Cobalt Lodge Health Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cobalt, Connecticut.
- Location
- 29 Middle Haddam Rd, Cobalt, Connecticut 06414
- CMS Provider Number
- 075232
- Inspections on file
- 23
- Latest survey
- September 29, 2025
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Cobalt Lodge Health Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a recent change to non-ambulatory status suffered a serious fall and injuries after staff used a walker for transfer, as the nurse aide care card was not updated to reflect the resident's current mobility needs. The aide, unaware of the updated status, did not use a gait belt and assisted the resident to ambulate, resulting in a fall with significant injuries.
A resident with dementia and other conditions was transferred to the hospital after elopement, but the facility failed to provide timely bed hold and discharge notices to the resident and responsible party, did not complete a discharge summary, and refused to readmit the resident when ready for return. The facility also backdated the discharge notice and did not follow required consultative or appeal processes, as confirmed by interviews with the conservator, hospital social worker, and ombudsman.
Multiple deficiencies occurred when two residents at risk for elopement were not adequately protected—one was able to leave the facility undetected due to lack of a care plan and delayed response, while another exited through a malfunctioning Wanderguard door and suffered serious injuries. Additionally, a resident dependent on staff for transfers was moved by a single agency aide without required assistance or equipment, resulting in a femur fracture.
A resident with dementia and significant cognitive impairment became agitated in the dining room and was approached by an LPN. Despite the resident holding a fork and being visibly upset, the LPN continued to engage and ultimately pushed the resident, causing a fall that resulted in arm fractures. The incident was confirmed by video and witness accounts, and it was determined that the staff member's actions violated the facility's abuse prevention policy.
Five nurse aides did not receive the required twelve hours of annual in-service training, with no documentation found in their personnel files. Facility leadership confirmed that annual in-service training had not been conducted since the departure of the Staff Development Coordinator, and no records of recent training could be located. Facility policy mandates annual in-service education for all staff, including job-specific training.
Annual performance evaluations were not completed or properly documented for multiple nurse aides, with missing or unsigned reviews and no evidence of evaluations in recent years. The DON and ADON confirmed the requirement for yearly evaluations but were unaware of the lapses due to lack of HR staff and could not provide a relevant policy.
A resident with dementia, Parkinson's disease, and osteoarthritis experienced new left leg pain and swelling, which was reported by a nurse aide to an RN during morning care. Despite repeated notifications, the RN delayed assessment and provider notification for approximately eight hours, even as the resident's symptoms worsened. The resident was eventually found to have a significant femur fracture and was transferred to the hospital only after further staff intervention.
The facility did not complete required weekly skin audits for a resident with significant cognitive and physical impairments, and failed to perform quarterly elopement risk assessments for another resident identified as high risk for wandering. These omissions were not in accordance with facility policy, as confirmed by the DON, and were documented through record review and staff interviews.
The facility failed to review its infection control policies annually and did not conduct monthly environmental rounds since June 2024. The new IP nurse was unaware of the environmental rounds policy, and the DNS confirmed the rounds were not conducted due to the absence of an IP nurse. Additionally, the facility did not adhere to its Water Management Plan Policy, lacking documentation and testing for legionella, as the previous maintenance director took all related documents.
The facility did not address resident council concerns, as meeting minutes lacked documentation of resolutions, and interviews revealed no formal follow-up. The Recreation Director failed to document or communicate resolutions, and the President/Owner confirmed the absence of documentation, violating facility policy.
The facility failed to maintain professional standards in medication administration for two residents. One resident did not receive Eliquis as ordered due to stock issues, and the physician was not notified. Another resident experienced discrepancies in Lorazepam administration records, with the MAR and CSDR showing inconsistencies. The Charge Nurse responsible was new and lacked adequate training. The facility's medication pass policy was not followed, leading to these deficiencies.
The facility failed to reconcile controlled medications, as the DNS stored unused substances in her office without conducting required audits. Since starting in August 2024, the DNS had not destroyed or reconciled any drugs, and the storage drawer was overflowing with medications. The facility's policy mandates regular audits to prevent drug diversion, but none were completed due to the DNS's workload.
The medication storage room on Wing 2 was found unsecured, with the door open and various medications and supplies accessible. A resident was observed in the hallway while the Charge Nurse was administering medication. The Nursing Supervisor confirmed the room should be closed, and the night shift Nursing Supervisor admitted to leaving it open. The DNS reiterated the policy that medication storage areas must be locked when not in use.
The facility failed to post accurate menus and announce changes, as observed during a lunch service where the meal served did not match the posted menu. Two residents reported that the menu was not followed and food often ran out. The head cook used improper utensils for portion control, and the dietician noted that this could affect nutritional intake. The facility's policy requires approved menus to be posted and changes announced, but the president/owner admitted the wrong menu was posted.
The facility lacked written policies and procedures for feedback, data collection, and monitoring, including adverse event monitoring. The President and DNS acknowledged this deficiency, noting reliance on an anonymous suggestion box and customer surveys, with concerns typically addressed in person. There was no formal tracking system unless a pattern was noticed, and issues were brought to the QAA committee, which met quarterly.
