Grimes Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 1354 Chapel St, New Haven, Connecticut 06511
- CMS Provider Number
- 075275
- Inspections on file
- 17
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Grimes Center during CMS and state inspections, most recent first.
Failure to Protect Resident from Verbal Abuse and Intimidation: A resident with dementia-related behavior issues was documented as verbally aggressive, intimidating, and using sexually explicit profanity toward another resident outside that resident’s room. The affected resident, who had bipolar disorder, anxiety, and borderline personality disorder, reported the altercation and later showed increased anger, paranoia, and distress. Facility records did not identify the other resident involved, and staff did not complete an incident report, investigation, or state report for the resident-to-resident abuse allegation.
Failure to Report Resident-to-Resident Verbal Abuse: A resident with dementia-related behavior issues sat outside another resident’s room, played loud music, and became verbally aggressive, intimidating, and used sexually explicit profanity after being told to turn it off. Staff removed the resident and spoke with both residents, but the event was not reported as a reportable abuse incident, and no incident report or investigation was completed despite policy requiring immediate reporting of abuse, intimidation, or resident-to-resident altercations.
Failure to investigate resident-to-resident verbal abuse: Staff knew one resident was verbally aggressive, intimidating, and used sexually explicit profanity toward another resident, but no incident report or full investigation was completed. The targeted resident later reported ongoing intimidation and retaliation concerns, and psych notes documented increased anger, paranoia, delusions, and distress. Facility records did not identify the other resident involved, and staff stated they did not report the event because they did not view it as abusive.
Failure to incorporate PASARR Level II recommendations into the care plan. A resident with bipolar disorder, psychotic disorder, borderline personality disorder, and a history of suicide attempts, homicidal ideation, violence, and substance abuse had a positive PASARR Level II that called for crisis intervention and a safety plan, but the record did not show the recommendations were reviewed, addressed, or added to the care plan. Interviews confirmed the MDS coordinator, SW, APRN, and psychologist were not aware of the PASARR findings or had not developed a formal safety plan.
A resident admitted with chronic diastolic CHF had physician-ordered CHF monitoring, including O2 sat checks, daily weights, edema checks, and monitoring for fatigue, SOB, cough, and lung sounds, but the care plan did not reflect the CHF diagnosis or related interventions. The admission MDS showed severe cognitive impairment and dependence on staff for ADLs, yet the care plan failed to include the CHF protocol.
Failure to Use Backboard During CPR: A resident with a trach, respiratory failure history, and full code status was found unresponsive in a recliner and staff initiated CPR after transferring the resident to bed, but no backboard or hard surface was used. Video and staff interviews showed the emergency cart arrived without a backboard attached, and multiple staff members confirmed CPR was performed without one. The physician present observed the absence of a backboard, and the CPR instructor stated a hard surface is needed for effective chest compressions.
Missed Daily Weight Documentation for Resident with CHF: A resident admitted with bilateral humerus fractures, AFib, and CHF had a physician order for daily weights and provider notification for significant weight gain, but the facility failed to document weights on multiple days. The care plan did not address CHF or daily weights, and the record lacked any explanation for the missed weights; the unit manager stated the resident’s pain initially made weighing difficult, but daily weights should have been done once movement was better tolerated.
Failure to apply a prescribed right-hand C-grip splint was identified for a resident with CVA, severe cognitive impairment, and limited ROM who required extensive ADL assistance. The splint was ordered for day-shift use after morning care, with instructions posted in the room, but observations showed the resident without the device on multiple occasions. NA staff said they were aware of the posted directions but did not routinely apply the splint, were unsure who was responsible, and had not been formally in-serviced; nursing staff also did not verify the device was in place or complete the expected skin check.
Failure to Implement EBP for Residents with Indwelling Devices and Chronic Wounds: Two residents were not placed on EBP despite having qualifying conditions. One resident had chronic bilateral foot wounds, a PICC/Hickman line, wound VAC care, and IV antibiotics; the other had ESRD and was dialyzed through a permacath. Nursing staff stated they were not aware the residents were on EBP or whether they met criteria, and the care plans and orders did not reflect EBP.
