Apple Rehab Laurel Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in East Haven, Connecticut.
- Location
- 451 North High Street, East Haven, Connecticut 06512
- CMS Provider Number
- 075389
- Inspections on file
- 39
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Apple Rehab Laurel Woods during CMS and state inspections, most recent first.
Staff failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene requirements during high-contact care for three residents with chronic wounds and skin issues. One resident with a buttock wound and multiple comorbidities had an EBP order and posted signage, yet a NA provided personal care wearing only gloves and no gown, and an LPN performed wound care without hand hygiene before entry, between glove changes, or in accordance with the EBP sign. Another resident with a stage 4 sacral pressure ulcer had EBP ordered for toileting and incontinent care, but a NA entered with linens to provide bowel incontinence care using only gloves despite knowing a gown was required. A third resident with multiple sclerosis and moisture-associated skin damage had ordered wound care and EBP signage, but an LPN donned a gown without hand hygiene, applied gloves without cleansing, and completed the dressing change without changing soiled gloves or performing hand hygiene as required by facility policy.
A resident with moderate cognitive impairment, a history of cerebral infarction sequelae, PTSD, and dependence on staff for ADLs was found on two occasions with bruises of unknown origin to the flank and upper arm. In both instances, the resident could not explain the cause and facility investigations did not identify how the injuries occurred. Despite an abuse policy requiring identification and reporting of suspicious bruising and notification of DPH, review of the state incident reporting system and staff interviews showed that the DNS and ADNS did not report these bruises to the State Agency because the DNS believed reporting was only required when abuse was substantiated.
Two residents who were cognitively intact but dependent on staff for ADLs, including hygiene, were observed on multiple occasions with long fingernails containing debris and, for one resident, unshaven facial hair despite expressing a desire to be clean shaven. Care plans and MDS assessments documented their need for staff assistance with daily washing, grooming, and nail care, and facility policy required shaving and fingernail care, including trimming, as part of routine care. Nursing documentation showed that showers were provided with no recorded refusals, yet nail and shaving care were not completed as expected, and staff could not explain the lack of hygiene care.
Two residents at high risk for skin breakdown did not receive care in accordance with physician orders and facility policy. One resident with moderate cognitive impairment, prior stage 3 coccyx ulcer, severe malnutrition, and a high Braden risk score had an order for a pressure-relieving mattress set to a specific weight and checked each shift, yet the mattress was observed to be sunken, set far above the ordered weight, and not functioning properly despite the resident’s repeated complaints; the assigned NA did not report the problem, the LPN signed off on checks without ensuring correct settings, and maintenance independently altered the settings without nursing direction. Another resident with severe cognitive impairment, decreased mobility, and orders for a low air loss mattress and heel offloading was repeatedly observed in bed without a low air loss mattress and with heels not offloaded, and both an LPN and the ADNS confirmed that current physician orders for the mattress and heel offloading were not being implemented.
A resident with multiple sclerosis, incontinence, high pressure-ulcer risk, and recurrent moisture-associated skin damage had a care plan and physician order for a low air loss mattress set to a specific weight and checked each shift. Surveyors repeatedly observed the mattress set far above the ordered weight, despite nursing documentation indicating checks were performed. An LPN could not identify the correct setting, explain a weight sticker on the pump, or locate the information, and the facility could not provide a policy on pressure-reducing mattresses, even though an RN stated that physician orders were supposed to dictate mattress settings for residents with wounds.
A resident with ESRD receiving hemodialysis had a physician-ordered 1200 ml fluid restriction based on hemodialysis center recommendations, and the care plan called for maintaining this restriction and monitoring intake/output (I/O). The facility entered the restriction as a diet order rather than a monitoring order, resulting in no I/O monitoring being ordered or documented. Physician/APRN notes, nursing notes, and nurse aide assignments did not reflect the fluid restriction or any I/O tracking, despite facility policies requiring I/O monitoring for residents on fluid restrictions. The DON and an LPN confirmed that I/O should have been monitored but was not, and the hemodialysis policy required adherence to fluid restrictions and I/O monitoring, which did not occur for this resident.
A resident with COPD, dementia with psychotic disturbance, and atherosclerotic heart disease had orders for Aspirin DR, Depakote DR, and Pantoprazole DR. During a medication pass, an LPN asked if the resident wanted medications crushed, then crushed all three DR medications together, mixed them with applesauce, and administered them. Review of orders, facility policy, and FDA guidance confirmed that these delayed release medications should not be crushed, and this practice contributed to a medication error rate above 5%.
A resident with type II DM and osteomyelitis had an order for Insulin Lispro via pen injector to be given per sliding scale. During a medication cart review, the resident’s insulin pen was found dated in a way that indicated it should have been discarded after 28 days, but MAR review showed it was administered on multiple occasions after that discard period. An LPN reported the insulin was used as needed and not recently, yet documentation showed administrations beyond the allowed timeframe, contrary to facility policy requiring Humalog (Lispro) insulin to be discarded within 28 days.
The facility failed to provide required written notice of bed-hold rights to two residents or their responsible parties when they were transferred to the hospital for acute medical issues, including confusion after a fall and vomiting coffee-ground emesis with abdominal tenderness. Record reviews showed no documentation that bed-hold options were communicated at the time of hospitalization, despite a facility policy directing that such notices be given upon discharge to the hospital and maintained in the resident’s record. Interviews revealed that social workers did not issue bed-hold forms for hospital transfers and believed this was the responsibility of business office or admissions staff, while the Regional Business Office Manager acknowledged that the forms were missing and should have been provided.
The facility did not consistently monitor or document the mood, behavior, or physical condition of residents involved in resident-to-resident abuse incidents, despite care plans and policy requiring such actions. Multiple residents with cognitive and psychiatric conditions were not assessed or documented for injuries or emotional distress on several shifts following altercations, and required monitoring orders were absent from physician directives and MARs.
A resident with cognitive and respiratory conditions was transferred to the hospital, leaving personal belongings at the facility. During the resident's absence and after their passing, a staff member accessed the resident's phone and PayPal account, transferring over $1,700 to themselves and attempting to change account details. The misappropriation was discovered by the resident's financial POA, and the facility's investigation confirmed the staff member's involvement.
A resident with cognitive and respiratory conditions was transferred to the hospital and later passed away. After the transfer, the resident's family discovered unauthorized financial transactions linked to a staff member. The facility initiated an internal investigation and suspended the implicated staff member, but failed to conduct a comprehensive investigation as required by policy, including obtaining statements from the accused, other staff, and residents.
A resident with multiple chronic conditions and significant ADL needs did not have complete nurse aide documentation in the electronic health record for several care areas, including elimination, eating, hygiene, and fluid intake, across multiple shifts. This occurred despite facility policy requiring CNAs to document care every shift, and the issue was acknowledged by the DNS as an ongoing compliance problem.
A resident with cognitive and mental health diagnoses, dependent on staff for toileting, was verbally abused by a nurse aide who became argumentative, raised her voice, and refused to leave the room or call a supervisor when requested. Audio evidence and witness accounts confirmed the aide's unprofessional conduct, resulting in fear and distress for the resident and roommate.
A resident with cognitive and psychiatric diagnoses reported an upsetting interaction with a nurse aide, providing a recording of the incident to an LPN. The LPN did not report the allegation to the Nursing Supervisor within the required timeframe and allowed the accused aide to continue working with other residents, contrary to facility policy requiring immediate reporting and suspension pending investigation.