The facility failed to offer pneumococcal vaccines to two residents with severe cognitive impairment, as required by policy. Both residents' admission assessments indicated their vaccinations were not up to date, and reviews of their records showed no evidence of the vaccine being offered. The Infection Preventionist, new to the role, was unsure of the responsibility for offering the vaccine and could not locate the necessary consents.
A resident's advance directive indicating a preference for CPR was not accurately reflected in the physician's order, which stated a DNR status. Despite being alert and oriented, the resident's wishes were contradicted by a form signed by the responsible party. Facility staff failed to resolve this inconsistency, and the signed advance directive was not found in the designated location.
A resident experienced significant weight loss, but the facility failed to notify the dietician and physician as required. Despite physician's orders to monitor weight changes, the staff did not follow the protocol for reporting significant weight loss. Interviews revealed a lack of awareness and training among staff regarding the facility's weight loss policy.
A resident with severe cognitive impairment and multiple diagnoses was found with a bruise of unknown origin, which the facility failed to report to the state survey agency. The DNS believed the cause was known but lacked documentation or witness statements to support this. The facility's policy to investigate such injuries as potential abuse was not followed, and the incident was not properly documented or discussed.
A resident with severe cognitive impairment was found with a bruise below the left eye, but the facility failed to conduct a thorough investigation or report the incident to the state survey agency. Despite the DNS believing the cause was known, no documentation or witness statements were provided, violating the facility's abuse/neglect policy.
A facility failed to develop a comprehensive care plan for a resident on anticoagulant therapy, Eliquis, despite the resident's diagnoses of peripheral vascular disease and acute coronary thrombosis. The care plan did not address the anticoagulant use or its potential side effects, such as bruising and bleeding, as recommended by a pharmacy consultant. The facility's policy required daily updates to care plans, but this was not followed, resulting in a deficiency.
A facility failed to administer medications accurately for a resident with anxiety disorder, leading to incorrect dosages and missed doses of Lorazepam. Additionally, another resident with respiratory issues received incorrect oxygen flow rates, and lung assessments were not documented as required. These deficiencies were due to inadequate staff training and failure to follow physician's orders and facility policies.
A resident with dementia and risk for contractures did not have their splint applied as per physician's orders. Observations showed the resident without the splint during required times. Staff interviews revealed misunderstandings and lack of training on splint application, despite facility policy requiring clear orders and training.
A resident with multiple health conditions experienced significant weight loss, but the facility failed to ensure timely assessment by the dietician or physician. Despite orders for regular weight checks and notifications, the weight loss was not addressed, and staff interviews revealed a lack of clarity on the facility's weight loss policy.
A facility failed to ensure that a resident's medication regimen was appropriately managed. The resident, with diagnoses including long-term anticoagulant use, had pharmacy recommendations for monitoring that were not incorporated into their care plan. The MAR and TAR did not reflect these recommendations, and the DNS had not been receiving pharmacy recommendations since August. The facility's policy required documentation and communication of pharmacy recommendations, but this process was not followed.
A resident with atrial fibrillation and hypertension was prescribed Metoprolol Succinate ER, which should not be crushed. An LPN was observed crushing the medication before administration, contrary to the physician's order. The LPN admitted to this practice, realizing the error only after re-reading the medication packaging. The facility's policy requires adherence to the five rights of medication administration and a physician's order for any change in medication form.
A facility failed to offer a COVID-19 booster vaccine to a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's disease and dementia. The new Infection Preventionist was unsure of the responsibility for offering the vaccine and could not find the necessary consent documentation. Facility policy requires offering the vaccine unless contraindicated or already administered.
The facility did not provide monthly notifications to the state Regional Ombudsman's Office about resident transfers and discharges. A review showed 34 residents were transferred or discharged without proper reporting. A social worker acknowledged receiving training on this process but could not explain the lack of submissions. The facility also lacked a policy for notifying the Ombudsman.
The facility failed to label and date opened food items in the kitchen's dry storage area, including dry mashed potato flakes, cornstarch, peanut butter, granola, chocolate baking chips, and walnuts. Additionally, two squeeze bottles with a brown syrup-like substance were found without labels or dates. The Food Service Director, newly hired for almost three months, acknowledged the requirement for labeling but was unaware of the facility's specific policy. The facility's kitchen policy mandates proper labeling and dating of all food items.
The facility failed to document competencies for four nursing staff members, including two NAs, an LPN, and an RN, despite policy requirements for initial competency assessments upon employment. Personnel files lacked documentation, and interviews revealed that competencies were not retained, with the DNS unable to provide evidence of completed assessments.
The facility did not complete performance reviews for three nurse aides, as required by its policy. Personnel records lacked evaluations for 2024, 2023, and 2022. A business office staff member and the DON confirmed the absence of reviews, which should occur at the end of probation and annually.