A resident with multiple blood disorders, cancer, and on medications known to increase bruising risk was admitted with existing bruises and developed further bruising during their stay. Despite clear documentation and staff awareness of the resident's high risk for bruising, the care plan did not include specific interventions to address this risk, contrary to facility policy.
A nurse aide failed to notify the charge nurse after observing purple discoloration to a resident's groin and upper inner thighs, despite the resident's complex medical history and facility policy requiring immediate reporting of significant changes in condition. The issue was discovered after the resident was hospitalized and the bruising was reported by hospital staff.
The facility did not ensure that their designated Infection Control Nurse, RN #4, completed the required CDC Infection Prevention Course. Although RN #4 had completed a certificate of achievement course in infection control, she had not finished two modules or taken the final exam for the CDC course. The Administrator and DNS were unaware of this incomplete training. RN #4 was the sole certified infection control nurse since her hire date.
The facility failed to complete advanced directive forms for three residents, resulting in incomplete documentation and lack of proper signatures and witness verification as required by policy.
The facility failed to notify the Office of the State LTC Ombudsman when three residents were transferred to the hospital. Interviews revealed a lack of awareness and miscommunication regarding the correct procedure for notifying the Ombudsman, and the facility did not provide a policy on the notification process.
The facility failed to provide adequate supervision for a resident, resulting in a fall and fracture, and did not ensure consistent monitoring for another resident with recurrent falls. Staffing issues and inconsistent documentation contributed to these deficiencies.
A resident with Alzheimer's, dementia, dysphagia, and diabetes experienced significant weight loss over several months. Despite documented weight decreases, the dietitian did not reassess the resident or bring the issue to the interdisciplinary team for intervention until months later, violating facility policy.
The facility failed to provide adequate nursing staff for a resident with multiple falls, leading to inconsistent 1:1 monitoring. Despite a care plan intervention, the resident was often left unsupervised due to staffing issues, resulting in multiple falls. Staff interviews confirmed that monitoring levels fluctuated based on staffing availability, and the DNS was unaware of these adjustments.
The facility failed to monitor targeted behaviors for a resident on antipsychotic medication. Despite directives to document specific behaviors, the behavior flow sheets were not individualized, and documentation was inconsistent. This failure to properly monitor and document behaviors led to a deficiency in care.
An LPN failed to properly sanitize a glucometer and perform hand hygiene as per facility policy, leading to a deficiency in infection control practices. The LPN did not know the correct procedure and did not allow for the required dwell time for sanitization, necessitating intervention from a supervisor.
A resident with a history of heart conditions did not receive anticoagulant medication for 13 days due to a missed INR test, resulting in a significant medication error. The facility's policy required INR testing per physician's order, but the nursing staff failed to follow up, leading to the resident missing the medication. The resident's INR level was found to be below the therapeutic range when tested later.
Failure to Protect Resident from Verbal Abuse and Intimidation
Penalty
Summary
The facility failed to protect a resident from verbal abuse and intimidation by another resident who was on a different unit. The other resident, who had diagnoses including dementia with agitation, adjustment disorder, and anxiety disorder, was documented as having behavior issues, verbal aggression, profanity toward other residents, and a history of antagonizing and intimidating others. Facility notes showed that this resident had been verbally aggressive toward another resident on the morning of 9/7/25, and later records described additional aggressive and intimidating behavior involving other residents, including use of sexually inappropriate profanity. The affected resident had diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder, with intact cognition and use of a walker and wheelchair. The resident’s care plan identified psychosocial risk related to depression, anxiety, psychosis, PTSD, and borderline personality disorder. Facility documentation and staff interviews showed that the resident reported a verbal altercation in which the other resident was sitting outside the room playing loud music, became yelling and profane when asked to turn it off, and intimidated the resident. The resident later reported that the other resident was attempting to retaliate, and psychiatric documentation noted increased