Complete Care At Glendale
Inspection history, citations, penalties and survey trends for this long-term care facility in Naugatuck, Connecticut.
- Location
- 4 Hazel Ave, Naugatuck, Connecticut 06770
- CMS Provider Number
- 075240
- Inspections on file
- 23
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Complete Care At Glendale during CMS and state inspections, most recent first.
A resident with a left humerus fracture, chronic kidney disease, and type 2 diabetes was discharged from the hospital with a left arm sling, but the facility did not obtain physician orders for the sling or include its use in the resident’s care plan or nurse aide care card. The resident was cognitively intact but dependent on staff for dressing and transfers, and the existing care plan only addressed self-care deficit and fall risk with one-person assistance for dressing, omitting any sling-related interventions. A complaint later alleged the resident was seen without the sling, and staff interviews revealed that while an LPN, NA, and COTA understood the sling was to be worn at all times and believed directions should have been reflected in orders and the RCP, the DON confirmed the facility failed to follow its care plan policy requiring inclusion of necessary services and treatments.
Unsafe food storage and incomplete kitchen monitoring records: A Dietary Director found dry goods stored with torn or open packaging, and fruit flies were observed in the dry storage area. Kitchen sanitizing buckets tested below the facility’s expected quaternary levels, while staff reported sanitizing solution testing and log use were not routine. Food temperature logs were incomplete and did not capture all meal types or required details, and nourishment refrigerator logs were missing temperatures, freezer readings, and staff initials.
Delayed Ombudsman Notification for Transfers and AMA Discharge: The facility did not timely notify the State LTC Ombudsman when a resident with epilepsy, TBI, and acute embolism was transferred to the hospital, when a resident with CHF, CKD, and bladder cancer had two hospitalizations, or when a resident with low back pain, DM, pneumonia, and gait abnormalities left AMA. The record also lacked timely nursing documentation of the AMA departure and notification of the resident representative, and the monthly discharge/transfer lists were submitted late.
A resident with dementia, PVD, and antiplatelet therapy developed an unexplained skin tear and later bruising/discoloration to the back, hip, thigh, and buttocks. Documentation did not include clear measurements, descriptions, or origin of the injuries, and although the care plan was updated to note the skin discoloration, it did not include interventions to prevent further injury. Staff noted the resident was confused, ambulated independently, and may have bumped into something, but no preventive measures were documented.
An LPN observed a resident with dysphagia and Parkinson’s disease coughing with a wet, congested cough and notified the provider, who ordered a chest x-ray that showed pneumonia. The record did not show a timely RN assessment after the change in condition, and ordered antibiotics were not given on time because staff reported difficulty finding supplies and the delay was not documented in the chart.
A resident with a reopened pressure injury did not receive a timely nutritional assessment after the wound was identified, and two residents had specialty mattresses set incorrectly instead of matching the MD orders. One resident admitted with a coccyx pressure injury also lacked a complete admission wound assessment with measurements and staging. Staff stated the charge nurse was responsible for checking mattress settings each shift, and the wound nurse and dietitian described routine wound-related monitoring that was not completed on time for the reopened wound.
Failure to supervise a resident at high aspiration risk during meals. A resident with Lewy body dementia, Parkinson’s disease, dysphagia, and severe swallowing impairment was ordered a puree diet with honey thick liquids and extensive feeding assistance, with staff directed to monitor for aspiration and stop intake if coughing occurred. However, the resident was observed alone with a lunch tray and drink placed within reach, a straw was left in the cup, and staff later confirmed the resident should not have been set up to self-feed. Interviews showed staff knew the resident was an aspiration risk, but the meal ticket did not identify that risk and the resident had been coughing during meals, with a subsequent CXR showing bilateral lower lobe pneumonia.
Pain Assessments Not Completed Before PRN Analgesic Use: A resident with chronic pain, migraines, and osteoarthritis had orders for pain monitoring every shift and pain evaluation for new or changed pain, but the record showed PRN tramadol was given multiple times without documented pre-administration pain assessments. The MAR repeatedly listed the resident as pain-free despite pain medication use, and nursing notes did not consistently identify pain location or a complete pain evaluation. Interviews with the resident, an LPN, and the DNS/RN showed the resident often requested migraine medication at night and that the chart lacked the expected pain rating and location documentation.
A resident with Parkinson's disease, HTN, and dementia had a pharmacy recommendation to consider switching Metoprolol Tartrate to Metoprolol Succinate, but the record did not show that the APRN or physician reviewed or addressed it. Staff could not locate documentation that the recommendation was given to the provider, and the DNS reported that some pharmacy recommendations were missing from the record; a later provided form showed the provider disagreed without a rationale.
Failure to document AMA discharge: A resident admitted with low back pain, DM, PNA, and gait abnormalities left the facility AMA, and although a voluntary discharge form and MD order were present, the nurse's notes did not document the AMA departure or notification of the resident representative. The DNS and Administrator confirmed the clinical record was missing the required documentation.
Hand hygiene was not performed in accordance with infection control practices during wound care for a resident with DM, AFib, severe cognitive impairment, and a recent MDRO urine history. An LPN handled the bed remote and wound supplies, then continued wound care without removing gloves or performing hand hygiene between dirty and clean tasks, and later removed gloves and donned new ones without hand hygiene; the IP/wound nurse and DNS stated hand hygiene should occur between tasks and after glove removal.