A resident with severe cognitive impairment and total dependence for ADLs and transfers was sent alone by transportation to a medical appointment, despite care plan and facility policy requiring accompaniment. Due to a miscommunication about the appointment location and lack of staff or family presence, the resident was dropped off at the wrong address and later brought to the emergency department by an unknown individual, before being returned to the facility by family.
The report details several incidents of abuse and inadequate supervision within the facility. A resident with dementia and traumatic brain injury experienced staff abuse when an LPN forcefully administered medication, causing a cut on the resident's lip and using profanity. Another resident with hemiplegia and hemiparesis was involved in a physical altercation with a resident diagnosed with vascular dementia, who exhibited wandering behavior and struck the former in the face. Additionally, a resident with congestive heart failure was struck on the hand and hip during a confrontation initiated by the same resident with vascular dementia. These incidents highlight the need for adequate supervision and effective management of residents with behavioral disturbances.
The facility failed to conduct required background checks for newly hired licensed nurses and certified nurse aides, resulting in several employees starting work without completed ABCMS background checks, fingerprinting, and reference checks. The HR Coordinator confirmed the absence of these documents, and the Administrator expected all pre-hiring screenings to be completed per the facility's checklist.
The facility failed to properly label and date food items in the walk-in refrigerator and did not maintain the required concentration levels for sanitizing solutions used in the kitchen. Observations revealed unlabeled and outdated food, and sanitizing solutions tested below the required ppm levels due to a clogged metering tip.
The facility failed to conduct quarterly interdisciplinary care conferences with the resident representative for a resident with Alzheimer's and dementia. The resident representative only received phone updates from the social worker, and no progress notes were entered into the medical record. The MDS coordinator confirmed that attendance sheets often lacked signatures, indicating that required meetings were not held as per facility policy.
The facility failed to accurately document life support choices for a resident and did not review advance directives with another resident upon admission. One resident's code status was changed without proper consent, and another resident did not have any advance directive documentation reviewed or signed.
A resident with severe cognitive impairment and at risk for pressure ulcers developed a skin blister that was not promptly communicated to the APRN/physician or the resident's representative. Facility policies requiring immediate notification were not followed, leading to a delay in medical response and family notification.
A resident's Morphine Sulfate medication was misappropriated when it was borrowed for another resident on multiple occasions, contrary to facility policy. Staff interviews revealed a lack of awareness and adherence to the policy prohibiting the borrowing of controlled substances, leading to the misappropriation.
A facility failed to notify law enforcement of a staff-to-resident abuse incident involving a resident with dementia and other conditions. Multiple staff members witnessed an LPN forcefully administering medication, causing a cut on the resident's lip. Despite reporting the incident internally, the LPN continued to work for 2.5 hours, and the police were not notified, violating the facility's abuse policy.
A resident with dementia and other conditions was allegedly mistreated by an LPN, who forcefully administered medication and used profanity. Multiple staff members witnessed the incident and reported it, but the initial response from the RN was inadequate, and the LPN continued to work for 2.5 hours after the incident. The facility failed to follow its abuse policy, resulting in a deficiency.
The facility failed to complete timely social worker assessments for three residents, resulting in missed quarterly and annual assessments. Staff shortages and personal leave were cited as reasons for the delays.
The facility failed to update the PASARR for a resident with a new diagnosis of dementia. Despite multiple indications of the diagnosis in medical records and physician's orders, the Social Worker missed updating the PASARR, and the facility lacked a policy to ensure such updates. This oversight led to a deficiency in compliance with PASARR requirements.
The facility failed to complete required neurological assessments after multiple falls for two residents, did not ensure a physician's order for hospice services for a resident, and neglected to perform an RN assessment for a newly identified skin blister. Additionally, the facility did not follow physician's orders for repeated labs and failed to obtain weights according to policy for two residents.
The facility failed to monitor a resident's weight per physician's order, leading to significant weight loss over several months. Despite a history of stroke, hypertension, and diabetes, the resident's weights were not consistently documented weekly as required, resulting in an 11.1% weight loss over six months.
The facility failed to ensure proper labeling, dating, and storage of respiratory equipment for two residents. One resident's oxygen and nebulizer equipment were not labeled, dated, or bagged, while another resident's BiPaP tubing was not dated or bagged. Staff interviews confirmed that the facility's policies were not followed.
The facility failed to complete annual performance reviews for certified nurse aides, as evidenced by a personnel file showing no review for 2023. The DNS, who started in July 2023, acknowledged the backlog and developed a plan to address it.
The facility failed to document and monitor specific behaviors with the use of antipsychotic medication for two residents. One resident with paranoid schizophrenia and other diagnoses was prescribed Zyprexa, but behavior monitoring was not documented. Another resident with vascular dementia and other diagnoses was prescribed Seroquel, but behavior monitoring was inconsistently documented. The DNS and MD were unaware of these lapses, which violated the facility's policy requiring behavior monitoring every shift.
The facility failed to ensure complete and accurate documentation of neurological checks and RN assessments following unwitnessed falls for a resident with dementia and repeated falls. The clinical records did not reflect the initiation of neurological checks or vital sign monitoring after multiple falls, as required by the facility's policy. Interviews with the DNS revealed concerns about the clinical documentation and confirmed that comprehensive RN assessments and updated vital signs should have been completed following each fall.
A resident with Alzheimer's and dementia receiving hospice care had an incomplete medical record, missing the hospice election form and physician certification of terminal illness. Interviews revealed confusion and lack of communication regarding responsibility for obtaining these documents, and the facility lacked a policy for required hospice documentation.
The facility failed to ensure timely completion and transmission of MDS assessments for three residents, leading to significant delays. The Director of MDS coordinators cited increased workload and insufficient staffing as primary reasons for the delays. The Administrator was aware of the issue and was in the process of hiring additional MDS coordinators.
Observations revealed missing signatures on narcotic count sheets for multiple shifts across various units. Staff interviews indicated a lack of awareness and adherence to the protocol of counting and signing off on controlled substances at the beginning and end of each shift. The DON acknowledged awareness of the issue.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Wound and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) and hand hygiene policies during high-contact care for residents with chronic wounds. For one resident with cellulitis of the buttock, obesity, chronic congestive heart failure, atherosclerosis of extremities, and hypertension, the care plan and physician orders required EBP, including use of gown and gloves and hand hygiene before and after care. Despite an EBP sign posted outside the room, a nursing assistant entered to provide personal care wearing only gloves and no gown, acknowledging she knew a gown was required but forgot and was helping a resident not assigned to her. For the same resident, a physician order required wound care to the buttock twice daily, with cleansing and dressing changes. An LPN entered the room for wound care without performing hand hygiene and without donning gloves and a gown before entry, despite the posted EBP sign. During the procedure, the LPN put on gloves without prior hand hygiene, removed the old dressing, then removed the soiled gloves and donned a new pair without cleansing or sanitizing her hands between glove changes. The LPN stated she knew the resident was on EBP but did not notice the sign and admitted she should have cleansed her hands between removing dirty gloves and putting on clean ones. Another resident with a stage 4 sacral pressure ulcer had a care plan and physician order requiring EBP, including gown and gloves for high-contact activities such as toileting and incontinent care, and hand hygiene before entering and when leaving the room. An EBP sign was posted outside the room. A nurse aide entered carrying washcloths, towels, and bed linens to provide incontinent care for bowel incontinence but did not apply a gown, using only gloves, and later confirmed she was aware of the sign and should have worn a gown. A third resident with multiple sclerosis, abnormal posture, and moisture-associated skin damage had orders for twice-daily wound care to the buttocks and an EBP sign instructing everyone to clean their hands before entering and when leaving. An LPN donned a gown without performing hand hygiene, entered with wound care supplies, applied gloves without prior hand cleansing, removed the dirty dressing, and continued the treatment without removing the soiled gloves, performing hand hygiene, or applying clean gloves, despite acknowledging that hand hygiene should have been performed before entering, after care, and after exiting the room.