anger, delusions, anxiety, paranoia, and distress following the events. The record did not contain additional documentation identifying the other resident involved in the incident, and the facility did not complete an incident report or investigation for the resident-to-resident altercation. Interviews showed that the DNS was not aware of reportable event reports for the incidents, and the SW and ADNS stated they did not complete an investigation or report to the state agency because they did not believe the incident required reporting. Staff interviews also confirmed that the resident involved in the aggressive behavior frequently traveled to other units and had ongoing issues with yelling and antagonizing the affected resident, while the facility policy required immediate reporting, documentation, and investigation of abuse, intimidation, and resident-to-resident altercations.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to immediately report a resident-to-resident verbal abuse incident involving two residents on different units. One resident had diagnoses including dementia with agitation, adjustment disorder, and anxiety disorder, and the care plan identified a risk for behavior issues related to mental illness and cognitive deficits. The other resident had diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder, with intact cognition and a care plan identifying psychosocial risk related to depression, anxiety, psychosis, PTSD, and borderline personality disorder. The incident occurred when one resident was sitting outside the other resident’s room, playing loud music, and became verbally aggressive, intimidating, and used sexually explicit profanity after being told to turn the music off. Facility staff removed the resident from the area, and nursing staff later spoke with both residents. Documentation showed the resident who was targeted reported the other resident was attempting to retaliate, and later psychiatric notes described increased anger, paranoia, delusions, and distress following the events. The record also reflected that staff were aware of ongoing antagonizing and intimidating behavior by the resident who initiated the confrontation. Despite the nature of the event and the facility policy requiring immediate reporting of abuse, intimidation, or mental anguish, the incident was not reported to the state agency as a reportable event. Interviews showed the DNS was not aware of any reportable event for the incident, the SW did not complete an incident report or investigation, and the ADNS did not complete an investigation or incident report and did not feel the event required reporting because the targeted resident did not identify additional issues. Facility policy required immediate reporting, incident documentation, investigation, and notification for abuse-related events and resident-to-resident altercations.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to complete a thorough investigation and failed to protect a resident from further potential abuse after another resident sat outside the resident’s room, played loud music, and became verbally aggressive, intimidating, and sexually explicit toward the resident. The involved resident had diagnoses including dementia with agitation, adjustment disorder, and anxiety disorder, and the record identified a history of behavior issues, mental illness, and cognitive deficits. Facility documentation showed prior behavior concerns involving profanity, intimidation, and attempts to target other residents, but the clinical record did not contain complete documentation identifying the other resident involved in the incidents or a full incident investigation. The resident who was targeted had diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder, with intact cognition and use of a walker and wheelchair. The record documented that the resident reported a verbal altercation with another resident and stated that the other resident made a vulgar comment, intimidated the resident, and was later attempting to retaliate. Psychologist documentation later noted that the resident reported multiple incidents with the other resident, including verbal altercations and attempts to intimidate, and that these events contributed to worsening symptoms, including increased anger, paranoia, delusions, and distress. Interviews with the DNS, SW, ADNS, APRN, psychologist, and RN showed that staff were aware of the incidents but did not complete an incident report or a formal investigation for the resident-to-resident altercation. The SW stated she did not complete an incident report because the issue was addressed and did not report the incident to the state agency because she did not view it as abusive. The ADNS similarly stated she did not ask follow-up questions or complete an investigation or incident report because the resident did not identify additional issues. The facility policy required immediate reporting, documentation, notification, and investigation of abuse or mistreatment, including interviewing witnesses and the accused person, but those steps were not completed for the incident.
