves. The nurse aide acknowledged that the resident was upset and yelling, and called the charge nurse to intervene. The charge nurse also confirmed that the resident reported being yelled at by the aide. Facility policy states that residents have the right to be treated with consideration, respect, and dignity, which was not upheld in this instance.
Inconsistent Advanced Directive Documentation
Penalty
Summary
The facility failed to ensure that the physician's orders and the signed advanced directive forms were congruent for several residents, leading to discrepancies in their code status documentation. For Resident #33, there was a mismatch between the advanced directive form indicating a Do Not Resuscitate (DNR) status and the care plan and physician's orders, which indicated a full code status. Despite the resident's decision to change their code status to full code, the physical clinical record was not updated to reflect this change, as confirmed by interviews with staff. Resident #51's case involved a change in code status from full code to DNR and Do Not Intubate (DNI) as per a Probate Order Decree. However, the care plan and advanced directive form did not reflect this change until after surveyor inquiry. Similarly, Resident #69's advanced directive form indicated a DNR status, but the care plan and physician's orders showed a full code status. The facility was unable to provide a Probate Court order to support this change, highlighting a lack of documentation and communication. For Resident #78, a Probate Decree changed the code status to DNR/DNI, but this was not reflected in the resident's clinical record until after the decree was received. The facility's process for updating code status was not followed, as the order was entered before receiving the decree. Resident #107's case involved a discrepancy between the advanced directive form and the physician's orders, with the resident expressing a desire for CPR despite the orders indicating DNR/DNI. The facility failed to verify the authority of the Power of Attorney to make medical decisions, leading to further confusion in the resident's code status documentation.
Pharmacy Consultant Fails to Identify Medication Order Discrepancy
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified a discrepancy in a written physician's order for a resident with diagnoses including dementia, psychotic disturbance, type 2 diabetes mellitus, and pain. The resident's quarterly MDS assessment indicated moderately impaired cognition and required assistance with certain activities of daily living. A physician's order directed the administration of Gabapentin 300 mg, but the intent was to administer 100 mg twice daily. Despite monthly pharmacy regimen reviews, no recommendations addressed the discrepancy in the Gabapentin order. During a medication pass, an LPN was observed preparing three 100 mg Gabapentin capsules for the resident, contrary to the physician's order. Interviews with the Pharmacist Consultant Supervisor and the APRN who wrote the order revealed that the pharmacy consultant should have identified the confusing order and recommended clarification. The pharmacy provider's pharmacist acknowledged that the protocol to notify the facility of the discrepancy was not followed, as there was no record of communication, and the order was never corrected. The facility's pharmacy policy indicated that issues should be communicated and suggestions made for service improvement, which was not adhered to in this case.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for a resident with severe cognitive impairment and physical limitations, leading to a deficiency in personal hygiene. The resident, who required total assistance with activities of daily living due to conditions such as dementia, anxiety, and a contracture of the right hand, was observed with excessively long and thick fingernails. Despite a care plan and physician's orders that included regular washing of hands and nails, the resident's nails were not adequately maintained. Observations revealed that the resident's right middle fingernail was particularly long, thick, and curved, indicating neglect in nail care. Interviews with staff revealed a lack of awareness and communication regarding the resident's nail condition. A nurse aide reported trimming the resident's nails two weeks prior but did not address the thick and discolored middle fingernail, assuming it was the responsibility of the charge nurse. The charge nurse and other staff members were either unaware of the nail condition or assumed it was being managed through routine washing. The facility's policies on nail care and weekly body audits were not effectively implemented, as evidenced by the failure to address the resident's nail condition during these assessments.
Failure to Assess and Monitor Resident's Wound
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a non-pressure related wound for a resident with multiple diagnoses, including heart failure and venous insufficiency. The resident's care plan included interventions for skin inspection and treatment, but the clinical record review revealed that the wound on the resident's right great toe was not initially assessed by a registered nurse upon observation, nor were there any documented weekly assessments as required by the facility's policy and state regulations. Interviews with facility staff, including two LPNs and the Director of Nursing Services (DNS), confirmed that the wound nurse was not informed of the resident's wound, resulting in a lack of weekly monitoring. The facility's policy mandates that non-pressure wounds be assessed and documented to ensure optimal outcomes, but this was not adhered to in the case of the resident's wound, leading to the identified deficiency.
