Southport Center For Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Southport, Connecticut.
- Location
- 930 Mill Hill Terrace, Southport, Connecticut 06890
- CMS Provider Number
- 075200
- Inspections on file
- 24
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Southport Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Two residents experienced delays in receiving necessary dental care due to failures in scheduling and communication among staff. One resident's broken tooth was not extracted for an extended period despite repeated recommendations, leading to infection and a fistula. Another resident did not have a needed oral surgeon consultation scheduled after referral, with no documentation of scheduling or refusal. These deficiencies occurred despite facility policies requiring timely coordination and documentation of ancillary services.
The facility failed to notify physicians and/or resident representatives in multiple cases, including when a resident left AMA, when a resident experienced significant blood sugar abnormalities, and when a dental provider identified a possible abscess. Required notifications and documentation were not completed by nursing staff, contrary to facility policy.
The facility did not ensure that the dishwasher's sanitizing solution was properly tested and maintained, resulting in inadequate sanitation of tableware. Dietary staff relied on temperature readings instead of using test strips to measure sanitizer concentration, and there was a lack of documented staff training on proper procedures. A mechanical issue also prevented the sanitizer from dispensing, and the facility could not provide a relevant sanitation policy.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of tracking or evaluating antibiotic administration among residents.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents did not receive comprehensive care plans addressing their specific needs: one with a hand contracture was not provided with documented interventions or goals, and another with schizoaffective disorder and PTSD did not have a care plan addressing management of disruptive behaviors. Staff were unaware of or unable to implement appropriate interventions, and facility policy requiring individualized, interdisciplinary care planning was not followed.
Multiple deficiencies were identified, including failure to address a resident's hand contracture in the care plan, lack of ongoing assessment and intervention for contractures, missed and undocumented skin checks and treatments for a resident with venous ulcers, improper medication self-administration without assessment, and lack of RN assessment or documentation following an elevated blood sugar in a diabetic resident. Staff interviews and observations confirmed that required care, monitoring, and documentation were not consistently provided according to physician orders and facility policy.
Two residents with pressure ulcers did not receive consistent weekly skin audits as required by facility policy, and documentation of these checks was missing for multiple weeks. Additionally, a low air loss mattress intended to prevent further skin breakdown was not set according to the physician's order, with staff failing to verify or document the correct settings and function each shift. Communication barriers and lack of care planning for resident behaviors further contributed to the deficiencies.
A resident did not receive appropriate care or services to maintain or improve ROM or mobility, and there was no documented medical reason for the decline.
Multiple residents with high risk for accidents, including those with substance abuse history and those requiring aspiration precautions, were not adequately supervised. One resident experienced two unresponsive episodes requiring Narcan after self-administering pain medication and taking a Methadone pill. Two other residents with dysphagia were left unsupervised during meals, did not receive required 1:1 feeding assistance, and consumed inappropriate food or liquids, resulting in repeated coughing episodes. Staff were unaware of or did not follow prescribed dietary and supervision orders.
Surveyors found that appropriate care was not provided for residents regarding continence management, catheter care, and UTI prevention, resulting in a deficiency.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A nurse aide did not receive the required 12 hours of annual in-service education or annual competency evaluations, as confirmed by documentation review and staff interviews. The staff development nurse lacked a tracking system for monitoring staff training, and education was provided only as time allowed, with limited assistance from other nursing leadership who were also managing multiple responsibilities.
The facility did not notify the State-designated authority when several residents received new mental health diagnoses, and failed to implement PASARR recommendations for a resident with a history of self-harm and violent behavior. Required crisis/safety plans were not included in care plans, and staff were unaware of PASARR directives, resulting in noncompliance with regulatory requirements.
A resident with a history of dental issues and other diagnoses did not have complete or readily accessible dental records in their clinical file after receiving services from a consulting dentist. The resident reported a tooth extraction and requested their dental records, but the facility did not follow up or ensure documentation was present as required by policy. Staff interviews confirmed the records were not immediately available until requested by surveyors.
A resident with advanced breast cancer was not followed up with their oncology office within the timeframe specified in hospital discharge instructions. Facility records and staff interviews confirmed that the required contact was not made, and there was no documentation to show that the follow-up occurred, despite facility policy requiring timely scheduling of such appointments.
