Mary Wade Home, The Incorporated
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 118 Clinton Ave, New Haven, Connecticut 06513
- CMS Provider Number
- 075325
- Inspections on file
- 28
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mary Wade Home, The Incorporated during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple psychiatric and medical diagnoses, and dependence for ADLs and transfers fell forward from a wheelchair while an LPN was repositioning the resident, resulting in a forehead laceration requiring sutures. Although the care plan identified fall risk and altered mobility, the facility’s post-fall documentation did not include staff witness statements or a root cause analysis. The DON confirmed that no staff statements or analysis of the cause of the fall were available, despite facility policy requiring written witness documentation and a root cause analysis after witnessed incidents.
A resident with Alzheimer's and other cognitive impairments, who was dependent on staff for daily care, was verbally abused by a nurse aide who yelled at the resident during care. The aide's actions were witnessed by two nurses, and the behavior was loud enough to be heard by others. The resident's care plan required staff to use calm approaches and reapproach if care was refused, but these interventions were not followed, resulting in a substantiated incident of verbal abuse.
A resident with Alzheimer's and other conditions, who was dependent on staff for care, was subjected to verbal abuse by a nurse aide, as witnessed by two LPNs. Although the incident was substantiated through investigation, law enforcement was not notified as required by facility policy, since the abuse was not physical.
A resident with a history of depression and epilepsy, identified as an elopement risk and equipped with a wander guard, was able to leave the facility unsupervised after the security guard deactivated the wander guard alarm without intervening or notifying nursing staff. The resident crossed a street to visit a library and was later escorted back by staff, with no injuries reported. The incident was compounded by a lack of staff awareness of the resident's risk status and the absence of a specific wander guard policy.
Two residents who were dependent on staff for personal hygiene and incontinent of bowel and/or bladder did not receive incontinent care as required by their care plans. Documentation and staff interviews confirmed that, during a specific shift, both residents were left in soiled linens and briefs, with no record of care being provided as directed.
Two residents dependent on staff for toileting and personal hygiene did not receive required incontinent care during an overnight shift, as documented by care records and resident interviews. Both reported that a nurse aide failed to provide care or assist with repositioning, and the call bell was not accessible for one resident. Facility documentation confirmed the lack of care provided, in violation of established care plans and policies.
The facility did not provide a way for residents who were not at risk for elopement to independently open secured doors on two nursing units, requiring all residents to rely on staff for entry and exit. Despite many residents not being at risk, all were subject to locked-door restrictions, and the facility lacked policies and risk assessments for placement on secured units. An incident occurred where a resident became distressed after being unable to enter their unit without staff assistance.
The facility did not ensure that food was served at safe temperatures, as meal delivery carts lacked covers and warming systems, resulting in food being served below the required 135°F. Additionally, the dishwasher failed to reach the necessary hot water temperature of 160°F for proper sanitization, as confirmed by staff and equipment readings.
The facility did not complete or maintain required annual performance evaluations for four nurse aides, as confirmed by missing documentation in their personnel files and facility policy review. The DON was unaware of the missing evaluations, which were the responsibility of the previous DON.
Surveyors found that three opened multi-dose Tuberculin PPD vials in two medication rooms were not dated upon opening, contrary to facility policy requiring nurses to date vials and relabel them with a beyond-use date. Interviews with nursing staff and the pharmacist confirmed the expectation for dating and the importance of this practice for medication efficacy and test accuracy.
Residents were not provided with selective menus to make meal choices, resulting in repeated meals, lack of awareness about upcoming food, and delays in receiving alternative options. Dietary staff shortages contributed to the inability to assist residents with menu selection, despite facility policy requiring this option.
Surveyors found that oxygen tubing for several residents receiving oxygen therapy was frequently unlabeled, undated, and improperly stored, despite facility policy and provider orders requiring weekly changes, labeling, and storage in labeled bags. Nursing staff interviews confirmed responsibility for these tasks, but observations showed lapses in practice and inconsistencies in care plans, leading to a deficiency in the infection prevention and control program.
A resident with an indwelling urinary catheter was repeatedly observed without a privacy cover over the drainage bag, leaving urine visible from the hallway. Although a privacy cover was present, it was not used correctly, and staff interviews confirmed it should have concealed the bag to maintain dignity. The resident's care plan required the use of a privacy cover, but this intervention was not followed.
A resident with dementia and cognitive impairment was physically restrained by an LPN during medication administration after becoming agitated and resistant, with the LPN holding the resident's hands against their stomach. The incident was witnessed by a nursing assistant, and the facility's investigation was incomplete, lacking statements from all relevant staff and proper documentation.
A resident with cognitive impairment and behavioral issues was allegedly hit on the arm by an LPN during medication administration. The facility's investigation into the abuse allegation was incomplete, as not all staff present were interviewed and required documentation was missing, contrary to facility policy.
