Fairview
Inspection history, citations, penalties and survey trends for this long-term care facility in Groton, Connecticut.
- Location
- 235 Lestertown Rd, Groton, Connecticut 06340
- CMS Provider Number
- 075288
- Inspections on file
- 19
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Fairview during CMS and state inspections, most recent first.
A resident with CHF, respiratory failure, edema, cognitive impairment, incontinence, and documented risk for pressure injury did not receive an accurate, comprehensive care plan reflecting their assessed needs. The admission MDS and PT/OT evaluations showed the resident was dependent for ADLs, required assist of two and a mechanical lift for bed mobility and transfers, and had poor activity tolerance with fatigue and SOB, yet the care plan and NA Kardex continued to direct assist of one and did not include the Hoyer lift. Braden assessments by staff scored only mild risk and did not match clinical documentation of bedfast status, very limited mobility, edema, incontinence, and open skin areas. Although nursing and a wound specialist documented multiple wounds, including a right lower leg wound and later coccyx moisture-associated skin damage and a stage 3 coccyx pressure injury, the skin care plan remained generalized, did not list specific wounds or wound MD treatments, and was not revised as new wounds developed, contrary to facility policies requiring individualized, measurable, and updated care plans based on comprehensive assessment.
A resident with CHF, respiratory failure, pulmonary edema, dementia, severe edema, incontinence, and dependence for bed mobility and transfers was repeatedly scored as only mildly at risk for pressure injuries on Braden evaluations completed by an LPN. Therapy and nursing documentation described the resident as bedfast most of the time, incontinent, requiring a mechanical lift or stander with assist of two, and having +3 pitting edema with some open areas, which supported a much lower Braden score and high risk status. The care plan carried over outdated interventions (assist of one for transfers) and did not fully reflect current PT/OT recommendations or the resident’s true functional status. Facility leadership confirmed that Braden tools completed by LPNs were not reviewed or co-signed by an RN, despite state practice standards that LPNs cannot independently perform nursing assessments, and the ADNS later acknowledged that the Braden scores were inaccurate and understated the resident’s risk.
A resident with multiple comorbidities, impaired mobility, incontinence, edema, and cognitive impairment was assessed with Braden scores indicating only mild pressure injury risk, despite therapy and nursing documentation showing dependence for bed mobility and transfers, bedfast status much of the time, and frequent incontinence. The care plan was carried over from a prior admission, remained vague, and did not reflect current therapy recommendations, existing open skin areas, or wound MD involvement, while the Kardex therefore did not direct care based on the resident’s actual condition. Turning and repositioning were considered standard of care but were not documented, staff could not clearly identify responsibility for ensuring these interventions, and the dietician was not notified of the development of a Stage 3 coccyx wound or the wound MD’s request for a dietary consult. The facility’s own pressure injury prevention policy required systematic risk assessment, individualized care planning, and appropriate pressure redistribution and moisture management, but inaccurate Braden assessments, non-specific care plans, and failure to implement and document preventive interventions contributed to the resident developing a Stage 3 pressure ulcer to the sacrum.
A resident with paraplegia who required staff assistance for transfers was not safely transferred when two nurse aides used a standard sling instead of the required full body sling, as specified in the care plan. During the transfer, the resident slid out of the sling and sustained a head injury, later diagnosed as a subdural hematoma. Staff interviews confirmed that the correct procedures and equipment were not used, leading to the resident's fall and injury.
A resident with severe cognitive impairment and risk for pressure ulcers did not have a physician's order specifying the required settings for a pressure redistribution air mattress. Staff set the mattress above the resident's actual weight and relied on estimation rather than precise adjustment, with no documentation that licensed staff checked the settings as required. The resident later developed two new unstageable wounds.
The facility failed to maintain proper food safety and sanitation standards in the Dietary Department. Open food items were not dated, and there was a heavy accumulation of dirt and dust in various areas. Additionally, the dishwasher was not operating at the correct temperatures, and staff failed to report or address these issues.
