Apple Rehab West Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in West Haven, Connecticut.
- Location
- 308 Savin Avenue, West Haven, Connecticut 06516
- CMS Provider Number
- 075403
- Inspections on file
- 40
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 37 (1 serious)
Citation history
Health deficiencies cited at Apple Rehab West Haven during CMS and state inspections, most recent first.
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 a history of needing a Kennedy cup for all liquids was readmitted without the adaptive device being re-ordered or provided, resulting in the resident being served hot coffee in a regular cup. The resident spilled the coffee and sustained a significant burn. Staff interviews revealed that the need for the Kennedy cup was not communicated or documented on the drink cart list, and there was no process to reconcile previous adaptive equipment orders upon readmission.
A resident with Alzheimer's disease and diabetes was prescribed an antibiotic for a UTI, but five doses were missed due to unavailability, refusal, and leave of absence. Nursing staff did not notify the provider or supervisor of the missed doses, and documentation was incomplete, contrary to facility policy. Interviews revealed staff were unaware of the requirement to notify the provider for each missed dose, and the APRN was not informed, missing the opportunity to adjust the treatment plan.
A resident with diabetes and myotonic muscular dystrophy was admitted with a physician's order for an endocrinology follow-up within 1-2 weeks. The facility failed to schedule the appointment over a period of more than three months, despite daily documentation of the outstanding order. Interviews confirmed that nursing staff were responsible for scheduling such appointments, but the process was not completed and no relevant policies were provided.
A resident with multiple complex diagnoses experienced a significant change in condition, including unresponsiveness and abnormal vital signs. Nursing staff failed to document a body temperature and blood glucose level prior to transferring the resident to the hospital, despite facility policy and the resident's diabetic status. The omission resulted in an incomplete clinical record of care provided before the transfer.
Staff responsible for water temperature maintenance lacked knowledge of safe temperature ranges, leading to multiple instances where hot water in resident bathrooms exceeded safe limits. Water temperatures were not routinely monitored or documented in resident care areas, and no policy existed for temperature checks. Staff and management were unaware of the correct limits, and no corrective actions were taken for several months despite elevated readings, resulting in Immediate Jeopardy due to the risk of scalding.
The facility did not have a written policy or procedure for monitoring and maintaining safe water temperatures, as evidenced by water at resident sinks reaching up to 130°F and only verbal instructions available for staff response. This deficiency was identified through observations and staff interviews.
A nurse aide was hired without documentation of a completed state or federal background check, including the required fingerprint-based screening. The facility's abuse policy did not specify procedures for background checks, and no pre-employment screening policy was available, resulting in the staff member being employed without proper verification.
Multiple residents did not receive medications and treatments as ordered by physicians, including missed weekly weights, unavailable medications, and late or undocumented medication administration. Staff failed to follow facility policies for timely administration, documentation, and physician notification, resulting in missed doses and incomplete records.
The facility did not maintain adequate nursing staff coverage on weekends, as PBJ data and staff interviews revealed lower staffing levels compared to weekdays. Multiple callouts among nursing aides led to shifts being understaffed, and the facility was unable to consistently replace absent staff. The staffing plan required more aides than were present, and there was no documentation provided to show that resident care needs were met during these periods.
A nurse aide did not receive a required annual performance evaluation or the minimum 12 hours of in-service education, including training based on identified weaknesses. Staff interviews and record reviews confirmed the absence of documentation and completion of these requirements, with no explanation provided for the oversight.
Several residents with medical conditions did not receive meals within the required 14-hour window, as dinner and breakfast were served 15 hours apart. Residents reported that substantial snacks were not consistently provided between these meals, with snack carts offering only limited options like crackers and apple sauce, and requests for more substantial food were often denied or met with resistance from staff.
Surveyors found that staff used uncovered ice cube trays handled with bare hands to provide ice due to a broken ice machine, with food stored above the trays. Multiple food items in kitchen storage were unlabeled and undated, a dented can was not removed from dry storage, food temperature logs were incomplete, and cleaning schedules lacked signatures or clear responsibility. Staff interviews confirmed these practices did not follow facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents receiving psychotropic medications did not have documented consent from their representatives, as required by facility policy. Staff were unable to provide signed consent forms or evidence that representatives were informed of the risks and benefits, despite the residents' cognitive impairments and need for representative involvement.
A resident with osteoarthritis, an artificial knee, and lower back pain did not receive a timely comprehensive assessment as required. Although pain management interventions were in place, the MDS assessment was not completed within the mandated timeframe, and the responsible staff member could not explain the delay. Facility policy required individualized care planning but did not specify the MDS process.
The facility did not update care plans for two residents after significant changes in their conditions. One resident experienced multiple falls and had ongoing oral care needs that were not reflected in the care plan, despite dental findings and staff observations. Another resident receiving continuous oxygen therapy did not have this intervention included in the care plan, even though it was ordered by a physician and observed in use. The DON acknowledged that care plans should have been revised to address these changes.
A resident with schizophrenia, dementia, and anxiety did not receive a prescribed medication or a urine culture because a nurse failed to transcribe the physician's orders into the electronic health record, despite marking them as noted. Only laboratory blood work was processed, and the facility could not provide its policy on physician's orders when requested.
A resident with dementia and incontinence was left unattended for an extended period after requesting bathroom assistance, despite repeated requests and staff awareness. Interviews and observations confirmed that the resident did not receive timely help with toileting, contrary to facility policy and staff expectations.
A resident with hearing loss and cognitive impairment was left without hearing aids after they went missing, despite care plan requirements for daily use and prompt audiology follow-up. Staff interviews revealed uncertainty and lack of documentation regarding the process for replacing the hearing aids, and the audiology vendor confirmed no appointments were scheduled. Facility policy did not clarify expectations for resolving missing sensory devices.
