Riverside Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Hartford, Connecticut.
- Location
- 745 Main St, East Hartford, Connecticut 06108
- CMS Provider Number
- 075257
- Inspections on file
- 34
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Riverside Health & Rehabilitation Center during CMS and state inspections, most recent first.
Smoking Area Contained Hazards and Debris: The facility failed to keep the resident smoking area free from accident hazards. Surveyors observed a wooden pallet on the ground in the smoking area, a detached ash/butt receptacle lying on its side, and numerous cigarette butts between the pallet slats. Staff were unsure why the pallet was there or why butts were on the ground, and the DON/maintenance leadership stated environmental staff were responsible for cleaning and supervising the area during smoking times.
Ventilator and suction equipment were not consistently changed per facility policy for residents with trachs and ventilators. Two residents had ventilator circuit tubing dated from an earlier month, and one resident’s suction canister was still dated from the prior month despite orders for weekly suction equipment changes. RT and the DON of Respiratory stated ventilator circuit components and suction equipment were to be changed on a regular schedule, but the observed equipment did not match those expectations.
Medication Storage and Labeling Deficiencies: An RN found torn labels on resident-specific chlorhexidine bottles in a med room, and a locked narcotics box in the med refrigerator was not permanently affixed. In another med room, food items for residents were stored with medications, including sandwiches, packaged snacks, and an open cookie package, while a mini refrigerator used for narcotics was also not permanently affixed and held morphine and lorazepam. Staff stated they were unsure why some items were stored in the med rooms instead of the nourishment area.
Failure to Honor Resident Meal Choices: A resident with CHF, respiratory failure, and lymphedema, and another resident with DM, CKD, and weight changes, were documented as cognitively intact yet repeatedly did not receive requested meal items or substitutions they selected on menus. Surveyors found meal tickets and tray items did not match handwritten requests, staff did not consistently notify residents when selections could not be filled, and care plans did not consistently reflect food preferences or meal-choice communication needs. Other sampled residents also reported menu substitution concerns, with inconsistent documentation of discussions about unavailable items.
A resident with cardiac disease developed marked bradycardia, but staff did not timely notify the correct provider; the first documented provider call occurred many hours later, and the resident was later hospitalized with complete heart block and received a pacemaker. In a separate case, an LPN gave a resident’s scheduled Robaxin doses outside the allowed time window on multiple occasions without documentation or timely notification to the supervisor or APRN, despite facility policy requiring timely provider notification for late or otherwise not administered medications.
Failure to complete timely significant change assessment after ADL decline: A resident with a neuromuscular disorder, pressure ulcers, and DM had worsening ADL dependence, including increased assistance needs for eating, toileting, dressing, bed mobility, transfers, and bathing, along with an additional stage 3 pressure ulcer. RN stated the resident should have had a significant change MDS completed when the decline was recognized, but the decline in ADL status was overlooked.
Care plan not updated for PASRR status and contractures. A resident with depression had PASRR findings that changed over time, but the care plan remained listed as PASRR in progress and staff could not show it had been revised to reflect the updated PASRR results. Another resident with dementia, severe ROM limits, and contractures had APRN and therapy documentation of worsening stiffness and attempted splinting, yet the care plan lacked specific directions for the contractures and related care needs.
A resident with CHF, CAD, and hypercholesterolemia had an order for Metoprolol ER with hold parameters. An LPN noted bradycardia and did not give the medication, but the resident’s provider was not properly notified of the change in cardiac status. The resident was later sent to the hospital with HR in the 30s and complete heart block, and received a dual-chamber pacemaker.
Wander Guard devices remained on two residents after orders to discontinue them had ended, including one resident on a secure unit and another with an elopement care plan that did not include the device. In addition, a resident with chronic pain received scheduled Robaxin doses late, with no documented reason for the delay and no evidence the LPN notified the supervisor or APRN as expected.
Failure to address significant weight loss: A resident with dysphagia, dementia, MS, and feeding difficulties had repeated significant weight loss while on a regular, whole texture, thin liquid diet. The care plan identified the resident as at risk for weight loss, but the record showed no added MD orders or other nutrition interventions, and the RD acknowledged awareness of the loss but did not follow up.
Incomplete RN documentation after a resident's change in condition: a resident with CHF, CAD with angina, and hypercholesterolemia had bradycardia with heart rates in the 30s to 40s, and an LPN notified an RN. The RN said she assessed the resident and thought the resident seemed okay, but she forgot to document the RN assessment in the clinical record, despite the facility policy requiring a complete physical and mental evaluation with findings documented.
Two residents with histories of anxiety and aggression engaged in a verbal altercation that escalated to a physical assault in a common area, resulting in one resident sustaining serious facial injuries and requiring hospital transfer. The incident was witnessed by others and occurred despite both residents being identified as having aggressive tendencies in their care plans.