Kitchen Infestation and Inadequate Pest Control: Surveyors observed live fruit flies at the kitchen entryway, in dry storage near an open package of bread, and near the range hood, along with dead winged insects and food debris around the grease trap. The Dietary Director reported sanitation and debris concerns, and staff said fruit fly activity had been present for months, but no documentation was provided for pest control services related to the flying insects during the survey period.
A resident with moderate cognitive impairment and risk factors for malnutrition had a critical sodium lab result. While the physician and APRN were involved and new treatment orders were communicated to the family, there was no documentation that the family was specifically informed of the critical lab value, contrary to facility policy.
A resident with a history of hyponatremia experienced a critical drop in serum sodium. Although a provider ordered a follow-up BMP, delays and miscommunication in processing and notifying the lab resulted in the blood draw occurring much later than intended. The resident was later found unresponsive and required hospital transfer for severe electrolyte imbalances and acute respiratory failure.
The facility failed to maintain nourishment refrigerators in a clean and sanitary manner, with various unlabeled, undated, and expired food items found during an inspection. The Director of Dietary acknowledged the responsibility for cleanliness and adherence to labeling policies, but multiple violations were observed.
The facility failed to conduct a required background check for an LPN hired, as the personnel file lacked the state-required ABCMS background check, including fingerprinting. The Director of HR confirmed the oversight during an interview.
The facility failed to submit a PASSAR when a resident received a new diagnosis. The resident was initially admitted with mild or situational depression and later diagnosed with dementia, anxiety disorder, and other conditions. The oversight was acknowledged by the MDS Coordinator and social worker, who admitted that a new PASSAR should have been completed but was missed.
The facility failed to complete a required status change Level 1 PASRR screen for a resident with major depressive disorder and other diagnoses, despite continued behavioral health symptoms and recommendations for reevaluation. Interviews confirmed the oversight, and the facility's policy was not followed.
A resident with muscle weakness and dementia was found self-propelling in a wheelchair without leg rests, causing discomfort due to a new, higher cushion. Staff interviews confirmed the absence of leg rests and lack of communication about their unavailability, contrary to facility policy.
The facility failed to timely apply a low air loss mattress for a high-risk resident and did not complete an RN assessment on a newly identified skin issue. Despite a physician's order, the mattress was delayed, and the new pressure injury was not assessed by an RN within the required timeframe.
The facility failed to follow manufacturer recommendations for cleaning and storing a CPAP machine for a resident with obstructive sleep apnea. The CPAP mask was found unbagged and undated, and the resident reported that the mask and tubing had never been changed since admission. The DNS was unable to provide clear answers on the frequency of changing and cleaning the CPAP components, leading to the deficiency.
The facility failed to have physicians' orders signed in a timely manner for a resident with multiple diagnoses, including obstructive sleep apnea and epilepsy. Despite the facility's policy requiring timely signatures, the orders were not signed for several months, and staff interviews confirmed the oversight.
The facility failed to ensure that the attending physician reviewed and responded to the pharmacy consultant's recommendations for a resident with heart failure and atrial fibrillation. Despite repeated recommendations to evaluate the resident's Amiodarone dosage, there was no documented follow-up or action taken by the cardiologist or facility staff, indicating a lapse in communication and adherence to policy.
The facility failed to monitor medication refrigerator temperatures as per policy, with multiple instances of missing or incomplete temperature recordings over three months. An RN responsible for the logs was unsure of the requirements, and the facility policy was not followed.
A resident with a sacral pressure ulcer did not receive proper infection control and hand hygiene during a dressing change. The LPN placed dressing supplies on an unclean dresser, used unclean bandage scissors, and failed to perform hand hygiene after glove changes. The RN identified these actions as deviations from the facility's policies, which require a clean field, proper hand hygiene, and the use of clean instruments.
Failure to Care Plan and Obtain Orders for Required Arm Sling After Humerus Fracture
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan and corresponding physician orders for a resident who required a left arm sling following a humerus fracture. The resident’s diagnoses included a left humerus fracture, chronic kidney disease, and type 2 diabetes. Hospital discharge documents dated 11/21/25 indicated the resident was fitted with a left arm sling due to the fracture. However, review of physician orders from 11/21/25 through 12/2/25 showed no order for a left arm sling. A five-day MDS assessment identified the resident as cognitively intact with a BIMS score of 13 and dependent on staff for dressing and transfers. The Resident Care Plan dated 11/27/25 documented a self-care deficit and fall risk with an intervention for one-person assistance with dressing, but it did not include the use of a sling or interventions specific to the left arm fracture. The nurse aide care card also lacked instructions that the resident was to wear a left arm sling at all times. A complaint filed on 1/2/26 reported that during a visit on 12/3/25, the resident was observed without the sling. In interviews, an LPN recalled that the resident had a sling that was to be worn all the time and stated that directions for sling use should have been on the physician’s order or the care plan. A nurse aide reported that the resident wore the sling all the time except when being changed, and that she learned sling directions from the therapist and believed they were on the care card, while also noting the sling sometimes came off with the resident’s independent movement. The COTA stated she was informed of sling orders by the OT and that such orders should have appeared on the physician’s orders, care plan, and care card. The DON acknowledged that directions for sling use should have been on the physician’s orders or the care plan and that the facility failed to follow its Care Plan Policy, which requires care plans to include instructions and services/treatments needed to provide effective, person-centered care.