The facility failed to timely address pharmacy recommendations for two residents regarding psychotropic medications. One resident, with Alzheimer's and dementia, was prescribed PRN Trazodone without a stop date, despite multiple pharmacy recommendations. Another resident, with anxiety and insomnia, had delayed responses to recommendations for stop dates on PRN medications. The facility's policy lacked a specific timeframe for addressing these recommendations.
A resident with vascular dementia and a history of falls had a clip alarm in place, but the facility failed to update the care plan and NA care card to reflect this intervention. Observations confirmed the use of the alarm, but staff interviews revealed that the documentation was not updated as required by the facility's policy.
A resident with cognitive impairment and dependency on staff for personal hygiene was found with unclean and lengthy fingernails, contrary to their care plan and facility policy. The facility's policy required routine nail care during ADL and on weekly bath days, but the responsible NA did not document any reason for the oversight, and attempts to contact them were unsuccessful.
The facility failed to follow physician orders for two residents regarding compression stockings and heel offloading, and did not provide necessary 1-to-1 assistance during meals for another resident. Observations showed non-compliance with orders, lack of updated care cards, and inadequate supervision during meals, leading to deficiencies in care.
A resident with a pressure ulcer on the coccyx did not receive proper infection control during a dressing change. An LPN failed to perform hand hygiene after changing gloves, violating the facility's clean dressing technique policy. The resident had a history of Parkinson's disease and cognitive decline, and the care plan included specific interventions for pressure ulcer management.
A resident with Alzheimer's and dementia was prescribed PRN Trazodone for anxiety without a stop date, contrary to CMS guidelines. Despite pharmacy recommendations to include a stop date, the prescriber did not address this in a timely manner, and the facility lacked a policy for stop dates on psychotropic medications.
A resident with dysphagia, paraplegia, and osteoporosis did not receive follow-up dental treatment for an upper denture due to a lack of communication and coordination within the facility. The resident's request was not documented, and necessary treatment for root tips was not pursued. The Unit Secretary failed to seek an alternative dental provider or inform the DNS, resulting in the resident not receiving the desired dental care.
A resident with dementia attempted to pull another resident out of bed, causing injuries. Despite the facility's policy requiring notification of Adult Protective Services (APS) within three days, the Director of Nursing (DON) did not report the incident, citing a lack of awareness of state guidelines and believing the situation did not warrant notification.
The facility failed to maintain a safe and sanitary environment in three shower rooms, with issues such as open bleach wipes, broken tiles, and soiled toilets. Staff interviews revealed a lack of awareness and responsibility for maintaining cleanliness and safety, with the Director of Maintenance unaware of some issues and relying on a ticket system for repairs.
Failure to Develop and Update Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple medical conditions and identified risk factors. The resident was admitted with acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, and dementia, and was placed on a sodium-restricted diet. The admission MDS identified moderately impaired cognition, dependence on staff for toileting, bathing, transfers, position changes, and wheelchair mobility, frequent bowel and bladder incontinence, risk for pressure ulcers/injuries, use of pressure-reducing devices, and use of anticoagulant and diuretic medications. These assessments triggered care areas including nutritional status, pressure ulcer, cognitive loss/dementia, ADL functional/rehabilitation potential, and urinary incontinence. Despite these findings, the resident’s care plan did not accurately reflect the resident’s functional and skin status or the therapy recommendations. The care plan dated 12/2 identified a self-care deficit related to ADLs and activity intolerance and directed an assist of one for bed mobility and transfers, and documented the resident as non-ambulatory. These interventions were carried over from a previous admission and did not incorporate the physical and occupational therapy evaluations completed on 11/29, which documented that the resident required an assist of two for bed mobility, sit-to-lying, lying-to-sitting, and sit-to-stand, and that transfers were not attempted due to medical condition. Therapy notes further indicated the resident required a mechanical Hoyer lift for transfers, had poor activity tolerance, fatigue, shortness of breath with activity, and decreased O2 saturation, yet the care plan and nurse aide care card continued to direct an assist of one and did not include the Hoyer lift. The care plan was not updated to reflect subsequent therapy