A resident with dementia and a history of falls experienced increased mobility and exhibited wandering and agitation over several days. Despite these changes, staff did not timely reassess the resident's elopement risk, as required by facility policy. The resident subsequently eloped from the facility and was found outside without injury.
A resident with a history of psychiatric disorders and suicidal ideation expressed intent to self-harm and was hospitalized twice for evaluation. Despite these incidents, the care plan was not revised to include specific interventions for managing suicidal behaviors, and facility policy requiring care plan updates after such events was not followed.
A resident with a history of mental disorders and repeated suicidal ideation was not adequately protected from environmental hazards, as staff failed to promptly remove access to knives and other potentially harmful items despite multiple incidents of self-harm attempts and hospital transfers. The care plan was not timely updated to address these risks, and hazardous items remained accessible in the resident's environment.
A resident with a history of stroke, dysphagia, and cognitive impairment did not receive the required supervision during a meal, as specified in their care plan. Due to miscommunication and incorrect documentation on care cards, staff believed only setup assistance was needed, leading to the resident being left unsupervised and experiencing a choking episode that required emergency intervention.
A nurse failed to accurately transcribe a hospital discharge order for Quetiapine, resulting in a resident receiving the medication in the morning instead of at night as prescribed. The error was not caught during the required double-check process, and the resident, who had multiple neuropsychiatric diagnoses, was subsequently evaluated for somnolence related to medication timing.
A resident with diabetes and end stage renal disease experienced multiple episodes of low blood sugar, including critically low readings and the need for Glucagon administration. Despite physician orders and facility policy requiring provider notification in these situations, staff did not inform the provider of these events, and documentation of such notifications was absent.
A resident dependent on staff for toileting and transfers was left unattended on the toilet for over an hour after a nurse aide failed to inform other staff before leaving the unit. Other staff responded to the call light but did not assist or notify anyone, resulting in the resident not receiving timely hygiene and transfer assistance as required by their care plan.
Staff did not consistently follow physician orders and facility policy for treating and monitoring hypoglycemia in a resident with diabetes and end stage renal disease. After multiple low blood sugar readings, required rechecks and provider notifications were not documented, and a scheduled endocrinology follow-up was missed and not rescheduled.
A resident with multiple medical conditions who required two staff for transfers using a mechanical lift was transferred by only one nurse aide, despite physician orders and facility training materials specifying the need for two staff. The aide was aware of the requirement but did not seek assistance, and the incident was confirmed through documentation and interviews.
A resident with diabetes and end stage renal disease experienced multiple episodes of hypoglycemia, during which the facility failed to maintain accurate physician orders for Glucagon administration and did not document nursing actions, symptoms, or provider notifications as required by facility policy. Staff confirmed that nursing notes were missing for these events and could not explain the lack of documentation.
Smoking Area Contained Hazards and Was Not Kept Free of Debris
Penalty
Summary
The facility failed to ensure the resident smoking area was free from accident hazards. On 1/22/2026 at 10:02 AM, observation of the outdoor smoking area with Environmental Worker #3 showed the area was located to the right outside the exit door in a parking space under a full overhang of the building. A wooden pallet was on the ground, and on the pallet was the bottom of an ash/butt receptacle with its long neck piece detached and lying on its side. Another receptacle was located to the right side of the area, and numerous cigarette butts were observed on the ground between the slats in various locations of the wooden pallet. During interview, Environmental Worker #3 was unsure why the pallet was on the ground and stated the receptacle may have been emptied but did not know why cigarette butts were on the ground within the pallet. The Administrator stated that environmental services were responsible for keeping the smoking area clean and safe, and the Director of Environmental Services/Maintenance stated Environmental Workers #1 and #3 were responsible for checking and keeping the smoking area clean, including supervising the two smokers and checking the area during smoking times for butts, cleaning the area, and emptying trash. Later, the Administrator observed the smoking area clean and stated the pallet had been placed in the parking spot used for the smoking area to prevent someone from parking there, but it should not have been placed there.
