Complete Care At Harrington Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Colchester, Connecticut.
- Location
- 59 Harrington Ct, Colchester, Connecticut 06415
- CMS Provider Number
- 075253
- Inspections on file
- 41
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Harrington Court during CMS and state inspections, most recent first.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
A resident with rheumatoid arthritis and multiple comorbidities was discharged from the hospital with Methotrexate ordered once weekly, but an RN transcribed the order as a daily dose, and the pharmacy filled it as written. Despite an EMR MAR dose warning that the daily Methotrexate regimen exceeded usual weekly dosing parameters, pharmacists reviewing the new admission orders did not identify or report the irregularity. The resident subsequently developed thrush, neutropenia, and altered respiratory status, was hospitalized with neutropenic fever, Methotrexate toxicity, and sepsis, required ICU care with intubation, and later died after extubation.
A resident with significant cardiac and respiratory diagnoses experienced respiratory symptoms and wheezing that prompted multiple APRN evaluations and orders, including a chest x-ray and IV Lasix. Staff notes later documented hypoxia, oxygen administration, and stat orders for labs and a chest x-ray on the day the resident died from heart failure related to sick sinus syndrome and COPD. However, the clinical record lacked documentation of an earlier chest x-ray order, any reason it was not performed, and respiratory assessments prior to the acute decline, despite staff recalling prior wheezing. Leadership acknowledged that nursing staff should have documented the change in condition and related assessments in accordance with the facility’s documentation policy.
A resident with multiple health conditions who was dependent on staff for ADLs repeatedly refused scheduled showers, but the care plan was not updated to reflect these refusals or to document alternative interventions such as bed baths. Staff reported the refusals verbally but did not document them, and the shower schedule was inconsistent with actual care provided. Facility policy requiring timely care plan updates and documentation of alternative interventions was not followed.
A resident with multiple risk factors for malnutrition did not have weekly weights obtained or documented as ordered, and after a significant weight loss was recorded, a re-weight was not performed promptly to confirm accuracy. Staff interviews revealed confusion about responsibilities and lack of a clear policy for re-weighing after significant changes, while the MAR allowed weights to be signed off without actual documentation.
A resident with dementia, depression, and other behavioral health issues, who was non-weight bearing after a toe amputation, repeatedly self-transferred and entered a roommate's space without assistance. Despite staff awareness and multiple observations of these behaviors, the care plan did not address them prior to a significant incident, and interventions were not formally documented or implemented until after the event.
A resident with mood disturbances and intact cognition reported being treated disrespectfully by an agency nurse aide, who entered the room without a name badge, responded with a false name, made inappropriate comments about the resident's belongings, and referenced race during their interaction. The incident was witnessed by another resident and reported to the night shift RN. Facility policies require staff to treat residents with dignity and respect, but these standards were not upheld in this case.
The facility failed to notify physicians and resident representatives as required when residents experienced missed medication doses, new pressure ulcers, and episodes of hypo- and hyperglycemia. In several cases, staff did not document or communicate these significant changes, delaying necessary assessments and interventions. Interviews revealed gaps in staff understanding and adherence to notification protocols.
Multiple residents with cognitive and behavioral disorders were involved in physical and verbal altercations, including incidents where a resident struck a roommate and a nurse aide verbally abused and handled a resident roughly. Staff and resident statements confirmed that abuse occurred, but there were delays in reporting and failure to immediately remove the staff member involved, as required by policy. Documentation also showed inconsistencies in care plans and monitoring, contributing to the failure to protect residents from abuse.
Three residents experienced incidents involving missing money or alleged abuse that were not reported to the Administrator or State Agency within required timeframes. In one case, a resident's missing money was treated as a grievance rather than a theft, delaying proper reporting. In another, an LPN witnessed a nurse aide verbally and physically mistreating a resident, but the incident was not escalated or acted upon according to policy. In the third case, a resident reported missing money, but the allegation was not promptly communicated to the DON or authorities.
A resident with cognitive impairment and incontinence was subjected to aggressive and inappropriate behavior by a nurse aide, including being yanked in a wheelchair and spoken to in a derogatory manner. Despite reports to supervisory staff, immediate protective actions were not taken, and the aide was not removed from the unit during the investigation, contrary to facility policy.
Two residents with significant or newly identified mental health conditions did not receive required PASARR rescreens, as facility staff failed to recognize or communicate the need for further screening and did not follow policy for coordinating assessments and referrals for Level II review.
A nurse prepared to administer a discontinued antibiotic instead of the currently prescribed one to a resident with multiple medical conditions, due to the discontinued medication not being removed from the medication cart. The error was identified before administration, and the correct medication was given after review of the orders. Facility policy requires adherence to physician orders and removal of discontinued medications from the cart.
The facility failed to follow physician orders and professional standards for several residents, including not ensuring the functionality of a cardiac remote transmission device, not administering scheduled medications due to unavailability without notifying the provider, and not documenting RN assessments or provider notification after multiple episodes of hyper- and hypoglycemia. Staff interviews revealed lack of awareness and confusion about responsibilities, and required documentation and communication were not completed.