The facility did not ensure that nurse aides received required annual in-service training, as personnel files for two aides lacked documentation of such training. Interviews revealed that training records were not maintained in employee files, and the Director of Nursing Services confirmed that annual in-service training had not been completed for the past year. The facility's policy requires annual in-service education to comply with regulations and best practices.
Failure to Update Care Card Leads to Resident Fall and Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to update the nurse aide care card to reflect a resident's current non-ambulatory status. The resident, who had diagnoses including unsteadiness on feet, polyneuropathy, atrial fibrillation, and cognitive communication deficit, was dependent on staff for transfers and toileting. Physician orders and therapy documentation indicated the resident was not functionally ambulatory and required assistance for transfers, but the care card did not specify the resident's ambulation status, leaving the section blank. The care card only listed a walker and wheelchair as assistive devices, without clarifying that the resident should not ambulate independently or with a walker. On the day of the incident, a nurse aide, assigned as the resident's caregiver, assisted the resident out of bed using a walker to ambulate to the bathroom. The aide did not use a gait belt and was unaware of the resident's non-ambulatory status, as the care card was not updated. During the transfer, the resident lost balance while reaching to turn on the bathroom light, causing the walker to topple and resulting in a fall. The resident sustained a traumatic subarachnoid hemorrhage, a right femoral neck fracture requiring surgery, and a right distal clavicle fracture. Interviews and documentation confirmed that the physical therapist had communicated the resident's non-ambulatory status to nursing staff and updated the physician orders, but the nurse aide care card was not revised accordingly. The Director of Nursing acknowledged that the care card failed to reflect the resident's ambulation status both before and after the change, contributing to the incident. Facility policy required care plans and care cards to accurately reflect residents' functional status, transfer methods, and ambulation ability, but this was not followed in this case.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
A resident with diagnoses including dementia, anxiety, and a history of alcohol abuse, who rarely or never made decisions regarding daily living, eloped from the facility and was subsequently sent to the hospital for evaluation and treatment. The facility failed to provide a bed hold notice to the resident or their conservator upon transfer to the hospital, and there was no documentation of a discharge summary in the clinical record. Additionally, the discharge notice provided to the resident was dated several weeks after the actual discharge date, and the notice was not issued to the resident, conservator, or ombudsman on the day of discharge as required. Interviews revealed that the hospital social worker received documentation from the conservator regarding a meeting with the facility to discuss a safe discharge plan, but later received a letter from the facility refusing to readmit the resident. The ombudsman confirmed that the facility did not follow the required consultative and involuntary discharge processes, failed to issue timely discharge notices, and did not allow the resident to return while an appeal was pending. The conservator reported not receiving or signing discharge paperwork and indicated that the resident's bed and belongings remained at the facility, with no bed hold notice issued. The facility administrator acknowledged not issuing the required notices at the appropriate time and not initiating the consultative process with the hospital. The administrator also confirmed that the discharge notice was backdated and only filed after being informed of the correct process by the ombudsman. The facility continued to refuse readmission of the resident during the appeal process, contrary to regulatory requirements and facility policy.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents at risk for elopement and those requiring assistance with transfers, resulting in multiple deficiencies. For one resident with dementia and severe cognitive impairment, the facility identified a risk for wandering but did not develop or implement a care plan or interventions to address this risk. When the resident was discovered missing, staff did not follow the facility's elopement policy, including failing to call a missing person code or notify the police and DON promptly. The resident was eventually found by police several miles away after walking along a dangerous road, but only after a significant delay in response. Another resident, identified as an elopement risk with Alzheimer's disease, was able to exit the facility through a Wanderguard-alarmed door that was not properly closed and latched. The door had a history of malfunctioning, and staff failed to ensure it was secured after use. As a result, the resident exited into the parking lot and sustained serious injuries, including head lacerations, a subdural hematoma, a subarachnoid hemorrhage, and a nondisplaced fracture, after falling. Interviews revealed ongoing issues with the door hardware, which had not been addressed by the facility owners despite repeated concerns from maintenance staff. A third resident, dependent on staff for transfers due to dementia and Parkinson's disease, was transferred by a single agency nurse aide without the required two-person assistance or use of a mechanical lift, contrary to physician orders and care plan directives. The aide did not check the assignment sheet or care card before performing the transfer and did not use a gait belt. The resident subsequently sustained a significant femur fracture, requiring transfer to a trauma center for surgical intervention. The investigation confirmed that the aide was unaware of the resident's transfer requirements and failed to follow established protocols.
Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with vascular dementia, psychosis, and major depressive disorder, who had significant cognitive impairment and required moderate assistance with transfers and ambulation, was involved in an incident in the dining room. The resident, who had been confused and argumentative, was observed sitting at a table before standing up with a fork in hand. A staff member, an LPN, approached the resident despite the resident's agitated state. The LPN and the resident exchanged words, and the LPN continued to walk towards the resident. Video surveillance and witness interviews indicated that the LPN made physical contact by pushing the resident, causing the resident to fall to the floor. As a result of the fall, the resident sustained fractures to the right distal radius and ulna, requiring medical intervention and hospitalization. Facility documentation and interviews confirmed that the LPN should not have engaged with the resident while agitated and should have avoided physical contact. The facility's abuse and neglect policy states that residents have the right to be free from abuse, including physical abuse by staff. The incident demonstrated a failure to protect the resident from physical abuse, as the staff member's actions directly resulted in harm to the resident.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that five sampled nurse aides received at least twelve hours of annual in-service training, as required by state and federal regulations. Review of the personnel files for these nurse aides showed no documentation of completed annual in-service training. Interviews with the DON and ADON revealed that the facility had been without a Staff Development Coordinator since the previous coordinator was terminated for not fulfilling job requirements, and that annual in-service training had not been conducted since at least December 2024. Additionally, the facility was unable to locate any in-service records from the past year. The facility's own policy requires all employees to complete annual in-service education, including job-specific training for nurse aides.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three out of five nurse aides reviewed. Specifically, one nurse aide's last documented performance review was in 2023, with no available documentation for the required 2024 review. Another nurse aide had an annual performance review from 2019 that was unsigned by both the employee and evaluator, with no subsequent reviews available. A third nurse aide had a performance review from 2021, also unsigned by both parties, and no documentation of later reviews could be found. Interviews with the DON and ADON confirmed that annual evaluations are required but acknowledged that they were unaware of the lapses due to the absence of Human Resources staff and could not provide a facility policy for nurse aide performance evaluations.
Delayed Provider Notification After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to promptly notify a provider of a resident's change in condition. The resident, who had diagnoses including dementia with behavioral disturbances, Parkinson's disease, and osteoarthritis, was dependent on staff for mobility and had a physician's order for transfer with a mechanical lift. During morning care, the resident complained of left leg pain and swelling, which was unusual for this individual. The nurse aide immediately reported these symptoms to the supervising RN, but the RN did not assess the resident until several hours later. Despite repeated notifications from the nurse aide regarding the resident's pain and swelling, the supervising RN delayed both assessment and provider notification. The resident's pain and swelling increased throughout the day, and it was not until the afternoon that the RN assessed the resident and noted significant symptoms, including a large bruise and deformity of the leg. The RN still did not notify the provider or administer pain medication until approximately eight hours after the initial complaint. Other staff, including an LPN and the DON, became involved later in the day when it was apparent the resident's condition was serious. The facility's fracture management policy required immediate stabilization and provider notification for suspected fractures, but this protocol was not followed. The delay in assessment and notification resulted in a significant delay in the resident being transferred to the hospital, where a periprosthetic femur fracture was diagnosed.
Failure to Complete Required Skin and Elopement Assessments
Penalty
Summary
The facility failed to complete required assessments for two residents in accordance with its own policies. For one resident with dementia, Parkinson's disease, and osteoarthritis, weekly skin audits were not documented for two consecutive weeks, despite facility policy requiring weekly monitoring and documentation in the electronic health record. The resident was dependent on staff for mobility and had a low BIMS score, indicating significant cognitive impairment. The Director of Nursing confirmed that weekly body audits are required for all residents and could not provide documentation for the missed weeks. For another resident with dementia and a history of restlessness and agitation, quarterly elopement risk assessments were not completed as required. The resident was identified as high risk for wandering, but the clinical record did not show that Wandering Risk Scale evaluations were performed during two required quarters. This resident was later reported missing, with staff discovering an open window and screen in the resident's room. The DON acknowledged that quarterly assessments for elopement risk are required and could not explain the missed evaluations. Facility policy directs that all residents be assessed for wandering risk on admission and quarterly, with appropriate interventions if risk is identified.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to review its infection control program policies and procedures annually for the years 2022, 2023, and 2024. The Infection Preventionist (IP) nurse, who started working at the facility on November 13, 2024, was unable to locate documentation confirming the annual review of these policies. The facility's Infection Prevention Program policy mandates that these policies be reviewed annually and signed off by the Medical Board. Additionally, the facility did not conduct monthly environmental rounds as per its practice, with the last documented round occurring in June 2024. The new IP nurse was unaware of the facility's policy regarding environmental rounds, and the Director of Nursing Services (DNS) acknowledged that these rounds were not conducted due to the absence of an IP nurse for a period of time. The facility also failed to adhere to its Water Management Plan Policy, which includes maintaining logs for various maintenance activities to prevent water-borne pathogens. The Director of Maintenance had no information or documentation regarding the water management plan and could not confirm if the facility had tested for legionella. The administrator reported that the previous maintenance director took all related documents, leaving the facility without records of completed maintenance or water testing. The facility's Water Management Plan Policy requires that sampling, management plans, and results be retained, emphasizing the facility's commitment to preventing water-borne contaminants.