Two residents with respiratory conditions did not receive safe and appropriate respiratory care. One resident was administered supplemental oxygen without a current physician's order, despite facility policy requiring such orders. Another resident experiencing acute shortness of breath was not properly evaluated by an LPN, who failed to assess the resident's oxygen therapy and did not recognize that the oxygen supply was disconnected. The facility's oxygen administration policy lacked criteria for evaluating residents in respiratory distress.
Surveyors found that open ophthalmic solutions and an insulin pen on two medication carts were not labeled with open or expiration dates as required by facility policy. Nursing staff acknowledged the responsibility to label medications upon opening but could not explain the omissions. The DON confirmed that these medications should be labeled and discarded after 28 days, as outlined in facility policy.
A resident with multiple chronic conditions was prescribed several medications, including metformin, which requires periodic lab monitoring due to potential risks. The pharmacy consultant recommended A1c and BMP labs, but the recommendation was not communicated to the physician or acted upon, and no lab orders were placed. This lapse was due to a backlog in the process for handling pharmacy recommendations after a change in DON.
Two residents experienced significant medication errors when one did not receive a prescribed topical medication due to unavailability, and another was nearly given an expired multivitamin. Nursing staff failed to ensure timely reordering and proper checking of medication expiration dates, and did not consistently notify the physician when doses were missed, resulting in a 7% medication error rate during the observed period.
Surveyors found that required shift-to-shift controlled substance reconciliation logs were missing numerous signatures across multiple medication carts. Nursing staff and the DON confirmed that both off-going and oncoming nurses are responsible for counting and signing for controlled substances at each shift change, but logs showed consistent non-compliance with this policy. Staff could not explain the missing signatures, and the deficiency was identified through observation and interviews.
The QAA Committee did not consistently include all required members during its meetings, as shown by missing signatures from the Infection Preventionist, DON, and Medical Director on sign-in sheets. Staff interviews confirmed that the committee met quarterly, but some required members were absent, and at one point, there was no Infection Preventionist employed.
Staff failed to follow infection control practices during a wound dressing change for a resident with a pressure ulcer, including not performing hand hygiene and using unclean surfaces. Dirty linens and personal care items were left in a shower area for consecutive days, and laundry areas were unsanitary and lacked adequate emergency linen supplies. Additionally, tube feeding for a resident was not labeled or discarded according to policy, with inconsistent dates on feeding equipment and staff unaware of proper procedures.
Surveyors found that staff failed to administer influenza, pneumococcal, and COVID-19 vaccines in a timely manner after consent was obtained for several residents, and did not consistently follow up with responsible parties to secure or document consent. Incomplete consent forms, lack of documentation for family communications, and unexplained delays in vaccine administration were observed, resulting in noncompliance with facility immunization policies.
Two residents were not properly offered or timely administered the COVID-19 vaccine. In one case, an LPN failed to follow up with a family for consent, leaving the consent form incomplete and undocumented. In another case, a resident's family gave verbal consent, but the vaccine was not administered for over two months, with no documented reason for the delay.
A resident with respiratory conditions was found unable to access the call bell, which was on the floor and out of reach while the resident was in bed. The resident, dependent for mobility and transfers, was unaware of the call bell's location and later had to yell for help due to breathing difficulties. An LPN responded after being alerted by a surveyor, and the call bell was then returned to the bed. The assigned nursing assistant was unaware of how the call bell became inaccessible, despite facility policy requiring call bells to be within easy reach.
A review of staff training records showed that nurse aides did not receive the required 12 hours of annual in-service education, with documented hours ranging from none to four. Training included a skills day and some dementia care modules, but the total hours were insufficient. The RN responsible for training confirmed the records were complete and that not all staff completed the available training.
A resident with severe cognitive impairment who sustained a second-degree burn did not receive several scheduled medications, treatments, and assessments as ordered, and the provider was not notified of these omissions. Nursing staff confirmed the missed doses and lack of documentation, and facility leadership was unaware of the lapses until the survey. Facility policy requiring prompt provider notification and documentation of medication errors or omissions was not followed.
A resident with severe cognitive impairment and a recent burn injury did not receive multiple physician-ordered medications, treatments, pain assessments, and vital sign checks as required. Nursing staff did not administer or document these interventions, nor did they notify the provider of the omissions, contrary to facility policy.
A resident with dementia and severe cognitive impairment did not have complete documentation for several ordered medications and treatments, including pain assessments, Miralax, Risperdal, and Silvadene cream. An LPN admitted to administering the medications and treatments but failed to document them after leaving early, and records did not show evidence of administration as required by facility policy.
A resident with dementia, dysphagia, and GERD experienced a change in condition involving respiratory distress and vomiting. Facility staff failed to perform and document a complete and current assessment, did not provide up-to-date vital signs to EMS, and did not carry out all care plan interventions before the resident was transferred to the hospital. Interviews confirmed that required assessments and documentation were not completed during the emergency.
A resident with dementia, dysphagia, and GERD experienced a change in condition and was found by EMS in respiratory distress with vomit in the mouth and no staff present. Staff failed to monitor, implement care plan interventions, or provide a thorough handoff report, resulting in the resident being transferred to the hospital with aspiration pneumonia.
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 Provide Required Adaptive Drinking Device Upon Readmission
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, diabetes, peripheral vascular disease, congestive heart failure, and chronic obstructive pulmonary disease was readmitted to the facility following a hospital transfer. The resident had a documented need for a Kennedy cup, an adaptive drinking device, for all hot and cold liquids due to a risk of aspiration and a history of spilling drinks. Upon readmission, the nursing assessment did not identify any changes in functional status, but the order for the Kennedy cup was not reactivated, as it had been discontinued during the hospital transfer and was not included in the hospital's transfer documentation. On the day of readmission, the resident was served hot coffee in a regular cup with a lid, rather than the required Kennedy cup. The resident removed the lid and spilled the coffee on their right thigh, resulting in a second-degree burn measuring 17 cm by 9.5 cm. The temperature of the coffee was measured at 171 degrees Fahrenheit. Nursing staff responded to the incident, and subsequent assessments documented the extent of the burn and the resident's pain level. The Kennedy cup was not provided until after the incident occurred. Interviews with staff revealed that the nurse aide assigned to the drink cart was unaware of the resident's need for a Kennedy cup, as the resident was not listed as requiring special equipment on the drink cart list. The occupational therapist confirmed the resident's long-standing need for the Kennedy cup and noted that the order had not been reactivated upon readmission. The Director of Nursing acknowledged that there was no process in place to reconcile previous orders or interventions upon readmission, which led to the omission of the Kennedy cup and contributed to the resident's injury.
