Complete Care At Groton Regency
Inspection history, citations, penalties and survey trends for this long-term care facility in Groton, Connecticut.
- Location
- 1145 Poquonnock Rd, Groton, Connecticut 06340
- CMS Provider Number
- 075270
- Inspections on file
- 26
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Complete Care At Groton Regency during CMS and state inspections, most recent first.
Resident areas on the C/D and E/F units were found with rust-stained drop ceiling frames, damaged wallpaper, bowed or broken ceiling tiles, loose cove base molding with debris or black growth behind it, missing thresholds, and chipped flooring tiles. Facility interviews showed the QAPI plan addressed only Units A and B, and leadership reported no written plan or timeline for repairs on the other units; maintenance relied on requests and limited rounds rather than a building-wide audit.
A resident with severe cognitive impairment, delusions, and a history of physical and verbal aggression was known to wander, resist care, and be difficult to redirect, yet the care plan did not address the risk of entering other residents’ rooms. After this resident slapped another resident in a bathroom, staff documentation continued to show wandering into rooms, agitation, and aggression toward staff and others. Later, the same aggressive resident entered another resident’s room, yelled, demanded compliance, then slapped the resident’s face and grabbed the resident’s arm, resulting in resident-to-resident abuse that was not prevented by effective behavioral interventions or care plan measures.
Care plan did not reflect secured unit placement. Two residents living on a secured dementia unit had records showing dementia, wandering risk, behavioral monitoring, and other significant cognitive or physical impairments, but their care plans did not identify residence on the secured unit or unit-specific interventions. Interviews with the UM and Social Services Director confirmed the care plans were not updated to address the residents’ secured-unit placement, despite facility policy requiring interdisciplinary review and resident-specific interventions.
Failure to Place a Resident With an Open Wound on EBP: A resident with severe cognitive impairment and an open sacral wound was not placed on EBP despite facility staff stating that any resident with an open wound should be on EBP. The resident’s wound care was performed by an LPN and an NA using gloves but no gown, and the EBP signage outside the room was believed to apply to the roommate with a foley catheter rather than this resident. The resident was not listed on the facility’s EBP list or identified in the chart locations staff used to track EBP status.
A resident with dementia, AFib, and anxiety disorder was found not up to date with the COVID-19 vaccine. Although the POA gave consent for the COVID-19 vaccine and boosters, the chart did not show that the 2025-2026 booster was given or refused, and the IP RN stated the resident should have been offered the vaccine when the facility began administering it.
A resident with a positive Level II PASRR was coded incorrectly on the MDS as not having a serious mental illness or related condition, even though the PASRR record showed a positive Level II status. In addition, three residents with diagnoses including dementia, bipolar disorder, PTSD, heart failure, atrial fibrillation, and spinal stenosis had section C of the MDS marked “not assessed,” meaning the BIMS and any alternate cognition assessment were not completed during the look-back period.
A resident requiring extensive assistance for daily living, who was alert and oriented, was subjected to disrespectful language by an RN during a medication pass. The RN uttered an inappropriate phrase while assisting the resident, which was later confirmed by facility documentation and acknowledged as unprofessional by the DON. Facility policy requires staff to treat residents with respect and dignity at all times.
A resident who required extensive assistance was left unattended with a partially administered dose of sodium polystyrene sulfonate mixture during a medication pass. After the LPN left the medication on the bedside table and stepped away, the resident was found on the floor with wet marks and reported vomiting after taking the medication. Facility policy and the DON confirmed that staff are required to observe residents taking their medications in full before leaving.
The facility failed to keep the Main dining room open on weekends, resulting in residents receiving meals in their rooms. Staff confirmed the closure was due to a staffing shortage, and the decision was made collaboratively between dietary and nursing departments. The DNS acknowledged low participation on weekends and a QAPI project was initiated to address the issue.
The facility failed to ensure adequate staffing to transport residents to the dining room on weekends, resulting in the closure of the dining room during these times. Staff and residents confirmed that meals were delivered to residents' rooms instead. The facility's QAPI documentation identified the goal of reopening the dining room by a specific date, but staffing shortages persisted.