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address resident concerns and grievances as evidenced by a review of resident council meeting minutes and interviews. The minutes from August, September, and October 2024 did not document how concerns were addressed by the facility administration, nor did they include any follow-up on old business. Interviews with the Resident Council group revealed that concerns raised during meetings were not formally addressed or followed up on in subsequent meetings. The residents noted that they only became aware of any follow-up actions if they observed changes within the facility. The Recreation Director, responsible for facilitating the resident council meetings, admitted to not documenting resolutions to the concerns expressed by the group. Although concerns were discussed during morning meetings, there was no written or verbal communication back to the resident council to indicate that issues were addressed. The President/Owner also confirmed that while concerns were discussed, there was no documentation of the issues addressed or their resolutions. The facility's policy requires the Recreation Director to act as a liaison and ensure proper communication between the council and facility leadership, which was not adhered to in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain professional standards in medication administration for two residents. For one resident with a history of atrial fibrillation and on anticoagulant therapy, the facility did not administer Eliquis as ordered due to the medication being out of stock. The Licensed Practical Nurse (LPN) did not notify the physician about the missed dose, which could have led to alternative arrangements for medication. The medication was reordered on a routine basis rather than emergently, and the physician was not informed of the situation until later. Another resident, who was prescribed Lorazepam for anxiety, experienced multiple discrepancies in medication administration records. The Medication Administration Record (MAR) and the Controlled Substance Disposition Record (CSDR) showed inconsistencies in the administration and documentation of Lorazepam doses. The resident's MAR indicated doses were given, but the CSDR did not reflect these administrations accurately. The Charge Nurse responsible for these discrepancies was new to long-term care and had not received adequate orientation or competency training. Interviews with staff revealed a lack of communication and documentation regarding medication administration. The physician was not informed of the discrepancies in medication administration for the second resident until after the survey. The facility's medication pass policy requires immediate documentation and notification of any withheld or refused medications, which was not adhered to in these cases.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were periodically reconciled to prevent diversion. The Director of Nursing Services (DNS) admitted to storing returned and unused controlled substances in her office drawer, which had not been reconciled since the previous DNS left. The DNS, who started working at the facility in August 2024, had not destroyed or reconciled any controlled drugs. A folder containing Controlled Substance Disposition Records was found on her desk, with both yellow and white copies of the records that had not been matched. The storage drawer was observed to be overflowing with blister packets, patches, and bottles of liquid controlled substances, making it difficult to open. The DNS acknowledged that audits of controlled substances should be conducted monthly, but none had been completed since her employment began. She was unable to locate any audits conducted by the previous DNS. The facility's policy requires thorough documentation of all controlled substance transactions and mandates regular audits to prevent drug diversion. However, the DNS had not reconciled or destroyed the returned/unused controlled substances due to her workload. The facility's failure to adhere to its policy and procedure for controlled medications resulted in a deficiency related to the prevention of drug diversion.
Medication Storage Room Security Lapse
Penalty
Summary
The facility failed to ensure the security of the medication storage room on Wing 2, as observed on 11/17/24. The door to the medication room was found open more than 12 inches, exposing various unsecured items including over-the-counter medications, overflow prescription medications, and treatment supplies. Additionally, a filled sharps container was on the counter, and lower cabinets and drawers containing medical supplies were not secured. A functioning refrigerator without a securement device contained a locked box, a tuberculin vial, an unopened insulin vial, and other medications. During the observation, a resident was seen ambulating in the hallway while the Charge Nurse was administering medication from the medication cart. The Nursing Supervisor confirmed the medication room was left open and unsecured, acknowledging it should be kept closed. The night shift Nursing Supervisor admitted to leaving the door open after accessing the room earlier. The Director of Nursing Services (DNS) confirmed that the medication room should remain closed at all times, even when nurses are at the nursing station, as per the facility's Medication Storage policy, which mandates that all medication storage areas must be locked when not in use.
Failure to Post Accurate Menus and Ensure Portion Control
Penalty
Summary
The facility failed to post accurate menus and announce changes to the daily menu, as observed during a lunch service. The posted menu indicated garlic cheddar chicken, broccoli, pasta, and roll, but the meal served included pulled pork, noodles, carrots, and teriyaki chicken. No announcements were made regarding these changes, and the menu was not updated to reflect the substitutions. Additionally, the facility did not utilize measured serving utensils, which could affect portion control and nutritional intake. Two residents, one with chronic obstructive pulmonary disease and osteoporosis, and another with type 2 diabetes and dementia, reported that the menu was not being followed and that food often ran out before reaching their rooms. The head cook confirmed that the staff used slotted spoons and tongs instead of portion control utensils, and the president/owner acknowledged that menu changes were announced overhead but not posted. The dietician, who works part-time, indicated that the Maryland Diet Manual is used for dietary requirements, but the last menu review was in June. The facility's policy requires approved menus to be posted visibly and any changes to be announced or posted before meal service. However, the president/owner admitted that the wrong menu was posted and that the head cook orders food based on experience rather than precise measurements. The dietician noted that improper serving utensils could lead to meals not meeting the required calorie intake, potentially causing issues like weight loss. The facility's failure to adhere to its policies and ensure accurate menu postings and portion control led to the identified deficiencies.