documentation that the resident required an assist of two for safety during transfers and had a new level of ability with fatigue and shortness of breath. The facility also failed to accurately assess and care plan the resident’s skin integrity and pressure injury risk. On admission, nursing notes documented multiple skin issues, including a right shin abrasion, red/blanchable buttocks, bruising, edema to bilateral lower extremities, and later a right lower leg wound treated by a wound specialist. Braden Scale assessments completed by facility staff scored the resident at 16 and 17 (mild risk), indicating no sensory impairment, occasional moisture, chairfast status with frequent slight position changes, and adequate or probably inadequate nutrition. However, based on the admission assessment, therapy assessments, and nursing notes, the surveyor’s Braden scoring indicated the resident should have been classified as high risk, with very limited sensory perception, bedfast activity, very limited mobility, probably inadequate nutrition, and friction/shear as a problem. The care plan for “risk for potential impairment to skin integrity” remained generalized, did not identify the resident’s open wounds, did not incorporate the wound physician’s specific treatment orders, and was not revised when new coccyx moisture-associated skin damage and a stage 3 coccyx pressure wound were identified. Interviews with MDS and nursing leadership confirmed that open areas and wound MD involvement should have been reflected in the care plan, that Braden assessments were not accurate, and that interventions in the care plan did not align with assessments or therapy recommendations, contrary to facility policies requiring individualized, measurable, and updated care plans based on comprehensive assessment and risk factors.
Inaccurate Braden Scoring and Lack of RN Oversight for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pressure injury risk assessments met professional standards of quality for a resident with multiple serious medical conditions. The resident was admitted with acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, gait and mobility abnormalities, difficulty walking, cognitive communication deficit, and dementia. An LPN completed Braden Scale evaluations on two occasions, assigning scores of 16 and 17, which indicated only mild risk for pressure injury development. These Braden assessments documented no sensory impairment, occasional moisture, chairfast status with frequent slight independent position changes, and either inadequate or adequate nutrition, with friction and shear listed as a potential problem. In contrast, other clinical documentation at and shortly after admission described the resident as significantly more impaired. Physical therapy and occupational therapy evaluations identified the resident as dependent with assist of two for bed mobility and sit-to-stand, requiring a mechanical lift (Hoyer) or stander with assist of two for transfers, and ambulation only with therapy. Nursing documentation and an advanced skilled evaluation described the resident as bedfast most of the time, incontinent of urine and bowel, using adult briefs and a bedpan, with +3 pitting edema in all extremities and some open areas requiring ace wraps. The admission MDS documented that the resident was dependent for toileting, bathing, transfers, position changes, and wheelchair mobility, frequently incontinent of bowel and bladder, and at risk for pressure ulcers/injuries. Based on these records, the surveyor’s Braden scoring using the same tool yielded a significantly lower score, indicating high risk for pressure injury development. The facility also failed to ensure that Braden assessments completed by an LPN were reviewed by an RN, despite state scope-of-practice requirements that LPNs contribute to, but not independently perform, nursing assessments. The DNS and RN supervisor confirmed that Braden scales were completed and locked by the LPN without RN co-signature or review, and that the RN supervisor did not review LPN documentation for accuracy or consistency. The ADNS later acknowledged that the Braden assessments for this resident were not accurate, that the score should have been lower, and that there were inconsistencies and conflicting documentation in the clinical record. The facility’s own policy required licensed nurses to conduct Braden risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and the ADNS stated that the Braden score directs interventions for pressure injury prevention. However, the resident’s care plan carried over prior interventions that did not reflect current PT recommendations for mechanical lift transfers and assist of two for bed mobility, and the resident was provided only a pressure-reducing mattress rather than an overlay or air mattress, further illustrating the disconnect between the resident’s documented condition and the Braden assessments used to guide care. Additionally, the resident’s care plan for self-care deficit and skin integrity risk did not accurately incorporate the updated functional status and transfer needs identified by therapy. The care plan continued to direct assist of one for bed mobility and transfers and