Failure to Notify Provider of Missed Antibiotic Doses
Penalty
Summary
The facility failed to notify a provider when an antibiotic prescribed to treat a urinary tract infection was omitted five times for a resident with Alzheimer's disease and type 2 diabetes mellitus. The resident, who had memory recall deficits and was dependent on staff for personal hygiene and toileting, was prescribed cefuroxime axetil to be administered twice daily for ten days. The medication was not administered on five occasions due to reasons such as unavailability, resident refusal, and the resident being on a leave of absence. Documentation in the Medication Administration Record and nurse's notes indicated missed doses, but there was no evidence that the provider or nursing supervisor was notified of these omissions as required by facility policy. Interviews with nursing staff revealed a lack of awareness regarding the requirement to notify the provider for each missed medication dose. The Advanced Practice Registered Nurse confirmed she was not informed of the missed doses and stated that notification could have led to changes in the treatment plan. The Director of Nursing also acknowledged that each missed dose should have been documented with the reason and notification details, and that staff should have reapproached the resident after refusals and documented these actions. The facility's medication administration policy required documentation of refusals, provider notification, and actions taken when medications were unavailable, but these procedures were not followed in this case.
Failure to Schedule Required Endocrinology Appointment for Resident
Penalty
Summary
A deficiency occurred when the facility failed to schedule a required endocrinology appointment for a newly admitted resident with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, and myotonic muscular dystrophy. Upon admission, the resident was assessed as alert with good memory recall and required staff assistance for positioning and transfers. The care plan identified the resident as being at risk for hypo/hyperglycemia, and a physician's order directed that a follow-up appointment with endocrinology be scheduled within one to two weeks. However, review of the clinical record and medication administration records over a period of more than three months showed that the appointment was never scheduled, nor was the resident seen by endocrinology, despite daily documentation indicating the order remained active. Interviews with facility staff revealed that the process for scheduling outside appointments involved the charge nurse, who was responsible for making the appointment within 72 hours or notifying the nursing supervisor if unable to do so. The DON confirmed that nursing staff were responsible for scheduling such appointments and acknowledged that the order should have been followed. Despite this, the order remained unsigned for its intended purpose and was simply carried over daily for several months. No facility policies regarding following physician's orders or scheduling offsite appointments were provided upon request.
Failure to Document Critical Assessment Data Prior to Hospital Transfer
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a complete and accurate clinical record for a resident with Alzheimer's disease, type 2 diabetes mellitus, and myotonic muscular dystrophy who experienced a significant change in condition. The resident was found barely responsive, with labored breathing, tachycardia, pale and cold skin, and appeared very weak. Despite these symptoms and the resident's known diabetes diagnosis, neither a body temperature nor a blood glucose level was documented or communicated to the provider prior to the resident's transfer to the emergency department. The facility's own policy required prompt and complete documentation of assessments and significant events, but this was not followed. Upon review, it was found that the hospital documented the resident as febrile and with a critically high blood glucose level upon arrival. Interviews with nursing staff revealed that although a nurse performed an assessment and believed she had obtained vital signs and a blood sugar, she did not document these findings before the end of her shift, citing the resident's condition as a distraction. The Director of Nursing confirmed that documentation should have been completed as close to the event as possible, and was unaware that it had not been done. The lack of documentation resulted in an incomplete clinical record regarding the care provided prior to the resident's transfer.
Failure to Monitor and Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that staff responsible for maintaining water temperatures were knowledgeable about acceptable hot water temperature ranges, resulting in water temperatures in resident bathrooms that exceeded safe limits. Observations revealed that water temperatures at multiple resident bathroom sinks were measured between 127 and 133 degrees Fahrenheit, which is above the normal range of 110 to 120 degrees Fahrenheit. The Administrator and Maintenance Director were unaware of the correct temperature limits, and there was no documentation of water temperature checks in resident bathrooms prior to surveyor inquiry. Review of facility documents showed that monthly water temperature logs from May through July indicated consistently elevated temperatures, with no evidence of corrective action or documentation of subsequent temperature checks to confirm adjustments. The logs only included temperatures from shower and tub rooms on the 2nd and 3rd floors, omitting resident bathrooms. Additionally, the Maintenance Director believed the acceptable limit was 130 degrees Fahrenheit and only sought clarification after several months of elevated readings. No interventions were implemented during this period to address the high temperatures. Interviews with staff revealed a lack of awareness regarding the risks associated with hot water temperatures, and there was no facility policy or procedure for monitoring water temperatures. Staff reported that water from the hot tap was often too hot to touch, and adjustments were made informally without documentation. The lack of knowledge, monitoring, and policy resulted in Immediate Jeopardy due to the potential for resident scalding.
Failure to Maintain and Monitor Safe Water Temperatures
Penalty
Summary
The facility failed to ensure the existence and implementation of a policy and procedure for monitoring water temperatures to maintain them within acceptable ranges. During an observation, water temperatures at bathroom sinks shared by residents were found to be as high as 130 degrees Fahrenheit, which was confirmed by the administrator and felt hot to the touch. When requested, the facility was unable to provide a written policy or procedure for monitoring hot water temperatures, only offering verbal instructions on how staff would respond to elevated temperatures. The deficiency was identified through direct observation and interviews, revealing a lack of documented processes to prevent residents from exposure to excessively hot water.