A resident with dementia and severe cognitive impairment was identified as being at risk for elopement, but the care plan did not address this risk despite assessments and facility policy requiring such interventions. The care plan focused on cognitive issues and confusion, omitting specific measures for elopement prevention.
Two residents receiving oxygen therapy did not have their care plans updated to include required interventions such as administration details, equipment settings, and monitoring for complications. Nursing staff reported only updating interventions quarterly or after significant changes, and observations found unlabeled oxygen tubing in use. Facility policy required more timely and comprehensive care plan updates for oxygen therapy, which were not followed.
A resident with dementia and dysphagia, who had physician orders and care plans requiring 1:1 feeding assistance and supervision due to aspiration risk, was repeatedly observed eating alone without staff supervision. Staff were unaware of the resident's need for feeding assistance, and the resident was not included on the list of those requiring such care, resulting in a failure to follow prescribed aspiration precautions.
A resident with significant mobility and cognitive impairments, who was dependent on staff for bed mobility and hygiene, developed stage II pressure ulcers due to staff failing to follow the care plan for regular turning and repositioning and not ensuring the air mattress was functional. Staff did not consistently provide timely incontinence care or reposition the resident as required, and the care card lacked necessary interventions, leading to inadequate pressure ulcer prevention and care.
Two residents with cognitive impairments and identified elopement risks were able to leave the facility unsupervised due to failures in staff communication, lack of education on elopement risk, and incomplete implementation of care plans and elopement protocols. In both cases, staff were unaware of the residents' whereabouts until after the elopement occurred, and required documentation and reporting procedures were not followed.
Surveyors found that personal care items, including water pitchers and urinals, were not stored in a clean or sanitary manner for a resident with multiple health conditions, with items placed on the floor and overbed table. In a shared bathroom, two residents' personal care items and undergarments were left unlabeled and improperly stored. An LPN confirmed these practices did not meet facility expectations.
The facility did not ensure that an LPN and an RN completed and had documentation for required in-service training on Dementia, Communication, and Behavioral Health. Review of employee files and interviews with staff confirmed that the necessary training records were missing, and the facility lacked a qualified staff member on-site to conduct Dementia training, resulting in noncompliance with facility policy.
Required Communication in-service training was not documented for several direct care staff, including an LPN, an RN, and multiple nursing assistants. Facility staff could not provide evidence that this training was completed as required by policy, citing poor record-keeping by a previous staff development nurse.
The facility did not ensure that three nursing assistants received and had documentation of required Resident's Rights training upon hire and annually, as confirmed by review of employee files and facility policy. Interviews with the current Staff Development RN and DON indicated that the previous staff member responsible for training did not maintain proper records, resulting in missing documentation for these mandatory trainings.
The facility did not ensure that three nurse aides received and had documentation of required in-service training in areas such as Resident Rights, Dementia, Communication, Behavioral Health, and Infection Control. This deficiency was attributed to poor record-keeping by a previous staff member and the absence of a qualified staff trainer for Dementia care.
Three residents with varying medical conditions experienced verbal and physical abuse from a nurse aide, including rough handling, yelling, body-shaming, and dismissive comments. One resident was physically thrown into bed and tightly grabbed, while another was publicly criticized for their weight and incontinence. These actions were corroborated by another staff member and confirmed through interviews and facility documentation, demonstrating a failure to protect residents from abuse and uphold their rights.
Allegations of staff-to-resident abuse involving multiple residents were not reported to the administrator or authorities within the required two-hour window. Staff delayed escalation of concerns, and the accused aide continued working during the shift, contrary to facility policy. Fear of retaliation among staff and residents further hindered timely reporting and investigation.
A resident with dementia and major depressive disorder expressed self-harm intentions to an LPN, who reassured the resident and notified the ADNS. However, the physician was not informed, and there was no documentation of the resident being evaluated by a physician. The facility's policy requires timely notification of changes in condition, which was not followed in this case.
Failure to Conduct and Document Thorough Post-Fall Investigation
Penalty
Summary
The facility failed to ensure a complete and thorough post-fall investigation was conducted and documented for a resident who experienced a fall with injury. The resident had diagnoses including vascular dementia, hypertension, nonthrombocytopenic purpura, psychotic disorder, anxiety, restlessness, and agitation, and was identified on a quarterly MDS as severely cognitively impaired and dependent for ADLs and transfers. The resident’s care plan identified risk for falls and altered mobility, with interventions to reassess fall risk per policy and after each fall, provide a busy blanket when at a table, encourage out of bed as tolerated, and transfer per physician orders. On the date of the incident, an LPN documented that the resident, seated in a wheelchair and leaning forward, was repositioned but refused to lean back and then fell straight forward onto the floor, sustaining a small forehead laceration and requiring transfer to the hospital, where five sutures were placed. Review of the facility’s reportable event form and investigation for this fall documented that the LPN was repositioning the resident in the wheelchair when the resident leaned forward and fell, but the documentation did not show that staff interviews were conducted or that additional investigative measures were taken to identify the root cause of the incident. The DON was unable to provide evidence that staff statements were obtained or that an analysis of the cause of the fall had been completed, despite facility policy directing that, when an incident is witnessed, the supervisor or designee obtain written documentation from witnesses and submit it to the DON and/or Administrator. The same policy also directed that a root cause analysis be conducted to ascertain causative or contributing factors to avoid further occurrences. These required investigative steps were not documented as having been completed for this resident’s fall.
