Arden Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamden, Connecticut.
- Location
- 850 Mix Ave, Hamden, Connecticut 06514
- CMS Provider Number
- 075228
- Inspections on file
- 39
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at Arden Care Center during CMS and state inspections, most recent first.
Multiple residents with complex medical conditions did not receive their scheduled evening medications on a unit when an LPN left partway through the 3–11 PM shift without completing the medication pass and no other nurse assumed responsibility for the remainder of the shift. The LPN reported to an RN supervisor that the medication pass was incomplete before leaving, but the RN instructed the LPN to clock out, expecting an oncoming nurse to finish the pass. Later that night, another LPN arriving to cover the unit learned from staff and residents that evening medications had not been given, and review of MARs and a medication error report confirmed that numerous residents missed their ordered doses despite a facility policy requiring adherence to prescriber orders and the five rights of medication administration.
A resident with PVD, paraplegia, and a care plan noting resistance to care had a daily physician-ordered dressing change for a right shin wound that was not performed for three consecutive days. During wound rounds, an APRN and an LPN discovered the wound dressing was dated several days earlier, indicating missed treatments. The APRN reported that staff were required to notify a provider of any treatment refusals but had not been informed of the resident’s repeated refusals. The DON stated that an LPN acknowledged the resident had refused wound care on multiple days and that she forgot to notify the APRN/physician, contrary to facility policies requiring provider notification of treatment refusals and changes in condition.
A cognitively impaired, fully dependent resident with multiple neurologic and psychiatric diagnoses was exposed to sexually inappropriate comments and behavior from a roommate with dementia and behavioral issues. Nursing staff documented that the roommate made explicit sexual requests toward the resident and was later found sitting at the end of the resident’s bed while fondling themself, with the resident’s brief pulled down in a way the resident could not do independently. Although staff assessed the residents, pulled the privacy curtain, and later changed the vulnerable resident’s room, the facility did not initiate an abuse investigation after the first incident, did not report the allegation to the state agency, and failed to fully document the later incident in the clinical record. The DON and administrator acknowledged the sexual comments and behavior but did not classify them as sexual or verbal abuse, despite facility policy defining sexual abuse to include sexual harassment and coercion and staff recognition that sexual statements toward another resident constitute abuse.
The facility failed to ensure timely and complete reporting of alleged neglect and resident-to-resident sexual abuse to the State Agency. A CNA found multiple dependent, incontinent residents with saturated pads, wet briefs, clothing, and bedding at the start of the day shift, but delayed reporting the concern, and the DON later notified the State Agency hours after learning of the allegation and only reported one affected resident instead of all involved. In separate incidents, one cognitively intact resident with behavioral issues made sexually explicit comments and engaged in sexually suggestive behavior toward a cognitively impaired, fully dependent roommate, including being found at the end of the roommate’s bed while the roommate’s brief was pulled down, yet the DON and administrator did not initiate an abuse investigation or report these events, despite an abuse policy requiring immediate reporting of suspected neglect and resident-to-resident abuse.
Multiple residents with immobility, incontinence, and skin breakdown risk had care plans and NA care cards directing turning and repositioning at least every two hours with skin observation, but staff failed to follow these interventions. A CNA on the day shift reported that at the start of her shift she found several residents with saturated pads, wet briefs, night clothes, and top sheets, suggesting that incontinent care and repositioning were not provided as scheduled on the prior night shift. The DON confirmed that the night CNA reported only two rounds during the shift, video showed the CNA sleeping, and documentation of care was lacking, while the charge RN acknowledged seeing the CNA asleep after first rounds and only up again for second rounds, without notifying a supervisor. These findings show that residents were not consistently repositioned or checked according to their individualized care plans.
A resident with a history of kidney transplant was readmitted from the hospital with an order for Tacrolimus XR totaling 6 mg daily. During medication reconciliation, an RN used the prior EMR orders and changed the number of tablets from one to six but failed to adjust the tablet strength from 4 mg to 1 mg, creating an EMR order for six 4 mg tablets (24 mg total). The required second reconciliation by another RN was not completed, and an LPN administered the dose as entered, relying on the assumption that two supervisors had verified the orders and that the medication’s presence in the cart indicated correctness. This sequence of transcription error and missed double-check resulted in the resident receiving a fourfold overdose of Tacrolimus.
A deficiency was identified when a resident with PVD and paraplegia, who had orders for daily right shin wound dressings and a care plan noting resistance to care, was found with a dressing dated three days earlier, and the LPN-reported refusals of wound care over multiple days were not consistently or accurately documented in the medical record. In a separate incident, several residents with conditions such as dementia, multiple sclerosis, PVD, paraplegia, limited mobility, and incontinence, all care-planned for regular turning, repositioning, and incontinent care, were the subject of an allegation that they had not received timely care during an overnight shift; although video later showed an aide performing rounds, there was no documentation of first and second rounds care for these residents, despite facility policy requiring nursing documentation to reflect care provided.