A resident with severe cognitive impairment and mobility limitations developed a new pressure ulcer on the left heel that was not promptly recognized or assessed by nursing staff. The wound was not reported to the RN supervisor, and no treatment was initiated for several days. Additionally, the dietitian was not notified of the new wound, resulting in a significant delay in nutritional assessment and intervention to support wound healing.
Two residents requiring CPAP therapy did not have their equipment—including masks, tubing, and filters—cleaned or changed according to manufacturer and facility guidelines. Staff were unclear about responsibilities, documentation was inaccurate, and equipment was observed to be overdue for replacement, with some items not changed for over eight months.
A resident with multiple mental health diagnoses did not receive their prescribed Rexulti for several days because the facility failed to request a timely refill, resulting in missed doses and an exacerbation of anxiety. The facility did not follow its own policies for medication administration and timely pharmacy requests.
A resident was continued on Risperidone, an antipsychotic, without a documented psychiatric diagnosis to support its use. The medication was ordered for Bipolar disorder, but clinical records and screening did not confirm this diagnosis. The responsible APRN did not review hospital discharge paperwork or verify the diagnosis before continuing the medication, and a gradual dose reduction was not initiated as required by facility policy.
Two residents with cognitive and mental health diagnoses were subjected to verbal abuse by staff, including an LPN and a nursing assistant, who used profanities and derogatory language in response to care requests and behavioral challenges. These actions, witnessed by staff and a surveyor, violated facility policies requiring respectful and professional treatment of residents.
A resident with lymphedema and risk for skin breakdown did not receive timely ace wrap treatment as ordered by the practitioner because the order was incorrectly entered into the electronic medical record without a scheduled time, resulting in a five-day delay before the treatment was initiated.
A resident with a known pineapple allergy was served pineapple at dinner due to failures by dietary and nursing staff to follow established procedures for checking meal tickets and verifying tray contents. The resident ingested a small amount of the allergen, but no immediate allergic reaction was observed. Staff interviews confirmed lapses in protocol, including distractions and assumptions about responsibility for checking meals.
A resident with multiple sclerosis and psychiatric diagnoses was physically struck on the head by their roommate, who had a history of behavioral issues and cognitive impairment. The incident occurred after the resident told the roommate to leave the room, resulting in the roommate hitting the resident with a closed fist. The event was witnessed by another resident and confirmed by interviews and documentation, representing a failure to protect the resident from physical abuse as required by facility policy.
A LTC facility failed to prevent the misappropriation of narcotic medications for four residents, resulting in missing oxycodone tablets. The discrepancies were linked to a specific medication cart, where narcotic disposition sheets were soiled and later went missing. An LPN was found to have taken the medications for personal use, and the facility's medication destruction policy lacked a timeframe for removing narcotics after a resident's discharge or death.
A resident with insomnia and other conditions was prescribed Ambien 5 mg to be taken once daily as needed. However, an LPN administered the medication twice daily on several occasions, contrary to the physician's orders. The DNS was unaware of the error until informed by surveyors, and the resident confirmed the LPN's actions. The facility's policy on nursing documentation was not provided, and an interview with the LPN was not obtained.
A resident with chronic pain and insomnia was prescribed Ambien 5 mg as needed, but the facility failed to document its administration accurately. The Controlled Drug Receipt/Record/Disposition Form showed 28 administrations, while the MAR only documented 5. The DNS was unaware of the discrepancy, and the resident reported receiving the medication frequently from an LPN. The facility acknowledged the issue, but corrective actions are not detailed in the report.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
Failure to Identify and Report Methotrexate Dosing Irregularity During Pharmacy Review
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the consulting pharmacy identified and reported a significant medication irregularity involving Methotrexate dosing for a newly admitted resident. The resident’s hospital discharge orders specified Methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given once weekly. When the orders were transcribed at the facility, the Methotrexate frequency was incorrectly entered as once daily instead of once weekly, and these incorrect orders were sent electronically to the pharmacy. The pharmacy filled the Methotrexate as written on the incorrect daily orders. During the monthly drug regimen review for new admissions, the pharmacist did not identify the Methotrexate order as an irregularity, despite the EMR’s MAR dose warning indicating that the entered dose and daily frequency were outside the recommended regimen of one to ten tablets every seven days. Interviews with pharmacy personnel confirmed that two pharmacists reviewed and approved the order without recognizing the incorrect frequency, and the pharmacist in charge attributed the failure to human error. The resident had diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure, and was assessed as cognitively intact with moderate assistance needs for ADLs. Following the incorrect daily administration of Methotrexate, the resident developed thrush and later became neutropenic with altered respiratory status, as reflected in revisions to the resident’s care plan. Hospital records for a subsequent hospitalization documented admission for neutropenic fever, Methotrexate toxicity, and sepsis, during which the Methotrexate medication error was discovered. The resident required intubation and ICU care and ultimately expired after extubation.