described the resident as non-ambulatory based on prior admission information, failing to reflect the current requirement for mechanical lift transfers with assist of two. While the care plan for skin integrity risk included general interventions such as keeping skin clean and dry, providing a pressure-relieving/reducing mattress, frequent turning and repositioning, and encouraging nutrition and hydration, it did not appear to be driven by an accurate Braden risk level. Interviews with nursing leadership confirmed that Braden assessments were not being reviewed or co-signed by an RN when completed by an LPN, and that the facility relied on these unreviewed scores to direct pressure injury prevention interventions for this high-risk resident. The CT LPN Practice Act and state statute cited in the report specify that LPNs may participate in all phases of the nursing process under the direction of an RN and may collect, report, and record data, but cannot independently perform the nursing assessment. Despite this, the DNS and RN supervisor stated that Braden scales were considered evaluations rather than assessments and therefore did not require RN review or co-signature. This practice resulted in inaccurate Braden scoring for a resident with significant mobility, continence, and edema issues, and the ADNS ultimately agreed that the Braden assessments did not accurately reflect the resident’s status and that the resident’s risk for pressure injury development was greater than documented. The combination of inaccurate Braden scoring, lack of RN oversight of LPN-completed assessments, and care plans that did not align with current therapy and nursing findings led to the identified deficiency in ensuring services met professional standards of quality. The facility’s own policy for pressure injury prevention and management required licensed nurses to conduct Braden risk assessments at specified intervals and with significant changes in condition, but the implementation of this policy did not include RN validation of LPN-completed Braden tools. Interviews showed that leadership staff were either unable or unwilling to confirm the accuracy of the resident’s initial Braden scores at the time of survey, and only upon further review did the ADNS acknowledge that the scores were inaccurate and should have been lower. The surveyor’s independent Braden scoring, based on the admission assessment, PT and OT assessments, and nursing notes, demonstrated that the resident’s true risk level was high, underscoring the discrepancy between the facility’s documented Braden scores and the resident’s actual clinical condition as recorded elsewhere in the chart. Overall, the deficiency centers on the facility’s failure to ensure that Braden pressure injury risk assessments were accurate, consistent with other clinical documentation, and performed within the appropriate scope of practice, as well as the failure to ensure RN oversight of LPN-completed Braden tools. This resulted in care planning and interventions that were not properly aligned with the resident’s actual risk for pressure injury development, as evidenced by conflicting documentation regarding mobility, continence, edema, and skin status, and by leadership’s acknowledgment that the Braden scores were not accurate and that the resident’s risk was greater than documented.
Failure to Accurately Assess Pressure Injury Risk and Implement Preventive Measures
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s pressure injury risk and to implement appropriate preventive measures, resulting in the development of a Stage 3 pressure ulcer to the sacrum. The resident was admitted with multiple significant diagnoses, including acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, gait and mobility abnormalities, difficulty walking, cognitive communication deficit, and dementia. On admission, the Braden Scale assessment completed by an LPN scored the resident at 16 (mild risk), documenting no sensory impairment, chairfast status with frequent independent position changes, occasional moisture, probable inadequate nutrition, and friction/shear as a potential problem. Nursing admission notes, however, documented multiple skin issues, including red/blanchable buttocks, edema to both lower extremities, incontinence, and bedfast status most of the time, while therapy evaluations documented that the resident was dependent for bed mobility and transfers, required a mechanical lift, and had poor activity tolerance with desaturation and shortness of breath. Subsequent documentation continued to show inconsistencies between the resident’s actual condition and the Braden assessments and care plan. A later Braden assessment scored the resident at 17 (still mild risk), again indicating no sensory impairment, chairfast status with frequent independent position changes, occasional moisture, and adequate nutrition, despite the admission MDS identifying moderately impaired cognition, dependence for toileting, transfers, and position changes, frequent bowel and bladder incontinence, and use of pressure-reducing devices. Therapy notes described the resident as incontinent without awareness, requiring extensive assistance for mobility and transfers, and