Failure to Complete Required Background Checks Prior to Staff Hire
Penalty
Summary
The facility failed to conduct a thorough investigation into the background of a prospective staff member, specifically a nurse aide, prior to her hire date. Review of the employee file revealed that, although the nurse aide had signed consents for background checks, there was no documentation of a completed state or federal background check, including the required fingerprint-based screening through the Applicant Background Check Management System (ABCMS). The Human Resources Director was unable to provide evidence of an ABCMS screening and could not explain why it was missing from the file. The Administrator also could not account for the absence of the background check or ABCMS screening prior to employment. Additionally, the facility was unable to produce a policy for pre-employment screening when requested. The abuse policy provided during the survey only referenced ensuring an active license or certification and reviewing regulatory action reports, but did not outline a process for completing background checks or ABCMS screenings. This lack of documentation and policy resulted in the facility hiring a nurse aide without verifying her background as required.
Failure to Administer Medications and Treatments per Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with diagnoses including dysphagia and rhabdomyolysis, there was a physician's order for weekly weights, but only one weight was obtained over several weeks, and there was no documentation of refusal or explanation for the missed weights. Nursing assistants were responsible for obtaining weights, but the resident was only listed for monthly weights, contrary to the physician's order. The facility's policy required weights to be obtained as ordered, but this was not followed. Another resident with spina bifida and a stage 4 pressure ulcer did not receive a prescribed topical medication because it was not available in the facility. The LPN responsible for reordering the medication delayed faxing the request to the pharmacy, resulting in missed doses. There was no documentation that the physician was notified about the missed medication, as required by facility policy. Additionally, the medication was not available for administration for more than a day, and the resident missed several scheduled applications. For three residents, medications were not administered at the scheduled times according to physician orders. An LPN administered morning medications several hours late without notifying the physician, and the medication administration record was inaccurately documented to reflect the scheduled rather than actual administration times. Another resident missed multiple scheduled medications, including antipsychotics, blood thinners, and diabetic agents, with no documentation of refusal or explanation in the nursing notes or MAR. The facility's policies required timely administration and documentation, but these were not followed.
Insufficient Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available on weekends, as evidenced by a review of Payroll-Based Journal (PBJ) staffing data and staff interviews. PBJ data showed that weekend staffing levels were consistently lower than weekday staffing during two fiscal quarters. On specific weekends, scheduled staffing was not met due to multiple callouts, particularly among nursing aides. For example, on one Sunday, six nursing aides called out for the 7-3 PM shift, and only one could be called in, resulting in six aides working instead of the scheduled ten. Similarly, for the 3-11 PM shift, five aides called out, and only three could be called in, leaving the shift short-staffed for several hours. The facility did not provide documentation to demonstrate that resident care needs were met during these periods of reduced staffing. Interviews with the scheduler and administrator confirmed that callouts, including those due to inclement weather, contributed to the staffing shortages. The facility's staffing plan, as outlined in the Facility Assessment, called for 11 nursing aides for the 7-3 PM shift with an average daily census of 83 residents. The assessment also identified staffing as a weakness, citing a unionized workforce and limited availability of per-diem or temporary staff. The administrator was unaware that the facility had been flagged for low weekend staffing in PBJ reports and acknowledged that the facility was not utilizing agency staff during the periods in question. Additionally, the DNS and ADNS occasionally filled in as RN supervisors but did not clock in as direct-care staff.
Failure to Complete Annual Performance Evaluation and Required In-Service Education for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one nurse aide, despite the aide having been employed for over a year. Review of the personnel file showed no documentation of a required annual or earlier performance evaluation. Additionally, the nurse aide did not receive at least 12 hours of in-service education per year, nor was there evidence of education addressing any areas of weakness identified through performance review. Interviews with staff confirmed that the required evaluation and in-service education were not completed, and the responsible staff could not provide an explanation for the omission.
Failure to Provide Timely Meals and Substantial Snacks Between Dinner and Breakfast
Penalty
Summary
The facility failed to ensure that meals were served within the required 14-hour window for four residents with various medical conditions, including anxiety, adjustment disorder, epilepsy, Type 2 diabetes mellitus, hypertension, dysphagia, gastro-esophageal reflux disease, anemia, localized edema, and orthostatic hypotension. According to the facility's meal schedule, dinner was served at 4:45 PM and breakfast at 7:45 AM, resulting in a 15-hour gap between meals. Clinical record reviews and resident interviews confirmed that these residents did not receive a substantial snack between dinner and breakfast, with some reporting that the snack cart was not consistently available or only offered limited options such as crackers. Further observations and staff interviews revealed that the snack carts, which were supposed to be provided three times daily, typically contained only crackers, apple sauce, and oatmeal cookies. Residents reported that requests for more substantial snacks, such as sandwiches or peanut butter and jelly, were often met with resistance from staff or not fulfilled. The nourishment room observation supported these claims, showing a limited variety of snacks available. These findings indicate that the facility did not meet the nutritional needs and preferences of residents who required or requested food outside of scheduled meal times.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary food handling and storage practices in several areas. Observations revealed that the kitchen ice machine was non-operational and padlocked, with no scoop available, leading an LPN to use uncovered ice cube trays in the nourishment room freezer to provide ice. The LPN handled the trays with bare hands, and food items in a cloth bag were stored directly above the open trays. The ice machine had reportedly been broken for 1-2 months, and there was no documented policy for the use of ice cube trays in this manner. Additionally, the freezer had also been out of order for several months, with no alternative process for ice delivery in place. Further deficiencies were identified in the kitchen and storage areas. Multiple food items in the refrigerators and freezers were found without labels or dates, including containers of various substances and sandwiches. A dented can was found in dry storage, contrary to facility policy requiring such items to be removed and returned to the vendor. Review of food temperature logs showed missing entries for three consecutive days, and cleaning schedules lacked signatures or clear assignment of responsibility. Interviews with dietary staff and the director confirmed that these practices did not align with facility policies, and staff were unsure why proper procedures were not followed.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that when an event involving suspected abuse, neglect, or theft occurred, the facility did not fulfill its obligation to promptly notify the appropriate authorities or provide the outcomes of its internal investigation as required.