Ventilator and suction equipment not changed per policy
Penalty
Summary
The facility failed to ensure that ventilator equipment and suction equipment were consistently changed according to facility policy for residents with ventilators and tracheostomies. Resident #76 had chronic respiratory failure and ventilator dependence, and a 5-day MDS identified short-term and long-term memory problems and the need for tracheostomy and invasive mechanical ventilator care. A physician order dated 1/13/2026 directed that the ventilator circuit be changed on the first Saturday of every month starting 2/7/2026, and the record did not identify an earlier order for ventilator circuit changes. During an observation on 1/15/2026, Resident #76 was connected to the ventilator and the ventilator circuit tubing was dated 12/7/2025. Resident #198 had acute and chronic respiratory failure with carbon dioxide retention and ventilator dependence, and a quarterly MDS identified memory problems, dependence for self-care, and the need for tracheostomy care. Physician orders dated 12/26/2025 directed suction via tracheostomy every shift and changing the suction canister and tubing weekly and as needed. The TAR documented suction tubing and canister changes on 1/6/2026 and 1/13/2026, but respiratory therapy notes did not identify respiratory incidents on those dates. On 1/15/2026, the suction canister contained about 300 mL of green fluid and was dated 12/30/2025. Resident #261 had chronic respiratory failure with hypoxia and ventilator dependence, and a quarterly MDS identified memory problems and the need for tracheostomy and invasive mechanical ventilator care. A physician order dated 1/13/2026 directed ventilator circuit changes on the first Thursday of every month starting 2/5/2026, with no earlier order found in the record. On 1/15/2026, Resident #261 was connected to the ventilator and the ventilator circuit tubing and inhalation filter were dated 12/7/2025. RT stated suction canisters and tubing should be changed weekly and ventilator circuit tubing monthly, and the Director of Respiratory stated ventilator circuit tubing, including inhalation and exhalation filters, was a single-use component that should be changed in the first week of the month.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted professional principles in 3 of 4 medication rooms observed. In the 3AB medication room, two bottles of chlorhexidine gluconate 0.12% oral rinse were found on a shelf with other resident-specific medications, but the resident labels were torn and did not allow identification of the residents to whom the bottles belonged. In the same room, the medication refrigerator contained a locked narcotics box affixed to a shelf, but the shelf was not permanently affixed to the refrigerator and could be readily removed. Inside the box were five bottles of lorazepam 3 mg/1 mL, including three unopened bottles with 30 mL each and two open bottles with over 22 mL each. The nurse manager stated she was not sure why the chlorhexidine bottles had torn labels and said medications no longer being used would be set aside for return to the pharmacy or destruction; she also stated she was not aware the narcotics box needed to be permanently affixed. In the 3CD medication room, a food refrigerator contained an egg sandwich and a peanut butter sandwich with resident room numbers. On the medication room counter were multiple individually packed shelf-stable fruit smoothies and crackers with resident names and room numbers, along with an open 1-pound package of cream-filled chocolate sandwich cookies that was not effectively sealed. The LPN stated the sandwiches were for resident evening snacks but was unsure why they were kept in the medication room instead of the nourishment refrigerator, and said the smoothies, crackers, and cookies were food items brought in by family for specific residents and kept there for safekeeping. In the 2CD medication room, a black mini refrigerator on a counter contained an unopened 30 mL bottle of morphine oral concentrate 20 mg/5 mL and an unopened 30 mL bottle of lorazepam 2 mg/1 mL oral solution; the refrigerator was not permanently affixed and could be readily moved. The LPN stated the refrigerator did not have a lock box or separate compartment because the whole mini refrigerator was used for narcotics. The DNS later stated the lock box and narcotics refrigerator had been addressed after surveyor observations and that food items, including those belonging to residents, should have been stored in the nourishment room and not in the medication room.
Failure to Honor Resident Meal Choices
Penalty
Summary
The facility failed to support residents in exercising their right to make choices regarding meals by not honoring selected menu items, not informing residents when substitutions were made, and not consistently incorporating food preferences into care planning. Surveyors reviewed observations, clinical records, facility documentation, menu selections, policies, and staff interviews for 10 sampled residents and found repeated breakdowns in how meal choices were collected, entered, communicated, and served. Resident #220 had diagnoses including heart failure, respiratory failure, and lymphedema, and was documented as cognitively intact and independent with feeding and oral hygiene. The resident stated that weekly select menus and daily meal selections were completed, but requested items such as sausage for breakfast, a ham sandwich, a small salad instead of chef salad, and fresh fruit were not provided. Observations showed breakfast trays without sausage, and meal tickets did not reflect the resident’s handwritten requests. Interviews with dietary leadership and the dietitian showed that sausage was not an everyday item, that handwritten requests were not always entered into the meal tracker system, and that the resident had not been notified when requested items could not be filled. The dietitian also confirmed that the resident’s handwritten selections did not match the kitchen menu for at least one meal and would not be served as written. For Resident #238, records showed diagnoses including type 2 diabetes mellitus with circulatory complications, CKD stage 3 with anemia, hypothyroidism, and adjustment disorder with anxiety. The resident was cognitively intact, required assistance with eating and oral hygiene, and had significant weight changes while receiving a therapeutic diet. Documentation showed repeated meal dissatisfaction, including requests for milk with breakfast and dinner, reports that meals were unacceptable, and concerns that preferred items such as grilled cheese sandwiches and salads were no longer appearing on the menu because of renal restrictions. The record did not show that these preferences or communication needs were consistently incorporated into the care plan, and staff interviews confirmed there was no consistent process to notify residents when selections were changed. Additional sampled residents, including #82, #121, #55, #71, #183, #163, #174, and #290, also expressed concerns about menu substitutions, and their records showed inconsistent or absent documentation of discussions about unavailable selections or food preferences.