needing a mechanical lift or stander with two-person assist. The care plan carried over interventions from a previous admission, directing assist of one for bed mobility and transfers and non-ambulatory status, and did not reflect current therapy recommendations or the resident’s actual dependence. The skin integrity care plan was generalized, did not identify existing open skin areas or wound MD involvement, and did not individualize interventions based on the resident’s specific risks and condition. As the resident’s condition deteriorated, documentation showed increased edema, bedfast status, incontinence, and prolonged time in bed, but the facility did not demonstrate implementation or documentation of turning and repositioning or other enhanced interventions. Nursing advanced skilled evaluations later identified moisture-associated skin damage to the right and left coccyx that was painful and burning, with specific wound measurements, and interventions limited to position changes. A wound physician subsequently assessed the coccyx wound as a Stage 3 pressure injury with exposed subcutaneous tissue, moderate serosanguineous exudate, and associated factors including edema, pain, COVID-positive status, incontinence, and decreased activity. Interviews with staff revealed that turning and repositioning were considered a standard of care but were not documented, that there was no clear identification of who ensured these interventions were completed, and that Braden assessments for this resident were later acknowledged by the ADNS as inaccurate. The dietician reported not being notified of the Stage 3 wound or the wound MD’s request for a dietary consultation. The facility’s own pressure injury prevention policy required systematic risk assessment using the Braden tool in conjunction with other risk factors, individualized care planning, and appropriate pressure redistribution and moisture management, but the facility failed to ensure accurate assessment, specific and current care planning, implementation of recommended referrals, and documentation of preventive interventions for this resident. The facility’s policy also assigned responsibility to the ADNS for reviewing documentation related to skin assessments, pressure injury risks, and compliance, and for modifying interventions as needed. Interviews with the MDS staff indicated that all residents were considered at some risk and should have a care plan for potential skin impairment, with open areas and wound MD involvement reflected in the care plan. However, the MDS staff could not explain why this resident’s wounds and mobility status were not updated in the care plan, and one MDS staff member acknowledged that care plans were vague. The ADNS later confirmed that the resident’s Braden assessments were not accurate and that documentation did not demonstrate that turning and repositioning were being completed, and stated that a lower Braden score would have prompted consideration of an overlay or air mattress. The facility ultimately failed to ensure that the resident’s pressure injury risk was correctly assessed, that the care plan accurately represented the resident’s status and needs, that the Kardex directed care appropriately, and that referrals and preventive interventions were implemented and documented, leading to the development of a Stage 3 pressure ulcer to the sacrum.
Failure to Use Correct Mechanical Lift Sling Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when a resident with paraplegia, chronic pain, weakness, and anxiety disorder, who required staff assistance for transfers, was not safely transferred using the appropriate equipment. The resident's care plan specified the use of a small full body mechanical lift sling for transfers due to their high risk for falls. On the day of the incident, two nurse aides attempted to transfer the resident using a standard sling instead of the required full body sling because the correct sling could not be located. One aide was aware of the care plan instructions but did not seek assistance to find the correct sling and proceeded with the transfer using the available standard sling. During the transfer, the resident began to slide out of the standard sling, and the staff attempted to lower the resident to the floor. The resident complained of moderate pain to the right backside of the head and was found to have a small bump and a skin tear. Shortly after the incident, the resident experienced a change in level of consciousness and was transferred to the emergency department. Initial CT scans were negative, but a follow-up scan revealed a small subdural hematoma. Interviews with the involved nurse aides revealed that both were aware, or should have been aware, of the requirement to use the full body sling as indicated on the resident's care card. One aide admitted to not using the correct sling and not asking for help, while the other assumed the correct sling was in use based on visual cues. The facility's mechanical lift transfer policy required staff to ensure the proper sling size was used and that slings were securely attached before and during transfers, but these procedures were not followed, resulting in the resident's fall and injury.