The facility failed to ensure expired food was dated and removed from the refrigerator. During a tour, two large plastic zip bags of sliced ham and two undated peaches were found. The Food Service Directors acknowledged the oversight despite daily checks, and the facility's guide directs that ready-to-eat foods should be stored for up to seven days.
The facility failed to complete a Significant Change in Status MDS assessment for a resident admitted to hospice care. Despite the resident's severe cognitive impairment and multiple diagnoses, the required assessment was not completed within the mandated 14-day window due to the absence of an MDS Coordinator at the time.
The facility failed to ensure accurate documentation of advanced directives for a resident, resulting in the misfiling of another resident's DNR form in the clinical record. Interviews revealed that the Unit Coordinator did not verify names on documents before filing, contrary to facility policy.
Resident Areas Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure resident areas were kept in good repair on the C/D and E/F nursing units. Survey observations on multiple days identified resident rooms with drop ceiling frames showing excessive rust-like staining, wallpaper and wallpaper borders that were discolored, ripped, or hanging off the wall, ceiling tiles that were bowed, bulged, or broken, cove base molding that was not adhered to the wall with dirt, debris, or black growth behind it, missing room thresholds, and chipped flooring tiles. Facility interviews and document review showed that the environmental concerns on the C/D and E/F units were not included in the facility’s QAPI plan dated 10/21/25, which addressed renovation plans for Units A and B only. The Regional Maintenance Director stated the rooms throughout the facility were being redone, but the Administrator confirmed there was no written plan or timeline for repairs on the C, D, E, or F units. The Maintenance Director stated he had not completed a building audit and relied on maintenance requests or empty rooms to identify needed repairs, while EVS and nursing leadership described their rounds as focused on cleanliness or infection control rather than general maintenance issues.
Failure to Prevent Resident-to-Resident Abuse by Aggressive, Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing effective interventions for a resident with known wandering and aggressive behaviors. One resident had diagnoses including Alzheimer’s disease, anxiety disorder, and cognitive communication deficit, with an MDS showing severely impaired cognition, delusions, physical and verbal behaviors directed toward others, and rejection of care. The care plan identified this resident as resistive to care, physically and verbally aggressive, yelling, hitting, and pacing, with instructions to postpone care if combative and to monitor for anxiety, aggression, and delusions. Physician orders directed staff to monitor targeted behaviors of delusions and physical and verbal aggression toward staff and residents. Despite these known behaviors, the resident entered another resident’s bathroom and, after being told to leave, slapped that resident on the left cheek with an open hand. This first resident-vs-resident incident occurred in the context of documented wandering, agitation, and aggression, including notes that the aggressive resident hit staff, threw a cup of juice at staff, was verbally aggressive, refused to use a walker, refused to stop wandering into other residents’ rooms, and was not easily redirected. The care plan developed after the first incident identified that the resident used to work in a prison and was triggered when told “no,” and included interventions such as diversion, removal from the environment, and observation for non-verbal signs of physical aggression. However, the care plan did not address the possibility of this resident wandering into other residents’ rooms. Subsequently, another resident with Alzheimer’s disease, anxiety disorder, bilateral hearing loss, and moderate cognitive impairment, who had a care plan noting potential physical behaviors, lack of personal space boundaries, and yelling, was assaulted when the aggressive resident again entered a resident room. In this second incident, the aggressive resident entered the room, yelled at the other resident, demanded compliance, then slapped the resident on the left side of the face and grabbed the right upper arm. The psychiatric evaluation documented that the aggressive resident had a previous resident-to-resident incident and recent episodes of physical aggression without evidence of infection. The facility’s failure to incorporate the known wandering and room-entry behavior into the care plan and to implement effective interventions to prevent further resident-to-resident contact contributed to this second incident of abuse.