Failure to Report Bruises of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report bruises of unknown origin for one sampled resident to the State Agency (SA) as required. The resident had diagnoses including hyperlipidemia, unspecified sequelae of cerebral infarction, and PTSD, and an admission MDS showing a BIMS score of 12/15, indicating moderate cognitive impairment. The resident was dependent on staff for toileting and showering/bathing and required substantial/maximal assistance for transfers. The resident’s care plan identified a risk for falls related to impaired balance, with interventions such as keeping the call bell within reach, providing PT/OT as ordered, and offering toileting assistance at bedtime. A nursing note documented that the resident was observed with a purple-colored bruise on the left flank, the resident could not explain how it occurred, and the facility’s investigation did not conclusively identify a cause other than the resident’s tendency to lean to the left. A later nursing note documented that the same resident was observed with two bruises on the upper posterior right arm, again with the resident unable to identify how the bruises occurred and with no cause identified by the facility’s investigation. Review of the state agency’s incident reporting system showed that neither of these instances of bruises of unknown origin had been reported. In interviews, the DNS and ADNS, who were responsible for reporting incidents to the SA, stated that the DNS believed she did not have to report such incidents unless the facility’s investigation substantiated abuse. The facility’s undated abuse policy directed staff to identify and report suspicious bruising or patterns of injury and required the DNS or designee to notify the resident’s family, physician, DPH, and local police as needed, and to submit a follow-up report with conclusions and actions taken to DPH within five days of the alleged incident. Despite this policy, the bruises of unknown origin for this resident were not reported to the SA.
Failure to Provide Required Nail and Shaving Hygiene for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate hygiene assistance, specifically nail care and shaving, for two residents who were dependent on staff for activities of daily living (ADLs). Resident #45 had diagnoses including diabetes with diabetic neuropathy, muscle weakness, and dysphagia, and was documented on the quarterly MDS as totally dependent on staff for eating, hygiene, and toileting, and always incontinent of bowel and bladder. The resident’s care plan indicated a need for assistance with ADLs due to weakness, being bedbound, and a history of refusing showers, with interventions to offer assistance with washing, bathing, dressing, toileting, and oral hygiene, and to offer a comfort bed bath if showers were refused. Despite this, observations on two separate dates showed Resident #45’s fingernails were very long with brown debris underneath. A nurse aide acknowledged that nail care had not yet been provided that day, and later review with an LPN confirmed that showers had been documented for the month without any refusals, while the resident’s nails remained long and unclean. Resident #64 had diagnoses including metabolic encephalopathy, chronic respiratory failure with hypoxia, and hemiplegia/hemiparesis following cerebrovascular disease, and was documented on the annual MDS as requiring partial/moderate assistance with eating and total dependence on staff for hygiene, dressing, toileting, transfers, and being always incontinent of bowel and bladder. The care plan identified a need for ADL assistance, fluctuating continence, a preference to stay in bed most days, and that the resident might refuse shaving but would inform staff when shaving was desired, with interventions for daily washing, dressing, grooming, bathing, and mouth care. Observations showed Resident #64 with long fingernails and unshaven facial hair, despite the resident stating a desire to be clean shaven and not to grow a beard. On subsequent observations, the beard area had only been trimmed and fingernails remained long with debris underneath, even though the resident was agreeable to nail trimming and shaving supplies were available at the bedside. Interviews with an LPN, the DNS, and the ADNS confirmed that showers had been documented without refusals and that facility expectations and policy required shaving and fingernail care, including trimming, as part of daily care and on shower days, yet they could not explain why these hygiene needs had not been met for either resident.
Failure to Follow Physician Orders for Pressure-Relieving Mattresses and Heel Offloading
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and care plan interventions for pressure-relieving mattresses and settings for a resident at high risk for skin breakdown. One resident with diagnoses including dorsalgia, malignant neoplasm of skin, and severe protein-calorie malnutrition had physician orders for a pressure-relieving/low air loss mattress set to 95 pounds and checked every shift. The admission MDS showed moderate cognitive impairment and dependence on staff for dressing, toileting, and transfers, with a history of a stage 3 coccyx pressure ulcer and a Braden score of 16 indicating high risk for pressure ulcer development. Despite this, the resident reported for about a week that the bed was broken, the mattress was sunken to the point of feeling the metal, and that complaints to staff had not resulted in action. Observations confirmed the mattress appeared sunken and was set to 325 pounds, not the ordered 95 pounds. The NA assigned to the resident acknowledged the resident’s complaints of backache and an improperly inflated mattress but did not follow facility policy to notify maintenance via the maintenance book. The LPN responsible for checking the mattress each shift stated it was policy for the charge nurse to verify function and settings every shift and to report issues to maintenance immediately, yet the LPN had signed off on the checks despite the mattress not being set per the physician’s order and not functioning as intended. The Maintenance Director reported that staff had not alerted him to a problem, but when the resident complained the bed was too soft, he independently increased the setting from 125 to 325 pounds and stated that the department’s practice was to increase the setting when there was a complaint of a malfunctioning pressure-reducing bed. Observation with the Maintenance Director showed the mattress still soft, set at 325 pounds, and displaying a red exclamation mark alert. A second deficiency involved another resident with diagnoses including COPD, type 2 diabetes, and CHF, who had severe cognitive impairment and was dependent on staff for bathing, hygiene, bed mobility, and transfers. The care plan identified risk for altered skin integrity related to decreased mobility, with interventions including skin inspection and an anti-pressure mattress. Physician orders directed that the resident’s heels be offloaded while in bed and that a low air loss mattress be in place, set to 207 pounds and checked every shift. On multiple observations, the resident was seen lying in bed with the head of the bed elevated, without a low air loss mattress and with heels not offloaded. An LPN and the ADNS both confirmed facility policy to provide and set low air loss mattresses per physician orders and to offload heels using heel boots or pillows, acknowledged that the resident had current orders for heel offloading and a low air loss mattress, and observed that these orders were not being followed, without being able to explain why.
Incorrect Setting of Ordered Low Air Loss Mattress for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician-ordered pressure-reducing mattress was set correctly for a dependent resident with wounds. The resident had multiple sclerosis, abnormal posture, was always incontinent, and had moisture-associated skin damage, with a Braden Scale score of 14 indicating high risk for pressure ulcers. The care plan identified the need for a pressure-reducing mattress when in bed, and a physician’s order directed use of a low air loss mattress set to 173 pounds, with function to be checked each shift. The Medication Administration Record showed nurses initialed that they checked the mattress function on all shifts, and the resident’s electronic health record also reflected that the mattress should be monitored for function and set to 173 pounds. Despite these orders and documentation, surveyor observations on multiple occasions found the resident in bed with the pressure-reducing mattress set to 450 pounds, and a white sticker on the pump indicating 200 pounds. An LPN interviewed could not state what the mattress setting should have been for this resident, could not explain the meaning of the 200-pound sticker, and did not know where to find the correct setting information. A wound care specialist’s progress note documented ongoing moisture-associated skin damage and treatment to the buttock area. The Infection Prevention RN stated that facility policy was to provide pressure-relieving mattresses for residents with wounds, with physician orders dictating the appropriate weight setting, but the facility was unable to provide a policy on mattresses or pressure-reducing devices when requested.