Failure to Obtain and Document Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document consent from residents' representatives for the use of psychotropic medications for two residents reviewed for unnecessary medications. For one resident with diagnoses including anxiety disorder, dementia, and borderline personality disorder, the clinical record and care plan indicated regular use of antipsychotic medication. Despite multiple requests, staff were unable to provide a signed consent form for the psychotropic medication, and the required documentation was not available in the resident's record or psychiatric consultant notes. The facility's policy required involvement and documentation of the resident or representative in discussions about medication risks and benefits, which was not followed in this case. For another resident with dementia, diabetes, and chronic kidney disease, the clinical record also failed to show evidence that the resident's representative was informed of the risks and benefits of psychotropic medication use or that consent was obtained. Staff interviews confirmed that the consent form could not be located, and although a psychiatric note indicated the resident consented, the resident was cognitively impaired and conserved, making representative consent necessary. No documentation was provided to show that the conservator had given consent for the medication.
Failure to Complete Timely Comprehensive Assessment for Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive assessment for a resident in a timely manner. The resident, who was cognitively intact and had diagnoses including unilateral primary osteoarthritis, an artificial right knee, and lower back pain, was admitted and had a care plan identifying pain management interventions, including medication and ice packs for the right knee. Despite these interventions, the Minimum Data Set (MDS) assessment, which should have been completed within 14 days of admission, was not completed on time. The MDS coordinator confirmed the assessment was late and could not provide a reason for the delay. Facility policy required a comprehensive and individualized plan of care but did not address the MDS completion process.
Failure to Update Care Plans After Falls, Oral Care Changes, and Oxygen Therapy
Penalty
Summary
The facility failed to update and revise care plans for two residents following significant changes in their conditions and care needs. For one resident with schizophrenia and dementia, the care plan was not updated after multiple falls, including a recent incident where the resident was found unconscious with a hematoma and required hospital evaluation. The fall investigation documentation was incomplete, lacking supervisor review and signatures, and there was no evidence that the care plan was revised to address new interventions or needs following the fall or after the resident's return from the hospital. Additionally, the same resident's care plan did not reflect current oral care needs and preferences, despite a dental exam noting moderate plaque, gingivitis, and buildup on the teeth. Observations over several days confirmed visible buildup on the resident's gumline, and staff interviews revealed that the resident preferred to perform oral care independently but required assistance. The care plan was not updated to reflect these preferences or the findings from the dental evaluation. For another resident with acute respiratory failure and hypoxia, the care plan did not include specific interventions for oxygen use, despite physician orders for continuous oxygen therapy and observations confirming ongoing oxygen use. The care plan only referenced checking oxygen saturation but did not address the need for or management of oxygen therapy. The DON confirmed that the care plan should have been updated to reflect these interventions, but no explanation was provided for the omission.
Failure to Transcribe and Implement Physician's Orders for Medication and Lab Work
Penalty
Summary
A deficiency occurred when a physician's order for a resident with schizophrenia, dementia, and anxiety was not properly transcribed and implemented. The resident, who had moderate cognitive impairment and required assistance with daily activities, was evaluated by a psychiatry APRN due to behavioral disturbances, including increased confusion, agitation, and combativeness. The APRN ordered Seroquel 25 mg by mouth every 12 hours as needed for agitation and combative behaviors, as well as laboratory tests including a Depakote level, CBC with diff, CMP, and a urine culture with sensitivity. The written physician's order sheet was marked as 'noted' and initialed by a Registered Nurse Supervisor, indicating that the orders were to be transcribed and followed up on according to facility policy. However, upon review, it was found that only the laboratory work was transcribed into the electronic health record, while the medication order for Seroquel and the urine culture with sensitivity were not entered or acted upon. The laboratory book also showed that a urine sample pick-up was never arranged. Interviews and record reviews confirmed that the required medication and urine specimen orders were not transcribed, despite documentation indicating otherwise. The facility was unable to provide a copy of its Physician's Orders Policy when requested.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
Resident #29, who has diagnoses including unspecified dementia, Type 2 diabetes mellitus, and chronic kidney disease, was identified as requiring maximal assistance with activities of daily living, including toileting, due to moderate cognitive impairment and frequent urinary incontinence. Observations on 8/7/2025 documented that the resident requested to use the bathroom at 9:32 AM, but was not assisted by staff for an extended period, remaining unattended in the hallway and by the nursing station until at least 11:38 AM. Despite repeated requests and visible presence near staff, the resident did not receive timely toileting assistance. Interviews with nurse aides and an LPN confirmed that residents are expected to be assisted with toileting as soon as possible, and that waiting beyond two hours is considered excessive. One staff member reported this was the first time she was informed of the resident's need that day, while another visitor noted the resident had been left wet from urination the previous day. Facility policy requires prompt assistance with ambulating to the bathroom, and the Director of Nursing stated that 15 minutes is a reasonable timeframe for such assistance. The failure to provide timely care and assistance with toileting for Resident #29 constitutes a deficiency in meeting the resident's needs.