Failure to Document Respiratory Change in Condition and Ordered Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with multiple cardiac and respiratory diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease. The resident’s care plan directed staff to administer medications as ordered and monitor for abnormal breath sounds, difficulty breathing, and signs of heart failure. An APRN evaluated the resident due to respiratory symptoms and increased wheezing and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from that period did not contain an order for the chest x-ray, nor any documentation explaining why the x-ray was not performed. Subsequently, the APRN again evaluated the resident at nursing’s request for a change in respiratory condition and documented that there were no signs of dyspnea, CHF, or glycemic issues, and that the resident was not in apparent distress. Later, the APRN documented another visit for increased respiratory distress, during which Lasix 40 mg IV was administered and a stat chest x-ray was ordered. Nursing notes documented that the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and ordered stat labs, a stat chest x-ray, and continuation of oxygen. The resident’s death was later pronounced the same day, with the death certificate listing heart failure due to sick sinus syndrome and COPD as the primary cause of death. Record review showed no documentation of the chest x-ray order on the earlier date, no documentation for the reason the chest x-ray was not performed, and no documentation of respiratory-related assessments prior to the later date, despite staff recalling episodes of wheezing and respiratory concerns in the week prior. The APRN confirmed she had ordered a chest x-ray and discussed the plan with a nurse but could not recall which staff member or why the order was not entered or carried out, and could not locate documentation explaining the omission. The ADON and the President of Clinical Services stated that nursing staff should have documented the change in condition and related assessments when the APRN was asked to see the resident for respiratory changes, and that the facility failed to follow its Documentation Policy requiring complete, accurate, and timely documentation by the end of the shift in which assessments or care occurred.
Failure to Revise Care Plan and Document Alternative Interventions for Refusal of Showers
Penalty
Summary
The facility failed to review and revise the care plan for a resident who consistently refused showers, and did not implement or document alternative interventions as required. The resident, who had diagnoses including adult failure to thrive, anorexia, type II diabetes mellitus, muscle weakness, and lack of coordination, was dependent on staff for transfers, personal hygiene, and bathing. Despite being scheduled for showers on specific days and shifts, documentation showed that the resident was not provided showers on multiple occasions over several months, with no follow-up documentation explaining the missed showers or indicating whether the resident had refused them. Interviews with nurse aides revealed that the resident had been refusing showers since admission but would accept bed baths instead. The aides reported notifying charge nurses when the resident refused showers, but these refusals were not documented in the clinical record. Additionally, the care plan was not updated to reflect the resident's ongoing refusal of showers or to include specific interventions addressing this behavior until after a family-initiated care conference. The shower schedule itself was inconsistent and confusing, listing showers for multiple shifts and days, which did not align with the actual care provided. Facility policy required that the comprehensive care plan be person-centered, include measurable objectives, and be updated to reflect refusals of care and alternative interventions. The policy also required documentation of attempts to provide care and discussions with the resident or their representative. However, these requirements were not met, as the care plan was not promptly revised, alternative interventions were not documented, and staff responsible for carrying out interventions were not adequately informed of changes.
Failure to Obtain and Document Weekly Weights and Prompt Re-Weight After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document weekly weights for a resident at risk for weight loss, as ordered by the physician. The resident, who had diagnoses including adult failure to thrive, anorexia, dysphagia, and type II diabetes mellitus, was identified as being at risk for malnutrition due to poor intake and low albumin levels. Despite physician orders for weekly weights and care plan interventions to monitor weight, there was no documentation of weights being obtained on several scheduled dates, even though the Medication Administration Record (MAR) was signed off as if the weights had been taken. When a significant weight loss of 26.2 pounds in one week was documented, the facility failed to obtain a re-weight promptly to confirm the accuracy of this change. The re-weight was not performed until seven days later, and the dietician did not follow up on the significant weight loss until ten days after it was first identified. Interviews with staff revealed confusion and lack of clarity regarding responsibility for obtaining and documenting weights, as well as the absence of a facility policy on when to perform re-weights after significant changes. Further review showed that the MAR allowed nurses to sign off on weights without entering the actual measurement, and there was a period when the facility did not have a dietician on staff, resulting in a lack of interdisciplinary review of triggered weights. The facility's weight monitoring policy required timely recording and comparison of weights, but this was not followed, leading to a delay in identifying and responding to the resident's significant weight loss.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan to address the behavioral needs of a resident with multiple diagnoses, including dementia, depression, anxiety disorder, obsessive-compulsive disorder, and insomnia. The resident was non-weight bearing on the right lower extremity following a toe amputation and required assistance from two staff members for transfers. Despite physician orders and nursing notes indicating the resident's confusion, restlessness, poor safety awareness, and need for close observation, the care plan did not address the resident's behaviors of self-transferring, wandering, or obsessive-compulsive actions. Clinical documentation and staff interviews revealed that the resident frequently got out of bed unassisted, transferred independently despite being non-weight bearing, and entered a roommate's space, sometimes rummaging through belongings or sitting on the roommate's bed. These behaviors were observed by multiple staff members and reported by the roommate, but were not formally addressed in the care plan prior to a significant incident. The Treatment Administration Record also failed to include all relevant behaviors, omitting restless and non-compliant transfer behaviors. Staff, including nurse aides and the nursing supervisor, acknowledged awareness of the resident's behaviors and described redirecting the resident or bringing them to the nurse's station, but did not update the care plan to reflect these interventions. The social worker, responsible for developing non-compliance care plans, confirmed that a care plan addressing these behaviors was not created until after an incident occurred. The Director of Nursing also indicated that a comprehensive care plan should have been developed collaboratively by nursing and social services to address the resident's specific behavioral and safety needs.