Failure to Prevent Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A resident with Alzheimer's Disease, depression, and anxiety, who was dependent on staff for personal care and had altered cognition, was subjected to verbal abuse by a nurse aide. The resident's care plan required staff to use simple explanations, orientation guides, and to reapproach if the resident refused care. On the evening of the incident, a nurse aide was observed by a charge nurse aggressively gesturing and yelling at the resident while attempting to provide care. The charge nurse reported that the aide shouted phrases such as, "what's up with you? Don't be putting your hands on me, and you're not going to put your hands on me," after the resident became combative. Another LPN in the hallway also heard the aide yelling loudly at the resident, and both nurses confirmed the aide's behavior was extremely loud and could be heard by others. The incident was witnessed by two nurses, and the aide admitted to raising her voice in response to the resident's actions. The resident was known to resist care and could become combative, but staff were instructed to reapproach rather than escalate the situation. The facility's policies required staff to prevent abuse and treat residents with respect and dignity. The investigation substantiated that the nurse aide's actions constituted verbal abuse, as the aide failed to follow the care plan interventions and facility policies designed to protect residents from abuse.
Failure to Timely Report Verbal Abuse Allegation to Law Enforcement
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of verbal abuse to law enforcement in a timely manner. The incident involved a resident with Alzheimer's Disease, depression, and anxiety, who was dependent on staff for personal care and had limited decision-making ability. On the evening in question, a nurse aide was witnessed by two LPNs screaming at the resident while assisting with bedtime care. The nurse aide denied the behavior but was removed from the facility pending investigation. The investigation, conducted by the Assistant Director of Nursing, substantiated the allegation of verbal abuse based on statements from the LPNs who heard the incident. Despite the facility's policy requiring notification of law enforcement within two hours of any abuse allegation, the facility did not notify law enforcement because the abuse was not physical. The facility's documentation and staff interviews confirmed that the event was limited to verbal abuse, and the nurse aide was subsequently barred from future employment at the facility. However, the failure to report the substantiated verbal abuse to law enforcement constituted a violation of the facility's own policy and regulatory requirements.
Failure to Prevent Elopement of Resident Identified as Wandering Risk
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of major depression and epilepsy, was able to leave the facility without staff knowledge or intervention. The resident was assessed as alert and oriented, with a BIMS score of 14, and was independent in ambulation using a walker. Despite being under a voluntary court-appointed conservatorship and having interventions in place such as a wander guard and an elopement care plan, the resident was able to exit the facility and cross a street to access a library on another part of the campus. On the day of the incident, the resident exited through the front doors, triggering the wander guard alarm. The security guard at the front desk deactivated the alarm without interacting with the resident or notifying nursing staff, allowing the resident to leave the building. The security guard later stated he did not realize the alarm was triggered by this resident, as he was unaware of the resident's current status as a nursing home resident with a wander guard. The resident was later observed by an LPN returning from the assisted living facility across the street and was escorted back to the building by staff, with no injuries reported. Further review revealed that the facility did not have a specific wander guard policy, although their general policy on elopements and wandering residents directed that adequate supervision should be provided to prevent such incidents. The lack of staff awareness regarding the resident's elopement risk status and the improper response to the wander guard alarm directly contributed to the resident's unsupervised exit from the facility.
Failure to Provide Timely Incontinent Care as Directed by Care Plans
Penalty
Summary
The facility failed to provide incontinent care as documented in the care plans for two residents who were dependent on staff for personal hygiene and were incontinent of bowel and/or bladder. One resident, with neuromuscular dysfunction of the bladder and hemiplegia, was identified as always incontinent of bowel and dependent on staff for care. Documentation showed that on a specific day, there was no record of incontinent care being provided during the 7AM-3PM shift, despite care plans directing care every two hours. The resident was later found with soiled linens and evidence of inadequate care. Another resident, diagnosed with benign prostatic hyperplasia and also dependent on staff for personal hygiene, was always incontinent of urine and frequently incontinent of bowel. The care plan required incontinent care every two hours and as needed, but documentation for the 7AM-3PM shift was missing. This resident was also found with soaked pads, sheets, and briefs at the end of the shift. Staff interviews and facility documentation confirmed that the assigned nurse aide did not provide or document the required care during the shift in question.