Failure to Notify Provider of Change in Condition and Late Medication Administration
Penalty
Summary
The facility failed to ensure timely physician notification when Resident #195 experienced a change in cardiac status. Resident #195 had diagnoses including heart failure and atherosclerotic heart disease with angina and had an order for metoprolol succinate extended release 25 mg, 1/2 tablet twice daily, held for systolic blood pressure under 110 or heart rate under 55. On 1/5/2026, vital signs documented a heart rate of 40 beats per minute in the morning and 36 beats per minute in the evening, with an irregular rhythm noted later that day. The clinical record did not reflect notification of the APRN or physician at the time the low heart rate was identified in the morning. Facility interviews showed that LPN #5 recognized the resident was bradycardic and notified RN #2, who assessed the resident and stated she notified APRN #1, although APRN #1 later stated she was not the resident’s provider and that APRN #2 should have been notified. APRN #2 stated she was not notified of the change in cardiac status. The facility’s on-call log showed the first documented call to APRN #4 occurred at 9:24 PM, more than 13 hours after the first episode of bradycardia. The resident was then sent to the emergency room, where hospital documentation showed the resident arrived with a heart rate in the 30s and was found to be in complete heart block, with an elevated NT-proBNP level, and was admitted for treatment and placement of a dual-chamber pacemaker. The facility also failed to ensure physician notification when Resident #227’s scheduled pain medication was not administered timely. Resident #227 had diagnoses including chronic pain and major depressive disorder and received Robaxin 750 mg three times daily for muscle spasms. The facility identified the medication should be administered within a 2-hour window, one hour before or after the scheduled time. The MAR audit showed the 8:00 AM dose was given at 9:32 AM on one day and at 11:10 AM on another day, with the 12:00 noon dose then given at 1:02 PM, and there was no documentation explaining the late administration. Interviews with the DNS, ADNS, LPN #8, and APRN #3 confirmed the doses were late and that the physician/APRN should have been notified. The DNS stated the late administration may have been related to the influenza outbreak and increased medication pass workload, but the record still lacked documentation of notification or explanation for the delayed doses. APRN #3 stated notification was expected when the medication was given outside the allowed time window and that the timing of the remaining doses would have been adjusted.
Failure to Complete Timely Significant Change Assessment After ADL Decline
Penalty
Summary
The facility failed to ensure a significant change in status assessment was completed timely for Resident #10 after the resident experienced a decline in condition. Resident #10 had diagnoses including a neuromuscular disorder, pressure ulcers, and diabetes mellitus. The quarterly MDS assessment dated [DATE] showed the resident was cognitively intact and required varying levels of assistance with ADLs, including set-up and clean-up for eating, superficial touching assistance for personal hygiene, partial moderate assistance for toileting and upper body dressing, dependence for lower body dressing, and supervision/touching assistance for rolling in bed and transfers. That assessment also documented one stage 3 pressure ulcer present on admission and weight loss greater than 5% in the last 30 days or 10% in the last 6 months. The quarterly MDS assessment dated [DATE] later showed further decline, with the resident requiring set-up and clean-up assistance for eating and being dependent for toileting, upper and lower body dressing, bed mobility, transfers, and bathing/showering. It also documented two stage 3 pressure ulcers, reflecting the development of one additional pressure ulcer since the prior assessment on 7/25/2025. The care plan dated 11/06/2025 identified deficits in self-care and included interventions to provide substantial/maximum assist for bathing, dressing, and toileting and to monitor, document, and report changes including declines in function. During interview and record review on 1/22/2026, RN #4 stated Resident #10 should have had a significant change MDS assessment completed in October 2025 because of the ADL declines from the previous assessment and refusals to get out of bed were contributing to the decline, but the decline in ADL status was overlooked.