Failure to Monitor Intake/Output for Dialysis Resident on Fluid Restriction
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of dialysis-related care for a resident with end stage renal disease, hypertension, and peripheral vascular disease who received hemodialysis treatments. The resident’s care plan documented that the resident was on hemodialysis and required a fluid restriction per physician orders, with interventions including maintaining the fluid restriction, monitoring intake and output (I/O) per orders/policy, and observing for signs and symptoms of fluid overload. A physician’s order and nutritional assessment both specified a 1200 ml fluid restriction determined by the hemodialysis center’s registered dietician. However, review of the physician’s orders for the month showed no order for I/O monitoring, and the fluid restriction was entered as a diet order rather than a monitoring order. From 1/6/26 through 1/28/26, physician/APRN notes and nursing progress notes did not document that the resident was on a fluid restriction, did not address compliance with the restriction, and did not indicate that I/O was being monitored. The nurse aide assignment sheet also did not identify that the resident was on a fluid restriction or required I/O monitoring. During interviews, an LPN and the Director of Nursing (DNS) confirmed that facility policy required I/O monitoring for residents on fluid restrictions and that nursing was responsible for monitoring I/O to maintain the restriction, but they were unable to identify any I/O monitoring or documentation for this resident. The DNS acknowledged that entering the fluid restriction as a diet order did not trigger I/O monitoring. The hemodialysis center dietician confirmed the 1200 ml fluid restriction had been in place and communicated to the facility’s dietician, and the facility’s hemodialysis policy required maintaining fluid restrictions as ordered and monitoring I/O, which was not done for this resident.
Crushing of Delayed Release Medications Resulting in Elevated Medication Error Rate
Penalty
Summary
Surveyors identified that the facility failed to ensure delayed release medications were not crushed during administration, resulting in a medication error rate above 5% (11.11%). One resident with diagnoses including chronic obstructive pulmonary disease, dementia with psychotic disturbance, and atherosclerotic heart disease had physician orders dated 12/15/25 for Aspirin 81 mg delayed release (DR) daily, Depakote 250 mg DR daily, and Pantoprazole 20 mg DR twice daily. During a medication pass observed on 1/21/26 at 9:33 AM, an LPN asked the resident if they wanted their medications crushed; after the resident agreed, the LPN placed the three morning DR medications into an envelope, crushed them, mixed them in applesauce, and administered them. Subsequent review of the physician’s orders and interview with an RN confirmed that these delayed release medications should not be crushed. The facility’s Medication Administration and General Guidelines policy stated that tablets may be crushed when residents have difficulty swallowing only if it is safe to do so, and that long-acting or enteric-coated dosage forms should generally not be crushed. The report also cites U.S. Food and Drug Administration guidance that long-acting, extended release, delayed release, and enteric-coated medications should not be split, chewed, or crushed. This sequence of events, including the LPN’s crushing of ordered delayed release medications contrary to physician orders, facility policy, and FDA guidance, led to the cited deficiency and the calculated medication error rate above the 5% threshold.
Expired Insulin Pen Stored and Administered Beyond Discard Date
Penalty
Summary
Surveyors found that the facility failed to ensure proper disposal and non-use of expired insulin for a resident with osteomyelitis and type II diabetes mellitus. The resident had a physician’s order for Insulin Lispro via pen injector to be given subcutaneously three times a day per sliding scale. During an observation of a medication cart, the resident’s Lispro insulin flex pen was noted to be dated 12/19/25, and staff reported it was used as needed for coverage and had not been administered recently. However, review of the January Medication Administration Record showed that Lispro insulin was administered per sliding scale on multiple dates and times after the insulin should have been discarded, including administrations on 1/17/26, 1/18/26, 1/19/26, and 1/20/26. The ADNS confirmed that the insulin flex pen was expired at the time of at least one of these administrations and should have been discarded after 28 days in accordance with facility expectations and the facility’s policy, which directed that Humalog (Lispro) insulin be discarded within 28 days whether opened or unopened. This resulted in expired insulin being stored on the medication cart and administered beyond the 28-day discard date, contrary to the facility’s own policy and accepted professional standards for labeling and storage of drugs and biologicals.
Failure to Provide Bed-Hold Notices for Hospitalized Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of bed-hold rights to residents or their responsible parties when residents were transferred to the hospital for medical reasons. For one resident with extremity amputations, diabetes with neuropathy, and altered mental status, the clinical record showed that the resident had no cognitive impairment per a recent BIMS score and required varying levels of assistance with ADLs. Nursing documentation described a change in condition with increased confusion, trouble with word finding, and inability to complete sentences following a recent fall, leading to an APRN order to send the resident to the emergency room. Review of social services notes and the medical record from the relevant period did not show any documentation that the resident or responsible party/conservator was notified of the right to hold the bed during this medical leave of absence. For another resident with severe protein-calorie malnutrition, viral intestinal infection, hyperosmolality, and hypernatremia, the record indicated moderate cognitive impairment and total dependence on staff for most ADLs, with a care plan noting a guardian/conservator for health and safety decisions and a psychiatric level of care. A clinical form documented that the resident had reported vomiting coffee-ground emesis, with increased confusion and abdominal tenderness, and that the RN supervisor notified the APRN, who ordered transfer to the emergency room. Review of social services notes and the medical record showed no documentation that the resident or the responsible party/guardian was notified of the right to hold the bed during this hospitalization. Interviews with social workers indicated they did not issue bed-hold forms for hospital transfers and believed business office or admissions staff were responsible, while the Regional Business Office Manager confirmed that the records lacked bed-hold policy forms for these residents and that such forms should have been provided, contrary to the facility’s written bed-hold policy.
Failure to Monitor and Document Resident Status After Abuse Incidents
Penalty
Summary
The facility failed to ensure that residents involved in resident-to-resident abuse incidents were properly monitored for injuries, mood, and behaviors as required by facility policy and care plans. For four residents with varying degrees of cognitive impairment and psychiatric diagnoses, documentation and monitoring were not consistently completed following altercations. Specifically, after incidents where residents were struck or involved in altercations, there was a lack of documented assessments regarding their mood, behavior, and physical condition on multiple shifts over several days. For example, one resident with vascular dementia and a history of traumatic brain injury was involved in an altercation and subsequently had interventions listed in the care plan, including RN assessment and monitoring for mental distress. However, there were no physician orders or MAR entries for mood or behavior monitoring, and nurses' notes lacked documentation of these assessments on several shifts following the incident. Similar deficiencies were observed for other residents involved in altercations, including those with severe cognitive impairment and mood disorders, where care plans called for monitoring and support, but documentation and orders for such monitoring were absent. Interviews with facility leadership confirmed that nursing staff were expected to monitor and document mood, behavior, and skin condition for all residents involved in such incidents every shift for 72 hours. Despite this expectation, the Director of Nursing was unaware that monitoring and documentation were not completed consistently and acknowledged that education and audits regarding this requirement were lacking. Review of facility policy also indicated that staff should observe, intervene, and monitor residents following abuse incidents, but these actions were not consistently documented or carried out.