Failure to Provide Timely Dental Services and Specialty Referrals
Penalty
Summary
The facility failed to provide or obtain timely dental services for two residents, resulting in unaddressed dental issues and progression of oral health problems. For one resident with a history of stroke and hemiplegia, repeated recommendations for extraction of a broken tooth (#18) were not acted upon over a period of 17 months. Despite multiple dental consultations, nursing notes, and provider recommendations indicating the need for extraction and referral to an oral surgeon, the necessary appointment was not scheduled. This inaction led to the development of a fistula and abscess at the site of the affected tooth. Interviews with staff revealed ongoing communication breakdowns and lack of follow-through in scheduling and documenting specialty dental care, despite the issue being previously identified and discussed among nursing leadership. Another resident, admitted with hypertension and peripheral vascular disease, was identified as needing an oral surgeon evaluation for removal of excess tissue and biopsy of a growth in the mouth. Although a referral was made following a dental assessment, there was no documentation that the appointment was scheduled or that the resident or representative refused the consultation. The resident reported that the dental appointment was never completed, and staff interviews confirmed that the required oral surgeon consultation had not been scheduled due to oversight and lack of communication between the scheduler and nursing staff. Facility policy required that ancillary services, including dental care, be provided or coordinated and that all services and outcomes be documented. The policy also directed that outside medical appointments be arranged, documented, and communicated effectively. However, the facility failed to ensure timely follow-up on dental recommendations, proper scheduling of specialty appointments, and adequate documentation of actions taken, resulting in prolonged resident discomfort and progression of dental conditions.
Failure to Notify Physician and Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify physicians and/or resident representatives as required in several situations involving three residents. In one case, a resident who was admitted with multiple diagnoses, including acute embolism, alcohol abuse, and pain, left the facility against medical advice (AMA). The clinical record did not contain a physician’s order for the AMA discharge, nor was there documentation that the physician was notified when the resident left. The nurse’s note also lacked documentation of the resident’s departure and the required notifications, despite facility policy mandating immediate physician notification and documentation in such cases. Another resident, with a history of traumatic brain injury and diabetes, experienced both hypoglycemic and hyperglycemic episodes. The facility failed to notify the resident’s representative of a hypoglycemic event that required intervention, and there was no documentation that the physician was notified of a subsequent blood sugar reading above 400. Interviews confirmed that the advanced practice registered nurse (APRN) was not notified of the elevated blood sugar, and the LPN involved could not recall or document the necessary notifications or follow-up actions. Facility policy required prompt notification and documentation of abnormal blood sugar levels and changes in condition, which was not followed. A third resident, with a history of stroke and hemiplegia, was found by a dental provider to have moderate inflammation and a possible abscess of a tooth root. The clinical record did not show that the physician was notified of this finding, and the nurse who received the dental consultation did not communicate the change in condition as required. Interviews with dental and medical staff confirmed that the physician was not made aware of the dental issue, despite facility policy requiring notification of providers and families for any change in a resident’s baseline condition.
Failure to Maintain and Monitor Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the sanitizing solution in the dishwasher was tested and maintained at an adequate level according to manufacturer guidelines, resulting in tableware not being properly sanitized. Observations and documentation review revealed that while the kitchen service report previously showed satisfactory sanitizer concentration, a test run of the dishwasher later recorded a sanitizer level of 0-10 ppm, which is below the required 50-100 ppm range. Review of the dishwasher temperature log indicated that staff were recording only temperature readings from the dishwasher gauge and not using test strips to measure sanitizer concentration. Multiple dietary staff confirmed that they documented wash and rinse information based solely on temperature readings and did not use test strips as required. Further interviews revealed that the Food Service Director (FSD) was responsible for educating dietary staff on proper sanitation procedures but could not provide documentation of any prior training. One staff member misinterpreted the sanitizer test strip results, indicating a lack of understanding of the correct range. A dishwasher technician identified a mechanical issue that prevented the sanitizing solution from dispensing, which was subsequently fixed. Manufacturer guidelines confirmed that sanitizer levels should be maintained between 50-100 ppm, and the facility was unable to provide a policy for ensuring clean and sanitary plates and utensils.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating that the facility did not take necessary actions to ensure appropriate antibiotic stewardship.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Contracture and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, one with a contracture and another exhibiting disruptive behaviors. For the first resident, who was admitted with dementia, cerebral infarction, and adult failure to thrive, an admission observation identified a right-hand contracture. However, the care plan did not address this contracture, nor did it specify therapeutic or nursing interventions or functional goals. The Minimum Data Set (MDS) also failed to document the contracture, and the MDS Coordinator was unaware of its presence due to this omission. Facility policy requires individualized care plans for contractures, including specific interventions and goals, but this was not followed in this case. For the second resident, who had schizoaffective disorder and PTSD, the care plan included general interventions for anxiety and mood swings and instructions regarding smoking, but did not address the management of escalating or disruptive behaviors. An incident was observed where the resident became agitated and verbally aggressive after being denied a nicotine lozenge until after a shower. The assigned LPN did not implement any interventions to de-escalate the situation and was unable to articulate appropriate actions to address the resident's behavior. The nursing supervisor was not notified of the incident, and staff interviews revealed a lack of clarity regarding behavioral interventions for this resident. The facility's failure to develop and implement individualized, comprehensive care plans for both residents resulted in unmet needs related to contracture management and behavioral support. Staff were either unaware of the residents' specific conditions or unable to describe or implement appropriate interventions, contrary to facility policy and expectations for interdisciplinary care planning.