Failure to Ensure Timely Audiology Follow-Up for Missing Hearing Aids
Penalty
Summary
Resident #35, who has diagnoses including unspecified hearing loss, adjustment disorder, and age-related physical debility, was identified as moderately cognitively impaired and dependent on staff for activities of daily living. The resident's care plan required that hearing aids be in place daily and functioning, with audiology appointments made as needed. On 7/25/25, a missing property form documented that the resident's hearing aids were missing, and the interdisciplinary team was to add the resident to the audiology list for replacement. However, on 8/12/25, the resident was observed without hearing aids and was unable to hear the surveyor during an introduction. Interviews with staff revealed confusion and lack of follow-through regarding the process for replacing the missing hearing aids. The LPN was unsure if the resident had been added to the audiology list, and the social worker indicated that after the missing property form was completed, the DNS was responsible for contacting the audiology vendor. The DNS could not locate any documentation or email confirming that the resident had been added to the audiology list, attributing the lapse to her transition into the role. The audiology vendor confirmed that no residents were scheduled for services at the facility. The facility policy did not specify expectations for resolving missing items, contributing to the failure to ensure the resident received necessary audiology follow-up.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for two residents. For one resident with diagnoses including acute respiratory failure with hypoxia and hypercapnia, the facility failed to ensure there was a current physician's order for oxygen therapy. Despite the resident being observed on supplemental oxygen via nasal cannula at a specified flow rate, a review of both electronic and paper health records did not reveal an active physician's order for oxygen therapy. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that orders should be documented in the electronic health record, but no such order was present at the time of review. Facility policy requires a physician order for the admission of oxygen, which was not followed in this case. For another resident with chronic obstructive pulmonary disease, asthma, and respiratory failure, the facility failed to ensure that licensed staff appropriately evaluated the resident's oxygen therapy during a potentially urgent medical situation. The resident, who was dependent for bed mobility and transferring and was receiving oxygen therapy and non-invasive mechanical ventilation, was observed experiencing significant shortness of breath and calling for help. The LPN who responded did not initially assess the resident's oxygen therapy, instead attempting to adjust the room's air conditioner and fan. The resident's oxygen was later found to be disconnected from the concentrator, and only after intervention by another staff member was it reconnected. The LPN returned with a pulse oximeter and found the resident's oxygen saturation to be below the target level. Additionally, the facility's policy and procedure manual for oxygen administration did not include evaluation criteria for residents experiencing shortness of breath while receiving oxygen therapy. This lack of clear guidance contributed to the failure to provide appropriate and timely evaluation and intervention for the resident in respiratory distress.
Failure to Label and Discard Open Medications per Policy
Penalty
Summary
Surveyors observed that medication storage practices on two medication carts failed to comply with facility policy regarding the labeling and disposal of medications. Specifically, multiple open bottles of ophthalmic solutions and an insulin pen were found without open dates or expiration dates recorded. In some cases, open dates were present but indicated the medication had surpassed the 28-day expiration period as outlined in facility policy. Interviews with nursing staff confirmed that it is the responsibility of the nurse who opens a medication to label it with the open and expiration dates, but staff were unable to explain why this was not done for the medications observed. The Director of Nursing confirmed that both ophthalmic solutions and insulin pens are to be labeled with open and expiration dates and discarded after 28 days, in accordance with facility policy and manufacturer instructions. Policy reviews further supported these requirements, directing staff to record the date opened and the date to expire on containers of medications with shortened beyond-use dates. Despite these clear policies, the observed failure to label and discard medications as required constituted a deficiency in pharmaceutical services and medication management.
Failure to Communicate Pharmacy Lab Recommendations to Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician was made aware of a pharmacy consultant's recommendation for laboratory monitoring for a resident with multiple diagnoses, including atrial fibrillation, dementia, hypertension, heart failure, and diabetes. The resident was receiving several medications, including metformin, which carries a boxed warning for lactic acidosis risk, especially in those with kidney disease. The pharmacy consultant recommended checking A1c and BMP labs every six months, but this recommendation was not communicated to or acknowledged by the physician, and no corresponding order was found in the resident's electronic health record. The facility's process required pharmacy recommendations to be placed in a book for physician review, with the expectation that the physician would accept or deny the recommendation and sign the form. However, due to a backlog following a change in the Director of Nursing, this process was not completed, resulting in the physician not being informed of the pharmacy's recommendation and the necessary lab orders not being placed. The facility's policy directed that medication review recommendations be provided to relevant staff, but this was not followed in this instance.
Medication Errors Due to Unavailable and Expired Medications
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication availability and administration practices. One resident with spina bifida, paraplegia, and a stage 4 pressure ulcer did not receive prescribed clotrimazole-betamethasone cream as scheduled because the medication was not available in the facility. Nursing staff were unable to locate the cream in the medication cart or room, and although a paper pharmacy re-order form was completed in the morning, it was not faxed to the pharmacy until late at night. The resident missed multiple scheduled applications of the cream, and there was no clear documentation that the physician was notified of the missed doses, contrary to facility policy. Another resident with dementia and chronic kidney disease was nearly administered an expired multivitamin with minerals. During medication preparation, an LPN placed a tablet from a bottle with an expiration date that had already passed into the resident's medication cup. Upon surveyor inquiry, the LPN removed the expired medication and sought a replacement. The nursing supervisor confirmed that nurses are expected to check expiration dates daily and during monthly cart cleaning, but was unsure which shift was responsible for the monthly checks. The expired medication was found in the medication cart trash and was subsequently removed for proper disposal. Facility policy requires that medications be administered as prescribed, with doses checked against the Medication Administration Record and medication labels, and that physicians be notified when a dose is missed. In both cases, these procedures were not followed, resulting in a medication error rate of 7% during the observed period.
Failure to Complete Controlled Substance Shift-to-Shift Reconciliation Logs
Penalty
Summary
Surveyors observed that the facility failed to ensure proper completion of controlled substance shift-to-shift reconciliation sign off sheets for all four medication carts reviewed. Specifically, numerous required signatures were missing from the controlled substance logs for both July and August 2025 across multiple units. For example, on the 2-east medication cart, 31 out of 186 possible signatures were missing for July, and 20 out of 74 were missing for August. Similar deficiencies were found on the 2-west, 3-east, and 3-west medication carts, with missing signatures ranging from 9 to 61 per log. Interviews with nursing staff and the Director of Nursing confirmed that it is facility policy for both the off-going and oncoming nurses to count controlled substances together and sign the log at each shift change, but staff were unable to explain the missing signatures. Review of facility policy dated August 1, 2024, confirmed the requirement for incoming and outgoing nurses to count all schedule two controlled substances and other medications with a risk of abuse or diversion at each shift change or at least once daily, and to document the results on a verification sheet. Despite this policy, the observed logs showed consistent non-compliance, with staff acknowledging the process but not adhering to the documentation requirements. No explanation was provided for the missing signatures, and the deficiency was identified solely through observation and staff interviews. No specific residents or patient conditions were mentioned in relation to the deficiency.