Failure to Incorporate PASARR Level II Recommendations Into Care Plan
Penalty
Summary
The facility failed to incorporate recommendations from a positive PASARR Level II determination into the resident assessment and care plan for a resident admitted with diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder. The annual MDS identified intact cognition, continence, independence with toileting and transfers, and active diagnoses including bipolar disorder and psychotic disorder with daily antipsychotic medication, but it did not identify the resident as having a serious mental illness under the state PASARR process. The care plan addressed psychosocial risk related to depression, anxiety, psychosis, PTSD, and borderline personality disorder, but it did not include the resident’s history of suicidal ideation, suicide attempts, homicidal ideation, harm-directed behaviors, or substance abuse. The clinical record showed that the resident had a history of suicide attempts, homicidal ideation, physical violence toward strangers, and longstanding cocaine and illicit substance use documented in psychiatric treatment notes since admission. An initial psychiatric evaluation documented prior suicide attempts, a history of homicidal ideation, and chronic cocaine dependence, and the treatment plan included a verbal contract to notify someone if violent thoughts occurred and to begin talk therapy and substance abuse support. A psychotherapy assessment also documented drug use since the teen years, active crack cocaine use, a history of violence, and the resident’s report of being triggered, with therapy planned four times monthly including substance abuse counseling, relapse prevention, psychosocial education, and cognitive behavioral therapy. The record did not show that the care plan was revised to reflect these issues or that the PASARR Level II recommendations were reviewed, addressed, or implemented after the positive determination. The PASARR identified additional diagnoses including cocaine use, opioid use, alcohol abuse, suicide attempts, and attempts at harming others, and recommended crisis intervention and a safety plan with monitoring for increased symptoms or behavior changes and steps for the resident and staff to take. Interviews with the MDS Coordinator, SW, APRN, and Psychologist confirmed that the PASARR recommendations were not reviewed or formally incorporated into the resident’s care plan, and that no formal crisis intervention or safety plan had been developed or documented.
Care Plan Missing CHF Interventions
Penalty
Summary
The facility failed to ensure Resident #38’s care plan reflected the resident’s congestive heart failure diagnosis and the ordered CHF protocol. Resident #38 was admitted with diagnoses including bilateral humerus fractures, atrial fibrillation, and chronic diastolic CHF. Physician orders directed CHF monitoring measures including oxygen saturation every shift, daily weights, edema checks to the abdomen, legs, ankles, and feet every shift, and monitoring for fatigue, shortness of breath, cough, and lung sounds every shift. The admission MDS identified severely impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and dependence on staff for eating, bathing, and toileting, but the care plan did not identify CHF or related interventions.
Failure to Use Backboard During CPR
Penalty
Summary
The facility failed to use a hard surface, or backboard, beneath a resident during CPR in accordance with current American Heart Association guidelines. The resident was admitted with diagnoses including malignant neoplasm of the glottis and a history of acute and chronic respiratory failure with tracheostomy placement. The quarterly MDS identified the resident as cognitively intact, independent with bed mobility, transfers, and ambulation, and receiving tracheostomy care. The care plan identified a potential for altered respiratory status related to the tracheostomy and history of respiratory failure, and the resident’s advance directives indicated full code status. On the morning of the event, the resident was found unresponsive in a recliner in the room. Staff transferred the resident into bed and initiated CPR while emergency medical services were dispatched. The record states that high-flow oxygen was delivered via Ambu bag and an AED was applied, with no shock advised. EMS arrived and continued resuscitation efforts, including suctioning via the trach and orally, interosseous fluids, epinephrine, bicarbonate, and later use of a LUCAS device. The resident was intubated and later pronounced dead. The death certificate listed mucous plugging, tracheostomy, and laryngeal cancer as the cause of death. Facility video and staff interviews showed the emergency cart was brought to the room without a backboard attached, and the backboards on the units were observed next to the carts rather than attached to them. Multiple staff members who responded to the emergency stated they did not use a backboard during CPR. The physician present during the event observed that no backboard was in use and stated staff should have utilized one during CPR. The facility’s CPR policy did not include the requirement for a hard surface during CPR, and the certified CPR instructor stated that a resident must be placed on a hard surface in a clinical setting to deliver effective chest compressions.
Missed Daily Weight Documentation for Resident with CHF
Penalty
Summary
Failure to provide treatment and care according to orders, resident preferences, and goals occurred for Resident #38 when the facility did not obtain and document daily weights as ordered. Resident #38 was admitted in January 2026 with diagnoses including bilateral humerus fractures, atrial fibrillation, and chronic diastolic congestive heart failure. The physician ordered daily weights at 6:30 AM and to notify the MD/APRN for a weight gain of 3 lbs. or more in one day or 5 lbs. in one week. The admission MDS identified severely impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and dependence on staff for eating, bathing, and toileting. Review of the clinical record showed that daily weights were not documented on 1/17, 1/18, 1/19, 1/20, 1/22, 1/25, and 1/28/26, and there was no documentation explaining why the weights were not obtained on those dates. The care plan did not identify interventions related to congestive heart failure or the need for daily weights. During interview, the unit manager stated that weights were difficult to obtain during the first few days after admission because of the resident’s bilateral humerus fractures and pain with movement, but after 3 to 4 days the resident could tolerate more movement and daily weights should have been completed; the manager also stated that if weights could not be obtained, the reason should have been documented and the provider notified.