The facility failed to complete required Resident Care Conferences (RCCs), including 72-hour admission and quarterly care plan meetings, for three residents with conditions such as mild cognitive impairment, Alzheimer’s disease, major depressive disorder, chronic kidney disease, and functional dependence. One resident had a single documented RCC with a conservator, with no further RCCs held despite subsequent quarterly MDS assessments showing dependence in ADLs. Another resident had an RCC with a conservator but no documented RCCs after a later quarterly MDS that showed severely impaired cognition and dependence for mobility; no RCC signature sheet was available. A third resident had intact cognition and independence in mobility per quarterly MDS, yet there was no evidence of a 72-hour care plan meeting or any RCC, and no RCC signature sheet was obtained. The DON confirmed RCCs were expected within 72 hours of admission and at least quarterly, while the Director of Social Services cited staffing challenges and inconsistent completion of required RCCs, contrary to the facility’s person-centered care plan policy.
A resident with multiple comorbidities, including PVD, neuropathy, and onychomycosis, had severely thickened, debrided toenails with a planned podiatry follow-up that was repeatedly rescheduled without documented reasons and ultimately refused by the resident. Nursing staff did not document the refusal, did not assess or address the refusal per policy, and did not notify the provider or the resident’s healthcare decision maker about the toenail condition, need for follow-up, or refusal of podiatry care. The resident’s conservator later observed markedly overgrown, curling toenails at another facility and reported never having been informed of podiatry issues or refusals, while the DON and APRN confirmed they had not been notified and that required notification and documentation processes were not followed.
A resident with mild cognitive impairment, depression, left foot drop, and moderate protein-calorie malnutrition was admitted with a documented history of left foot drop, yet the facility did not include this condition or related interventions in the resident care plan over an extended period. PT reported multiple attempts to use an AFO brace and re-engage the resident in therapy, all of which were refused, but these refusals and the underlying condition were not care planned by nursing despite communication from therapy. Later podiatry documentation identified thick, yellow, brittle toenails with subungual debris and diagnoses of PVD, neuropathy, onychomycosis, and dermatophytosis, and described aseptic debridement of all toenails with planned follow-up; however, no podiatry-related problems or interventions were added to the care plan. The DON acknowledged that the IDT and licensed nursing staff should have developed comprehensive, individualized care plans for both the left foot drop and podiatry abnormalities in accordance with the facility’s person-centered care plan policy.
A resident with PVD, neuropathy, onychomycosis, dermatophytosis, left foot drop, and moderate protein calorie malnutrition received podiatry care with toenail debridement and a plan for follow-up in 6–8 weeks, but the care plan did not include foot or nail problems, and no subsequent podiatry treatment or refusals were documented over several months. Podiatry service lists repeatedly showed the resident was due for follow-up for tinea unguium, with visits rescheduled without documented reasons and one listed refusal not supported by nursing notes. The resident’s conservator later observed severely overgrown, curling toenails and reported not being informed of podiatry issues or refusals. The Administrator, DON, and APRN each reported they were not made aware of the podiatry findings or follow-up needs, and there was no designated nurse or process to ensure podiatry recommendations and visit outcomes were communicated to nursing staff or incorporated into ongoing care.
A resident with severe dementia, psychotic disturbances, and an adjustment disorder exhibited intrusive behaviors, including entering another resident’s room, following other residents, and briefly tugging another resident’s shirt collar. The existing care plan addressed mood, cognition, and communication issues but did not identify or include interventions for intrusive behaviors. Nursing notes and staff interviews described the resident frequently attempting to “help” by handing out cups and pushing other residents in wheelchairs, believing they were at work and enjoying staying busy. Although leadership and the IDT were aware of these behaviors, the care plan was not revised to include person-centered strategies to manage and redirect them, contrary to the facility’s person-centered care plan policy.
A resident with severe dementia, psychotic disturbances, and an adjustment disorder was moved to a new unit after being intrusive in another resident’s room and was placed on 15-minute safety checks. Social services initially met with the resident before and shortly after the room change, documenting confusion but no agitation and later noting that the resident was adjusting well, with a plan for two additional follow-up visits per protocol. However, no further social services follow-up was documented during the required 72-hour adjustment period after the move, and the Administrator confirmed that the mandated ongoing social services monitoring after a room change was missed when the responsible social worker was reassigned.
The facility failed to ensure accurate administration and documentation of controlled anxiolytic medications for three residents with dementia and psychiatric conditions. One resident repeatedly received double the ordered dose of Ativan due to nurses misreading the provider’s order and not comparing the eMAR with the blister pack label, and later received half the ordered dose after the prescription was changed. For two other residents, lorazepam and Xanax doses were signed as given on the MAR but were not recorded on the Controlled Substance Disposition Records, indicating omitted or undocumented doses. The APRN and DON stated that nurses are expected to follow the five rights of medication administration, fully read and verify orders, and ensure MAR entries match controlled substance records, consistent with facility policies defining medication errors as omissions and wrong doses.