Failure to Ensure Resident Dignity and Respect by Agency Nurse Aide
Penalty
Summary
A resident with a history of atrial fibrillation, congestive heart failure, and encephalopathy, and who was identified as having intact cognition but experiencing mood disturbances, reported being treated in an undignified manner by an agency nurse aide during the night shift. The resident described that the nurse aide entered the room without a name badge, responded with a false name when asked, and made comments perceived as rude, including referencing the resident's personal items on the bed and suggesting the resident should have cleaned up. The resident also reported that the nurse aide made a comment about race, asking if the resident disliked her because of her voice or because she was black. The resident became upset, asked the nurse aide to leave, and subsequently reported the incident to the night shift nurse supervisor. Other residents and staff provided varying accounts of the incident. A nearby resident reported hearing an argument and the resident expressing that the nurse aide was hurting and being rude, while the nurse aide denied making disrespectful comments and stated that the resident was argumentative. The nurse aide also acknowledged asking the resident if race was a factor in their interaction. The nurse supervisor confirmed that the resident reported the incident and that the nurse aide did not have another staff member accompany her, despite the resident's care plan indicating a need for two staff due to a history of accusatory statements. The resident's roommate did not recall hearing any verbal abuse or rude behavior. Facility policies require staff to treat residents with dignity and respect, and to speak respectfully at all times. The incident demonstrated a failure to uphold these standards, as the resident was not treated in a dignified manner by the agency nurse aide, and the staff did not ensure adherence to the resident's care plan regarding the presence of two staff members during care.
Failure to Notify Physician and Resident Representatives of Significant Changes and Missed Medications
Penalty
Summary
The facility failed to ensure timely and appropriate notification of physicians and resident representatives in accordance with facility policy for multiple residents. For one resident admitted with complex medical needs including leg surgery, chronic kidney disease, and hypertension, several prescribed medications were not available and thus not administered as ordered. Nursing staff did not notify the physician or APRN about the missed doses, nor did they document such notifications, despite facility policy requiring immediate action and provider notification when medications are unavailable. Interviews confirmed that the responsible nurses did not follow the required procedures for reordering medications or for notifying the provider and documenting the event. Another resident, admitted with a history of falls and dementia, developed a new pressure ulcer that was first identified during a weekly skin check. The wound was not assessed by an RN, and neither the APRN nor the resident representative was notified until nine days after the initial finding. During this period, no treatment was initiated for the pressure ulcer, and the dietitian was not informed in a timely manner, delaying nutritional interventions that could support wound healing. Staff interviews revealed a lack of understanding or adherence to the protocol for new wound identification, assessment, and notification. A third resident with diabetes experienced multiple episodes of hypo- and hyperglycemia, some requiring emergency interventions such as IM Glucagon or glucose gel. Despite physician orders and facility protocols requiring provider and resident representative notification for blood glucose levels outside specified parameters, there was no documentation of such notifications for numerous incidents. Nursing staff often failed to document the events or communicate them to the appropriate parties, and in some cases, did not administer insulin as ordered or notify the provider when doses were held. Interviews with staff indicated confusion about roles and responsibilities regarding assessment, documentation, and notification in these situations.