Failure to Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to ensure that a prescribed right C-grip hand splint was applied for a resident with cerebral infarction, severe cognitive impairment, limited ROM in the upper and lower extremities, and dependence on two staff for bed mobility, transfers, and dressing. The quarterly MDS and care plan identified the resident’s mobility limitations and need for ADL assistance, and a physician’s order directed the right C-grip hand splint to be applied every day shift after morning care for up to four hours. The resident’s room also had posted instructions showing the splint was to be applied after morning care, with staff directed to check that straps were not tight, follow numbered application steps, inspect skin for breakdown, and notify the supervisor with questions. Observation showed the resident up and dressed in a wheelchair on 1/27/26 and again up in a chair on 1/28/26 without the prescribed right-hand C-grip in place. The nurse aide care card did not include the splint schedule or related care, and NA #2 stated she was aware of the posted directions but did not routinely apply the device, was unsure who was responsible for placing it, did not know where to find it, had not been formally in-serviced, and had not reported the issue. RN #2 stated nurse aides were responsible for applying the device and nursing staff were responsible for ensuring application and skin checks, while the DNS expected aides to apply the splint and notify nursing for refusal or inability to locate it. LPN #5 stated she did not verify the splint on 1/29/26 because no concerns were reported.
Failure to Implement EBP for Residents with Indwelling Devices and Chronic Wounds
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with chronic bilateral foot wounds and an indwelling PICC/Hickman line. The resident had diagnoses including non-pressure chronic ulcers of both heels and midfoot with bone involvement, required daily wound care and wound VAC treatment, and was receiving IV antibiotics. The admission MDS identified intact cognition, substantial assistance needs for several activities of daily living, a foot infection, surgical wound care, and IV access, but the physician orders and care plan did not direct or include EBP. The resident’s record also showed a history of bilateral foot debridement, a left calcaneal biopsy showing acute osteomyelitis, ED transfer for necrotic heel wounds with purulent drainage, surgery for right foot incision and drainage, and later OR treatment with debridement, biological grafts, and negative pressure wound therapy. The resident was discharged to short-term rehab on IV Unasyn and Vanco. During interviews, nursing staff stated they were not aware the resident was on EBP or whether the resident met criteria for EBP. The facility also failed to ensure EBP was implemented for a resident receiving hemodialysis through a permacath. The resident had end-stage renal disease, dependence on renal dialysis, intact cognition, and required substantial assistance with personal care. The physician order directed transparent dressing changes for the permacath, and the care plan addressed the dialysis access site, but EBP was not in place. Staff interviews confirmed the resident was not on EBP and that the resident’s permacath was being used for dialysis because the AV fistula was not in use.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Bruising
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with appropriate interventions for a resident at risk for bruising. The resident had multiple complex diagnoses, including blood disorders, lymphoma, anemia, amyloidosis, and was taking medications such as Brukinsa (Zanubrutinib) and an antiplatelet, both of which increase the risk of bruising. Upon admission, the resident was noted to have multiple bruises and discoloration, and subsequent medical notes documented further bruising and purpura of unknown etiology, with concerns raised about medication side effects and possible trauma. Despite these findings and the resident's high risk for bruising, the care plan only addressed impaired skin integrity related to decreased mobility and incontinence, without specific interventions for bruising risk. Interviews with clinical staff, including the APRN and DNS, confirmed that the resident was at increased risk for bruising due to their diagnoses and medications, and that a comprehensive care plan addressing this risk should have been in place. The facility's care plan policy requires a care plan based on identified needs, strengths, and preferences, including measurable goals and interventions, but this was not followed for the resident in question. The deficiency was identified through review of clinical records, facility documentation, and staff interviews.