Care Plan Not Updated for PASRR Status and Contractures
Penalty
Summary
The facility failed to timely review and revise the comprehensive care plan for a resident with diagnoses including anxiety and major depression in relation to PASRR status. The resident’s PASRR Level 1 screen on 8/29/25 approved a 30-day hospital exemption for a suspected or confirmed mental health disability, and the care plan on 9/6/25 identified PASRR as in progress with interventions related to monitoring mental health symptoms and contacting the treating psychiatrist. A social work note on 9/8/25 stated the PASRR Level 2 was completed and that a psychiatry referral had been made, but the care plan was not documented as updated to reflect those results. A later PASRR Level 1 screen on 9/15/25 stated the resident did not require a Level 2 screen and noted the resident had a current diagnosis of major depression but no indicators requiring further evaluation at that time. Despite this change in PASRR status, the care plan dated 12/30/25 still listed PASRR as in progress with the same interventions. During interview and record review on 1/21/26, the Director of Social Services was unable to provide documentation showing the care plan had been updated and revised on 9/15/25 or 12/15/25, and stated she was responsible for tracking PASRRs and updating care plans. The facility also failed to revise the care plan for a resident with contractures and severe mobility limitations. The resident had diagnoses including contracture of the right wrist and elbow, legal blindness, bilateral hearing loss, and dementia, and the admission MDS showed severe cognitive impairment, range-of-motion limitations in all extremities, and dependence on staff for all ADLs. APRN notes documented contracted upper and lower extremities and severe muscle stiffness, and therapy documented that splints were attempted but were not used because of extreme resistance and concern for skin injury. On 1/15/26, the resident was observed asleep in bed with the right hand bent at the wrist and fingers curled inward, with no splints visible, and staff interviews confirmed the care plan did not include directions for the contractures even though the resident’s condition and related care needs had been documented.
Failure to Notify Provider of Bradycardia and Change in Cardiac Status
Penalty
Summary
The nursing facility failed to ensure services were provided in accordance with professional standards for a resident with heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia. The resident had an order for Metoprolol succinate ER 25 mg, 1/2 tablet by mouth twice daily, to be held if systolic blood pressure was under 110 or heart rate was under 55. On 1/5/2026 at 8:20 AM, the resident’s vital signs showed a heart rate of 40 beats per minute with a regular rhythm, and the TAR showed the LPN did not administer the Metoprolol at 9:00 AM. The resident’s record also identified severely impaired cognition on the annual MDS and congestive heart failure on the RCP. Later that day, the resident was sent to the hospital and arrived with a heart rate in the 30s and was found to be in complete heart block. Hospital documentation showed an elevated NT-proBNP level of 2693 pg/ml, and the resident was admitted, treated, and received a dual-chamber pacemaker. Interviews showed the LPN notified the unit manager of the bradycardia, but the APRN who was the resident’s provider was not notified at that time. The unit manager stated she assessed the resident and notified an APRN, but the APRN stated she was not the resident’s provider and that APRN #2 should have been notified. APRN #2 stated she was not notified of the change in cardiac status, and the evening supervisor and charge nurse stated they were not informed during shift report. The facility’s Change in Condition Notification policy stated the licensed nurse will notify the resident, healthcare provider, and family/legal representative when there is a change in condition.
Wander Guard devices not removed after orders discontinued; pain medication given late without provider notification
Penalty
Summary
Resident #49, who had dementia, a non-traumatic subarachnoid hemorrhage, and difficulty walking, was identified as being at risk for elopement and was placed on a secure unit. A physician order dated 1/25/2025 directed discontinuation of checking the expiration date on the Wander Guard, but observations on 1/15/2026, 1/16/2026, and 1/20/2026 showed the Wander Guard still on the resident’s left ankle. Staff interviews confirmed the device remained in place even though the order had been discontinued, and the nurse and DNS stated the device should have been removed when the order ended. Resident #269, who had dementia, traumatic subarachnoid hemorrhage, and difficulty walking, was also identified as at risk for elopement and was on a secure unit. The care plan included elopement precautions and constant supervision outside, but it did not include placement of a Wander Guard. A physician order dated 8/14/2025 directed discontinuation of checking the Wander Guard function, yet observation on 1/16/2026 showed the Wander Guard still on the resident’s right ankle. The LPN stated she was unaware the order had been discontinued, and the DNS stated the device should have been removed on the date the order was discontinued. Resident #227 had chronic pain and major depressive disorder and received scheduled Robaxin 750 mg three times daily for muscle spasms. Review of the MAR showed the 8:00 AM dose was administered at 9:32 AM on 1/1/2026 and at 11:10 AM on 1/2/2026, with the 12:00 noon dose on 1/2/2026 given at 1:02 PM, and there was no documented reason for the late administration. The DNS, ADNS, and APRN stated the physician/APRN should have been notified when the medication was given outside the expected time window, and the APRN stated the remaining dose times would have been adjusted if notified.