Misappropriation of Resident Property and Funds by Staff Member
Penalty
Summary
A deficiency occurred when a staff member misappropriated a resident's personal belongings and funds. The resident, who had acute respiratory failure with hypercapnia and a cognitive communication deficit, was admitted with personal items including an iPhone and iPad. After experiencing a medical emergency, the resident was transferred to the hospital and did not return, ultimately passing away. The resident's belongings, including the cell phone, remained at the facility following the transfer. Subsequently, the resident's financial Power of Attorney discovered unauthorized financial transactions from the resident's PayPal account, which was accessed via the resident's cell phone. These transactions, totaling approximately $1,735, were traced to a staff member whose contact information matched the PayPal account receiving the funds. The facility's internal investigation confirmed that the staff member had access to the resident's belongings during the period in question. Additionally, there were attempts to change the billing address and request a credit card in the resident's name, further indicating misuse of the resident's property and financial information. The facility's review of staff schedules and interviews revealed that the implicated staff member worked multiple shifts during the relevant period and that another staff member with a matching address was also employed, though no direct involvement was established for the second individual. The facility's abuse policy defined misappropriation as the deliberate misuse or theft of a resident's belongings or money without consent, and the events described met this definition. The deficiency was further compounded by the lack of interviews with other staff, residents, or representatives to determine if additional residents were affected.
Failure to Fully Investigate Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to fully investigate an allegation of misappropriation of money involving a resident who was admitted with acute respiratory failure and cognitive communication deficit. The resident was alert and oriented at admission, required assistance with activities of daily living, and brought personal electronic devices to the facility. After being transferred to the hospital for an acute change in condition, the resident did not return and subsequently passed away. The resident's family later reported unauthorized financial transactions from the resident's PayPal account, which were linked to a staff member's contact information. The facility initiated an internal investigation, notified the police, and suspended the implicated staff member. Despite these initial actions, the investigation was incomplete. The facility did not obtain statements from the accused staff member, other staff, other residents, or resident representatives. Key personnel, such as the social workers, were not involved in the investigation and were not instructed to conduct interviews or assist in gathering information. The investigation did not include interviews with other staff or residents to determine if additional individuals were affected by misappropriation, and there was no evidence that the facility attempted to contact all relevant parties. The facility's abuse policy required a thorough investigation, including interviews with all witnesses and individuals with relevant information, but this was not followed. Interviews with facility leadership confirmed that a full investigation should have been conducted, including interviews with other staff, residents, and their representatives. However, these steps were not taken, and the investigation was limited to the initial report and suspension of the accused staff member. The failure to conduct a comprehensive investigation as outlined in facility policy resulted in a deficiency related to the facility's response to an allegation of misappropriation of resident property.
Incomplete Documentation of Resident Care by Nurse Aides
Penalty
Summary
The facility failed to ensure complete and consistent documentation in the clinical record for a resident with multiple complex medical conditions, including type 2 diabetes mellitus with hyperglycemia, congestive heart failure, obesity, and muscle weakness. The resident required significant assistance with activities of daily living (ADLs) such as eating, toileting hygiene, showering, personal hygiene, bed mobility, and transfers, as identified in the admission MDS and care plan. Despite these needs, a review of the March 2025 documentation survey report revealed multiple instances where nurse aide documentation was missing for key care areas, including bladder and bowel elimination, eating, personal hygiene, showering, toileting hygiene, amount eaten, bowel and bladder diary, fluid intake, and output across several dates and shifts. The facility's policy required CNAs to complete flow sheets in the electronic health record for each resident every shift, documenting all care provided. However, interviews with the DNS confirmed that nurse aide compliance with documentation was inconsistent and ongoing education was being provided to address missing entries. The lack of complete documentation was observed despite the resident's complex care needs and the facility's established procedures for record-keeping. The resident in question was ultimately transferred to the emergency department following a change in condition and did not return to the facility.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with schizoaffective disorder, cognitive communication deficit, and anxiety, who was dependent on staff for toileting, experienced verbal abuse from a nurse aide during an overnight shift. The resident had requested assistance for incontinence care and, after a significant delay, questioned the aide about the wait. The interaction escalated, with the aide becoming argumentative and raising her voice. Audio evidence confirmed that the aide refused to leave the room when repeatedly asked by the resident, declined to summon a supervisor as requested, and continued to provide care despite the resident's objections. The resident and their roommate both reported feeling fearful during the incident, and the roommate described the aide as rude and was concerned for the resident's safety. Facility documentation and interviews corroborated the resident's account, including a statement from the aide admitting to raising her voice and failing to excuse herself or seek a nurse's intervention. The facility's abuse policy strictly prohibits any mistreatment of residents, yet the aide's actions did not align with expected standards of professionalism and resident care. The incident was reported, investigated, and substantiated as a failure to protect the resident from verbal abuse by staff.
Failure to Timely Report and Respond to Alleged Verbal Abuse
Penalty
Summary
A deficiency occurred when an allegation of staff-to-resident verbal abuse was not reported to the facility Administrator or designee within two hours as required. A resident with schizoaffective disorder, cognitive communication deficit, and anxiety reported an upsetting interaction with a nurse aide during the overnight shift. The resident played a recorded audio of the incident for the charge nurse (LPN), who then provided care to the resident for the remainder of the shift and instructed the nurse aide not to care for that resident further. However, the nurse aide was allowed to continue caring for other residents, and the charge nurse did not report the incident to the Nursing Supervisor. The facility's abuse policy requires immediate reporting of any abuse or mistreatment to a supervisor and immediate suspension of the accused individual pending investigation. Despite this, the charge nurse did not escalate the allegation as required, citing the resident's preference not to report the incident. The incident was only brought to the attention of facility leadership later, after another staff member became aware of the recording and reported it. The delay in reporting and failure to immediately remove the accused staff member from duty with all residents constituted noncompliance with facility policy and regulatory requirements.
Resident Sent Unaccompanied to Medical Appointment, Resulting in Drop-Off at Wrong Location and Emergency Department
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent on staff for activities of daily living (ADLs) and transfers, was sent unaccompanied to a medical appointment in the community. The resident had diagnoses including mild cognitive impairment, seizures, diabetes mellitus, peripheral vascular disease, and bipolar disorder, and was identified as having a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The care plan specified that the resident should be accompanied to medical appointments as necessary, but there was no leave of absence (LOA) order documented in the clinical record for this outing. On the day of the incident, the resident was picked up by a transportation company and sent out alone for a vascular appointment. The appointment location had been changed, but this information was not communicated to the facility prior to the resident's departure. Facility staff attempted to contact the resident's family before the resident left but were unsuccessful. The resident's family was not present at the facility at the time of departure, and no staff member was assigned to accompany the resident, contrary to facility policy and care plan directives. As a result, the resident was dropped off at the wrong location and subsequently transported by an unknown person to the emergency department. The emergency department noted that the resident arrived alone, was unable to provide history due to cognitive impairment, and only had paperwork indicating their medical history and facility of origin. The resident was later returned to the facility by a family member. Interviews with facility staff and the medical director confirmed that the resident should not have been sent out unaccompanied and that established procedures for ensuring supervision during offsite appointments were not followed.