Failure to Protect Residents from Abuse and Inadequate Staff Response
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident and staff-to-resident incidents. Several residents with cognitive impairments, psychiatric disorders, and behavioral disturbances were involved in physical altercations with each other. In one instance, a resident with paranoid schizophrenia and a history of combative behavior was observed striking a roommate, who had dementia and was identified as a wanderer. The care plans for these residents noted their behavioral risks, but conflicting documentation was found regarding their behaviors and interventions. Staff witnessed and documented physical altercations, and residents were found to have entered each other's rooms, leading to further incidents of aggression and distress. In another case, a resident with dementia and behavioral disturbances was reported by another resident to have been verbally abused by a nurse aide during the night shift. The nurse aide was overheard yelling at the resident to "shut up and be quiet" multiple times. Statements from staff and residents confirmed the occurrence of loud, inappropriate, and aggressive interactions between the nurse aide and both residents and other staff members. The nurse aide was also reported to have yanked a resident's wheelchair and made demeaning comments in the presence of the resident and others. These actions were witnessed by staff and reported by residents, but there was a delay in reporting the abuse to facility leadership, and the staff member was not immediately removed from the unit as required by facility policy. Documentation and interviews revealed that the facility's staff did not consistently follow established protocols for monitoring, redirecting, and protecting residents with known behavioral risks. There were lapses in communication and reporting among staff regarding incidents of abuse and altercations. The facility's failure to implement and adhere to its abuse prevention policies resulted in residents being subjected to physical and verbal abuse, as well as emotional distress, without timely and appropriate intervention.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to immediately report allegations of abuse and misappropriation of resident property to the Administrator and State Agency within the required timeframes for three residents. In the first case, a resident with chronic kidney disease and diabetes reported $150 missing from their wallet, which was last seen in their backpack. The wallet was found by a staff member in the laundry and returned to the resident, who immediately noticed the missing money. Despite the resident's insistence that the money was stolen, the Administrator treated the incident as a grievance rather than a theft, did not collect statements from involved staff, and did not report the incident to authorities until much later, stating she was not informed it was a theft until the day before the surveyor's interview. In the second case, a resident with Parkinson's disease and dementia was subjected to alleged verbal and physical abuse by a nurse aide, who was observed yanking the resident's wheelchair and making derogatory remarks. The incident was witnessed by an LPN, who reported it to the RN supervisor. However, the RN supervisor did not escalate the report to the Director of Nursing (DNS) or remove the alleged perpetrator from duty as required by facility policy. The DNS was unaware of the incident until the surveyor's inquiry and had not read the LPN's written statement. The facility's policy required immediate reporting and removal of staff in such cases, which was not followed. In the third case, a resident with cerebrovascular disease and dementia reported $80 missing from their purse, which was moved during the night without their knowledge. The resident informed the surveyor, who then notified the charge nurse. The charge nurse claimed to have reported the incident to the RN supervisor, who denied receiving the report. The DNS was not informed of the allegation until the following day, well beyond the required reporting timeframe. The facility's policy mandated immediate reporting of such allegations, but this was not adhered to in this instance.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
A deficiency occurred when the facility failed to take immediate steps to protect a resident from further potential abuse during an ongoing investigation. The incident involved a resident with multiple diagnoses, including Parkinson's disease, dementia, and mood disturbances, who was moderately cognitively impaired and required assistance with toileting. During a night shift, the resident was observed to have fallen, become restless, and subsequently urinated on the floor after requests for assistance were ignored by a nurse aide. The nurse aide was reported to have become agitated, yanked the resident's wheelchair, and made derogatory remarks to the resident in the presence of others. Multiple staff interviews confirmed that the nurse aide displayed aggressive and inappropriate behavior towards the resident and other staff, including yelling, cursing, and refusing to provide care when requested. The LPN on duty reported the incident to the RN supervisor, but the supervisor did not take immediate protective action or remove the nurse aide from the unit. Instead, the supervisor advised the staff to resolve their issues or take them to Human Resources, and did not escalate the report of potential abuse or ensure the safety of the resident. The Director of Nursing later confirmed that she was unaware of the full extent of the incident until prompted by surveyor inquiry and acknowledged that the facility's policy required immediate removal of staff accused of abuse. The facility's own policy mandates immediate protection of residents and removal of alleged perpetrators during investigations, but this was not followed, resulting in a failure to protect the resident from further potential harm while the investigation was ongoing.
Failure to Complete Required PASARR Rescreens for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required Pre-admission Screening and Resident Review (PASARR) rescreens were completed for two residents with significant mental health histories or new mental health diagnoses. For one resident admitted with a history of chronic psychiatric illness, including bipolar disorder and executive deficits, the initial PASARR Level 1 screen did not identify a need for a Level II review. However, the clinical record and psychiatric notes documented a long-standing history of serious mental illness and the use of antipsychotic medication. Despite this, there was no documentation of a PASARR rescreen being initiated or completed after admission. The Social Work Director was unaware of the full extent of the resident's psychiatric history and did not initiate the required rescreen, as the psychiatric provider and facility staff did not communicate the relevant information to her. Another resident was admitted with diagnoses including anxiety disorder, dysthymic disorder, and PTSD. The initial PASARR Level 1 screen indicated no evidence of a PASARR condition, and no Level II was required at that time. Subsequently, the resident was diagnosed with major depressive disorder, a new mental health diagnosis. The clinical record did not show that a new PASARR Level 1 screen was submitted following this diagnosis. The Social Work Director confirmed that she was not the assigned social worker at the time of the new diagnosis and was unaware that a rescreen had not been completed, but acknowledged that a new PASARR should have been submitted upon identification of the new mental health condition. Facility policy requires coordination with the PASARR program to ensure that residents with mental disorders or related conditions receive appropriate care and services, including prompt referral for Level II review when a new or previously unidentified serious mental disorder is evident. The policy also assigns responsibility to the social services director for tracking PASARR screening status and making necessary referrals. In both cases, the facility did not follow its own policy, resulting in a failure to complete required PASARR rescreens for residents with significant or newly identified mental health conditions.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
A deficiency occurred when a nurse failed to administer medication in accordance with the physician's orders for a resident with a history of fractures, anemia, and bipolar disorder. The resident had a current order for Cephalexin 500mg to be given four times daily for cellulitis, but the nurse initially prepared Cefadroxil 500mg, a discontinued antibiotic, for administration. This error was identified during a medication pass observation, where the nurse was seen removing the incorrect medication from the resident's bubble pack and placing it into the medication cup. Upon inquiry, the nurse reviewed the orders again, realized the mistake, and replaced the Cefadroxil with the correct Cephalexin capsule. The nurse stated she was not usually assigned to that unit and expected discontinued medications to be removed from the cart. The facility's policy requires that medications be administered as ordered by the physician and in accordance with professional standards, including verifying the correct medication against the medication administration record (MAR) and ensuring discontinued medications are not available for administration. The Director of Nursing confirmed that the expectation is for nurses to follow the six rights of medication administration and for discontinued medications to be removed from the medication cart. The failure to remove the discontinued Cefadroxil from the cart and the nurse's initial selection of the wrong medication led to the deficiency.