Failure to Address Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not implemented for a resident with dysphagia, dementia, multiple sclerosis, and feeding difficulties. The resident’s physician ordered a regular, whole texture, thin liquid house diet, and the care plan identified the resident as at risk for weight loss related to inadequate calorie intake and dementia, with interventions to notify the RD, family, and MD of significant weight changes and to obtain and record weights per facility protocol. The resident’s weight decreased from 153.4 lbs. to 140.4 lbs. in one month, then later to 134 lbs., reflecting an 8.5% loss over one month and a 12.8% loss over six months. The clinical record from 10/1/2025 through 1/3/2026 did not reflect additional physician orders for nutritional supplements or other interventions to address the weight loss. RN #2 stated Nutrition was responsible for monitoring residents with weight loss and that Nutrition did not address the resident’s significant losses in October 2025 or January 2026. The Dietitian stated he was aware of the October 2025 weight loss but did not implement interventions because he was thinking about hospice services, and then forgot to follow up; he also stated that an intervention in October 2025 could have slowed the resident’s weight loss.
Incomplete RN Documentation After Bradycardia
Penalty
Summary
The facility failed to ensure the clinical record was complete and accurate by not documenting an RN assessment for Resident #195 after a change in condition. Resident #195 had diagnoses including heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia. The annual MDS identified a BIMS score of 7, indicating severely impaired cognition, and noted the resident required setup assistance with personal hygiene and was independent with bed mobility and transfers. The resident's care plan included interventions to give cardiac medications as ordered, monitor vital signs, notify the medical doctor of significant abnormalities, and provide oxygen as ordered. On 1/5/2026, the vital signs report showed Resident #195 had a heart rate of 40 beats per minute with a regular rhythm in the morning and 36 beats per minute with an irregular rhythm in the evening. An LPN stated she observed the resident was bradycardic with a heart rate between 35 and 40 beats per minute and notified RN #2. RN #2 stated she was told the resident's heart rate was 35 to 40 beats per minute, assessed the resident, and thought the resident seemed okay with a heart rate maybe 60 beats per minute, but she forgot to document the RN assessment in the clinical record. The DNS stated that when a resident experiences a change in condition, an RN assessment is expected to be completed and documented, and the facility's Change in Condition Notification policy required a complete physical and mental evaluation with findings documented in the medical record.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident following a verbal altercation. The incident involved two residents, both of whom had documented histories of anxiety and mood disorders, and were identified as having the potential for verbal aggression. Both residents were alert, oriented, and independently mobile in wheelchairs. Earlier in the day, a verbal altercation took place between the two residents on one of the facility's units. Later, in a common area near the front lobby, one resident approached the other and initiated a physical assault by punching the resident multiple times in the face. The assault was witnessed by other residents, who notified staff, prompting an in-house emergency response. The assaulted resident sustained significant injuries, including an open fracture of the nasal bone, hematoma of the nasal septum, periorbital hematoma, and an open fracture of the ethmoid bone, and was subsequently transferred to the hospital for treatment. Documentation and interviews confirmed that the physical altercation was preceded by a verbal dispute and that the facility's care plans had identified both residents as having aggressive tendencies. Despite these risk factors, the incident escalated to physical violence, resulting in harm to one resident. The facility's abuse policy states that residents have the right to be free from abuse, including abuse by other residents.
Failure to Timely Reassess Elopement Risk Following Change in Resident Condition
Penalty
Summary
The facility failed to timely reassess a resident's risk for elopement and wandering following significant changes in the resident's condition and mobility status. The resident, who had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and a history of falls, was initially assessed as non-ambulatory and not at risk for elopement. However, subsequent physical therapy assessments documented progressive improvement in ambulation, with the resident eventually able to walk up to 100 feet with minimal assistance. Despite these changes, the resident's elopement risk was not reassessed as required by facility policy. Over several days, nursing notes documented the resident exhibiting agitation, wandering within their room and into other residents' rooms, and difficulty with redirection. The resident was also involved in an incident with a roommate, which led to a temporary hospital transfer. Upon return, the resident continued to display wandering behaviors and increased mobility, but no updated elopement or wander risk assessment was completed during this period. The deficiency culminated when the resident eloped from the facility after being left unattended for a brief period. The resident was found outside the building and returned without injury. Review of facility documentation and interviews confirmed that a reassessment of elopement risk should have been conducted when the resident began exhibiting increased mobility, agitation, and wandering behaviors, but this was not done in a timely manner.