Failure to Report Change in Resident's Skin Condition
Penalty
Summary
A deficiency occurred when a nurse aide observed purple discoloration to the groin and upper inner thighs of a resident with multiple complex medical diagnoses, including Waldenstrom macroglobulinemia, myeloproliferative disease, lymphoplasmacytic lymphoma, amyloidosis, post-traumatic stress disorder, delirium, and depressive disorder. The resident was noted to have moderately impaired cognition, was frequently incontinent, dependent with transfers, and required substantial assistance with activities of daily living. Despite observing the change in skin condition during care, the nurse aide did not report this significant change to the charge nurse, as required by facility policy. The failure to report the change in condition was discovered after the resident was sent to the hospital for abnormal bloodwork, where hospital staff identified bruising in the vaginal area and notified the facility. The facility's Director of Nursing confirmed that the nurse aide should have immediately reported the observed discoloration to the charge nurse, in accordance with facility expectations and policy. The facility's policy requires all significant changes in a resident's condition to be reported to the physician and family.
Infection Preventionist Certification Incomplete
Penalty
Summary
The facility failed to ensure a certified Infection Preventionist was employed, as evidenced by the review of documentation and interviews conducted during the survey. RN #4, designated as the Infection Control Nurse, had completed a certificate of achievement course in infection control in April 2022, which included various topics related to infection prevention. However, it was noted that RN #4 had not completed the final exam associated with a more extensive CDC Infection Control Training course, despite taking several modules. The Administrator and DNS were unaware of this incomplete training, and RN #4 was the only nurse certified for infection control since her hire date in June 2022. During an interview and review of the Infection Control curriculum with RN #4, it was revealed that she had not completed two modules and had never taken the final test to secure a certificate of completion for the CDC Infection Prevention Course. Subsequent to the surveyor's inquiry, RN #4 completed the outstanding modules, took the test, and obtained a certificate certifying completion of the CDC Infection Prevention Course.
Failure to Complete Advanced Directive Forms
Penalty
Summary
The facility failed to ensure the advanced directive forms were completed for three residents. Resident #53 was readmitted with diagnoses including dementia and end-stage renal disease. Despite being alert and oriented, the facility did not discuss the code status with the resident, and the consent form was only signed by one nurse without a witness. The care plan indicated the resident was a full code, but there was no physician's order for the code status, and the advanced directive form lacked proper signatures and documentation of attempts to contact the resident's representative. Resident #58, who had a stroke and moderately impaired cognition, was readmitted to the facility. The resident's representative requested a full code status, but the consent form was signed by only one nurse without a witness. Although a physician's order directed the resident to be a full code, the advanced directive form was incomplete, and there was no documentation of a second witness as required by the facility's policy. Resident #70, admitted with heart failure and severely impaired cognition, had a full code status per the hospital discharge summary. However, the facility did not discuss the code status with the resident's conservator, and the advanced directive form was blank. Despite the conservator visiting the facility, there was no documentation of the conversation or attempts to obtain the advanced directive within the first day or two following admission. The facility's policy required the advanced directive and physician order form to be completed upon admission, which was not adhered to in these cases.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when three residents were transferred to the hospital. Resident #1, who was admitted with chronic kidney disease, myocardial infarction, and atherosclerotic heart disease, was transferred to the hospital on two occasions in February and March 2024. The Action Summary for these periods did not reflect that the Ombudsman was notified of these transfers. Similarly, Resident #18, admitted with congestive heart failure, atrial fibrillation, and chronic kidney disease, was transferred to the hospital twice in March 2024, and the Ombudsman was not notified as required. Resident #71, admitted with Wegener's granulomatosis, epilepsy, and chronic pain syndrome, was transferred to the hospital in November 2023, and again, the Ombudsman was not notified. Interviews with the facility's Administrator, Director of Nursing Services (DNS), and medical record staff revealed a lack of awareness and miscommunication regarding the correct procedure for notifying the Ombudsman. The medical record staff indicated that discharges to the hospital were uploaded to the Ombudsman’s office monthly but were unaware that the incorrect Action Summary was being sent. The facility did not provide a policy regarding the notification process, indicating a systemic issue in ensuring compliance with notification requirements.