Unsafe food storage and incomplete kitchen temperature and sanitizing logs
Penalty
Summary
The facility failed to ensure dry storage items were stored under sanitary conditions. During an initial kitchen tour with the Dietary Director, a large prepackaged bag of corn flake type cereal was found with no label or date and with a large tear that left the cereal exposed to the air. A box of powdered liquid thickener was also observed fully opened at the top and placed in an open, nonsealable plastic bag. On a later observation, an open package of white sliced bread was found in the dry storage area, and two live flying insects that appeared to be fruit flies were seen in that area. The Dietary Director stated that dry food items should be stored securely with closed packaging. The facility also failed to ensure the sanitizing solution used in the kitchen was monitored at appropriate levels. Two of three red sanitizing buckets tested at 150 PPM, and the Dietary Director stated that the quaternary solution used by the facility should have been tested between 200 and 400 PPM. The Dietary Director reported he had only started working at the facility two weeks earlier and had identified issues with the kitchen, sanitization, and debris around the grease trap. He later stated he was unable to provide documentation or instructions related to the sanitizing solution issues and that the facility had not used any system to track or document the sanitizing solution used throughout the kitchen. Dietary staff also stated that kitchen staff did not routinely test the sanitizing solution or track test strip results, and that prior log sheets had been used only sporadically before they eventually stopped being used. The facility further failed to ensure food temperatures were monitored and logged for every meal, and failed to ensure nourishment refrigerator temperatures were checked and logged daily. Review of the food temperature logs showed forms that did not include cold items, did not identify the time or specific meal the temperatures were taken for, and did not identify the staff who recorded them. The Dietary Director stated he could not locate any prior food temperature logs for 2025. Review of nourishment refrigerator logs showed missing temperature documentation for multiple dates in December, and the Dietary Director stated he could not locate any additional nourishment refrigerator cleaning or temperature logs for other months in 2025. The logs posted for the nourishment refrigerators also did not document freezer temperatures and did not identify the staff who completed the checks.
Delayed Ombudsman Notification for Hospital Transfers and AMA Discharge
Penalty
Summary
The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified in a timely manner when residents were transferred to the hospital and when one resident left against medical advice (AMA). For Resident #7, who was admitted with diagnoses including epilepsy, traumatic brain injury, and acute embolism, the record showed the resident was transferred to the hospital on 6/3/25 and later readmitted to the facility on 6/9/25. Facility documentation showed the routine monthly resident transfers for June 2025 were not sent to the Ombudsman until 10/2/25, and the action summary report did not reflect the hospital transfer or Ombudsman notification. For Resident #117, who was admitted with diagnoses including CHF, stage 5 chronic kidney disease, and bladder cancer, the 5-day MDS identified intact cognition. The clinical record showed the resident was transferred to the hospital on 6/22/25 and returned on 6/26/25, then transferred again on 6/29/25 and returned on 7/5/25. Facility documentation showed the Ombudsman was not notified of either hospitalization until 10/2/25, and the Business Office Manager stated there was confusion about the process and that the hospitalizations were reported through the portal on that date. For Resident #119, who was admitted with diagnoses including low back pain, diabetes, pneumonia, and abnormalities of gait and mobility, the census form showed the resident left the facility AMA on 8/31/25. The voluntary discharge against medical advice form showed the resident signed at 5:30 PM and an LPN witnessed the signature, but the nurse's notes did not reflect that the resident left AMA or that the resident representative was notified. The action summary report later identified the AMA discharge, but the Ombudsman notification was not documented as timely, and the monthly discharge notifications for August 2025 were not sent until 10/2/25.
Care plan not revised with preventive interventions after unexplained injury
Penalty
Summary
The facility failed to revise the care plan with interventions to reduce future injury after a resident sustained an injury of unknown origin. Resident #1 was admitted with diagnoses including atherosclerosis of the native arteries, peripheral vascular disease, and dementia. The annual MDS identified the resident as moderately cognitively impaired, independent with bed mobility, and requiring one-person assistance with transfers, toileting, and locomotion using a wheelchair/walker. The existing care plan identified impaired cognition, independence with transfers and ambulation with a walker, antiplatelet therapy, and risk for skin breakdown, with interventions to cue and supervise as needed, monitor for adverse reactions to antiplatelet therapy, and observe skin for signs of breakdown. The resident sustained a skin tear to the right shin, followed later by an area of discoloration to the lower right back and right outer thigh/right hip and buttocks. The documentation for these injuries did not include a measurement, detailed description, or clear origin of the injuries. The resident was described as alert and confused, ambulating independently, and reporting that he/she probably bumped into something, while staff also noted the resident denied pain, known injury, or mistreatment. The resident was receiving prescribed medication that may have contributed to bruising and had dementia with poor safety awareness. Although the incident was reviewed and the care plan was updated to reflect the skin discoloration, the revised plan did not include interventions to prevent further injury. Facility staff and the interdisciplinary team acknowledged that the resident had repeated skin findings and that the care plan update did not contain preventative measures. The facility policy required the interdisciplinary team to discuss the resident’s condition and document new or modified interventions when a status change occurred, and the abuse policy identified bruises and injuries of unknown source as possible indicators of abuse.