Failure to Follow Physician Orders and Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide care and treatment according to professional standards, facility policy, and physician's orders for multiple residents. For one resident with a cardiac pacemaker, staff did not ensure the functionality of a remote cardiac transmission device. The device was found to be nonfunctional for over a month, with no documentation of daily checks or monitoring as required by the care plan and facility policy. Staff interviews revealed a lack of awareness regarding the device's status, and the last successful transmission was several months prior to the survey. The resident and staff were unaware of the device's malfunction, and there was no evidence that the physician or representative had been notified of the missed transmission. Another resident did not receive several scheduled medications, including Bumetanide, Gabapentin, and Lactobacillus, due to the medications being unavailable in the facility. Nursing staff failed to notify the physician or APRN of the missed doses, as required by facility policy. Documentation did not reflect any communication with the provider regarding the medication omissions, and the medications were not reordered in a timely manner. The facility's policy required immediate action and provider notification when medications were unavailable, but this was not followed. A third resident with insulin-dependent diabetes experienced multiple episodes of hyperglycemia and hypoglycemia, some requiring additional treatment such as glucose gel or IM Glucagon. The clinical record lacked documentation of RN assessments, provider notification, or notification of the resident's representative following these episodes, despite physician orders and facility policy requiring such actions. Staff interviews indicated confusion about roles and responsibilities for assessment and notification, with LPNs reporting that only RNs were allowed to contact providers or assess residents after a change in condition. The documentation did not reflect adherence to the hypoglycemia management protocol or communication requirements.
Failure to Provide Timely Pressure Ulcer Assessment and Nutritional Support
Penalty
Summary
A resident with a history of dementia, left femur fracture, and severe cognitive impairment was admitted and later readmitted to the facility. Upon readmission, the resident was identified as being at risk for pressure ulcers but had intact skin except for facial bruising. The care plan included interventions for skin integrity, such as barrier cream application and weekly skin checks. However, a new blister with slough was first documented on the resident's left heel during a weekly skin check, but it was not recognized as a new pressure ulcer by the nursing staff at that time. Both the RN and LPN who identified the left heel blister assumed it was an old injury and did not notify the RN supervisor or initiate a change of condition assessment as required by facility policy. As a result, no wound assessment or treatment was initiated for nine days after the initial identification of the pressure area. The first complete RN wound assessment and physician notification occurred only after the wound had deteriorated and was identified as an unstageable deep tissue injury (DTI). During this period, the resident did not receive appropriate wound care or interventions to address the new pressure ulcer. Additionally, the facility failed to notify the dietitian of the new pressure ulcer in a timely manner. The dietitian did not receive wound reports for the relevant period and was not made aware of the resident's new pressure ulcer until 49 days after its initial identification. Consequently, the resident did not receive a nutritional assessment or recommended protein supplementation to support wound healing until this late notification. These failures were contrary to the facility's policies on pressure injury prevention, management, and nutritional support.
Failure to Maintain and Change CPAP Equipment per Manufacturer Guidelines
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required CPAP therapy, as staff did not change or clean CPAP equipment—including tubing, filters, and masks—in accordance with manufacturer recommendations and facility policy. For one resident with sleep apnea and COPD, observations revealed that the CPAP mask was left unbagged, and the tubing and mask had not been changed for over eight months, despite orders and policy requiring more frequent changes. Staff interviews confirmed a lack of clarity regarding responsibility for equipment maintenance, with some nurses unaware of when equipment was last changed or cleaned, and one nurse admitting to signing off on cleaning tasks that were not performed due to lack of supplies and resident sleep schedules. For another resident with COPD and obstructive sleep apnea, similar deficiencies were observed. The CPAP tubing and mask had not been changed for over eight months, and the resident reported that no staff had cleaned the equipment in months. Staff interviews indicated confusion about the cleaning schedule and a lack of a system to ensure equipment was changed every three months as required. The facility's policy and physician orders referenced following manufacturer guidelines, but did not specify timeframes, contributing to inconsistent practices. Review of facility policy and manufacturer guidelines confirmed that CPAP masks and tubing should be changed every three months, with filters changed more frequently. However, both direct observation and staff interviews demonstrated that these protocols were not followed, and documentation of cleaning or changing equipment was inaccurate. The lack of adherence to established schedules and unclear staff responsibilities led to the failure to maintain respiratory equipment as required.