Failure to Revise Care Plan After Suicidal Ideation Incidents
Penalty
Summary
The facility failed to review and revise the care plan with appropriate interventions for a resident with a history of suicidal ideation and multiple psychiatric diagnoses, including paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. Despite physician orders to monitor behavioral occurrences every shift and an existing care plan that addressed general behavioral issues, the care plan did not specifically address the resident's suicidal ideations with intent or include personalized interventions following incidents where the resident expressed intent to self-harm. Notably, after the resident verbalized wanting to harm themselves with a weighted silverware knife and was subsequently transferred to the ER for psychiatric evaluation, there was no documented revision to the care plan upon their return from the hospital. Further, after additional episodes where the resident reported hearing voices instructing them to harm others and was again transferred for psychiatric evaluation, the clinical record still did not reflect any updates or new interventions in the care plan. Interviews with the Director of Nursing confirmed that the care plan was not revised after these incidents, and there was uncertainty about whether updates were necessary. Facility policy required episodic review and revision of the care plan, especially after hospital readmissions, but this was not followed in these instances.
Failure to Remove Environmental Hazards and Implement Safety Interventions for Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to remove environmental hazards and implement appropriate safety interventions for a resident with a history of mental disorders, including suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. The resident expressed suicidal ideation and intent on multiple occasions, resulting in four transfers to the emergency department over a 38-day period. Despite these incidents, the clinical record showed no timely revisions to the resident's care plan or mitigation of environmental risk factors, such as access to knives and other potentially harmful items. The resident was observed on several occasions with access to silverware, including butter knives, and was seen rubbing a knife against their wrist while expressing intent to self-harm. Staff interviews and documentation revealed that the resident was able to obtain knives from meal trays, and there was a lack of immediate action to restrict access to these items following repeated episodes of suicidal ideation and self-harm attempts. The facility's documentation did not reflect prompt updates to the care plan or consistent removal of environmental hazards, such as corded call lights and phone chargers, even after the resident's behaviors escalated. Multiple staff members, including nursing and medical personnel, indicated that access to knives and metal silverware did not pose a safety risk, despite the resident's documented history and visible evidence of self-harm. Observations confirmed that hazardous items remained accessible in the resident's environment after incidents of suicidal ideation and self-harm. The facility's failure to promptly identify and address these environmental risks contributed to repeated episodes of suicidal behavior and inadequate protection for the resident.
Failure to Provide Required Mealtime Supervision Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, dysphagia, aphasia, apraxia, epilepsy, and dementia did not receive the required supervision during mealtime as outlined in their care plan. The resident's care plan specified that all meals and fluid intake should occur under staff supervision due to swallowing difficulties. Despite this, the resident was left unsupervised during lunch, which resulted in a choking incident that required the Heimlich maneuver and emergency intervention. The resident had recently been discharged from speech therapy, which had reiterated the need for mealtime supervision due to swallowing safety concerns. However, the speech therapist did not verbally communicate the supervision requirement to the nursing staff, as the diet remained unchanged and the care plan already indicated supervision was needed. Nursing assistants and other staff members were unaware of the supervision requirement, as the resident's care card only indicated setup assistance for meals, not supervision. This miscommunication and lack of awareness led to the resident being left alone while eating. Interviews with staff revealed that the care plan interventions, including supervision with eating, were not correctly reflected on the quick-reference care cards used by nursing assistants. As a result, multiple staff members believed the resident only required setup assistance and not active supervision. This failure to ensure proper communication and implementation of the care plan directly contributed to the resident's choking incident.
Medication Order Transcription Error Resulting in Incorrect Administration Time
Penalty
Summary
A deficiency occurred when a nurse failed to accurately transcribe a physician's order from a hospital discharge summary into the resident's Medication Administration Record (MAR). The hospital discharge summary specified that Quetiapine 37.5 mg should be administered at night, but the nurse entered the order into the electronic medical record to be given at 9:00 AM. This error was not identified during the transcription process, despite facility policy requiring a double-check of the original order. As a result, the resident received Quetiapine in the morning on two consecutive days. The resident involved had multiple diagnoses, including Parkinson's Disease, vascular dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and multisystem degeneration of the autonomic nervous system. The resident's care plan included the use of psychotropic medications and required monitoring for side effects and effectiveness. The error was discovered after the resident was evaluated in the emergency department for somnolence, which was attributed to the timing and combination of medications. Interviews with facility staff confirmed that the transcription error occurred and was contrary to facility policy.
Failure to Notify Provider of Repeated Hypoglycemic Episodes
Penalty
Summary
The facility failed to notify the resident's provider in a timely manner when a resident with diabetes and end stage renal disease experienced multiple episodes of low blood sugar. Despite physician orders requiring notification if blood sugar was less than 70 or greater than 400, and further instructions to notify the provider if hypoglycemia persisted or if Glucagon was administered, there was no documentation that the provider was informed of several hypoglycemic events. These events included blood sugar readings as low as 42 mg/dl, repeated administration of Glucose Gel and Glucagon Emergency Injection Kit, and persistent low blood sugar levels over several days. Interviews with facility staff confirmed that the provider should have been notified during these episodes, especially when blood sugar was critically low or when Glucagon was required. However, the provider was not informed of these incidents, and staff were unable to explain the lack of notification. Facility policy also directed staff to notify the provider under these circumstances, but this was not followed, resulting in a failure to communicate significant changes in the resident's condition as required.