Delayed RN Assessment and Antibiotic Administration After Respiratory Decline
Penalty
Summary
The facility failed to ensure an RN assessment was completed timely after a resident’s change in respiratory condition and failed to ensure antibiotics were administered timely after pneumonia was identified. The resident had been admitted with diagnoses including metabolic encephalopathy, neurocognitive disorder with Lewy Bodies, type 2 diabetes mellitus, Parkinson’s disease, and dysphagia. The resident’s orders included a puree diet with honey-thick liquids, and the care plan and aide kardex directed staff to monitor for aspiration signs such as coughing, choking, and moist-sounding voice. On 1/11/26, the resident was observed coughing with a wet-sounding cough while in bed and later had a consistent wet cough during lunch. An LPN documented that the resident was coughing especially after eating or drinking, had a congested cough and rhonchi, and notified the provider, who ordered a chest x-ray and supportive treatments. The clinical record did not identify an RN assessment after the resident’s respiratory status changed, and interviews with the RN supervisor, infection control nurse, DNS, and regional nurse resource did not identify that an RN assessment had been completed after the change in condition. The chest x-ray showed modest bilateral lower lobe pneumonia. The provider initially ordered Cefpodoxime Proxetil, but the MAR did not show it was administered. A later order for IV Ceftriaxone was entered, and a peripheral IV was placed, but the MAR did not show the antibiotic was given at the scheduled time. Staff interviews indicated the medication was delayed because the overnight nurse could not find saline to reconstitute the medication, and the RN supervisor accepted that explanation. The first dose was not administered until later the next morning, after the delay was identified.
Pressure ulcer assessment, nutrition follow-up, and specialty mattress setting failures
Penalty
Summary
The facility failed to complete a nutritional assessment in a timely manner for a resident with a newly reopened pressure injury. Resident #12, who had diagnoses including type II diabetes and atrial fibrillation and was documented as severely cognitively impaired, dependent for toileting, and at risk for pressure injury, had a previously resolved stage II pressure injury to the left buttock. On 12/30/25, a wound consult identified a newly reopened unstageable pressure wound on the left buttock measuring 5 cm x 4.5 cm x 3 cm with 100% eschar, and the wound was debrided with new daily treatments started. A wound tracking report that same day did not include the newly identified pressure ulcer. The record showed the wound was discussed in morning report and at a risk management meeting on 12/31/25, and RN #3 stated she was present when the wound was identified during rounds on 12/30/25 and when it was discussed in morning report and risk management. Dietitian #1 stated she routinely monitored residents with wounds and completed nutritional assessments for newly identified or recurrent wounds, but she did not assess Resident #12 before 1/12/26 and would typically review a wound within one month of identification. The dietary progress note completed on 1/12/26, twelve days after discovery of the reopened wound, documented the resident was being evaluated for the pressure wound and recommended Pro-stat AWC daily to promote wound healing. The facility also failed to ensure specialty mattress settings matched physician orders for two residents. Resident #60, who had Parkinson’s disease, difficulty walking, spinal stenosis, and adult failure to thrive, had a physician’s order for a low air loss mattress set to 160 lbs., but observation showed the mattress was set to 400 lbs. RN #6 adjusted it to 160 lbs. Resident #121, admitted with metabolic encephalopathy, Lewy body neurocognitive disorder, chronic systolic heart failure, and type 2 diabetes, had a coccyx pressure injury documented on admission assessment without measurements or staging. The admission record failed to include a comprehensive wound assessment, and later observation showed the specialty mattress was set to 350 lbs. despite the order and sticker indicating a lower setting; RN #6 adjusted it to 130 lbs. The wound nurse and other staff stated the charge nurse was responsible for checking mattress settings each shift, and the facility policy required wound assessments on admission and documentation of wound type, stage, measurements, and characteristics.
Failure to Supervise a Resident at High Aspiration Risk During Meals
Penalty
Summary
The facility failed to ensure that a resident at risk for aspiration was supervised during a meal. Resident #121 had multiple diagnoses including metabolic encephalopathy, neurocognitive disorder with Lewy Bodies, Parkinson’s disease, dysphagia, chronic systolic heart failure, and type 2 diabetes mellitus. A bedside swallow evaluation and subsequent SLP assessment identified moderate oral and severe pharyngeal dysphagia, dependence for feeding, delayed and absent swallows, wet cough with puree and thickened liquids, and high aspiration risk across consistencies. The resident was ordered a puree diet with honey thick liquids and was documented as requiring extensive assistance with self-feeding and monitoring for aspiration signs. The care plan and nurse aide kardex directed staff to provide modified diet and liquids, encourage small bites and sips, monitor for aspiration signs, and stop food or liquids if coughing occurred. Despite these directions, observation on 1/12/26 found the resident alone in the room with a lunch tray and cranberry juice placed in front of him/her, with a straw containing residual red fluid hanging from the mouth. A nurse aide later stated that the juice had been thickened and the straw was left in the cup accidentally. An LPN confirmed the resident should not have had the tray and drink placed within reach and stated the resident was not able to self-feed and required feeding assistance. Additional interviews showed that staff understood the resident was an aspiration risk and that staff were expected to remain in the room during meals, yet the resident had previously been set up for breakfast without supervision because staff believed he/she could feed him/herself. The meal ticket did not identify the resident as being at risk for aspiration. The resident had also been noted coughing during meals, and after a change in condition note documented coughing after eating or drinking, congested cough, rhonchi, and a chest x-ray showed bilateral lower lobe pneumonia. Facility policy required adequate supervision during meals and individualized care planning, but the resident was observed receiving a meal without the required supervision.