Instances of Resident Abuse and Inadequate Supervision Leading to Physical Altercations
Penalty
Summary
The report details instances of abuse and inadequate supervision leading to physical altercations involving several residents at the facility. Resident #31, diagnosed with dementia and traumatic brain injury, was subjected to staff abuse when LPN #8 forcefully administered medication, resulting in a cut on the resident's lip. LPN #8 was reported to have used profanity during the incident. Resident #62, with hemiplegia and hemiparesis, engaged in a resident-to-resident altercation with Resident #74, resulting in physical contact between the two residents. Resident #74, diagnosed with vascular dementia, exhibited wandering behavior and engaged in altercations with other residents, including striking Resident #62 in the face. Resident #76, admitted with congestive heart failure, was involved in an incident with Resident #74, where Resident #76 was struck on the hand and hip during a confrontation initiated by Resident #74's delusions. The facility's failure to ensure adequate supervision and prevent abuse is evident in the detailed accounts of the altercations. LPN #8's actions towards Resident #31, including forcefully administering medication and using inappropriate language, highlight a lack of proper care and respect for the resident. The altercation between Resident #62 and Resident #74 underscores the need for enhanced supervision and interventions to prevent resident-to-resident conflicts. Resident #74's behaviors, including wandering and engaging in altercations, point to a lack of effective monitoring and management of residents with behavioral disturbances, leading to incidents of physical harm.
Failure to Conduct Required Background Checks for New Hires
Penalty
Summary
The facility failed to conduct required background checks for newly hired licensed nurses and certified nurse aides prior to hire. Specifically, the personnel files for several employees, including two nurse aides, two registered nurses, and one licensed practical nurse, lacked documentation of completed background checks. This includes missing ABCMS background checks, fingerprinting, and reference checks. The HR Coordinator, who started at the facility three months prior to the survey, confirmed the absence of these required documents in the personnel files and acknowledged that employees should not have started working without these checks being completed first. The HR Coordinator identified that the facility's pre-hire checklist mandates several screenings and verifications, including license/certification copies, sex offender registry checks, exclusion screening verification, ABCMS background checks, third-party background checks, and reference checks. However, these requirements were not met for the employees in question. The HR Coordinator also noted that he has begun auditing employee files to ensure compliance with these pre-hire requirements moving forward. The Administrator, who began her employment at the facility a few months prior to the survey, expressed that her expectation was for all pre-hiring screenings, including background checks, to be completed in accordance with the facility's pre-hire checklist. Despite this expectation, the facility's failure to adhere to its own policies and procedures resulted in the hiring of staff without the necessary background checks, potentially compromising the safety and well-being of the residents.
Food Storage and Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, several food items in the walk-in refrigerator were found not labeled or dated, including pancakes, salad mix, puree pancake mix, puree eggs, a brown liquid, diced fruit, cookies, and a pie. Cook #1 acknowledged that all prepared foods must be labeled and dated and discarded after three days, but this was not adhered to in practice. Additionally, the facility's policy for prepared foods was not provided upon request. Further observations revealed that the sanitizing solution used for cleaning countertops and washing pots and pans was not at the required concentration levels. The sanitizing water in the 3-bay sink and red buckets tested between 0-100 ppm, significantly below the required 400-600 ppm. The Director of Dietary identified an issue with the sanitizing chemical line, which was not flowing properly, and contacted the vendor for repair. The service report confirmed that the metering tip was clogged and replaced, restoring the sanitizer to 200 ppm, which is still below the required level since COVID-19 adjustments.
Failure to Conduct Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to conduct an interdisciplinary care conference at least quarterly with the resident representative for Resident #16, who was admitted with Alzheimer's disease and dementia. The significant change of condition MDS assessment indicated that Resident #16 had severely impaired cognition, frequent incontinence, and required extensive assistance with various activities of daily living. Despite these needs, the resident representative reported that they only received phone calls from the social worker every three months and had not attended a meeting with the entire interdisciplinary team in at least the last year. The social worker confirmed that while she tried to meet with the IDT, it was usually just her providing updates via phone calls since COVID-19, and no progress notes from these meetings were entered into the electronic medical record. The MDS coordinator indicated that she was responsible for scheduling care conferences and mailing out invites to families, but acknowledged that the attendance sheets often did not have signatures from the resident representative or other departments. The facility's Care Planning Policy requires a comprehensive and individualized plan of care developed by the IDT in collaboration with the resident and/or their representative, with care conferences held at least quarterly. However, the review of the sign-in sheets and interviews revealed that the interdisciplinary team meetings were not being conducted as required, and the resident representative was not adequately involved in the care planning process as stipulated by the facility's policies and the Resident Rights Policy.
Failure to Document and Review Advance Directives
Penalty
Summary
The facility failed to accurately document the life support choices for Resident #43 and did not ensure that advance directives were reviewed with Resident #315 upon admission. Resident #43 was admitted with severe cognitive impairment and had a conservator who initially chose CPR. However, during a hospital stay, the conservator and family decided to change the code status to DNR, which was not properly documented upon readmission to the facility. The Director of Nursing Services (DNS) confirmed that the code status should not have been changed without proper consent from the conservator, and there was a gap between the physician's order and the signed advance directive consent form. For Resident #315, the facility did not review or obtain signatures for advance directives and other consents upon admission. The resident, who had intact cognition, confirmed that no information related to advance directives had been reviewed or signed since admission. The admission checklist indicated that the review of code status and consents was incomplete. Interviews with the nursing staff revealed that it was the responsibility of the admitting nurse to ensure all admission documentation, including advance directives, was completed. However, this was not done for Resident #315. The facility's policy on advance directives requires that the resident be provided with the policy and education on advance directives upon admission, and that the advance directives form be signed and dated by the resident and the person who reviewed the directives. This policy was not followed for both Resident #43 and Resident #315, leading to deficiencies in documenting and reviewing advance directives for these residents.
Failure to Notify Physician and Family of New Skin Blister
Penalty
Summary
The facility failed to ensure timely notification of the APRN/physician and resident representative regarding a newly identified skin blister for Resident #66. Resident #66, who had severe cognitive impairment, was at risk for pressure ulcers, and was dependent on staff for transfers and rolling, developed a superficial dime-sized blister on the left hip. The nurse's note documented the blister and notified the nursing supervisor, but the APRN was only informed through a note in the communication book, which may not have been seen until the following Monday. The facility's policy required immediate notification of the attending physician and responsible party for significant changes in a resident's condition, which was not followed in this case. The nurse's notes from the date the blister was identified until the end of the month did not indicate that Resident #66's responsible party was notified of the change in skin condition. The wound specialist later noted that the blister had developed into a full-thickness wound, requiring specific treatment orders. Interviews with the DNS and APRN confirmed that the facility's communication process was not followed correctly, as the on-call provider should have been notified immediately. The facility's policies on Change in Resident Condition and Pressure Ulcer Prevention were not adhered to, leading to a delay in appropriate medical response and family notification.
Misappropriation of Controlled Substance Medication
Penalty
Summary
The facility failed to ensure that Resident #20 was free from misappropriation of a Schedule II Controlled Drug medication. Resident #20, who was admitted with Alzheimer's disease and vascular dementia, had Morphine Sulfate 100 mg/5 ml Solution prescribed for pain and shortness of breath. On 12/3/23, it was documented that 0.25 ml, 0.50 ml, and another 0.5 ml of the medication were borrowed for another resident, with two licensed staff signatures on the Controlled Substance Disposition Record (CSDR) for each instance. The facility's policy prohibits borrowing controlled substances from one resident to administer to another, and the licensed nurses are required to notify the supervisor and pharmacy if the medication is unavailable. However, this protocol was not followed in this case. Interviews with the facility staff revealed a lack of awareness and adherence to the policy. The Administrator was unaware of the borrowing incidents, and RN #1, who had been employed since October 2023, admitted to not knowing that borrowing controlled substances was prohibited until early 2024. The Director of Nursing Services (DNS) and the Medical Director also confirmed that borrowing controlled substances is against policy and that alternative measures should have been taken, such as checking the Omnicell or contacting the pharmacy and physician for further orders. The facility's abuse/resident policy and the Verification: Access to and administration of controlled substances form both clearly state that borrowing controlled substances is not allowed, yet these guidelines were not followed, leading to the misappropriation of Resident #20's medication.