Failure to Provide Care and Treatment According to Professional Standards
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for multiple residents, as evidenced by direct observations, record reviews, and staff interviews. For one resident with a right-hand contracture, the care plan did not address the contracture, and there was no documentation of ongoing assessment, monitoring, or specific nursing interventions for the contracture. Staff were unaware of any specific orders for the care of the contracture, and there was evidence of pain and skin issues, such as yellow crust between the contracted fingers, that were not reported or managed according to policy. The interdisciplinary approach required by facility policy was not implemented, and the contracture was not accurately reflected in the Minimum Data Set (MDS) assessments. Another resident with venous ulcers and lymphedema did not receive ace wraps to the lower extremities as ordered by the physician. Instead, the resident was observed multiple times with kerlix wraps and without the prescribed ace wraps, and the treatments were not completed before the resident was out of bed, as required. Additionally, weekly skin checks ordered by the physician were not consistently performed or documented, with only 3 out of 13 checks completed over a three-month period. Staff interviews confirmed that treatments and assessments were missed due to workload and lack of communication, and the facility's policies for implementing physician orders and documenting skin checks were not followed. A resident prescribed a Budesonide-Formoterol inhaler was found to have the inhaler at the bedside for self-administration without a completed self-administration assessment or a physician order permitting self-administration. The resident reported using the inhaler as needed without knowledge of the correct dosage or schedule, and the medication was not stored securely as required by policy. In another case, a resident with diabetes and a history of blood sugar fluctuations had an elevated blood sugar reading that was not followed by an RN assessment or proper documentation. The LPN involved could not recall if the appropriate notifications were made, and there was no evidence in the clinical record of follow-up or interventions as required by the facility's hyperglycemia management policy.
Failure to Complete and Document Weekly Skin Audits and Maintain Proper Air Mattress Settings
Penalty
Summary
The facility failed to ensure that weekly skin audits were completed and documented according to facility policy for two residents with pressure ulcers. For one resident with peripheral vascular disease, obesity, and diabetes, there was no physician's order for weekly skin checks until after surveyor inquiry, and the clinical record lacked documentation that weekly skin checks were being performed. Interviews with clinical staff confirmed that weekly skin checks were expected but not documented, and the facility's policy required these checks to be completed and recorded on shower days. The care plan for this resident also required weekly assessment of the pressure ulcer, but there was no evidence this was done. For another resident with spina bifida, hearing loss, and kidney disease, who had a stage 4 facility-acquired pressure ulcer, weekly body audits were inconsistently documented, with several weeks missing documentation over multiple months. The resident had a physician's order for a low air loss mattress set to a specific weight, but observations revealed the mattress was frequently set incorrectly, sometimes far above or below the resident's actual weight. The resident reported intermittent mattress function and communication barriers with staff, and staff interviews revealed that mattress settings were not always checked as required, with some staff signing off on checks without verifying the actual settings. Facility policies required that skin checks be completed and documented by nurses on shower days, and that air mattress settings be verified per physician's orders and checked every shift. However, documentation and staff interviews indicated these procedures were not consistently followed. There was also no documentation or care plan addressing the resident's reported habit of changing mattress settings, and staff were sometimes unaware of changes or malfunctions in the mattress equipment.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. The report indicates that the necessary interventions to maintain or improve the resident's physical abilities were not implemented or followed, resulting in a deficiency.
Failure to Provide Adequate Supervision and Implement Aspiration Precautions
Penalty
Summary
The facility failed to provide adequate supervision and implement care planned interventions for multiple residents at risk for accidents, including those with a history of substance abuse and those requiring aspiration precautions. One resident with a known history of opioid abuse and a recent drug overdose was not sufficiently monitored, resulting in two separate incidents where the resident became unresponsive and required Narcan administration. Documentation revealed that the resident was able to save and self-administer multiple doses of pain medication, and also admitted to taking a Methadone pill provided by another resident. The care plan interventions were limited to offering substance abuse group attendance and support, without specific measures to prevent medication hoarding or unauthorized drug use. Another resident with hemiplegia, dysphagia, and dementia required 1:1 supervision with meals and strict aspiration precautions, as recommended by speech therapy and hospital discharge documentation. However, observations showed that this resident was left unsupervised during meals, both in their room and in the dining room, and was able to access and consume food and liquids without staff present. Staff interviews revealed confusion about the resident's dietary orders and supervision requirements, and the care plan did not reflect the most current speech therapy recommendations. The resident was observed coughing repeatedly during meals, a sign of aspiration risk, without immediate staff intervention. A third resident with a history of traumatic brain injury and dysphagia, who had transitioned from tube feeding to oral intake, was also not provided with the required 1:1 feeding assistance. Despite physician and speech therapy orders for ground solids, nectar thick liquids, and close supervision, the resident was observed eating unsupervised, taking large bites, and consuming thin liquids not consistent with their prescribed diet. Staff were not present to monitor or assist during meals, and the resident experienced coughing episodes indicative of aspiration risk. Facility policies on aspiration precautions and therapeutic diets were not consistently followed, and staff were not always aware of or implementing the required interventions.