Inadequate Supervision and Monitoring Leading to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall resulting in a fracture for Resident #40. Despite being identified as at risk for falls and having interventions in place, Resident #40 experienced an unwitnessed fall in the shower, leading to a displaced fracture at the proximal humerus. The facility did not have documentation that Resident #40 was assessed by therapy to shower independently, and the nursing assistant left the resident alone in the shower, contrary to the expected supervision protocol. This lapse in supervision directly contributed to the resident's fall and subsequent injury. The facility also failed to ensure appropriate observation and monitoring for Resident #37, who had multiple recurrent falls. Despite being identified as requiring 1:1 monitoring after several unwitnessed falls, the facility's documentation revealed significant gaps in the monitoring records. Resident #37 experienced numerous falls without consistent 1:1 monitoring or documented checks, and the facility's staffing issues led to fluctuating levels of supervision. The facility's policy did not require physician orders for frequent monitoring, and the DNS was unaware that staffing shortages were affecting the implementation of the monitoring interventions. Interviews with staff, including the DNS and APRN, confirmed that the facility's monitoring practices were inconsistent and often altered due to staffing issues. The DNS acknowledged that neurological checks should have been completed for unwitnessed falls but were not consistently documented. The facility's failure to provide continuous and adequate monitoring for Resident #37, despite the known risk of falls, resulted in repeated incidents of unwitnessed falls and injuries, highlighting a significant deficiency in the facility's fall prevention and monitoring protocols.
Failure to Follow Up on Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure the dietitian followed up on significant weight loss for a resident diagnosed with Alzheimer's disease, dementia, dysphagia, and diabetes. The resident, who had severely impaired cognition and required meal setup, experienced a notable weight loss over several months. Despite the resident's weight being documented as consistently decreasing, the dietitian did not reassess the resident or bring the issue to the interdisciplinary team for intervention until months later. The resident's weight dropped from 236 lbs. to 219.5 lbs., representing an 8.2% weight loss over a short period. The facility's policy required the dietitian to assess residents experiencing significant weight changes and to update care plans with new interventions. However, the dietitian did not follow this protocol, as there was no documentation of assessment or intervention after the resident's weight loss was noted on multiple occasions. The dietitian's last assessment was on 12/13/23, and the next assessment did not occur until 3/8/24, despite the resident's ongoing weight loss. This failure to act contravened the facility's policy and contributed to the deficiency identified in the report.
Inadequate Staffing and Monitoring for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to provide close monitoring for a resident with multiple falls. Resident #37, who had diagnoses including repeated falls, muscle weakness, and dementia, was admitted to the facility and required substantial assistance with daily activities. Despite a care plan intervention for 1:1 monitoring due to a high risk of falls, the facility did not consistently provide this level of supervision. Observations on multiple occasions revealed that the assigned nursing assistant was either not present or was attending to other residents, leaving Resident #37 unsupervised. Interviews with staff confirmed that due to staffing issues, the level of monitoring fluctuated and was not always in line with the care plan requirements. The facility's daily nursing roster and staffing sheets indicated that Resident #37 was supposed to be on 1:1 monitoring, but this was not consistently implemented. On one occasion, the nursing assistant assigned to Resident #37 was observed assisting another resident, and on another occasion, the same nursing assistant was seen attending to Resident #37's roommate, leaving Resident #37 unsupervised. Staff interviews revealed that the facility often adjusted the monitoring levels based on staffing availability, which sometimes resulted in Resident #37 being monitored less frequently than required. The Director of Nursing Services (DNS) and other staff members acknowledged the staffing issues and the inconsistency in monitoring but did not take adequate steps to address the problem. The facility's policy on falls required that residents at risk for falls have appropriate fall prevention measures in place, including 1:1 sitters when necessary. However, the DNS admitted that she was not aware that the staff had adjusted Resident #37's monitoring based on staffing issues and that the monitoring intervention was not always being carried out. The Advanced Practice Registered Nurse (APRN) also confirmed that the monitoring level was determined based on the resident's risk but was not aware that it was being altered due to staffing shortages. The facility's failure to provide consistent 1:1 monitoring for Resident #37, as required by the care plan, led to multiple falls and demonstrated a significant deficiency in ensuring resident safety.