Failure to Specify and Document Pressure Mattress Settings for Resident at Risk for Pressure Injuries
Penalty
Summary
A deficiency was identified when the facility failed to ensure a physician's order specified the settings for a pressure redistribution air mattress for a resident with multiple diagnoses, including dementia, weakness, and risk for pressure injuries. The resident was dependent on staff for bed mobility and transfers, had severely impaired cognition, and was at risk for pressure ulcers. Physician orders directed staff to check the function of the air mattress every shift and evaluate for bottoming out, but did not specify the required mattress settings based on the resident's weight. During observation, the air mattress was set above 160 pounds, despite the resident's recorded weight being 122.2 pounds, and there were no markers to identify the exact setting. Staff estimated the dial position rather than using a precise setting, and there was no documentation that licensed staff were checking the settings as required. Interviews with facility leadership confirmed that the air mattress settings should be based on the resident's weight and that inaccurate settings could increase the risk for skin breakdown. The facility's policy required support surfaces to be used according to physician orders and checked each shift for proper functioning. However, the lack of specific orders for mattress settings and absence of documentation verifying checks contributed to the deficiency. The resident subsequently developed two new unstageable wounds to both feet, as documented by a wound care specialist.
Deficiencies in Food Safety and Sanitation in Dietary Department
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the Dietary Department. During a tour, it was observed that open food items in the walk-in freezer, refrigerator, and dry storage room were not dated, which is against the facility's policy. The Assistant Dietary Manager acknowledged that it was her responsibility to ensure that open items were dated and labeled correctly, but she had overlooked the non-dated items. Additionally, the facility's Date Marking for Food Safety policy requires that food be clearly marked with the date it was opened and the date it should be consumed or discarded, which was not adhered to. The facility also failed to maintain sanitary conditions in the kitchen and dish room. There was a heavy accumulation of dirt, dust, and dead insects on the windowsill and window tracking near the walk-in freezer and refrigerator. A brown substance was splattered on the door frame and ceiling tiles in the dish room, and fans over the 3-bay sink area and clean dish rack were covered in dust. The inside of a convection oven had crumbs and a dried splattered substance, and a bin of flour and a jug of molasses were noted to be dirty. The Assistant Dietary Manager admitted that there was a cleaning schedule in place, but she failed to ensure that the areas were clean. Furthermore, the facility did not ensure that the dishwasher was operating at the correct temperatures. Logs showed that the wash and rinse temperatures were consistently below the required levels, and there was no follow-up on these low temperatures. Dietary Aide #1, who was responsible for recording the temperatures, was unsure of which gauge to read and did not report the low temperatures. Similarly, Dietary Aide #2 continued to use the dishwasher despite low temperature readings. The Assistant Dietary Manager acknowledged that the aides should have reported the low temperatures and that she should have been notified to take corrective action.
Failure to Address Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for the use of psychotropic medications for two residents. Resident #23, diagnosed with Alzheimer's disease and dementia, was receiving hospice services and was prescribed Trazodone as needed for anxiety and agitation. Despite pharmacy recommendations on multiple occasions to include a stop date for the PRN Trazodone, the facility did not address these recommendations in a timely manner. The pharmacy consultant communicated the need for a stop date on 4/29/24, 5/30/24, and 6/27/24, but the prescriber did not respond until 7/3/24, and even then, the order was not consistently updated to include a stop date. Resident #48, with diagnoses of generalized anxiety disorder, depression, and insomnia, was prescribed Hydroxyzine and Trazodone as needed. The pharmacy consultant recommended on 1/23/24 that a stop date be provided for these medications or that they be discontinued, in accordance with CMS guidelines. This recommendation was not addressed until 4/23/24, 91 days later, when the psychiatric APRN discontinued the PRN Trazodone and added a stop date for Hydroxyzine. The facility's policy required staff to act upon all medication regimen review recommendations, but it did not specify a timeframe for doing so. Interviews with the Director of Nursing Services and the pharmacist revealed that there was no specific timeframe in the facility's policy for addressing pharmacy recommendations, although the pharmacist expected recommendations to be addressed within 14 days. The lack of timely response to pharmacy recommendations for both residents indicates a deficiency in the facility's medication management practices, particularly in ensuring compliance with CMS guidelines for psychotropic medications.