Pain Assessments Not Completed Before PRN Analgesic Use
Penalty
Summary
The facility failed to ensure pain assessments were completed per the physician’s order for a resident with a history of headache, polyosteoarthritis, chronic pain, schizoaffective disorder, borderline personality disorder, repeated falls, migraines, bilateral shoulder osteoarthritis, neuropathy, neuritis, and lower back pain. The resident had orders for pain monitoring every shift and for pain evaluation if there was new or changed pain, along with PRN pain medications including acetaminophen and tramadol. The care plan identified the resident as at risk for altered comfort and directed staff to complete pain assessments per protocol, use the pain scale, and monitor for non-verbal signs and symptoms of pain. Review of the MAR showed the resident was documented as free of pain on all shifts in December 2025 and early January 2026, even though tramadol was administered multiple times for pain. The MAR entries documented pain levels as “X” on several occasions, but the clinical record did not identify a numeric pain score. Nurse’s notes for the month did not identify the location of pain when pain medication was given, except for one note on 12/14/25 when the resident bumped his/her head against a chair and reported a pain level of 3. The notes also did not show that pain evaluations were completed before tramadol administration. During interview, the resident stated he/she gets migraines, especially at night, and usually requests a medication around 8:30 PM for the migraine, but the nurse does not always bring it. An LPN stated the resident had migraines and leg pain and that when she administered pain medication she would complete a pain evaluation including pain rating, location, quality, description, and whether the pain was new or chronic. The DNS and RN #8 reviewed the record and could not identify pain evaluations completed prior to tramadol administration; RN #8 stated the record only showed the tramadol was effective afterward and that he expected a pain scale rating and location of pain. He also stated he updated the eMAR to trigger entry of a numerical pain scale value when tramadol was administered.
Pharmacy recommendation not documented as reviewed by provider
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation was reviewed and addressed by the APRN or physician for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses including Parkinson's disease, hypertension, and dementia, and the quarterly MDS identified severely impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and the need for staff supervision with toileting, bathing, and dressing. The care plan addressed altered cardiovascular status related to hypertension and included administering cardiac medications as ordered, and a physician's order directed Metoprolol Tartrate 37.5 mg once daily. A pharmacy recommendation form identified a recommendation to consider switching Metoprolol Tartrate to Metoprolol Succinate, but the form did not identify any physician or prescriber response. Review of the clinical record found no documentation that the recommendation was reviewed or addressed by the resident's APRN or physician. The Regional Director of Resource Nurses was unable to locate documentation showing the recommendation had been given to and reviewed by the provider, and the DNS stated that pharmacy recommendations were emailed to the DNS and unit managers, then printed for the APRN and returned signed and completed for filing, although she could not locate some of them and did not quantify how many were missing. After surveyor inquiry, the facility provided two undated signed pharmacy recommendation forms, and the 5/23/25 form showed the provider disagreed with the recommendation without a rationale.
Failure to Document AMA Discharge
Penalty
Summary
The facility failed to ensure nursing staff documented when Resident #119 left the facility against medical advice (AMA). Resident #119 was admitted with diagnoses including low back pain, diabetes, pneumonia, and abnormalities of gait and mobility. The record showed the resident arrived alert and oriented, with weakness and pain to the lower back radiating to the left leg, denied shortness of breath and difficulty breathing, had no edema to the bilateral lower extremities, and was receiving Levofloxacin 500 mg every 48 hours for 5 days. The census form identified that Resident #119 left the facility AMA, and a voluntary discharge against medical advice form showed the resident signed at 5:30 PM with LPN #4 as witness, along with a physician order to discharge AMA with medications. However, the nurse's notes from 5:14 PM through 1:25 AM did not document that the resident left AMA, and the record also lacked documentation that the resident representative was notified. The Administrator, DNS, and Director of Social Service each confirmed during interview that the clinical record failed to reflect the AMA discharge and that nursing staff should have documented it.
Hand Hygiene Not Performed During Wound Care
Penalty
Summary
The facility failed to ensure hand hygiene was performed in accordance with infection control practices during wound care for Resident #12. Resident #12 was admitted with diagnoses including Type II diabetes, atrial fibrillation, and a recent MDRO of the urine. The quarterly MDS identified the resident as severely cognitively impaired, requiring one person assist for bed mobility and transfers, dependent for toileting needs, with no unhealed pressure ulcers and at risk for developing a pressure ulcer. The care plan noted ADL deficit, actual MASD, and enhanced barrier precautions after completing treatment for a multidrug resistant organism in the urine, with interventions including dependent two-person assist for bed mobility and transfers and weekly wound assessments. During observation of wound care, an LPN was at the bedside wearing gloves and a gown while setting up wound supplies and barrier materials. The nurse used one gloved hand to operate the bed remote and then, without removing gloves, performing hand hygiene, or donning a new pair of gloves, used the same hand to begin wound care after handling the remote and supplies. After cleansing the wound, the nurse removed both gloves and donned a new pair without first performing hand hygiene, then opened a skin barrier and reached for the peri-wound area before the task was interrupted. The LPN stated she should have removed gloves, performed hand hygiene, and put on new gloves between tasks but did not do so because she was nervous. The infection preventionist/wound nurse and the DNS both stated hand hygiene should be performed between dirty and clean tasks and between removing and replacing gloves.