Resident Left Unattended on Toilet Due to Staff Failure to Communicate and Assist
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration, who was alert and oriented but dependent on staff for activities of daily living and required two staff for toilet transfers, was left on the toilet for an extended period. The resident's care plan specified the need for assistance with toileting and transfers using a Sara lift. On the day of the incident, a nurse aide placed the resident on the toilet and left the room to assist another resident, then left the unit for lunch without notifying any staff that the resident was still on the toilet. Video footage confirmed that the resident remained unattended for approximately one hour and fifteen minutes, during which time other staff entered the room in response to the call light but did not assist or notify anyone about the resident's situation. The incident was reported by the resident to a family member, who then contacted the facility. Interviews confirmed that the resident had asked staff for help during the period but did not receive assistance. The facility's policy defines neglect as the failure to provide necessary goods and services, and the actions of the staff in this case resulted in the resident not receiving timely toileting hygiene and transfer assistance as required by their care plan.
Failure to Timely Respond to Hypoglycemia and Missed Endocrinology Follow-Up
Penalty
Summary
Staff failed to act in a timely manner on multiple low blood sugar test results for a resident with diabetes, IGG4-related disease, and end stage renal disease. The resident's care plan and physician orders required blood sugar checks before meals and at bedtime, with instructions to notify the provider if blood sugar was less than 70 or greater than 400, and to administer glucose gel or glucagon as needed. Despite these orders and facility policy, documentation showed repeated instances where the resident's blood sugar was below 70, and after initial interventions, staff did not consistently recheck blood sugar within the required timeframe or document further actions as directed by protocol. In several cases, blood sugar remained low after treatment, but there was no evidence of additional interventions or provider notification as required. Facility policy specified that after treating hypoglycemia, blood sugar should be rechecked in 15 minutes, and if still low, treatment should be repeated. If glucagon was administered, blood sugar was to be rechecked every 15 minutes until stable, and the provider notified if hypoglycemia persisted after three interventions, if blood sugar was critically low, or if glucagon was used. Interviews with facility staff confirmed that these steps were not always followed, and staff could not explain the lack of timely rechecks or provider notifications. Documentation also failed to show that the resident's blood sugar was monitored according to policy after several hypoglycemic episodes, including instances where blood sugar was critically low. Additionally, the resident was scheduled for regular endocrinology follow-up appointments, but a key appointment was cancelled due to a scheduling conflict and was not rescheduled by the facility. This resulted in a missed endocrinology evaluation for a resident with a known history of low blood sugars, contrary to the recommended follow-up interval. Interviews confirmed that the appointment should have been rebooked, but there was no evidence this occurred.
Failure to Follow Two-Person Transfer Protocol with Mechanical Lift
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration, who required two staff members for transfers using a mechanical lift, was transferred by only one nurse aide. The resident's care plan and physician's order both specified that two staff members were required for transfers with the Sara lift. Documentation and interviews confirmed that the nurse aide was aware of this requirement but proceeded to transfer the resident alone. The facility's Sit to Stand Lift Competency form also directed staff to use two people for such transfers, and the Assistant Director of Nursing confirmed that this protocol was not followed. The incident was identified after the resident reported being left on the toilet for an extended period, and subsequent investigation revealed the improper transfer procedure. There was no facility policy on the use of the Sara lift, but staff training materials clearly required two staff for these transfers.
Failure to Accurately Document and Manage Hypoglycemia Episodes
Penalty
Summary
The facility failed to ensure accurate and complete medical record documentation and physician orders for a resident with diabetes and end stage renal disease who experienced multiple episodes of hypoglycemia. Specifically, the physician order for Glucagon was incorrectly written to indicate administration for blood sugars over 70, rather than under 70, which was confirmed as an error by both the APRN and ADNS. Additionally, the clinical record lacked complete and accurate documentation of nursing actions, including the absence of nursing notes detailing interventions, resident symptoms, provider notifications, and responses to treatment following several low blood sugar events. Review of the Medication Administration Record revealed multiple instances where the resident had blood glucose levels below 70 and received Glucose Gel or Glucagon, but there was no corresponding nursing documentation of the events or follow-up actions. The facility's own Diabetes Management Protocol required documentation of all hypoglycemic episodes, including symptoms, interventions, provider notification, and resident response, but this was not followed. Interviews with facility staff confirmed that nursing notes should have been written for each episode, but they were not, and no explanation was provided for this omission.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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