Deficiency in Quality Improvement Processes
Penalty
Summary
The facility was found to have deficiencies in its quality and performance improvement processes due to the lack of written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. During an interview, the facility's President and Director of Nursing Services (DNS) acknowledged the absence of these written protocols. They noted that the facility relied on an anonymous suggestion box and customer surveys for feedback, and concerns were typically addressed in person due to the facility's small size. However, there was no formal system for tracking issues unless a pattern was observed. The DNS mentioned that any identified problems would be brought to the Quality Assessment and Assurance (QAA) committee, which met quarterly, but there was no structured approach to ongoing monitoring and documentation of quality deficiencies.
Failure to Offer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered and/or assessed for two residents, leading to a deficiency in immunization practices. Resident #33, who was admitted with diagnoses including Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies, was identified as having severe cognitive impairment. The admission MDS assessment indicated that Resident #33's pneumococcal vaccination was not up to date, and a review of the resident's immunization consents and records failed to show that the vaccine was offered. Similarly, Resident #35, admitted with major depression, dementia, and anxiety, also had severe cognitive impairment. The admission MDS assessment for Resident #35 similarly indicated that the pneumococcal vaccination was not up to date, and a review of the resident's records showed no evidence that the vaccine was offered. The Infection Preventionist, who had recently started in her position, was unsure of the responsibility for offering the vaccine and could not find the necessary consents for these residents. The facility's policy required that all residents be assessed for eligibility to receive the pneumococcal vaccine within 30 days of admission unless medically contraindicated or the vaccine series was already completed.
Discrepancy in Resident's Code Status and Advance Directive
Penalty
Summary
The facility failed to ensure that the physician's order accurately reflected a resident's chosen code status, leading to a discrepancy between the resident's advance directive and the physician's order. The resident, who was admitted with acute respiratory failure, congestive heart failure, and Alzheimer's disease, had a physician's order indicating a Do Not Resuscitate (DNR) status. However, an advance directive form signed by the resident indicated a preference for CPR. This inconsistency was not identified or resolved by the facility staff, leading to confusion about the resident's true wishes. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Medical Director, revealed that the resident was alert and oriented and should have been able to make decisions regarding their advance directive. Despite this, a form signed by the resident's responsible party contradicted the resident's wishes. The facility's policy required that all signed advance directives be kept in a code book and uploaded into the electronic chart, but the signed form for the resident was not found in the designated location. The Medical Director and Social Worker confirmed that the resident was capable of making their own decisions, and the discrepancy between the advance directive and the physician's order was not explained.
Failure to Notify Physician and Dietician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the dietician and physician regarding a significant weight loss for Resident #31, who had diagnoses including congestive heart failure, kidney disorder, depression, anxiety, and atrial fibrillation. Physician's orders required weight checks three times per week and notification for weight changes of 3 pounds or more. Despite a weight loss of 15.2 pounds on 10/3/24 and 19 pounds on 10/14/24, which constituted a significant weight loss, there was no documentation that the physician or dietician was informed. The resident's care plan included monitoring dietary intake and weight, but these measures were not effectively implemented. Interviews with facility staff revealed a lack of awareness and training regarding the policy for reporting significant weight loss. MD #1 and the DNS both acknowledged that the dietician and physician should have been notified. LPN #1 was unsure of the facility's policy and had not been trained on what constituted significant weight loss or when to report it. The facility's weight loss policy clearly stated the thresholds for significant weight loss and the requirement to notify relevant parties, but this protocol was not followed, leading to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with Parkinson's, dementia, and insomnia to the state survey agency. The resident was severely cognitively impaired, non-ambulatory, and required total assistance for various activities. A nurse's note documented a bruise below the resident's left eye, but the facility did not report this to the state survey agency, despite the bruise's unknown origin. The facility's documentation was incomplete, lacking signatures from the Administrator and DNS, and there was no evidence of an investigation or accident report. Interviews with the DNS and nursing staff revealed inconsistencies and a lack of documentation regarding the incident. The DNS believed the bruise's cause was known, but could not provide evidence or witness statements to support this. The facility's policy required that injuries of unknown origin be investigated as potential abuse, but this protocol was not followed. The DNS admitted to not having documentation to confirm the bruise's origin, and the incident was not discussed in the morning meeting as per usual practice.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for Resident #13, who was found with a bruise below the left eye. Resident #13, diagnosed with Parkinson's, dementia, and insomnia, was severely cognitively impaired and required total assistance for mobility and personal care. Despite the nurse's note documenting the bruise and notifying the appropriate parties, the facility did not complete the necessary investigation forms with signatures from the Administrator or DNS. Additionally, the incident was not documented in the 24-hour report, and the bruise was not reported to the state survey agency as required. Interviews with the DNS and nursing staff revealed a lack of clarity and documentation regarding the incident. The DNS initially believed the cause of the bruise was known and witnessed, but could not provide evidence or identify who witnessed the incident. The facility's policy on abuse/neglect requires that injuries of unknown origin be investigated and reported if the source is not observed, the resident cannot explain the occurrence, and the injury is suspicious. The DNS admitted to not having documentation to support the claim that the bruise was witnessed, and the necessary investigation and reporting procedures were not followed.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed an anticoagulant, Eliquis, for conditions including long-term use of anticoagulants, peripheral vascular disease, and acute coronary thrombosis. The physician's order required the administration of 5mg of Eliquis every 12 hours. Despite the resident being cognitively intact and requiring maximal assistance for mobility and personal care, the care plan did not address the use of the anticoagulant or the potential side effects and necessary precautions associated with its use. The care plan for the resident only identified risks related to cardiovascular status, such as elevated blood pressure and chest pain, without mentioning the anticoagulant therapy. A pharmacy consultant recommended monitoring for bruising, bleeding, and signs of thromboembolism, but the clinical record showed no evidence that these recommendations were addressed. The facility's policy required daily updates to care plans by any member of the interdisciplinary team, but this was not done in this case, leading to the deficiency.