Failure to Administer Psychotropic Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of anxiety disorder, dysthymic disorder, major depressive mood disorder (MDD), and post-traumatic stress disorder (PTSD) did not receive their prescribed Rexulti medication for several days. The resident was admitted with these mental health diagnoses and had a care plan in place that included administering psychotropic medications as ordered and monitoring for adverse reactions. Despite a physician's order to administer Rexulti 1mg at bedtime for depression, the medication was not given on multiple consecutive days due to it not being available at the facility. The medication administration record (MAR) and interviews confirmed that the resident did not receive Rexulti as prescribed from 3/19 through 3/24, and the facility did not complete a timely refill request to the pharmacy during this period. The consulting pharmacist confirmed that the facility failed to request a refill for Rexulti in a timely manner, resulting in a gap in medication administration. The pharmacy policy required refill requests to be made 2-3 days before the medication ran out, but the facility did not follow this process, leading to missed doses. The resident experienced an exacerbation of anxiety due to the missed medication, as documented in a psychiatric evaluation. Facility policies required medications to be administered as ordered and in accordance with professional standards, but these were not followed, resulting in the deficiency.
Failure to Conduct Gradual Dose Reduction and Verify Indication for Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with a physician's order for Risperidone, an antipsychotic medication, without a documented psychiatric diagnosis to support its use. The resident's diagnoses included cerebrovascular disease and dementia, and the PASRR Level 1 screening indicated no known or suspected mental health diagnosis. Despite this, the psychiatric APRN continued the Risperidone order for a diagnosis of Bipolar disorder, which was not supported by the hospital or facility clinical records. The clinical record review and interviews revealed that the psychiatric APRN did not verify the presence of a psychiatric diagnosis before continuing the antipsychotic medication. The APRN admitted to not reviewing the hospital discharge paperwork and simply continued the medication based on the hospital orders. Another APRN noted that the resident was admitted on Risperidone without a diagnosis and expected a gradual dose reduction should have been initiated, as the only diagnosis present was dementia without behavioral disturbances. Facility policy requires that psychotropic medications only be used when necessary to treat a specific, documented condition and that gradual dose reductions be attempted unless contraindicated. In this case, the required gradual dose reduction was not initiated upon admission, and the use of Risperidone was not supported by an appropriate diagnosis, resulting in a failure to comply with facility policy and regulatory requirements regarding unnecessary medications.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
Two residents experienced incidents of verbal abuse by staff members, resulting in a failure to protect them from abuse as required. One resident, with diagnoses including cerebral infarction, legal blindness, anxiety disorder, and depression, approached an LPN at the nurse's station to request assistance with incontinent care. The LPN responded dismissively, telling the resident they were providing too many details and, after a verbal exchange, mumbled or stated profanities and derogatory remarks within the resident's hearing. Multiple staff interviews confirmed that the LPN used inappropriate language, which escalated the resident's agitation and led to a verbal altercation. The resident reported feeling upset and indicated that the LPN was unprofessional and rude. Another resident, diagnosed with anxiety disorder and schizoaffective disorder, was subjected to harsh and loud verbal remarks by a nursing assistant (NA) in a public area. The NA spoke to the resident in a derogatory tone, complained about the resident's repeated requests for water, and made disparaging comments about the resident's behavior and her own workload, all within earshot of other residents and staff. The NA further expressed frustration about her assignment and used inappropriate language to describe the resident, stating that the resident had been verbally abusive to her. The resident later reported that the NA had been mean throughout the day and delayed providing assistance with mobility. Both incidents were observed or corroborated by staff and, in the second case, by a surveyor. The facility's policies define such behavior as verbal abuse and require staff to treat residents with respect and professionalism at all times. The actions of the LPN and NA in these cases constituted verbal abuse and a failure to uphold residents' rights to be free from abuse, as outlined in facility policy and federal regulations.
Delayed Initiation of Practitioner-Ordered Treatment Due to Incorrect Order Entry
Penalty
Summary
A deficiency occurred when a resident with diagnoses including lymphedema, atherosclerotic heart disease, and anxiety did not receive timely treatment as ordered by the practitioner. The resident's care plan identified a risk for skin breakdown and required the use of ace wraps for bilateral lower extremity lymphedema. The APRN instructed that the resident's lower extremities be elevated while in bed and ace wraps be applied at 6:00 AM and removed at 6:00 PM daily. However, the order was entered incorrectly into the electronic medical record as an ancillary order without a scheduled time, preventing it from appearing on the Medication Administration Report (MAR) with the appropriate schedule. As a result, the treatment to wrap the resident's lower legs with ace wraps was not initiated until five days after the practitioner's directive. The Director of Nursing Services confirmed that the standard practice was for the nursing supervisor to verify new orders, but the missing treatment schedule was not identified until several days later, causing the delay in the initiation of the resident's prescribed care.