Failure to Report Staff-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that local law enforcement was notified of a staff-to-resident abuse incident as per facility policy. Resident #31, who had diagnoses including dementia, traumatic brain injury, and dysphasia, was allegedly abused by LPN #8. The incident involved LPN #8 forcefully administering medication to Resident #31, resulting in a cut on the resident's lip. Multiple staff members witnessed the incident and reported it to RN #4, who did not take immediate action to address the situation or notify the police. LPN #8 continued to work for 2.5 hours after the incident, placing other residents at risk. The care plan for Resident #31 included interventions to report incidents to family and physician, watch for signs of distress, and investigate per facility policy. However, the facility's response was inadequate. Despite the severity of the allegations, including the use of profanity and physical aggression by LPN #8, the police were not notified, and the LPN was allowed to continue working. Statements from multiple staff members corroborated the incident, describing how LPN #8 held down Resident #31's arm and forcefully administered medication while the resident resisted and cried. The facility's abuse policy mandates immediate reporting of any alleged abuse to a supervisor and notification of the resident's representative, physician, DPH, and local police. However, this protocol was not followed. The incident was reported to the APRN and documented, but the failure to notify law enforcement and the delayed removal of LPN #8 from duty constituted a significant deficiency in the facility's handling of the abuse allegation.
Failure to Protect Resident from Potential Mistreatment
Penalty
Summary
The facility failed to protect Resident #31 from potential mistreatment following an allegation of abuse. Resident #31, who has diagnoses including dementia, traumatic brain injury, and dysphasia, was allegedly mistreated by LPN #8. The incident involved LPN #8 forcefully administering medication to Resident #31, holding the resident's wrist down, and using profanity in Spanish. Multiple staff members witnessed the incident and reported it to RN #4, who did not take immediate action to address the situation. LPN #8 continued to work for 2.5 hours after the incident, placing residents at further risk. The care plan for Resident #31 included interventions to report incidents to family and physician, watch for signs of distress, and investigate per facility policy. However, the facility did not notify the police, and the initial response from RN #4 was inadequate. Despite multiple staff members reporting the incident, RN #4 did not take the allegations seriously, and LPN #8 was not immediately suspended. The facility's abuse policy mandates immediate reporting and suspension of the accused individual, which was not followed in this case. Interviews with staff members revealed that Resident #31 was visibly distressed, crying, and had a cut on the lip following the incident. The facility's failure to act promptly and appropriately in response to the abuse allegation resulted in a deficiency. The facility's documentation and interviews indicate that the abuse policy was not adhered to, and the resident was not adequately protected from potential mistreatment.
Failure to Complete Timely Social Worker Assessments
Penalty
Summary
The facility failed to complete comprehensive social worker assessments in a timely manner for three residents. Resident #10, who was admitted with diagnoses including atrial fibrillation, anxiety, major depression, and paranoid schizophrenia, had only one social services assessment completed nearly two years after admission. The social worker admitted to being behind on assessments due to workload and staff shortages, resulting in missed quarterly and annual assessments for Resident #10 from the time of admission until over a year later. Resident #16, admitted with Alzheimer's disease and dementia, also did not receive timely social worker assessments. The clinical record showed no quarterly or annual assessments from the time of admission until the survey date, with only progress notes being completed. The social worker responsible for Resident #16 acknowledged the missed assessments and cited staff shortages and personal leave as reasons for the delays. Resident #31, admitted with a stroke and dementia, had only one social worker assessment completed at the time of admission. Subsequent quarterly and annual assessments were not completed, with the social worker attributing the delays to extended personal leave and an overwhelming workload. The facility's administrator was aware of the issue and was in the process of hiring additional staff to address the backlog of assessments.
Failure to Update PASARR for Resident with New Dementia Diagnosis
Penalty
Summary
The facility failed to ensure the PASARR was updated for Resident #5 when there was a significant change in condition. Resident #5, who was admitted with diagnoses including dementia, major depression, and schizoaffective disorder, had a PASARR dated 3/23/17 that did not include a diagnosis of dementia. Despite the hospital discharge summary and physician's orders indicating a diagnosis of dementia, the PASARR was not updated upon admission or during subsequent evaluations. The Social Worker responsible for updating the PASARR missed the dementia diagnosis on multiple occasions, including during the psychiatric provider's follow-up on 10/26/22. Interviews with the Social Worker and the Administrator revealed that the Social Worker was responsible for updating the PASARR but failed to do so due to oversight. The Administrator confirmed that the diagnosis of dementia was not communicated effectively to the Social Worker. Additionally, the facility did not have a policy regarding the updating of PASARRs, contributing to the oversight. As a result, Resident #5's PASARR was not updated to reflect the new diagnosis of dementia, leading to a deficiency in the facility's compliance with PASARR requirements.
Multiple Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure neurological assessments were completed after multiple falls for two residents. Resident #10 experienced several unwitnessed falls, and despite the facility's policy requiring neurological checks for such incidents, these assessments were not documented. The Director of Nursing Services (DNS) confirmed that the neurological assessments were not completed as per the facility's policy, which mandates checks every 15 minutes for the first hour, then hourly for four hours, every four hours for 24 hours, and every shift for 48 hours. Similarly, Resident #48 had multiple unwitnessed falls, and the clinical record lacked documentation of neurological checks following these incidents. The DNS acknowledged issues with the responsible nurse's documentation and confirmed that the required assessments were not performed consistently as per the facility's policy. The facility also failed to ensure a physician's order for hospice services for Resident #16. Despite the social worker's notes indicating that the resident was evaluated and admitted to hospice services, the clinical record did not reflect a physician's order for hospice evaluation and treatment. The DNS confirmed that nursing was responsible for obtaining the order, which was missing from the clinical record until the surveyor's inquiry prompted a late entry. Additionally, the facility did not complete an RN assessment for a newly identified skin blister on Resident #66. The nurse's notes indicated the presence of a superficial area on the resident's left hip, but there was no documentation of an RN assessment until the wound specialist's evaluation days later. The DNS confirmed that an RN assessment should have been conducted and documented immediately upon recognizing the new wound. Furthermore, the facility failed to follow physician's orders for obtaining repeated labs for Resident #104 and did not obtain weights according to policy for Residents #2 and #315. The DNS and other staff acknowledged these lapses in following the facility's protocols and physician's orders.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure that weights were monitored per physician's order for a resident with a significant weight loss. Resident #94, who had a history of stroke, hypertension, and diabetes, was admitted with an order for weekly weights and vital signs. Despite this order, the facility did not consistently document the resident's weight on a weekly basis. The resident experienced a significant weight loss over several months, with weights recorded sporadically and not in accordance with the physician's order. The resident's weight dropped from 149.6 lbs in early March to 124.1 lbs by mid-March of the following year, indicating an 11.1% weight loss over six months. The facility's policy required weights to be obtained upon admission, weekly for four weeks, and then monthly unless otherwise directed by a physician's order. However, this policy was not followed for Resident #94, leading to a failure in monitoring the resident's nutritional status adequately. Interviews with the Medical Director and the Director of Nursing Services (DNS) revealed that the facility was aware of the resident's weight loss but did not ensure that weights were obtained as ordered. The DNS was unaware of the weekly weight orders and could not explain why the weights were not documented as required. The facility's failure to adhere to its own policy and the physician's orders resulted in inadequate monitoring of the resident's nutritional status, contributing to the resident's significant weight loss over time.