Failure to Ensure RN Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the initial and weekly assessments of a wound for Resident #27 were completed by a registered nurse (RN), as required by their policy. Resident #27, who had diagnoses including type 1 diabetes mellitus and was at risk for pressure ulcers, was admitted with an unstageable pressure injury. The care plan included interventions such as weekly skin inspections and pressure-reducing measures. However, when a new deep tissue injury (DTI) was identified on the resident's right heel, it was initially assessed by an LPN instead of an RN, contrary to the facility's policy. The LPN responsible for wound care documented the assessments of the right heel wound on multiple occasions, but an RN did not assess the wound until much later. The Wound Specialist (APRN) also assessed the wound, but not until two weeks after the initial identification by the LPN. Interviews with the LPN and the Director of Nursing Services (DNS) confirmed that the wound should have been assessed by an RN initially and weekly, as per the facility's policy. This oversight led to a deficiency in the care provided to Resident #27.
Failure to Discuss Baseline Care Plan with Resident
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was discussed and provided to a resident and/or their representative. Resident #120, who was admitted with diagnoses including Covid-19, atrial fibrillation, hypertension, and polyarthritis, had their baseline care plan completed on January 13, 2024. The admission MDS assessment indicated that the resident had intact cognition and required extensive assistance for various activities of daily living. Despite the facility's policy to develop a care plan within 48 hours of admission, there was no documentation that the interdisciplinary team discussed this plan with the resident or their representative. Interviews with facility staff, including the RN nursing supervisor, the Admissions Coordinator, and the DNS, revealed that the interdisciplinary team, which includes rehabilitation, nursing, and social work staff, typically meets with residents and/or their representatives within 72 hours of admission to discuss the care plan. However, in this case, the Admissions Coordinator could not find any documentation indicating that such a discussion took place for Resident #120. The DNS confirmed that the interdisciplinary team did not discuss the baseline care plan with the resident or their representative, leading to the identified deficiency.
Incomplete Medical Records for Laboratory Results
Penalty
Summary
The facility failed to ensure that laboratory and diagnostic medical records were readily accessible and complete in the residents' physical charts and/or electronic medical record systems. For Resident #9, who had diagnoses including anxiety disorder and bipolar disorder, the last laboratory testing results in the medical record were from June 2023, despite having blood work drawn on nine occasions between November 2023 and March 2024. The Advanced Practice Registered Nurse (APRN) reviewed the results but was unaware of their subsequent handling, indicating a breakdown in the process of filing or uploading these results into the medical record system. Similarly, Resident #64, with diagnoses such as chronic obstructive pulmonary disease and type 2 diabetes mellitus, had no laboratory or diagnostic testing results in their clinical records for the past year, despite having blood work drawn on seven occasions. The Assistant Director of Nursing Services (ADNS) provided documentation from the laboratory company, but the results were not present in the resident's records, highlighting a failure in maintaining complete and accessible medical records. Resident #74, diagnosed with conditions including atrial fibrillation and hypertension, also lacked laboratory testing results in their clinical records for the past year, despite having blood work drawn on eight occasions. The facility's policy required complete and accurately documented medical records, but the process for reviewing and filing laboratory results was not effectively implemented, as evidenced by the absence of these results in the residents' records. Interviews with staff revealed a lack of clarity and accountability in the handling and filing of laboratory results, contributing to the deficiency.
Deficiency in Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that the clinical record for a resident receiving hospice care contained the necessary hospice documentation. The resident, who had diagnoses including senile degeneration of the brain, dementia, and abnormal weight loss, was admitted to hospice care as per a physician's order. Despite this, the clinical record lacked interdisciplinary team notes, the plan of care, and the Certificate/Recertification of Terminal Illness for specified periods. This deficiency was identified during a review of the clinical record and facility documentation. Interviews with facility staff, including an LPN, social workers, the Director of Nursing Services (DNS), and the Executive Director of Hospice, revealed confusion and uncertainty regarding the location and organization of hospice documentation. The hospice company was in the process of changing its filing system, which contributed to the missing documentation. The Executive Director of Hospice was unable to explain the absence of the required documentation for the resident. The facility's Medical Record policy mandates that all medical records be complete, accurately documented, and readily accessible, which was not adhered to in this case.
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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