Failure to Provide Required Incontinent Care and Neglect of Dependent Residents
Penalty
Summary
Two residents who were dependent on staff for toileting and personal hygiene did not receive the required incontinent care during an overnight shift. Both residents had care plans directing staff to provide incontinent care every two hours and as needed, to keep them clean and dry, and to ensure the call bell was within reach. Documentation and interviews revealed that a nurse aide failed to provide this care from the evening through the following morning, with no evidence of toileting hygiene being performed during the overnight hours. One resident, with diagnoses including peripheral neuropathy and morbid obesity, reported that after being put to bed in the evening, no staff entered the room to provide care or assist with toileting, and the call bell was not accessible. The resident was found soaked in the morning by the day shift staff. The other resident, with osteoarthritis and a history of recurrent urinary tract infections, similarly reported not receiving any care after a certain time in the evening, and that the nurse aide refused to assist with repositioning in bed, instructing the resident to do it independently despite their dependency. Facility documentation, including nurse notes and incident reports, corroborated the residents' accounts, and point of care records lacked evidence of overnight care being provided. The facility's policies require prevention of neglect and the provision of care as outlined in residents' care plans, but these were not followed during the incident in question.
Failure to Allow Independent Egress for Residents Not at Elopement Risk
Penalty
Summary
The facility failed to ensure that residents who did not meet clinical criteria for residing on a locked unit were provided with a method to independently open secured doors. Observations across multiple days revealed that both nursing units had locked doors requiring a keypad code for entry and exit, and only staff were observed inputting the code for residents and visitors. Signage instructed individuals to call a phone number if staff were unavailable, and knocking on the door or window was discouraged. Review of facility records showed that a significant number of residents on both units were not at risk for elopement, yet were still subject to the same locked-door restrictions as those who were at risk. Interviews with staff and leadership confirmed that all residents, including those who were independent and cognitively intact, were not allowed to leave the units without staff accompaniment. The facility was unable to provide risk assessments or criteria for placement on secured units, and there was no policy available regarding secured/locked units or assessment for such placement. Additionally, the Director of Nursing Services acknowledged that there was no strategy in place to secure only those residents identified as elopement risks, resulting in all residents being restricted regardless of their assessed risk. An incident was observed where a resident was unable to enter their unit after exiting the elevator because they did not have the keypad code, leading to visible distress. Staff interviews indicated that residents on one unit were given the code, while those on the other were not, and there was no clear process for ensuring door security or tracking which residents were permitted to leave. The facility's elopement and wandering policy referenced the use of locks and alarms for residents at risk, but did not address the needs or rights of residents not at risk for elopement.
Failure to Maintain Safe Food and Dishwashing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at safe temperatures and that dishwashing equipment met required sanitization standards. During observations of the tray line, it was noted that meal delivery carts lacked doors and did not use a pellet system to keep plates warm. As a result, test tray food temperatures for vegetables were recorded below the required 135 degrees Fahrenheit, with readings between 121.5 and 130.1 degrees Fahrenheit. Staff interviews confirmed that the carts had always been uncovered and that a pellet system had never been used for food transport within the facility. Facility policy indicated that food should be held at or above 135 degrees Fahrenheit to minimize the risk of foodborne illness, and appropriate transport equipment should be used to maintain safe temperatures. Additionally, the facility failed to maintain the dishwasher's hot water temperature at or above 160 degrees Fahrenheit, as required. Observations showed that the dishwasher's hot water temperatures ranged from 149 to 150 degrees Fahrenheit, which was below the standard indicated on the machine's label. The Dietary Manager confirmed that the wash temperature did not rise above 150 degrees Fahrenheit after several cycles. The facility's food safety best practices and manufacturer guidelines require minimum wash and rinse temperatures to ensure effective cleaning and sanitization of tableware.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete required annual performance evaluations for four nurse aides, as evidenced by the absence of these evaluations in their personnel files. Specifically, for four employees with varying hire dates, no documentation of annual performance evaluations was found, and the facility was unable to provide these records upon request. The Director of Nursing (DNS) confirmed during an interview that performance evaluations should be present in the personnel files and acknowledged that she was unaware the evaluations had not been completed. The DNS also stated that the previous DNS would have been responsible for these evaluations, as she had only recently assumed the role. A review of the facility's policy, dated July 2012, indicated that employees are to receive an evaluation after 90 days of service and then annually thereafter. The policy further specifies that evaluations are to be prepared by supervisors, reviewed by the administrator, and maintained in the employee's personnel file. Despite these requirements, the facility did not have the necessary documentation for the four nurse aides, resulting in noncompliance with their own policy and regulatory expectations.
Failure to Date Multi-Dose Tuberculin Vials Upon Opening
Penalty
Summary
Surveyors identified that in two medication storage rooms, three multi-dose vials of Tuberculin PPD were found opened and stored in the refrigerator without being dated. Specifically, two vials on the K1 unit and one vial on the K2 unit were observed to be partially used but lacked any indication of the date they were first opened. Facility policy requires that the nurse who opens a multi-use vial must date it at the time of opening, and this was confirmed in interviews with both a registered nurse and a licensed practical nurse. Additionally, the facility's policy states that multi-dose vials should be relabeled with a beyond-use date 28 days after opening, and the label should include the initials of the nurse who opened the vial. The pharmacist interviewed confirmed that multi-use vials are considered good for 28-30 days and should be dated upon opening to ensure efficacy and accuracy, particularly for the Mantoux test, which uses Tuberculin PPD. The facility's policy also requires unit managers to perform random checks of opened multi-dose vials for appropriate dating. Despite these policies, the failure to date the vials upon opening was observed during the survey, constituting a deficiency in medication labeling and storage practices.