QAA Committee Lacked Required Members During Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee included all required members during scheduled meetings, as evidenced by missing signatures from key committee members on multiple occasions. Record review of QAA Committee sign-in sheets revealed that on one date, the Infection Preventionist, Director of Nursing, and Medical Director did not sign in, and on another date, the Infection Preventionist's signature was missing. Staff interviews confirmed that the QAA committee met at least quarterly, but the Administrator could not explain the absence of required members at certain meetings, noting that there was no Infection Preventionist employed at the time of one meeting. Facility policy specifies that the QAA committee must include the Administrator, DNS, Medical Director, Infection Control Nurse, and at least three other members.
Infection Control and Linen Management Deficiencies
Penalty
Summary
Staff failed to follow infection prevention and control practices during a wound dressing change for a resident with a pressure ulcer. The LPN did not perform hand hygiene before donning gloves, between glove changes, or after removing gloves, despite handling soiled dressings and clean supplies. The LPN also placed clean dressing supplies on an unclean tray table surface and used tape from her pants pocket, further breaching infection control protocols. The facility's policy required cleaning the work surface and performing hand hygiene before applying clean gloves, which was not followed. Observations over two consecutive days revealed that dirty linens were left on the floor and on surfaces in a shower area, and personal care items were improperly stored in the same area. The same linens and personal items remained in place from one day to the next, indicating a lack of timely removal and cleaning. In the laundry area, dirty linen bags were stored on the floor due to limited space and equipment breakdowns, and clean linens were stored in unsanitary conditions. Wall fans and ceiling exhaust fans blowing toward clean linen areas were found to be dirty, and the emergency linen supply was inadequate, lacking essential items such as washcloths, top sheets, pillowcases, blankets, bed pads, and bedspreads. Sinks in both the dirty and clean sides of the laundry were unclean and obstructed, with one sink cracked and used for storage of dry supplies, and the other surrounded by dust and debris. For a resident receiving tube feeding, the facility failed to ensure that the tube feeding was labeled correctly and discarded in a timely manner. The tube feeding bottle was found hanging without a date, time, or feeding rate, and the water bag and tubing had inconsistent labeling dates. Staff interviewed were unaware of the labeling discrepancies or how long the feeding had been hanging, despite facility policy requiring clear labeling of tube feeding systems with resident name, date, time, contents, rate of flow, and nurse's initials.
Delayed and Incomplete Vaccine Administration and Consent Documentation
Penalty
Summary
Surveyors identified deficiencies in the facility's administration of influenza, pneumococcal, and COVID-19 vaccinations for residents. In four out of five clinical records reviewed, staff failed to provide vaccines in a timely manner after consent was obtained and did not consistently follow up with responsible parties to secure consent or declination. For one resident, the consent form was incomplete, lacking a signature or date, and although the family was noted as deciding, there was no documentation of follow-up attempts after the initial entry. Another resident's family provided verbal consent for vaccinations, but the vaccines were not administered until over two months later, with no documented reason for the delay. In a third case, the consent form indicated the resident was conserved and awaiting family decision, but there was no date or documentation of follow-up efforts. For a fourth resident, vaccines were administered 17 days after consent was given, again with no explanation for the delay. Facility policies for influenza, pneumococcal, and COVID-19 vaccines require timely offering and administration of vaccines, documentation of refusals, and re-offering as appropriate, in accordance with CDC guidelines. However, staff interviews and record reviews revealed lapses in following these policies, including lack of documentation for family communications, delays in vaccine administration after consent, and incomplete consent forms. These actions and omissions resulted in noncompliance with the facility's own infection control and immunization protocols.
Failure to Offer and Timely Administer COVID-19 Vaccinations
Penalty
Summary
The facility failed to properly offer and document COVID-19 vaccinations for two out of five residents reviewed for immunizations. For one resident, the clinical record showed a consent form with a refusal box checked and handwritten notes indicating the family was deciding, but there was no signature or date from the resident or responsible party. The LPN responsible acknowledged that after an initial note stating 'awaiting family consent,' no further attempts were made to follow up with the family, and there was no documentation of any conversation or outreach to obtain consent or declination. This resulted in the resident or responsible party not being given a clear opportunity to accept or refuse the COVID-19 vaccine. For another resident, the family member had provided verbal consent for the COVID-19 vaccine, but the vaccine was not administered until approximately two and a half months later. The LPN could not provide a reason for this delay or any documentation explaining why the vaccine was not given in a timely manner. The facility's policy required that residents or responsible parties be offered the vaccine according to CDC guidance and that refusals and re-offers be documented, but these procedures were not followed for the two residents in question.
Inaccessible Call Bell in Resident Room
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, asthma, and respiratory failure was found in bed with the call bell lying on the floor, out of reach. The resident, who was cognitively intact but dependent for bed mobility and transfers, was unaware of the call bell's location and could not access it when needed. During the surveyor's observation, the resident was seen facing away from the call bell, which was on the opposite side of the bed and not accessible. Shortly after the initial observation, the resident began yelling for help due to difficulty breathing and was visibly short of breath. The surveyor responded by alerting an LPN, who attended to the resident. The call bell remained on the floor until the LPN placed it back on the bed after being notified by the surveyor. When interviewed, the nursing assistant assigned to the resident was unaware of why the call bell was out of reach and stated that call bells are typically clipped or wrapped onto the bed. Facility policy requires that call bells be positioned so residents can easily access them.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required minimum of 12 hours of annual in-service training. A review of training records for five nurse aides revealed that none had documentation of completing the mandated training hours, with recorded in-service hours ranging from zero to four. The training records included participation in a yearly skills day and some dementia care modules, but the total documented hours fell short of regulatory requirements. During an interview, the RN responsible for training confirmed that the records were complete and acknowledged the deficiency, noting that while training was made available, not all staff completed it.