Care Plan Did Not Reflect Secured Unit Placement
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised to reflect each resident’s changing goals, preferences, and needs, including placement and continued placement on a secured unit. For Resident #4, the record showed a consent form for the E/F secured unit identifying dementia and wandering risk, with verbal consent obtained from the responsible party and signed by facility staff. The physician’s orders later directed staff to monitor target behaviors of agitation and insomnia, and the resident’s responsible party stated she had no concerns with the resident’s placement on the secured unit because of wandering behaviors, confusion, and safety decline. Interviews with the Unit Manager and Social Services Director identified that admission to the secured unit was interdisciplinary and that social services was responsible for updating the care plan to reflect residence on the secured unit. However, the Social Services Director stated Resident #4’s care plan failed to identify interventions related to being on a secured unit. The facility’s Comprehensive Care Plans policy required the care plan to describe services needed to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, along with resident-specific interventions, and the Secure Dementia Care Unit Policy required quarterly and periodic interdisciplinary reviews for residents on the secured unit. For Resident #73, diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, Alzheimer’s disease, and vascular dementia with other behavioral disturbances. The quarterly MDS showed moderately impaired cognition, no behaviors, dependence for position changes, transfers, and mobility, and no alarms or restraints. The resident was observed living on the secured unit and stated he/she could not leave without permission. Although the care plan addressed behaviors such as irritability, restlessness, swearing, yelling, and forgetting care, it did not identify that the resident resided on a secure unit. The Unit Manager and Social Services Director both stated the care plan failed to address the resident’s residence on the secure unit and/or interventions for care on the unit.
Failure to Place Resident With Open Wound on EBP
Penalty
Summary
The facility failed to appropriately track and place a resident with an open sacral wound on Enhanced Barrier Precautions (EBP) to ensure the appropriate PPE was used during wound care. Resident #23 had diagnoses including vascular dementia, a non-pressure chronic ulcer of skin with fat layer exposed, and anxiety disorder, and the quarterly MDS identified severely impaired cognition, dependence on staff for bed mobility, personal hygiene, dressing, eating, and transfers, and non-ambulatory status. The care plan identified the resident as at risk for skin breakdown with interventions including a low air mattress, treatment per provider order, and weekly wound assessment. The physician ordered daily sacral wound care with cleansing, xeroform, and a dry protective dressing. Wound evaluations documented an end stage skin failure wound to the sacrum with moderate serosanguinous exudate, measuring 3 cm by 0.8 cm by 0.2 cm on 12/18/25 and 0.5 cm by 0.8 cm by 0.2 cm on 1/22/26. Although facility staff stated that any resident with an open wound should be on EBP, the facility’s EBP list dated 1/13/26 did not include Resident #23. During observation, EBP signage was posted outside the room, but staff identified it as being for the roommate with a foley catheter. During wound care, an LPN and an NA provided treatment and repositioning while wearing gloves but not a gown. Interviews confirmed the resident was not on EBP in the chart, on the list, or in the other locations staff used to identify EBP status, and the wound nurse stated it was her responsibility to ensure the resident was placed on EBP because the resident had an open sacral wound.
COVID-19 Booster Not Offered or Documented
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccination was offered or that the resident’s vaccination history was assessed for one resident reviewed for immunizations. The resident had diagnoses of dementia, atrial fibrillation, and an anxiety disorder, and the quarterly MDS identified severely impaired cognition and that the resident was not up to date with the COVID-19 vaccination. Review of the COVID-19 Vaccine Administration and Consent Form showed the resident’s POA gave permission for the COVID-19 vaccine and boosters, but the physician’s orders, preventative health care report, and progress notes did not show that the resident received the 2025-2026 COVID-19 booster or that the vaccine was refused when attempted. The Infection Preventionist stated that a prior consent from August 2025 reflected refusal, but the new consent signed in October 2025 was not seen, and the resident should have received the vaccine because the facility had started administering it to residents. The POA still wanted the resident to be offered the vaccine.