Failure to Provide Selective Menus for Resident Meal Choices
Penalty
Summary
The facility failed to provide residents with a selective menu, preventing them from making meal selections according to their preferences, allergies, or intolerances. Multiple residents reported that they did not receive menus to choose their meals, were unaware of what food would be served until it arrived, and experienced repeated servings of the same foods. Residents also indicated that if they requested an alternative meal, it could take up to 30 minutes to receive it. These concerns were raised during interviews and Resident Council meetings, with several residents stating that their requests for selective menus had been ongoing and unaddressed. The Interim Dietary Manager confirmed that the lack of staff in the dietary department contributed to the inability to assist residents with filling out selective menus. Review of the facility's Selective Menus policy showed that residents should be offered the option to select their own menus, but this was not being implemented. Residents expressed dissatisfaction with the quality and variety of food, and some noted that staff had not reviewed menus with them for extended periods.
Failure to Label, Date, and Store Oxygen Tubing per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the management of oxygen therapy equipment for four residents with various diagnoses, including COPD, congestive heart failure, Alzheimer's disease, chronic kidney disease, and pneumonia. Facility policy and provider orders required weekly changing, labeling, and dating of oxygen tubing, as well as proper storage of tubing in labeled bags when not in use. However, multiple observations revealed that oxygen nasal cannulas were frequently found unlabeled, undated, and improperly stored, such as being left exposed on chairs, blankets, or near trash cans, rather than in labeled bags. Interviews with nursing staff, including LPNs and RNs, confirmed that it was the responsibility of the 11 PM to 7 AM shift to change, label, and date oxygen tubing weekly. Despite documentation in the treatment administration records indicating that tubing changes were performed as ordered, direct observations contradicted these records, showing that tubing was not consistently labeled or stored according to policy. Staff interviews further revealed a lack of awareness or lapses in following the labeling and storage procedures, with some staff unable to explain why tubing was not properly managed. Additionally, review of resident care plans showed that for some residents, interventions related to changing and labeling oxygen tubing were not included, despite provider orders and facility policy. This inconsistency between documented care, observed practice, and care planning contributed to the facility's failure to implement its infection prevention and control program as required for residents receiving oxygen therapy.
Failure to Maintain Resident Dignity with Catheter Drainage Bag Privacy
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed on multiple occasions lying in bed without a privacy cover over the catheter drainage bag, resulting in urine being visible from the hallway. The privacy cover, although present, was positioned above the drainage bag and not used to conceal it. This was observed on two consecutive days, and the issue was confirmed during interviews with a nursing assistant and the unit manager, both of whom acknowledged that the privacy cover should have been used to cover the drainage bag for dignity purposes. The resident involved had a history of osteoarthritis, neuromuscular dysfunction of the bladder, generalized muscle weakness, and cognitive communication deficit, and was dependent on staff for personal care. The resident's care plan included the use of a privacy cover for the catheter drainage bag as an intervention to maintain dignity. Despite this, staff failed to ensure the privacy cover was properly used, and facility leadership confirmed that the cover should have concealed the drainage bag. No facility policy regarding urinary catheter drainage bags or privacy covers was provided upon request.
Failure to Prevent Use of Physical Restraint During Medication Administration
Penalty
Summary
A resident with Alzheimer's disease, dementia with behavioral disturbances, and anxiety disorder, who was cognitively impaired and dependent for most activities of daily living, was involved in an incident where a staff member failed to keep the resident free from physical restraint. During an attempt to administer medications, the resident became resistant and scratched the LPN's arm. The LPN responded by placing her hands on top of the resident's hands and holding them against the resident's stomach. This action was observed by a nursing assistant, who also reported seeing the LPN hit the resident's arm. The LPN did not call for help or attempt to step away when the resident became agitated, and admitted that holding the resident's hands was a reaction to being scratched. The LPN also stated she had not received training on restraining residents. The facility's investigation into the incident was incomplete, as statements were not obtained from all staff present on the unit, and the Director of Nursing was unable to provide documentation of conflicting witness statements. The facility's policy prohibits abuse and requires thorough investigation and staff training, but these procedures were not fully followed in this case. The incident resulted in the resident being subjected to a physical restraint without medical necessity, in violation of regulatory requirements.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of abuse involving a resident with Alzheimer's disease, dementia with behavioral disturbance, and anxiety disorder. The resident was cognitively impaired, dependent for mobility and toileting, and non-ambulatory. An incident was reported in which a nursing assistant alleged that an LPN hit the resident on the arm while administering medications. The LPN stated that the resident became combative and scratched her, and that she held the resident's hands against their stomach as a reaction. The LPN did not call for help or attempt to step away during the incident, and reported not having received training on restraining residents. The facility's investigation was incomplete, as the Director of Nursing Services (DNS) did not interview all staff members present on the unit at the time of the incident, nor did she interview other residents. The DNS also could not provide documentation of the conflicting statements that led to the determination that the allegation was unsubstantiated. The facility's policy required immediate and thorough investigation of abuse allegations, including interviewing all involved persons and witnesses, but this was not followed in this case.