Medication and Oxygen Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered accurately according to physician's orders for Resident #17, who was prescribed Lorazepam for anxiety disorder. The Controlled Substance Disposition Record and Medication Administration Record (MAR) revealed multiple instances where the incorrect dosage of Lorazepam was administered, or doses were missed entirely. The Charge Nurse and LPN involved did not follow proper procedures for documenting and administering the medication, leading to discrepancies in the records. The LPN admitted to being new to the facility and not receiving adequate orientation or competency training, which contributed to the medication errors. Additionally, the facility failed to follow physician's orders for Resident #26, who required continuous oxygen due to acute respiratory failure with hypoxia. Observations and interviews revealed that the oxygen was set at an incorrect flow rate of 3 liters instead of the prescribed 2 liters. Furthermore, there was a lack of documentation regarding lung assessments in the nursing notes, despite the resident's ongoing respiratory issues. The RN responsible for checking the oxygen admitted to not noticing the incorrect flow rate and only performing lung assessments when the resident showed signs of breathing difficulty. The deficiencies in medication administration and oxygen management highlight a lack of adherence to physician's orders and facility policies. The absence of proper documentation and failure to conduct necessary assessments contributed to the deficiencies observed in the care of both residents. These issues were compounded by inadequate training and orientation for the nursing staff, leading to errors in medication administration and monitoring of residents' conditions.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a resident's splint was applied according to the physician's orders. The resident, who had diagnoses including dementia and delusional disorders, was at risk for contractures in the left upper extremity. The care plan required the splint to be worn at all times except during activities of daily living (ADLs) and patient care. However, observations on multiple occasions revealed that the resident was without the splint during times it should have been applied, such as in the morning and during meals. Interviews with staff, including an LPN and a nurse aide, revealed a lack of understanding and training regarding the splint application. The LPN believed the splint was only to be worn at night, while the nurse aide had not received training on its application. The occupational therapist confirmed the splint was necessary to prevent further contractures and should be worn except during care and ADLs. The facility's splinting policy required clear physician orders and staff training, which were not adequately followed, leading to the deficiency.
Failure to Assess Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely assessment of significant weight loss for a resident with multiple health conditions, including congestive heart failure and depression. Physician's orders required weight checks three times a week and notification for weight changes of 3 pounds or more. Despite these orders, the resident experienced a significant weight loss of over 5 percent within a month, which was not assessed by the dietician or physician. The resident's care plan identified potential nutritional risks, but interventions such as dietician evaluation and monitoring intake were not effectively implemented. Interviews with facility staff revealed a lack of clarity and adherence to the facility's weight loss policy. The Medical Director and Director of Nursing acknowledged the dietician's responsibility to assess weight loss, but neither the dietician nor the physician was notified of the resident's significant weight loss. Additionally, the Licensed Practical Nurse was unaware of the policy for reporting weight loss and had not been trained on identifying significant weight loss. Attempts to interview the dietician were unsuccessful, and the facility's weight loss policy was not followed, leading to the deficiency.
Failure to Implement Pharmacy Recommendations for Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that medication reviews were provided to the provider and appropriate actions were taken for a resident. The resident had diagnoses including long-term use of anticoagulants, bipolar II disorder, and anxiety disorder. A medication regimen review conducted by the pharmacy consultant on October 4, 2024, recommended monitoring for bruising, bleeding, and signs of thromboembolism due to the resident's use of an anticoagulant. However, these recommendations were not incorporated into the resident's plan of care, nor was there any rationale documented for why the monitoring was deemed unnecessary. The medication administration record (MAR) and treatment administration record (TAR) for October 2024 did not reflect the pharmacy consultant's recommendations. Interviews revealed that the Director of Nursing Services (DNS) had not been receiving pharmacy recommendations since starting in August 2024, and previous recommendations could not be located. The facility had transitioned to a new pharmacy in November 2024, and discussions with the provider regarding the recommendations had only recently occurred. The facility's policy required that each pharmacy recommendation be documented in the resident's medical record and communicated to the attending physician and nursing team. The attending physician was responsible for reviewing the recommendation and deciding whether to implement it. If the physician disagreed with the recommendation, they were to document the rationale for not following the advice. However, in this case, the process was not followed, leading to a failure in ensuring the resident's medication regimen was appropriately managed.