Kitchen Infestation and Inadequate Pest Control
Penalty
Summary
The facility failed to ensure that the kitchen was free of flying insects. During an initial tour of the kitchen with the Dietary Director, surveyors observed 2 live flying insects at the interior entryway of the kitchen area that appeared to be fruit flies. In the same area, the grease trap had a significant amount of food debris and multiple dead winged insects on top of it, in the gap between the wall and the grease trap, and along the wall surface next to the grease trap. The Dietary Director stated he had started working at the facility 2 weeks earlier and had identified issues with the kitchen, sanitization, and debris around the grease trap, but had not noticed active pest activity during that time. On a later observation, an open package of white sliced bread was found in the dry storage area, and 2 live flying insects that appeared to be fruit flies were seen in that area. The Dietary Director stated that dry food items should be stored securely with closed packaging. Additional observations identified 3 live flying insects near the range hood, and staff interviews indicated there had been fruit fly activity in the kitchen for several months, with heavier activity in the summer months and continued presence throughout the kitchen area. Facility pest control reports showed treatment for crawling insects on prior dates, but no documentation was provided for pest control services related to the flying insects during the survey period.
Failure to Notify Family of Critical Lab Value
Penalty
Summary
The facility failed to notify the family member of a resident regarding a critical lab value. The resident, who was moderately cognitively impaired and at risk for malnutrition due to hyponatremia and other medical conditions, had a critical serum sodium level of 99 identified in lab results. Although nursing notes documented that the resident was seen by a physician and an APRN, and that new orders were communicated to the family member, there was no documentation that the family member was specifically informed of the critical sodium level. Subsequent nursing notes indicated the initiation of intravenous hydration and further lab testing, with continued documentation that the family member was aware of new orders. However, at no point did the records show that the family member was notified of the critical lab value itself, as required by the facility's Notification of Changes policy. This omission constituted a failure to promptly inform the resident's representative of a significant change in the resident's condition.
Failure to Ensure Timely Follow-Up Labs for Critical Sodium Levels
Penalty
Summary
The facility failed to ensure timely follow-up laboratory testing for a resident with a history of hyponatremia and other medical conditions following a critical lab result. The resident, who was moderately cognitively impaired and at risk for malnutrition, was discharged from the hospital with improved sodium levels but later had a critical serum sodium level of 99 identified in the facility. Although a provider ordered a Basic Metabolic Panel (BMP) to be drawn the following day, the order was canceled and replaced with a STAT order later that morning after it was discovered the initial lab had not been drawn. The STAT order was not entered into the lab portal until one hour and thirty minutes after being written, and the required notification to the lab service provider was not documented. The blood draw did not occur until late that evening, and the results again showed a critical sodium level. Interviews with facility staff revealed a lack of communication and understanding regarding the urgency and process for STAT lab orders, especially on non-routine lab days. The Director of Nursing acknowledged the facility's failure to process the initial BMP order, and the lab service provider confirmed that STAT orders required both entry into the portal and direct notification. The resident was ultimately found unarousable and transferred to the hospital with multiple critical diagnoses, including severe electrolyte imbalances and acute respiratory failure.
Failure to Maintain Clean and Sanitary Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain nourishment refrigerators in a clean and sanitary manner, as observed during a tour with the Director of Dietary. The inspection revealed various issues, including dried liquid and splatter marks inside the refrigerators, partially eaten and unlabeled food items, and expired food. Specific items found included minestrone soup, sausage cubes, cheese cubes, a chicken sandwich, a peanut butter and jelly sandwich, brown pudding, applesauce, a small round cheesecake, cheese sticks, and tangerines, all of which were either not labeled, not dated, or expired. Additionally, the second nourishment refrigerator had crumbs, liquid spots, a torn freezer seal, and various unlabeled and undated items such as a frozen yogurt, a metal water bottle, a red liquid in an Arizona bottle, a half-eaten ice cream caramel cookie crunch, a pitcher of liquid, a sandwich, and soup in a bowl with a lid. The Director of Dietary indicated that it was the responsibility of the kitchen and housekeeping to keep the nourishment refrigerators and freezers clean. She usually cleaned them daily but was off on Friday, Saturday, and Sunday, during which time the cook was responsible. The Director of Dietary acknowledged that all items in the nourishment refrigerator should be discarded after three days and that all staff and visitors were aware of the labeling and dating requirements. Despite this, the inspection found multiple violations of the facility's policy on maintaining and labeling food items in the nourishment refrigerators, leading to the identified deficiencies.
Failure to Conduct Required Background Check for LPN
Penalty
Summary
The facility failed to conduct a required background check for one of five personnel files reviewed. Specifically, an LPN hired on 1/17/22 consented to a background check on 1/6/22, but the personnel file did not contain the state-required ABCMS background check, including fingerprinting. During an interview on 1/26/24, the Director of HR acknowledged that the required background check was not completed prior to the LPN's hire and was unable to provide a reason for this oversight, as it occurred before her employment at the facility. The facility's policy mandates that all employment offers are contingent upon clear results from a thorough background check, including state-specific requirements.