Failure to Develop Comprehensive Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop a comprehensive Resident Care Plan (RCP) for a resident identified as being at risk for elopement. The resident, admitted in May 2024, had diagnoses including dementia, hypertension, and depression. An Elopement Risk assessment indicated the resident was at risk for elopement and required precautions. The annual Minimum Data Set (MDS) assessment documented severe cognitive impairment, fluctuating behaviors, and the ability to ambulate independently. Despite these findings, the RCP did not address the resident's elopement risk, instead focusing on altered cognition, confusion, and forgetfulness, with interventions such as providing a daily routine and monitoring cognitive changes. A provider progress note further described the resident as alert but disoriented, with poor safety awareness and a tendency to ambulate around the unit. Facility policy requires that residents at risk for elopement receive adequate supervision and care in accordance with a person-centered care plan, including systematic monitoring and management of elopement risk. The facility's Comprehensive Care Plans policy also mandates the inclusion of measurable objectives and timeframes to address all identified needs. The omission of elopement risk from the resident's care plan represents a failure to meet these requirements.
Failure to Update Care Plans for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to revise and update the Resident Care Plans (RCPs) for two residents receiving oxygen therapy, as required by facility policy. For one resident with Alzheimer's disease, COPD, and diabetes, the RCP did not include specific interventions for the administration of continuous or intermittent oxygen, such as the flow rate, type of delivery system, procedures for changing and labeling nasal cannula tubing, or monitoring for complications related to oxygen use. Despite provider orders specifying oxygen administration and tubing changes, these interventions were not reflected in the care plan. Interviews with nursing staff revealed a lack of awareness regarding the resident's oxygen orders and a practice of only updating interventions quarterly or upon significant change, rather than promptly after new orders or assessments. Similarly, another resident with pneumonia, dysphagia, and chronic kidney disease had an RCP that omitted necessary interventions for oxygen therapy, including details on administration, equipment settings, and monitoring for complications. Observations showed the use of unlabeled oxygen tubing, and staff interviews confirmed that care plan interventions were not updated in a timely manner. Facility policy required that care plans for residents on oxygen therapy include specific interventions based on assessments and provider orders, but this was not consistently implemented for the residents reviewed.
Failure to Provide Required Supervision During Meals for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, respiratory failure with hypoxia, and dysphagia did not receive the required supervision during meals as ordered by the physician and outlined in the care plan. The resident had multiple physician orders and therapy notes specifying the need for supervision and 1:1 feeding assistance due to aspiration risk, including after a recent episode of aspiration pneumonia. Despite these orders, the resident was observed eating alone in both the dining room and in bed, without staff present to provide supervision or assistance. Documentation and interviews revealed that the resident was not included on the facility's list of individuals requiring feeding assistance, and staff were unaware of the specific feeding supervision needs. Nursing assistants relied on the resident care cards (RCCs) for guidance but did not consistently review them, leading to a lack of awareness about the resident's requirements. The care plan and RCC both indicated the need for 1:1 feeding assistance and aspiration precautions, but these interventions were not implemented during observed meals. Therapy and nursing staff confirmed that the resident required supervision to manage swallowing difficulties and to prevent further aspiration events. The facility's aspiration precautions protocol required staff to monitor residents for signs of difficulty during meals and to intervene as needed, but this protocol was not followed for the resident in question. As a result, the resident was left unsupervised during meals, contrary to physician orders and established care plans.
Failure to Follow Pressure Ulcer Prevention Plan and Inadequate Pressure Ulcer Care
Penalty
Summary
A resident with multiple medical conditions, including neuromuscular dysfunction, generalized muscle weakness, and cognitive impairment, was identified as being at risk for skin breakdown and pressure ulcers. The resident was dependent on staff for bed mobility, transfers, and personal hygiene, and had an indwelling catheter with a history of bowel incontinence. The care plan included the use of an air mattress and required turning and repositioning every two hours to prevent pressure ulcers. However, the resident care card did not include the turning and repositioning intervention, and staff did not consistently implement or document this requirement. Observations and interviews revealed that the air mattress was left unplugged and nonfunctional after incontinence care, and staff failed to check its operation before leaving the resident's bedside. The resident reported discomfort and inability to feel the mattress functioning. Additionally, the resident experienced significant delays in receiving incontinence care, sometimes waiting up to four hours, and was not repositioned after care was provided. Staff interviews indicated a misunderstanding of the resident's need for regular turning and repositioning, as some believed it was only necessary for bed-bound residents, despite documentation and assessments showing the resident was dependent on staff for bed mobility. Further review showed that the care plan intervention for turning and repositioning every two hours was not added to the resident care card, and no physician's order was obtained for this intervention. As a result, staff did not routinely turn and reposition the resident, contributing to the development and worsening of stage II pressure ulcers on the resident's buttocks. Facility policy required turning and repositioning for residents at risk of pressure injuries, but this was not followed in the resident's care.