Failure to Notify Provider of Medication and Treatment Omissions After Resident Burn
Penalty
Summary
A deficiency occurred when the facility failed to notify a provider of medication and treatment omissions following an incident in which a resident with dementia and severely impaired cognition sustained a second-degree abdominal burn from spilled coffee. The resident required significant assistance with daily activities and had multiple physician orders in place, including pain assessments, administration of medications for agitation and constipation, wound care, and vital sign monitoring. After the burn, new orders were obtained for wound care and increased monitoring. On a specific day, several scheduled medications and treatments, including pain assessments, Miralax, Risperdal (both oral solution and tablet), Tylenol, vital sign checks, and Silvadene cream application, were not documented as administered. There was no evidence in the clinical record that these omissions were communicated to the provider, as required by facility policy. Interviews with nursing staff confirmed that the medications and treatments were not given or documented, and that the provider was not notified of these omissions. The Director of Nursing Services (DNS) and the Advanced Practice Registered Nurse (APRN) both stated that all medication omissions should be reported to the provider and documented, but were unaware of the lapses until the survey. Facility policy requires accurate administration and documentation of medications and treatments, as well as prompt provider notification of any errors or omissions, which did not occur in this case.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
A deficiency occurred when a resident with dementia and severe cognitive impairment, who had recently sustained a second-degree burn from spilled coffee, did not receive medications and treatments as ordered by the physician. The resident's care plan included specific interventions for the burn, such as the application of Silvadene cream, regular pain assessments, administration of Tylenol for pain, and monitoring of vital signs. However, documentation and review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that on a specific day, several medications and treatments—including Miralax, Risperdal (both oral solution and tablet forms), Tylenol, Silvadene cream, and required pain assessments and vital sign checks—were not administered or documented as given. There was also no evidence that the provider was notified of these omissions, as required by facility policy and physician orders. Interviews with nursing staff confirmed that the medications and treatments were not administered or documented, and that the provider was not notified of the missed doses. The nurse involved acknowledged the difficulty in administering medications to the resident but admitted that if medications were not signed off, they were not given. The nurse also recognized the failure to document the omissions and notify the provider, as well as the lack of completed pain assessments. The APRN and Director of Nursing both stated that all medication omissions should be reported to the provider and that physician orders must be followed and documented, but were unaware of the lapses until the survey. Facility policy required that all medications and treatments be administered according to physician orders, with immediate documentation in the MAR or TAR, and that any medication errors or omissions be reported and documented. Despite these requirements, the facility failed to ensure compliance, resulting in the resident not receiving prescribed care and treatments, and the provider not being notified of these deficiencies.
Failure to Document Medication and Treatment Administration
Penalty
Summary
A deficiency was identified when a resident with dementia and severely impaired cognition did not have complete and accurate documentation in their medical record regarding medication and treatment administration. Multiple physician orders, including those for pain assessments, Miralax for constipation, Risperdal for agitation and anxiety, and Silvadene cream for a burn, were not signed off as completed or administered on specific dates and times. Review of the Medication Administration Record (MAR), Treatment Administration Record (TAR), and clinical notes failed to show evidence that these medications and treatments were provided as ordered. An LPN interviewed acknowledged that although she administered the medications and treatments, she failed to document them due to leaving her shift early. The Director of Nursing Services (DNS) confirmed that all medication and treatment administration should be documented and that omissions should be reported to the provider. Facility policies reviewed required timely and accurate documentation of care provided, but these were not followed in the instances cited.
Failure to Complete Timely Assessment and Documentation After Resident Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to conduct a complete and accurate assessment for a resident who experienced a change in condition requiring emergency services and hospital transfer. The resident, who had diagnoses including dementia, dysphagia, and GERD, was dependent on staff for all activities of daily living and had care plan interventions to prevent aspiration. On the morning of the incident, the resident was found unresponsive and in respiratory distress, with documentation showing outdated vital signs and no evidence that current or repeated assessments were performed. EMS arrived to find the resident with rapid, gurgling respirations, low oxygen saturation, and evidence of recent vomiting, with staff unable to provide current vital signs or details about the timing of the vomiting episode. Interviews revealed that staff did not remain with the resident during the emergency, did not document or communicate up-to-date assessments, and failed to perform or record appropriate interventions such as airway clearance and positioning as outlined in the care plan. The DON confirmed that the expectation was for staff to check vital signs, complete an assessment, perform interventions, and document all actions when a resident has a change in condition, which was not done in this case. The lack of timely and thorough assessment and documentation contributed to the deficiency identified during the survey.
Failure to Monitor and Intervene During Resident Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to monitor and implement appropriate interventions for a resident with dementia, dysphagia, and GERD who experienced a change in condition and required transfer to the hospital. The resident, who was dependent on staff for all activities of daily living and had a care plan indicating a risk for aspiration, was found by EMS in respiratory distress, unresponsive, and with vomit and sputum in the mouth. Facility staff were not present in the room when EMS arrived, and the resident was only on two liters of oxygen with no other interventions being performed. EMS had to clear the airway, increase oxygen, and reposition the resident to improve breathing. Staff were unable to provide details about when the resident had vomited and did not provide vital signs or a thorough handoff report to EMS, only written transfer paperwork. Facility documentation and interviews confirmed that staff did not follow care plan interventions such as elevating the head of the bed, turning the resident on the side, or cleaning the mouth after vomiting. The DON stated that the expectation was for staff to remain with the resident, monitor vital signs, perform appropriate interventions, and provide a verbal report to EMS, none of which were done in this case. The resident was later diagnosed with aspiration pneumonia, influenza A, and a urinary tract infection at the hospital.
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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