Deficient Continence and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Required Annual In-Service Education and Competency Evaluations for Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide received the required 12 hours of annual in-service education and annual competency evaluations. Documentation review for the years 2023, 2024, and 2025 did not show evidence that education and competency assessments were completed for a nurse aide who began employment in December 2022. Interviews with staff revealed that the staff development and infection control nurse, who was responsible for tracking and providing education, did not have a system in place to monitor which staff members needed updated training or competencies. Education was provided as time allowed, and there was reliance on sign-in sheets and competency packets without a comprehensive tracking mechanism. Additional interviews indicated that the assistant director of nursing provided some help with in-services and competencies but was also responsible for multiple other roles, limiting her availability. The director of nursing was not aware of any issues related to in-service education and stated that staff should receive required education and competencies after hire and annually. The facility's own assessment tool specified that annual in-servicing, training, and competencies would be provided, and that the staff development nurse was responsible for maintaining these records, but this was not consistently implemented.
Failure to Notify State Authority and Implement PASARR Recommendations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to comply with requirements for the Pre-Admission Screening and Resident Review (PASARR) process for several residents with mental health diagnoses. For three residents, the facility did not notify the State-designated authority when new mental health diagnoses were identified. Specifically, one resident was diagnosed with major depressive disorder, recurrent, but this was not reported to the State authority as required. Another resident received a new diagnosis of schizoaffective disorder, bipolar type, which was also not communicated to the State. A third resident was diagnosed with schizoaffective disorder, but the facility did not update the State-designated authority with this information. Additionally, for a resident with a history of schizoaffective disorder, bipolar disorder, attempted self-harm, and violent behaviors, the facility did not incorporate PASARR recommendations into the care plan. The PASARR had recommended a crisis/safety plan due to the resident's history, but the care plan lacked this intervention. Interviews and record reviews confirmed that the required crisis/safety plan was not present in the clinical record, and staff were unaware of the PASARR recommendations for this resident. The facility's own PASARR policy requires notification of the State-designated authority when a resident receives a new mental health diagnosis or shows signs of mental illness not previously identified. Despite this, the responsible staff did not conduct audits to ensure compliance, and new diagnoses were not consistently reported or incorporated into care plans as required. These failures were identified through review of clinical records, facility documentation, and staff interviews.
Failure to Maintain Complete and Accessible Dental Records
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident who was reviewed for dental services. The resident, who had diagnoses including partial loss of teeth, anxiety, and obesity, was care planned to attend appointments without an escort and to receive education about appointment status. Despite the resident's report of a dental extraction performed by the facility's Consultant Dentist and subsequent complaints of pain and requests for dental records, the clinical record did not contain documentation of dental care and services provided by the consulting dental group for a significant period. The resident also reported that after the extraction, they began receiving dental care from a community dentist and had requested their dental records from the facility without follow-up. Upon surveyor inquiry, dental records from the Consultant Dentist were obtained and made accessible, revealing details of the extraction and subsequent dental complaints. Interviews with facility staff indicated a lack of awareness regarding the resident's request for dental records and confirmed that the dental records from the consulting provider were not immediately available in the resident's clinical record as required by facility policy. The facility's policy directs that all ancillary services, including dental, must be documented in the resident's medical record, specifying the type of service and outcome.
Failure to Follow Up with Oncology Office Post-Discharge
Penalty
Summary
Staff failed to follow hospital discharge instructions for a resident with a diagnosis of Stage 4 left breast cancer. The discharge summary and nursing admission note both directed that the resident's oncology office be contacted within two weeks post-discharge. However, record review did not show any evidence that this follow-up contact was made within the specified timeframe. Interviews with the oncology office RN, the Director of Nursing Services (DNS), and the Administrator confirmed that the oncology office did not receive a call from the facility, and facility leadership could not locate documentation of any such contact. The facility's own policy required the admitting RN to review discharge instructions and schedule necessary follow-up appointments in a timely manner, but this was not done for the resident in question.
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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