Failure to Prevent Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for two residents identified as being at risk. One resident, admitted with diagnoses including alcohol and opiate use disorder, cognitive impairment, major depressive disorder, and diabetes, was assessed as an elopement risk and had a physician's order for a wander guard. Despite these interventions, the resident was able to leave the facility premises after returning from a medical appointment. The nursing assistant escorting the resident was not informed of the elopement risk and left the resident unattended outside the facility to seek help, during which time the resident crossed a busy intersection and continued to a liquor store. The staff member reported not receiving any education or information about the resident's risk prior to the appointment, and the facility did not provide elopement drills or education to other staff following the incident. Another resident, with diagnoses including dementia, hypertension, and depression, was also identified as an elopement risk. This resident, who was severely cognitively impaired and had a history of confusion and wandering, exited the unit through a stairwell door and left the building unaccompanied. The resident re-entered the facility through the front door and was returned to the unit by a security guard. Staff were unaware that the resident was missing until the security guard brought the resident back, and there was no clear record of how long the resident was off the unit. The care plan and care card for this resident did not initially identify the elopement risk, and the resident's photo was not included in the elopement book as required by facility policy. Interviews with staff revealed a lack of communication and education regarding residents' elopement risks. Staff responsible for escorting residents to appointments were not always informed of the risks, and there was confusion about the procedures for reporting and investigating elopement incidents. The facility's policies required reporting and investigation of such incidents, as well as the maintenance of elopement books with photos of at-risk residents, but these procedures were not consistently followed.
Failure to Maintain Sanitary Storage of Personal Care Items
Penalty
Summary
Surveyors observed that personal care items were not stored in a clean and sanitary manner for multiple residents. For one resident with diabetes, anxiety, and chronic kidney disease, water pitchers were repeatedly found on the floor next to the bed, and a urinal containing urine was placed on the overbed table near meal trays. The resident reported having no other place to keep the water pitchers except on the floor. There was no documentation in the clinical record of care refusal or infection prevention education provided to the resident regarding the placement of water pitchers or urinal storage. Additionally, in a shared bathroom used by two residents, personal care items were found unlabeled on top of the toilet tank, and undergarments were observed in an unlabeled basin on the floor beneath the toilet tank. These items remained unlabeled and improperly stored during multiple observations. An LPN confirmed that personal care items in shared bathrooms should be labeled and kept at the resident's bedside, not in the bathroom. The facility did not provide a policy on the storage of personal care items when requested.
Failure to Complete and Document Required Staff Training
Penalty
Summary
The facility failed to ensure that required employee training and in-service education were completed and properly documented for two nursing staff members. Review of employee files for an LPN and an RN revealed that there was no documentation of completed in-service training on Dementia, Communication, and Behavioral Health from the previous year to the present. Despite requests, the facility was unable to provide evidence that these mandatory trainings had been completed for either staff member. The staff development nurse and the Director of Nursing both confirmed that the documentation was missing and attributed the lapse to the previous staff development nurse's failure to maintain adequate records. Further review indicated that the facility did not have a staff member trained to conduct Dementia training on-site, as the only qualified individual worked in another building. Facility policy requires that all staff complete the necessary in-service trainings upon hire and annually, but the required documentation was not found in the employee files. The policy also states that the training program should be maintained effectively for all employees, but the lack of current training records for the LPN and RN demonstrated noncompliance with this requirement.
Failure to Document Required Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that required Communication in-service training was completed and documented for all direct care staff members reviewed. Specifically, the employee files for five staff members, including licensed nurses and nursing assistants, did not contain evidence that the mandated Communication training had been provided from the time of hire through the present. Despite requests, facility staff were unable to produce documentation confirming completion of this training for any of the five employees. The absence of this documentation was noted for both newly hired and long-term staff, with gaps identified for multiple years in some cases. Interviews with the current Staff Development RN and the Director of Nursing revealed that the lack of documentation was attributed to the previous staff development nurse's failure to maintain adequate records. Both confirmed that, according to facility policy, Communication in-service training is required upon hire and annually for all staff. However, the necessary records were not available for review, and the current staff were unable to verify that the training had been completed as required.