Failure to Properly Label, Date, and Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of respiratory equipment for two residents. Resident #49, who had diagnoses including dementia, hypertension, and Covid-19, was observed with oxygen tubing and nebulizer equipment that were not labeled, dated, or bagged as per facility policy. Interviews with LPN #1 and RN #1 confirmed that there were no physician orders for changing the oxygen and nebulizer tubing and mask, and that the equipment should have been labeled and dated. The DNS also confirmed that the equipment should be bagged when not in use to maintain cleanliness. Resident #268, diagnosed with metabolic encephalopathy, COPD, and dementia, was observed with BiPaP tubing that was not dated or bagged. LPN #6 acknowledged that the night shift should have updated the tubing and provided a bag. The DNS confirmed that the tubing should be changed weekly, labeled with the date, and bagged when not in use. The facility's policy on BiPaP/CPAP care and oxygen and nebulizer tubing changes was not followed, leading to the deficiencies observed during the survey.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete annual employee performance reviews for certified nurse aides. Specifically, the personnel file of a certified nurse aide hired on 9/1/21 showed no performance review for the year 2023. The Director of Nursing Services (DNS), who began employment in July 2023, acknowledged that there were outstanding performance reviews and had developed a plan to address the backlog. The facility's policy mandates formal and documented performance reviews at the end of an employee's introductory period and annually thereafter.
Failure to Document and Monitor Behaviors with Antipsychotic Medication
Penalty
Summary
The facility failed to document and monitor specific behaviors with the use of antipsychotic medication for two residents. Resident #10, who was admitted with diagnoses including paranoid schizophrenia, major depressive disorder, anxiety disorder, and sleep disorder, was prescribed Zyprexa for anxiety. However, the Medication Administration Record (MAR) from 2/1/24 to 3/14/24 did not reflect documentation for specific behavior monitoring for the use of this antipsychotic medication. The Director of Nursing Services (DNS) was unaware that Resident #10's behavior was not being monitored daily, contrary to the facility's policy which requires behavior monitoring every shift for residents receiving antipsychotic medications. Resident #74, admitted with diagnoses including vascular dementia with behavioral and mood disturbances, psychotic disturbance, and anxiety, was prescribed Seroquel for dementia, delusions, and combativeness. The MAR from 1/1/24 to 3/8/24 failed to reflect consistent documentation of Resident #74's behaviors every shift. Despite a physician's order to monitor behaviors every hour for 48 hours starting on 1/14/24, the MAR and nurse's notes did not document Resident #74's behaviors during several shifts. The DNS was also unaware that Resident #74's behavior was not being monitored daily, as required by the facility's policy. Interviews with the DNS and MD #1 revealed that they were not aware of the lack of behavior monitoring for both residents. The facility's policy on behavior monitoring and antipsychotic medications mandates that specific target behaviors be identified and monitored every shift, with documentation on behavior flow sheets. The failure to adhere to this policy resulted in the deficiency noted in the report.
Failure to Document Neurological Checks and RN Assessments
Penalty
Summary
The facility failed to ensure complete and accurate documentation related to neurological checks and RN assessments following unwitnessed falls for Resident #48. The resident, who had diagnoses including dementia, repeated falls, and psychophysical visual disturbances, experienced multiple unwitnessed falls. The clinical records did not reflect the initiation of neurological checks or vital sign monitoring after these falls, as required by the facility's policy. Specifically, there were discrepancies in the documentation of falls on 9/2/23, with conflicting notes about whether the resident hit their head, and no additional documentation of neurological checks or vital sign monitoring was found for falls on 9/8/23, 9/11/23, and 9/22/23. The care plan for Resident #48, dated 9/4/23, identified a history of falls and included interventions such as offering toileting and incontinent care during the 3 PM-11 PM shift. Despite this, the clinical record showed that the resident had multiple unwitnessed falls, with no documentation of neurological checks or vital sign monitoring following these incidents. The admission MDS assessment indicated that the resident had severely impaired cognition, was frequently incontinent, and required assistance with transfers, toileting, and dressing. The resident had two or more falls with injury since admission. Interviews with the DNS revealed concerns about RN #10's clinical documentation and acknowledged that the documentation related to the falls on 9/2/23 appeared to be duplicate entries. The DNS confirmed that comprehensive RN assessments and updated vital signs should have been completed following each fall, and neurological checks should have been conducted per facility policy. The facility policy directed that neurological checks should be initiated for unwitnessed falls or head injuries and that these checks should be documented in the resident's medical record. However, the clinical records for Resident #48 did not reflect adherence to these policies, leading to incomplete and inaccurate documentation of the resident's condition following falls.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to maintain a complete medical record for a resident receiving hospice care. Specifically, the medical record for a resident with Alzheimer's disease and dementia did not include the hospice election form and the physician certification of terminal illness. The care plan indicated that the resident was receiving hospice care, but the necessary documentation was missing. Interviews with the Director of Nursing Services (DNS), Business Office staff, and Social Worker revealed that there was confusion and lack of communication regarding who was responsible for obtaining and maintaining these documents. The Business Office staff had requested the necessary forms from the hospice agency but had not received them in a timely manner. The hospice contract with the facility required that all services provided to hospice residents be documented accurately and promptly. However, the facility did not have a policy in place for required documentation from hospice services. The Business Office staff eventually received the consent and election of hospice benefit form, but it was not available at the time of the survey. This deficiency highlights a gap in the facility's process for managing hospice documentation, leading to incomplete medical records for residents receiving hospice care.
Delayed MDS Assessments and Transmissions
Penalty
Summary
The facility failed to ensure the timely completion and transmission of quarterly MDS assessments for three residents. Resident #10, who had diagnoses including atrial fibrillation, anxiety, major depression, and paranoid schizophrenia, had significant delays in the completion and transmission of MDS assessments. The significant change in condition MDS assessment was completed 22 days late and transmitted 14 days late, while the quarterly MDS assessment was completed 25 days late and transmitted 14 days late. RN #6, the Director of MDS coordinators, acknowledged these delays and attributed them to an increased workload due to the state optional MDS assessment for increased payment. Resident #16, diagnosed with Alzheimer's disease and dementia, also experienced delays in MDS assessments. The quarterly MDS assessment was completed 26 days late and transmitted 12 days late, while another quarterly MDS assessment was completed 18 days late and had not been transmitted as of the interview date. Resident #31, with diagnoses including stroke and dementia, had multiple instances of late MDS assessments, with delays ranging from 8 to 33 days for completion and up to 26 days for transmission. RN #6 indicated that the increased workload and lack of sufficient MDS coordinators were the primary reasons for these delays. The Administrator was aware of the issue and was in the process of hiring additional MDS coordinators to address the problem. The facility did not provide a policy for MDS assessments and transmission, but they followed state and federal requirements.
Inconsistent Shift-to-Shift Controlled Drug Counts
Penalty
Summary
The facility failed to consistently complete shift-to-shift controlled drug counts as required. Observations on March 11, 2024, revealed missing signatures on narcotic count sheets for multiple shifts across various units. Interviews with staff members indicated a lack of awareness and adherence to the protocol of counting and signing off on controlled substances at the beginning and end of each shift. The Director of Nursing Services acknowledged being aware of the issue and had implemented an educational form to reinforce the importance of accurate narcotic counts and documentation by licensed nurses.
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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