Incorrect PASRR Coding and Missing Cognitive Assessments
Penalty
Summary
The facility failed to ensure an accurate PASRR assessment for Resident #15. The resident’s diagnoses included schizoaffective disorder bipolar type, pseudobulbar affect, and post-traumatic stress disorder. A PASRR Level II screening dated 2/7/2023 identified the resident as having a positive Level II PASRR, but the annual MDS assessment dated [DATE] was coded “no” in the PASRR section for whether the resident was currently considered by the Level II PASRR process to have a serious mental illness, intellectual disability, or related condition. The correct response should have been “yes,” which would have led to additional PASRR-related questions. During interview, the Director of Social Services stated social workers were responsible for completing section A1500 on admission, annual, and significant change MDS assessments. He stated that during his initial orientation, a per diem MDS Coordinator had been completing the PASRR section, and he acknowledged that Resident #15 had a positive Level II PASRR assessment and the MDS should have been coded accurately. The MDS Coordinator stated she was responsible for coding the PASRR section of the MDS assessment dated [DATE], obtained information from the electronic record, saw a document titled level of care in the miscellaneous section, but did not open it. She stated the assessment was coded incorrectly and that she had submitted a correction because MDS assessments should be coded accurately. The facility also failed to complete the Brief Interview for Mental Status or an alternate staff assessment of cognition for Resident #12, Resident #14, and Resident #44. Resident #12 had diagnoses including vascular dementia, anxiety, and type 2 diabetes mellitus; Resident #14 had bipolar disorder, PTSD, and type 2 diabetes mellitus; and Resident #44 had heart failure, atrial fibrillation, and spinal stenosis. Their quarterly or annual MDS assessments dated [DATE] identified section C as “not assessed,” meaning the BIMS was not completed and cognition was not assessed by staff. The Director of Social Work stated the social worker was responsible for conducting the BIMS and completing section C during the seven-day look-back period, and that “not assessed” meant neither the BIMS nor an alternate staff assessment had been completed. He could not provide a reason why the interviews or staff assessments were not completed. The MDS Coordinator stated she coded section C as not assessed because there was no BIMS completed during the seven-day look-back period and noted she had explored why the cognitive function was not assessed.
Failure to Maintain Respectful Communication During Medication Administration
Penalty
Summary
A resident with a history of congestive heart disease, anxiety, and Type 2 diabetes mellitus, who required extensive assistance with activities of daily living, reported being treated without respect during medication administration. The resident, who was alert and oriented, informed the assigned RN that they could not take medications without applesauce. The RN left to obtain applesauce and, upon returning, observed the resident fumbling with the bed remote. During this interaction, the RN uttered 'Jesus Christ' under their breath before taking the remote from the resident. The resident later alleged that the RN used inappropriate language and demeanor during the encounter. Facility documentation confirmed the incident, and the RN acknowledged making the statement, expressing uncertainty about why it was said. The Director of Nursing Services confirmed that such language was considered poor bedside manner and offensive, and that facility policy required staff to maintain professionalism and respect at all times. The facility's Resident Rights policy directed that residents have the right to be treated with respect and dignity.
Resident Left Unattended with Medication Leading to Fall
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including congestive heart disease, anxiety, and Type 2 diabetes mellitus, was left unattended with a partially administered dose of sodium polystyrene sulfonate mixture. The resident required extensive assistance with activities of daily living due to recent hospitalization, fatigue, activity intolerance, and confusion. During a medication pass, an LPN administered half of the resident's medications and, upon the resident's request for more applesauce, took the remaining pills to the medication cart but left the half-filled cup of sodium polystyrene sulfonate mixture on the bedside table in front of the resident. Shortly after, the LPN heard a noise and found the resident lying on the floor with wet marks on their clothing, and the resident reported vomiting after consuming the liquid medication. The LPN later acknowledged that the medication should not have been left unattended and was unsure if the resident had consumed the remaining mixture before the fall. Facility policy and the DON confirmed that staff are required to observe residents taking their medications in full before leaving them or their room, and the policy directs staff to observe resident consumption of medication.
Dining Room Closure on Weekends
Penalty
Summary
The facility failed to ensure the Main dining room was open and utilized for resident dining consistently on the weekends. Observations and interviews revealed that approximately 30 residents were eating in the dining room during the week, but the dining room had been closed on weekends for several weeks. Dietary aides and the Food Service Director confirmed that meals were delivered to residents' rooms on weekends due to a staffing shortage, and the decision to close the dining room on weekends was made collaboratively between the dietary and nursing departments. Interviews with nursing staff corroborated that the dining room was closed on weekends, and residents were not transported to the dining room for meals. The Director of Nursing Services (DNS) acknowledged that the dining room was available every day but had low participation on weekends. The facility had initiated a Quality Assurance and Performance Improvement (QAPI) project to increase weekend participation in the dining room, with a goal to reopen it by a specified date. Despite the QAPI plan, the DNS denied a staffing shortage after reviewing the QAPI materials. The facility's policy on promoting and maintaining resident dignity during mealtime emphasized treating residents with respect and enhancing their quality of life, which was not upheld due to the dining room closure on weekends.