Failure to Document and Complete Required Resident's Rights Training for Staff
Penalty
Summary
The facility failed to ensure that required Resident's Rights training and in-service education was completed and documented for three nursing assistants. Review of employee files for these staff members showed that, despite their active employment during the review period, there was no documentation of Resident's Rights training upon hire or as part of annual in-service requirements. The facility was unable to provide evidence that these trainings had been completed, even after requests for documentation. Interviews with the current Staff Development RN and the Director of Nursing revealed that the prior Staff Development nurse did not maintain adequate records of completed trainings. Both acknowledged that it was facility policy for staff to complete Resident's Rights training upon hire and annually, but the necessary documentation was missing from the employee files. Review of facility policy confirmed the requirement for an effective training program, including annual in-service training for all employees.
Failure to Provide and Document Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that required in-service training and education were completed and documented for three nurse aides. Specifically, for two recently hired nurse aides, there was no documentation in their employee files to show that they had received mandatory training in areas such as Resident Rights, Dementia, Communication, and Behavioral Health from the date of hire to the present. For a third nurse aide, who had been employed since 2021, there was no documentation of annual in-service training in Resident Rights, Dementia, Infection Control, Communication, and Behavioral Health for the most recent years reviewed. Despite requests, the facility was unable to provide evidence that these trainings had been completed for any of the three nurse aides. Interviews with the Staff Development RN and the Director of Nursing revealed that the lack of documentation was due to poor record-keeping by the previous Staff Development nurse. Additionally, the facility did not have a staff member trained to conduct Dementia training on-site, as the only qualified individual worked in another building. Facility policy requires that staff complete the necessary in-service trainings upon hire and annually, but the required documentation was not available for the nurse aides in question.
Failure to Prevent Staff-to-Resident Abuse and Verbal Mistreatment
Penalty
Summary
The facility failed to protect three residents from verbal and physical abuse by a nurse aide. One resident, who had diagnoses including Parkinson's, depression, diabetes, and dementia, required moderate assistance with daily living and was unable to make decisions regarding daily tasks. This resident reported that the nurse aide was rough during care, yelled frequently, and on one occasion, picked the resident up from behind and threw them into bed, causing fear. The resident also described the aide grabbing their arm tightly and yelling at them to get into bed. Another resident, with chronic obstructive pulmonary disease, muscle weakness, and depression, was dependent on staff for daily living activities and had no memory deficits. This resident reported that the same nurse aide often yelled, complained about her job, made rude comments about the resident's weight, and criticized them in front of others. The resident avoided calling for help when this aide was working and described an incident where the aide was dismissive and critical after an episode of incontinence, as well as witnessing the aide push and tightly grab another resident's arm. A third resident, diagnosed with diabetes, chronic kidney disease, and dementia but independent in daily living, reported being yelled at by the nurse aide regarding hearing and the need for hearing aids. Another staff member corroborated these accounts, stating they witnessed the aide yelling at a resident, pushing their head back, and making body-shaming comments to residents. Facility documentation and interviews confirmed that the aide's actions violated facility policies on abuse, neglect, and resident rights.
Failure to Timely Report and Respond to Alleged Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident verbal and physical abuse to the Administrator and/or designee within the required two-hour timeframe, as outlined in facility policy. On 11/24/24, three separate incidents involving a nurse aide and three residents occurred during the 3-11PM shift. A nurse, who wished to remain anonymous, reported concerns about the nurse aide's conduct to the DON the following day, rather than immediately. The DON confirmed that another nurse aide had initially reported concerns to the nurse on the day of the incidents, but the nurse did not escalate the matter or remove the alleged perpetrator from duty, allowing the aide to continue working that shift. Interviews revealed that staff and residents were hesitant to provide information due to fear of retaliation from the accused nurse aide. Review of the facility's Abuse, Neglect, and Exploitation policy indicated that any suspicion of abuse or neglect requires immediate investigation and reporting to the administrator, state agency, adult protective services, and law enforcement within two hours. The facility did not adhere to this policy, as the allegations were not reported in the required timeframe and the alleged victims were not immediately protected.
Failure to Notify Physician of Resident's Self-Harm Verbalization
Penalty
Summary
The facility failed to ensure timely notification of a physician or APRN after a resident expressed self-harm intentions. The resident, diagnosed with dementia and major depressive disorder, had a history of suicidal ideation. On the date in question, the resident expressed feelings of depression and asked an LPN if she had anything to kill themselves with. The LPN reassured the resident and offered a social services visit, which was declined. The LPN notified the ADNS, who was the acting RN Supervisor, but there was no documentation that the physician was informed of the resident's self-harm verbalization. Interviews revealed that the LPN was unaware if the resident was placed on one-to-one supervision or if the physician was notified. The DON later communicated with the ADNS, who confirmed she was not informed of the incident. The facility's policy requires licensed nurses to notify an attending physician and responsible party of a change in condition within 24 hours, which includes changes in mental status or behavior. However, there was no evidence that the resident was evaluated by a physician or that the 24-hour report sheet was reviewed by the DON.
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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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