Failure to Properly Administer Metoprolol Succinate ER
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Metoprolol Succinate ER. The resident, who had diagnoses including unspecified atrial fibrillation, dysphagia, and long-term use of anticoagulants, was prescribed Metoprolol Succinate ER 50mg twice a day for hypertension. The physician's order explicitly stated that the medication should not be crushed or chewed. However, during a medication administration observation, an LPN was identified as having crushed the Metoprolol Succinate ER before administering it to the resident. The LPN admitted to crushing the medication daily, realizing only after re-reading the blister pack that it was an extended-release medication. The physician confirmed that crushing the medication could be dangerous, as it would release the medication all at once instead of over time. The facility's medication pass policy emphasized the importance of following the five rights of medication administration and required a physician's order for any change in the form of medication. This incident highlights a significant deviation from the prescribed medication administration protocol, posing potential risks to the resident's health.
Failure to Offer COVID-19 Booster Vaccine to Resident
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered and/or assessed for a resident, leading to a deficiency. Resident #33, who was admitted with diagnoses including Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies, was identified as having severe cognitive impairment. Upon review of the resident's immunization consents and records, it was found that the COVID-19 booster vaccine was not offered to the resident. An interview with the Infection Preventionist (RN #1) revealed that she had recently started her position and was unsure of who was responsible for offering the vaccine when due. She also could not locate the consent for the resident's COVID-19 booster vaccine. The facility's policy indicated that residents should be offered the COVID-19 vaccine unless medically contraindicated or already immunized.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to provide evidence of monthly notification to the state Regional Ombudsman's Office regarding resident transfers and discharge status. A review of the facility's transfer and discharge summary report from May 1, 2024, through November 19, 2024, revealed that 34 residents were discharged or transferred during this period. However, the facility's documentation did not show that these transfers and discharges were reported to the Regional Ombudsman Office on a monthly basis. An interview with a social worker (SW #1) on November 19, 2024, indicated that she had received training on submitting these reports in September 2024 but could not explain why the reports were not submitted. The facility also failed to provide a policy regarding the submission of notices of transfers and discharges to the Regional Ombudsman's office.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure that food items were appropriately labeled and dated when opened, as observed during a survey. In the kitchen's dry storage area, several food items, including a large carton of dry mashed potato flakes, a box of cornstarch, a canister of peanut butter, and a cereal-like substance identified as granola, were found without labels or dates. Additionally, chocolate baking chips and walnuts were stored open without labels or dates, and four butterfly crackers were observed in small plastic cups covered with plastic wrap. Two squeeze bottles containing a brown syrup-like substance were also found without labels or dates. During an interview, the Food Service Director (FSD), who was newly hired almost three months ago, acknowledged that all food should be labeled when opened but was unable to state the facility's policy for labeling and dating foods. The facility's kitchen policy, dated 8/5/24, directed that all food be properly labeled and dated, and manufacturer's recommended use-by dates should be used for any products stored in the kitchen unopened.
Failure to Document Staff Competencies
Penalty
Summary
The facility failed to ensure that nursing staff competencies were completed for four of five sampled staff members, including two nurse aides (NA), one licensed practical nurse (LPN), and one registered nurse (RN). The personnel files for NA #4, NA #6, LPN #4, and RN #8 lacked documentation of completed competencies, despite the facility's policy requiring initial competency assessments upon employment. NA #4 was hired in November 2022, NA #6 in July 1980, LPN #4 in September 2024, and RN #8 in August 2024. Interviews with Business Office Staff #1 and the Director of Nursing Services (DNS) revealed that the competencies were not retained in the employee files, and the DNS could not provide documentation of completed competencies, although she mentioned conducting random observations. The facility's policy, effective November 19, 2024, mandates that all staff possess the necessary competencies to deliver high-quality, safe, and effective care to residents.
Failure to Complete Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure performance reviews were completed for three sampled nurse aides. Personnel records indicated that the nurse aides started their employment on various dates, but their files did not contain performance evaluations for the years 2024, 2023, or 2022. An interview with a business office staff member revealed that she was responsible for part of the employee file but did not retain training or competencies, which were to be completed by the nursing department. The Director of Nursing (DON) confirmed that performance reviews were not being completed and could not be located from before her tenure. The facility's Performance Review policy mandates that all new employees receive a performance review at the end of their probationary period and annually thereafter, unless otherwise required by regulations or contractual obligations.
Failure to Document Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required annual in-service training, as evidenced by the review of personnel files and interviews. Specifically, the personnel files of two nurse aides, one hired in November 2022 and the other in July 1980, lacked documentation of completed annual in-service training. Interviews with the Business Office Staff and the Director of Nursing Services (DNS) revealed that in-service training records were not maintained in employee files and had not been completed for the past year. Additionally, the DNS could not locate any in-service records from before her tenure. The facility's Training Policy mandates that all employees complete annual in-service education to comply with state and federal regulations and to stay updated with best practices.
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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