Inadequate Staffing Leads to Dining Room Closure on Weekends
Penalty
Summary
The facility failed to ensure adequate staffing to transport residents to the dining room on weekends, resulting in the closure of the dining room during these times. Multiple residents reported that the dining room had been closed on weekends for several weeks, and staff interviews confirmed this. The facility's Quality Assurance and Performance Improvement (QAPI) documentation identified the goal of reopening the dining room by a specific date, with plans to reach safe staffing levels through training new nursing assistants (NAs). However, staffing schedules showed a shortage of NAs on the weekends, and dietary aides confirmed that meals were delivered to residents' rooms instead of using the dining room. Interviews with various staff members, including dietary aides, the Food Service Director (FSD), nursing assistants, and the Director of Nursing Services (DNS), revealed that the decision to close the dining room on weekends was due to insufficient staff to transport residents. The DNS and other staff members acknowledged the low participation rate in the dining room on weekends and the ongoing QAPI efforts to address this issue. Despite the facility's action plan, the dining room remained closed on weekends, and the facility was aware of the staffing shortages during these times.
Expired Food Not Properly Dated and Removed
Penalty
Summary
The facility failed to ensure expired food was dated and removed from the refrigerator. During an initial tour of the dietary department, two large plastic zip bags full of sliced ham were found with a handwritten date, and two peaches in a plastic produce bag were undated. The Food Service Director (FSD #2) acknowledged that the ham should be discarded three days past the labeled date and could not explain why the peaches were undated. Another Food Service Director (FSD #1) confirmed that the ham should have been discarded seven days past the labeled date and admitted that the oversight occurred despite daily checks of the refrigerator by herself and the Dietary Manager in Training. The facility's Food Storage and Retention Guide directs that ready-to-eat prepared foods should be stored in the refrigerator for up to seven days, with Day 1 being the day of preparation.
Failure to Complete Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status MDS assessment for a resident when they were admitted to hospice care. Resident #12, who had diagnoses including dementia, adult failure to thrive, bipolar disorder, and malignant neoplasm of the colon, was admitted to hospice on 6/28/23. Despite the physician's order and the Resident Care Plan indicating the need for hospice services, the facility did not complete the required MDS assessment within the 14-day window as mandated by the Resident Assessment Instrument (RAI) 3.0 manual. The MDS record review from 6/28/23 to 7/11/23 confirmed this omission. Interviews with the MDS Coordinator and LPN revealed that they were aware of the requirement but had only started working at the facility in July 2023, after the resident's hospice admission, and noted that the facility lacked an MDS Coordinator at that time. The Director of Nursing Services (DNS) also confirmed the absence of an MDS Coordinator during the critical period. The deficiency was identified during a clinical record review and interviews conducted on 3/25/24. The staff responsible for MDS assessments acknowledged that a significant change MDS assessment should have been completed for Resident #12 by 7/12/23. The failure to complete this assessment was attributed to the absence of an MDS Coordinator at the time of the resident's hospice admission. This oversight resulted in non-compliance with the RAI 3.0 manual's requirement for a significant change MDS assessment following a resident's enrollment in a hospice program.
Failure to Ensure Accurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure the clinical record of Resident #119 contained accurate documentation pertaining to advanced directives. Resident #119, who had diagnoses including cerebrovascular disease, type 2 diabetes mellitus, and aphasia, was identified as having intact cognition and required moderate assistance with various activities of daily living. The care plan and physician's order indicated that Resident #119 had full code status. However, the clinical record did not contain a completed Resident/Patient Health Care Instructions form for Resident #119, but instead contained a form for another resident, Resident #379, who had a DNR code status and had been discharged from the facility. Interviews with the Unit Manager, Unit Coordinator, and DNS revealed that the misfiling occurred because the Unit Coordinator did not verify the names on the documents before filing them, assuming that all records in the chart belonged to the resident. The DNS confirmed that it is the responsibility of the nurse, unit manager, and unit coordinator to file documents and that the resident's name should be double-checked, especially if the names are similar. The facility's policy on the maintenance of clinical records requires that medical records be completely and accurately documented, which was not adhered to in this case.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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