Failure to Update Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for a resident with a history of falls and vascular dementia, upon the initiation of a clip alarm. The resident's care plan, dated June 30, 2024, did not include the use of a clip alarm as an intervention, despite the resident being identified as a fall risk. Observations on July 9 and July 11, 2024, confirmed the presence of a clip alarm attached to the resident's sweatshirt while seated in a chair. However, the Nurse Aide (NA) Assignment sheet, last updated on April 8, 2024, and the resident's care card did not document the use of the clip alarm. Interviews with staff, including a nurse aide and a registered nurse, revealed that the clip alarm was used on both the resident's bed and chair, but this was not documented in the care plan or the NA care card. The Director of Nursing Services (DNS) acknowledged the need for the clip alarm due to the resident's fall history but was unsure when it was initiated. The DNS also confirmed that the documentation should have been updated by the nursing staff responsible for implementing the alarm. The facility's Comprehensive Care Plan policy requires that staff be notified of their roles and responsibilities for interventions, initially and when changes are made, which was not adhered to in this case.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure that a resident's fingernails were clean and trimmed, as required by their care plan and facility policy. The resident, who was moderately cognitively impaired and dependent on staff for personal hygiene, was observed with unclean and lengthy fingernails. The resident expressed that the nurse aides had not cut their fingernails in the past few weeks, despite the care plan's directive to maintain short nails to prevent skin impairment. The facility's policy required routine nail care during activities of daily living and on a regular schedule with weekly bath days. However, the assigned nurse aide responsible for the resident's care on the designated shower day did not document any reason for failing to perform the nail care. Attempts to contact the responsible nurse aide were unsuccessful, indicating a lapse in adherence to the facility's nail care policy and documentation procedures.
Failure to Follow Physician Orders and Provide Required Care
Penalty
Summary
The facility failed to adhere to physician orders for two residents regarding the application of compression stockings and heel offloading. Resident #6, who had a history of cerebral infarction, hyperlipidemia, and hypertension, was observed multiple times without the prescribed compression stockings, despite documentation indicating they were applied. The nurse responsible for documentation admitted to signing off on the application without verifying it, and the facility lacked a specific policy for compression stockings, relying instead on the expectation that orders be followed. Resident #25, diagnosed with stroke, peripheral artery disease, and diabetes mellitus, was not provided with the required heel offloading as per physician orders. Observations showed the resident's heel was flat on the mattress, contrary to the directive to keep it elevated. The care card used by nurse aides was not updated to reflect the physician's order, and staff were unaware of the symbols and instructions on the card. Additionally, weekly skin assessments were not completed as required, with two out of four assessments missing in June. Resident #82, with dementia and dysphagia, was not provided with the necessary 1-to-1 assistance during meals. Observations showed the resident left alone with a meal tray within reach, contrary to the APRN's orders for supervision. The care card contained contradictory instructions, and staff documentation inaccurately reflected the resident's independence in eating. Interviews with staff revealed a misunderstanding of the supervision requirements, and the facility's policy was not followed, leading to the resident being unsupervised during meals.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change for a resident with a pressure ulcer. The resident, who had diagnoses including Parkinson's disease, generalized muscle weakness, abnormal posture, and age-related cognitive decline, was identified to have a stage 2 pressure injury on the coccyx upon transfer from the hospital. The resident's care plan noted an unstageable pressure ulcer and included interventions such as administering treatments as ordered, monitoring nutritional status, and documenting changes in skin status. During an observation of the treatment, an LPN donned personal protective equipment and removed the soiled dressing from the resident's coccyx wound. However, the LPN failed to perform hand hygiene after changing gloves, which is a breach of the facility's policy for clean dressing technique. The LPN attempted to open a clean foam dressing with the same gloved hands used to remove the soiled dressing, prompting the surveyor to intervene. The facility's policy requires removing gloves, washing hands, and putting on clean gloves when transitioning from dirty to clean tasks.