Failure to Monitor Targeted Behaviors for Antipsychotic Medication
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident on antipsychotic medication. Resident #16, who was admitted with diagnoses including bipolar disorder, dementia, depressive episodes, and anxiety, was receiving antipsychotics and antidepressants. The care plan included monitoring for side effects and considering dose reduction when clinically appropriate. However, the facility did not document targeted behaviors as required by the physician's order dated 2/21/24, which directed documentation on a behavior monitoring flow sheet every shift. The psychiatric APRN progress notes and physician progress notes indicated specific behaviors to monitor, such as disorganized behaviors, delusions, and restlessness. Despite these directives, the behavior flow sheets were not individualized for Resident #16's specific behaviors. The documentation was inconsistent, with some shifts missing signatures and others signed off by nursing assistants instead of licensed nurses. The DNS confirmed that the behavior monitoring was not tailored to Resident #16's specific needs and that the computerized template used was not individualized. Review of the facility's Antipsychotic Drug Use Indications Policy revealed that antipsychotic drugs should only be used for specific conditions and behaviors, which must be documented. The facility's failure to consistently and accurately document targeted behaviors for Resident #16, as required by the physician's order and facility policy, led to the deficiency. This lack of proper monitoring and documentation could potentially impact the resident's care and the appropriateness of continued medication use.
Failure to Sanitize Glucometer and Perform Hand Hygiene
Penalty
Summary
The facility failed to ensure proper sanitization of the glucometer and adherence to hand hygiene protocols. During an observation, an LPN obtained a blood sugar reading for a resident and placed the glucometer on the medication cart without sanitizing it. The LPN then performed hand hygiene but did not sanitize her hands again after touching the glucometer before preparing insulin for administration. When questioned by the surveyor, the LPN admitted to not knowing the facility's policy for glucometer cleaning. The LPN then attempted to clean the glucometer with a Sani-Purple wipe but did not allow for the required dwell time before using it again. The supervisor had to intervene to instruct the LPN on the correct procedure, which includes a total dwell time of 4 minutes for proper sanitization. Further interviews revealed that agency staff, including the LPN in question, receive an overview of facility policies upon initial entrance, but the LPN failed to follow these protocols. The facility's policy for cleaning and disinfecting the glucometer includes using Sani-wipes or Purple Cap Wipes PDI with a dwell time of 2 minutes. The manufacturer's recommendations for the glucometer suggest using a germicidal bleach wipe with a total dwell time of 2 minutes. Despite these guidelines being available on the medication carts, the LPN did not adhere to them, leading to the deficiency in infection control practices.
Failure to Administer Anticoagulant Due to Missed INR Test
Penalty
Summary
The facility failed to ensure a laboratory test was obtained per physician's order for a resident receiving anticoagulant medication, resulting in a significant medication error. The resident, who had a history of prosthetic heart valve, endocarditis, atherosclerotic heart disease, and congestive heart failure, was admitted in January 2023. The care plan required administering anticoagulant as ordered and scheduling laboratory tests to monitor coagulation factors. However, the resident did not receive the anticoagulant medication, Coumadin, for 13 days due to a missed laboratory test for INR on 2/7/23, which was not followed up by the nursing staff. The resident's Medication Administration Record (MAR) showed that Coumadin was not administered from 2/7/23 to 2/19/23. The INR test, which was supposed to be conducted on 2/7/23, was not performed, and the resident's INR level was found to be below the therapeutic range when tested on 2/20/23. The facility's policy required licensed nursing staff to perform INR testing per physician's order, but this was not adhered to, leading to the medication error. Interviews with the involved staff revealed a lack of follow-up on the INR test, contributing to the resident missing 13 days of anticoagulant therapy.
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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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