Failure to Update PASSAR for New Diagnosis
Penalty
Summary
The facility failed to submit a Pre-Admission Screening and Resident Review (PASSAR) when a resident received a new diagnosis. Resident #40 was initially admitted with diagnoses including mild or situational depression, myocardial infarction, and urinary tract infection. A PASSAR Level 1 assessment identified mild or situational depression with no major mental illness or dementia, granting a 120-day short-term approval. Upon readmission, Resident #40 had new diagnoses including anxiety disorder, congestive heart disease, depression, and cerebral infarction. The care plan and annual MDS indicated severely impaired cognition, dementia, anxiety disorder, depression, and psychotic disorder, with the resident receiving antidepressants daily. However, the social worker's annual assessment did not consider the resident for a Level 2 PASSAR process for serious mental illness or intellectual disability. Interviews revealed that the MDS Coordinator and social worker acknowledged the oversight. The MDS Coordinator noted that the resident was admitted without a dementia diagnosis, which was later identified in October 2022. The social worker admitted that a new PASSAR should have been completed when the new diagnosis was identified but was missed. The oversight was not caught during an audit by a previous social worker. The current social worker submitted a new PASSAR only after the surveyor's request, which resulted in a Level 1 exemption due to the new dementia diagnosis. The facility's policy mandates that social services ensure appropriate pre-admission screening and updates for mental illness and intellectual disability, which was not adhered to in this case.
Failure to Complete Required PASRR Screening
Penalty
Summary
The facility failed to ensure a status change Level 1 PASRR screen was completed for Resident #83, who was admitted with diagnoses including neoplasm of the brain, anxiety, and major depressive disorder. The initial PASRR Level 1 Outcome report indicated that if Resident #83's symptoms did not improve within 30-60 days, an updated status change Level 1 screen should be submitted. Despite this recommendation, no updated screen was submitted even though Resident #83 continued to exhibit behavioral health symptoms and was on antidepressant medication as noted in the care plan and annual MDS. Interviews with the social workers confirmed that four Level of Care evaluations had been completed since admission, but the required updated PASRR screen was not submitted. The facility's policy directs staff to ensure appropriate pre-admission screening for mental illness and/or intellectual/developmental disability, but this was not followed in Resident #83's case. The Director of Social Services acknowledged the oversight and indicated that an audit would be conducted to ensure no other residents had missed screenings or evaluations.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to ensure proper positioning in a wheelchair for Resident #74, who was admitted with diagnoses including muscle weakness, difficulty in walking, and dementia. The resident was identified as a fall risk and dependent on staff for footwear. An occupational therapy note indicated the resident could sit unsupported for 30 seconds but was unable to stand unsupported. A physician's order directed the use of a pressure redistribution cushion, and the care plan included applying pressure redistribution surfaces to the chair. However, observations revealed that the resident was self-propelling in a standard wheelchair without leg rests, causing discomfort as the resident's legs were dangling above the floor due to the new cushion's height. Interviews with staff confirmed the absence of leg rests and the lack of communication regarding their unavailability. The Director of the Rehabilitation Department acknowledged the issue, noting that the new cushion was higher than the previous one, causing the resident's feet to be 4 inches from the floor. The resident expressed discomfort and requested leg rests. Despite the resident's inability to self-propel with their legs, the wheelchair lacked leg rests, contrary to the facility's policy. The staff development nurse confirmed that nursing staff are educated on the requirement for leg rests if a resident cannot self-propel with their legs. Further interviews and observations confirmed that the resident was later provided with a smaller cushion and leg rests, improving comfort. The facility's policy on wheelchair use emphasized the importance of proper sizing and the use of leg rests for non-ambulatory residents. The deficiency was identified due to the failure to adhere to this policy, resulting in the resident's discomfort and potential risk for further complications.
Failure to Timely Apply Low Air Loss Mattress and Complete RN Assessment
Penalty
Summary
The facility failed to ensure timely application of a low air loss mattress for a resident at high risk of skin breakdown and did not complete an RN assessment on a newly identified skin issue. Resident #29, who was admitted with a wound vac for a right hip abscess, had a high risk of developing pressure ulcers as identified by the Braden Scale. Despite a physician's order on 12/5/23 to apply a low air loss mattress, the mattress was not placed until 12 days after admission. Additionally, a newly identified sacral pressure injury on 12/17/23 was not assessed by an RN until 12/19/23, contrary to facility policy requiring RN assessment within 24 hours of a new skin issue being identified by an LPN. Interviews with facility staff revealed confusion and lack of documentation regarding the placement and settings of the low air loss mattress. LPN #2 and RN #3 were unsure about the exact timing and documentation of the mattress placement. The facility's system did not have a record of the mattress request, and the Regional Clinical Manager could not determine when it was applied. Furthermore, the facility failed to provide policies on Braden Scale assessments, newly identified skin issues, or low air loss mattresses when requested. The care plan for Resident #29 included interventions for skin breakdown due to decreased mobility, incontinence, and existing wounds. However, the facility did not adhere to these interventions promptly. The resident's representative expressed concern about the development of a new pressure ulcer, feeling that the facility should have had preventive measures in place given the resident's history with wounds. The DNS confirmed that an RN assessment should have been completed for the new skin issue, and the facility policy was not followed in this instance.