Failure to Include Stop Date on PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to include a stop date on an as-needed (PRN) psychotropic physician order for a resident diagnosed with Alzheimer's disease and dementia, who was receiving hospice services. The resident was prescribed Trazodone, an antidepressant, to be administered every 8 hours as needed for anxiety and agitation. However, the physician's order did not specify a stop date, which is a requirement according to CMS guidelines. The resident's Medication Administration Records (MAR) showed that Trazodone was administered multiple times over several months without a stop date being added to the order. Despite pharmacy reviews and recommendations on multiple occasions, including on 4/29/24 and 6/27/24, to include a stop date for the PRN Trazodone, the prescriber did not address these recommendations in a timely manner. The facility's Director of Nursing Services (DNS) was verbally informed of the need for a stop date, but the issue persisted until the Advanced Practice Registered Nurse (APRN) eventually responded to the pharmacy's recommendations. The facility lacked a policy for including stop dates on psychotropic medications, contributing to the oversight.
Failure to Follow Up on Dental Treatment for a Resident
Penalty
Summary
The facility failed to follow up on dental treatment for a resident with diagnoses including dysphagia, paraplegia, and osteoporosis. The resident was cognitively intact and required assistance with oral and personal hygiene. The care plan identified oral health problems related to missing teeth and denture placement, with interventions to coordinate dental care and consult with a dietitian if chewing or swallowing issues arose. Despite a facility agreement with a dental service provider, the resident's request for an upper denture was not documented, and necessary treatment for root tips was not pursued. The resident expressed uncertainty about the status of the upper denture after the previous dental group left the facility. The Unit Secretary was aware the resident did not want to return to a community dentist seen earlier in the year but did not seek an alternative provider or communicate the issue to Social Services or the Director of Nursing Services (DNS). The DNS was unaware of the resident's preference and indicated that she would have taken action had she known. The lack of communication and follow-up resulted in the resident not receiving the desired dental treatment.
Failure to Report Resident Altercation to APS
Penalty
Summary
The facility failed to notify Adult Protective Services (APS) of a resident-to-resident altercation involving two residents. Resident #50, who has dementia, insomnia, and anxiety, was identified as moderately cognitively impaired and at risk of wandering. On the night of the incident, Resident #50 was found attempting to pull Resident #55 out of bed, causing discolored areas on Resident #55's face. Resident #55, who has dementia, contracture, and weakness, was severely cognitively impaired and dependent on staff for assistance. Despite the altercation and the facility's policy requiring APS notification within three days, the Director of Nursing Services (DNS) did not report the incident to APS, citing a lack of awareness of state guidelines and a belief that the situation did not warrant notification. The incident was documented in a Reportable Event form, and staff interviews confirmed the details of the altercation. LPN #7 heard yelling and found Resident #50 in Resident #55's room, attempting to remove Resident #55 from the bed. The DNS admitted to not notifying APS in similar past situations and was unaware of the facility's policy requirements. The facility's Resident Abuse policy clearly states the need to report such incidents to APS within three days, highlighting a deficiency in following established protocols for reporting suspected abuse or neglect.
Facility Fails to Maintain Safe and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a homelike, sanitary, and safe environment in three of its six shower rooms. During an initial tour, several issues were identified in Shower Room A on the second floor, including an open container of bleach wipes, chipped tiles and paint, broken blinds leaning against the wall, a walker left on shower equipment, and a commode stored behind the tub. In Shower Room B, a foot cradle was left on the floor, a basin and empty coat hanger were on the sink, and the toilet was soiled with brown stains. Shower Room C had broken trim hanging along the doorway, an unsecured drain cover, and unidentified substances in the corners of the floor. Interviews with staff revealed a lack of awareness and responsibility for maintaining the cleanliness and safety of the shower rooms. An LPN acknowledged the hazards posed by the equipment and conditions in the shower rooms, while a nursing assistant noted the presence of broken blinds during a resident's bath. The Director of Maintenance admitted to being unaware of some of the issues, such as the broken tile, and explained that environmental rounds are conducted monthly but do not include common areas. The maintenance process relies on staff reporting issues through a ticket system, which may contribute to delays in addressing deficiencies.
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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