Resident Served Allergen Despite Documented Food Allergy
Penalty
Summary
A resident with a documented allergy to pineapple was served pineapple at dinner, despite clear indications in the care plan and electronic medical record regarding the allergy. The resident's care plan listed multiple allergies, including pineapple, and required that the allergy be noted in the electronic record and that staff monitor for allergic reactions. On the day of the incident, the resident, who had intact cognition and required assistance with personal care, was given pineapple with their meal. Nursing notes confirmed the resident ingested a small amount of pineapple, but no immediate allergic reaction was observed. Interviews revealed that the Food Services Director was aware of the incident and that a dietary aide initially removed the pineapple from the tray but inadvertently replaced it due to a distraction. The nursing assistant responsible for serving the meal did not check the tray against the meal ticket, assuming a family member would do so. Facility policies required dietary staff to check meal tickets for allergies and for nursing staff to verify trays before serving, but these procedures were not followed, resulting in the resident being exposed to an identified allergen.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, schizoaffective disorder, and major depressive disorder was physically struck on the head by their roommate, who had diagnoses including respiratory failure with hypoxia, schizoaffective disorder, adjustment disorder, and dementia. The incident took place after the resident told their roommate to get out of the room, at which point the roommate walked over and hit the resident on the left side of the head with a closed fist. The roommate had a documented history of behavioral issues, including verbal and physical aggression, and required staff assistance for most activities of daily living due to severe cognitive impairment. The facility's policy states that each resident has the right to be free from abuse, including abuse by other residents. Despite this, the altercation occurred, and was witnessed by another alert and oriented resident who confirmed the physical assault. Interviews and documentation confirmed that the resident who was struck did not sustain physical injury and felt fine emotionally, but the event itself constituted a failure to protect the resident from physical abuse as required by facility policy.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of controlled narcotic medications for four residents, leading to a significant deficiency. Resident #1, who had chronic pain syndrome and required oxycodone for pain management, was found to have 200 tablets missing from the facility's records. The discrepancy was discovered when staff attempted to reorder the medication, and the pharmacy indicated it was too soon for a refill. The facility's documentation showed that 360 tablets had been received, but only 160 were documented as administered. Resident #2, diagnosed with cancer and experiencing moderate pain, had 31 tablets of oxycodone missing. The facility had received 60 tablets, but only 29 were documented as administered before the resident's death. Similarly, Resident #3, who suffered from fibromyalgia and chronic pain, had 21 tablets missing from the 30 received by the facility. Resident #4, with chronic gout and diabetes, had 111 tablets missing from the 210 received. The discrepancies were linked to the West-1 medication cart, where the narcotic disposition sheets were reportedly soiled and later went missing. Interviews with staff revealed that LPN #7 was associated with the missing medications. The LPN had reported incidents of the narcotic book being soiled and was later found to have taken the oxycodone for personal use. The Director of Nursing Services (DNS) identified that the facility's medication destruction policy lacked a timeframe for removing narcotics after a resident's discharge or death, contributing to the oversight. The facility's failure to secure and accurately document the administration of narcotic medications resulted in the misappropriation of residents' medications.
Medication Administration Error Due to Non-Compliance with Physician's Orders
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for a resident diagnosed with insomnia, chronic pain syndrome, low back pain, and polyneuropathy. The resident, who had intact cognition and was independent in daily activities, was prescribed Ambien 5 mg to be administered once every 24 hours as needed for insomnia. However, the Controlled Drug Receipt/Record/Disposition Form revealed that the medication was administered twice daily on multiple occasions by an LPN, contrary to the physician's directive. The Director of Nursing Services (DNS) was unaware of the medication error until notified by the surveyor. Upon verification with the Advanced Practice Registered Nurse (APRN), it was confirmed that the resident was only supposed to receive the medication once per day. The resident corroborated that the LPN administered the medication more frequently, providing an additional dose if the initial dose was reported as ineffective. The DNS confirmed that borrowing narcotics from other residents' stock is prohibited and that the duplicate administrations were medication errors. An interview with the LPN involved was not obtained, and the facility's policy on nursing documentation was not provided.
Failure to Document and Evaluate As-Needed Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation and evaluation of as-needed narcotic administration for a resident diagnosed with chronic pain syndrome, low back pain, and polyneuropathy. The resident, who had intact cognition and frequently experienced moderate pain, was prescribed Ambien 5 mg as needed for insomnia. However, the Controlled Drug Receipt/Record/Disposition Form indicated that Ambien was administered 28 times over a period, while the Medication Administration Record (MAR) only documented administration on 5 occasions. This discrepancy suggests a failure in maintaining accurate records of medication administration. Interviews revealed that the Director of Nursing Services (DNS) was unaware of the discrepancy and confirmed that nurses are expected to document all as-needed medications in the MAR and follow up on their effectiveness. The resident reported receiving Ambien from an LPN every time she worked, and if the medication was ineffective, the LPN would administer another dose. The facility's Administrator acknowledged the issue and noted that a Plan of Correction was in place, but the report does not detail the corrective actions taken.
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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