Failure to Follow CPAP Cleaning and Storage Guidelines
Penalty
Summary
The facility failed to follow the manufacturer recommendations in the cleaning and storage of a CPAP machine for a resident with obstructive sleep apnea. The resident's care plan indicated the need for CPAP maintenance, but the physician's orders lacked specific instructions on cleaning and changing the CPAP components. During an observation, the resident's CPAP mask was found unbagged and undated, and the resident reported that the mask and tubing had never been changed since admission. The Director of Nursing Services (DNS) was unable to provide clear answers on the frequency of changing and cleaning the CPAP components and subsequently discarded the mask and tubing without following proper procedures. The facility's CPAP/BiPAP Cleaning Policy was not adhered to, as the CPAP mask and tubing were not cleaned or stored according to the manufacturer's guidelines. The policy required the CPAP frame to be cleaned when visibly soiled, covered with a plastic bag when not in use, and the equipment to be replaced routinely. The manufacturer manual specified that the filter should be rinsed every two weeks and replaced after 30 nights of use, and the tubing and mask should be hand-washed daily. These procedures were not followed, leading to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Timely Sign Physician's Orders
Penalty
Summary
The facility failed to have physicians' orders signed in a timely manner for Resident #102, who was admitted with diagnoses including obstructive sleep apnea, stroke, heart disease, and epilepsy. The care plan identified the resident was at risk for seizures, requiring medication per physician order and monitoring effectiveness. However, a review of physician's orders from 8/31/23 to 10/31/23 and from 12/1/23 to 12/31/23 revealed that the physician/APRN had not signed and dated the orders. Interviews with various staff members, including RN #3, RN #4, Medical Records Person #1, and the DNS, confirmed that the physician's orders were not signed as required, either electronically or in the paper chart. MD #2, responsible for signing the orders, acknowledged the oversight and indicated he only signed the orders electronically on 11/8/23 and 1/10/24, missing the required signatures for other months. The facility's policy required physicians to sign admission orders within 48 hours and then monthly for the first three months, followed by every 30 or 60 days. Despite this policy, the orders for Resident #102 were not signed for several months. Medical Records Person #1 admitted to not knowing how to check the electronic medical record for signatures, and MD #2 confirmed that he did not sign the admission orders or the monthly orders for September, October, and December 2023. The deficiency was further highlighted by the lack of a specific policy regarding the signing of physician's orders, as requested but not provided by the facility.
Failure to Review and Respond to Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and responded to the pharmacy consultant's recommendations for Resident #65, who was admitted with diagnoses including heart failure, bradycardia, and chronic atrial fibrillation. The consultant pharmacist's medication regimen review on 7/15/23 recommended evaluating the need for the resident's current Amiodarone dosage of 200mg twice daily, suggesting a reduction to 100mg once daily to minimize side effects. However, the facility deferred this recommendation to the consultant cardiologist, and there was no documentation that the cardiologist reviewed or acted upon this recommendation during subsequent visits on 10/25/23 and 11/8/23. The same recommendation was repeated in the pharmacist's review on 12/5/23, with the facility again deferring to the cardiologist without documented follow-up or action taken. Interviews with the consultant cardiologist and facility staff revealed gaps in communication and documentation. The cardiologist could not recall reviewing the pharmacist's recommendations and indicated that he would not have agreed to the dose reduction but would evaluate the resident during his next visit. The Unit Manager, responsible for preparing and communicating the resident's medication list to the cardiologist, could not explain why the pharmacist's recommendations were not documented as reviewed. Similarly, the APRN indicated that she would defer to the cardiologist for recommendations related to Amiodarone dosing but did not provide specific answers without access to her documentation. The facility's policy directs that the consultant pharmacist's recommendations should be communicated and responded to in a timely manner. However, the lack of documentation and follow-up on the pharmacist's recommendations for Resident #65 indicates a failure to adhere to this policy. The Regional Clinical Manager suggested that going forward, the nurse passing along information to the consultant should write a confirmation note if there are no changes to the medication regimen based on the pharmacist's recommendations, highlighting the need for improved communication and documentation practices within the facility.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that medication storage refrigerator temperatures were monitored in accordance with facility policy. Observations and reviews of the medication refrigerator temperature logs for the L/M and S/R units identified multiple instances of missing daily temperature recordings over a three-month period. Specifically, for the M/L unit refrigerator, no temperatures were recorded on several days in November, December, and January, and for many days, only one temperature was recorded instead of the required two. Similar issues were found with the S/R unit refrigerator logs, with numerous days missing temperature recordings and many days having only one recorded temperature. Additionally, a future date temperature was documented, indicating a lack of proper monitoring and recording practices. An interview with an RN responsible for collecting and reviewing the medication refrigerator logs revealed uncertainty about the requirement for completing the logs once or twice daily. The RN acknowledged awareness of the missing temperatures and was working with nursing supervisors to ensure compliance. The facility's policy directed that medication refrigerator temperatures be checked twice daily by licensed staff and logged accordingly. However, the observed and documented practices did not align with this policy, leading to the identified deficiency.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to ensure proper infection control techniques and hand hygiene during a dressing change for a resident with a sacral pressure ulcer. The resident, who had a history of cerebral infarction, osteomyelitis of the right femur, and insulin-dependent diabetes, was admitted with a wound vac in place due to a right hip abscess. During the dressing change, the LPN placed dressing supplies directly on an unclean dresser top without a barrier, reached into her pockets with gloved hands, and used unclean bandage scissors. Despite being directed by the RN to correct these actions, the LPN continued to make errors, including not performing hand hygiene after glove changes and using gloved fingers to apply ointment instead of a tongue depressor. The LPN also failed to set up a trash collection bag for soiled items and left a soiled brief on the resident's bed during the procedure. The RN identified these actions as deviations from the facility's policies on clean dressing changes and wound care, which require a clean field, proper hand hygiene, and the use of clean instruments. The LPN admitted to being nervous due to the observation, which contributed to her mistakes. The facility's documentation showed that the LPN had completed annual competencies related to hand hygiene and PPE use, but these were not followed during the dressing change. The facility's policies clearly outlined the correct procedures for dressing changes, including the use of a clean field, proper disposal of soiled items, and the use of clean instruments, all of which were not adhered to during this incident.
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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