A resident with epilepsy, multiple sclerosis, repeated falls, and impaired decision-making experienced a seizure and was transferred to the ED after receiving Ativan. Hospital records reflected that the family reported concerns that the facility had withheld the resident’s anti-seizure medications prior to the seizure. The former DON documented the family’s allegation in a nurse’s note but did not enter it into the grievance system, did not complete an Accident and Investigation report, and did not report the allegation to the State Agency as required by facility policy. The Administrator was only vaguely informed of a medication issue and was not made aware that it was an allegation of neglect or of the nurse’s note documenting the concern, resulting in the allegation not being reported or fully investigated.
A resident with epilepsy and multiple sclerosis experienced a seizure and was sent to the ED, where family members reported to hospital staff that the facility had withheld the resident’s anti-seizure medications. The former DON documented awareness of this allegation and reviewed the resident’s MARs but did not initiate a formal investigation, enter the allegation into the risk management system, or report it to the State Agency. No related grievance entry, A&I report, or state reportable event was found, and the Administrator stated she was only vaguely informed of a medication issue and was unaware it was an allegation of neglect. These omissions conflicted with the facility’s abuse prohibition policy requiring timely reporting and thorough investigation of suspected neglect.
A resident with epilepsy and multiple other conditions had standing orders for levetiracetam and oxcarbazepine twice daily for seizure control, but pharmacy order audits showed repeated delays in reordering these 14‑day supplies, with refills often requested days to weeks after the prior supply should have run out. MARs reflected that all doses were signed as given, yet the pharmacist confirmed no STAT orders were requested and Pyxis records showed no emergency pulls for this resident’s levetiracetam. An RN and several LPNs reported that when they could not locate the resident’s anti-seizure medications on multiple occasions, they did not notify a supervisor, use Pyxis, or contact the pharmacy; instead, they took doses from other residents’ anti-seizure medication supplies, contrary to facility policy and professional standards.
A resident with vascular dementia, anxiety, depression, and bipolar disorder was receiving Depakote and other psychotropic medications and had a care plan identifying risk for complications requiring monitoring. A physician ordered a CBC, CMP, and Depakote level to be drawn on the next lab day, but review of the clinical record showed no documentation that these labs were obtained. The DON reported that lab orders entered into the EHR should be transcribed into a lab book and verified by the night shift, yet there was no evidence the order was written in the lab book or that the bloodwork was drawn, and the facility could not provide related policies.
A resident with multiple chronic conditions and intact cognition was not informed of a new Clostridium Difficile diagnosis, was not offered antibiotic treatment, and did not receive education on the risks of refusing treatment. Facility staff and documentation confirmed that the required discussions and documentation did not occur, contrary to facility policy.
The facility did not consistently document the removal and wasting of controlled substances on the CSDR for a resident, and failed to record the administration of controlled medications on the MAR for two residents. This included missing documentation for Fentanyl patches and Tramadol, despite facility policy requiring timely and accurate recording by nursing staff.
A resident with multiple chronic conditions did not receive controlled medications in accordance with provider orders. Documentation showed inconsistencies in the timing and dosage of Fentanyl patch administration, with one instance of a patch being given before a provider order was obtained and another where the correct dose and time could not be confirmed. The DON confirmed that medication administration did not follow established protocols.
A staff LPN removed and ingested a resident's prescribed oxycodone from the medication cart for personal use, bypassing required narcotic count procedures and altering documentation. Surveillance footage and staff interviews confirmed the LPN's suspicious behavior and the disappearance of both the medication and its disposition record, in violation of facility policy prohibiting misappropriation of resident property.
A resident with chronic pain and diabetic polyneuropathy did not have their scheduled dose of oxycodone properly administered and documented. The MAR showed the medication as given by an LPN, but the Controlled Substance Disposition Record did not confirm this, and the DON could not verify if the dose was actually provided. Facility policy required accurate documentation and adherence to physician orders, which was not followed in this case.
The facility did not ensure that two licensed nurses conducted the required shift count of controlled substances during the handoff of narcotic keys, resulting in missing oxycodone and incomplete, altered documentation on the Controlled Drug Inventory Sheets. An LPN received the narcotic keys without a count, and another LPN was rushed during the process, leading to discrepancies and missing records. Facility policy requiring two-nurse counts and accurate recordkeeping was not followed.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that residents, including those with cognitive capacity and those with conservators, were included in the development and updating of their person-centered care plans or provided with advance notification of changes. Documentation and interviews showed that care plan meetings were either not held as scheduled or residents were not invited to participate, contrary to facility policy.
Care plans were not consistently updated to reflect residents' changing needs, physician orders, or interventions, and documentation of care plan meetings and resident involvement was lacking. Several residents did not have timely care plan revisions for new treatments or discharge planning, and advance notice or records of care plan meetings were missing, contrary to facility policy.
The facility failed to maintain kitchen sanitation and proper equipment function, with water and food debris accumulating due to missing drain strainers and improper drainage. Broken thermometers and missing temperature logs were found in refrigeration units, and food items in a kitchenette refrigerator were not consistently labeled or dated as required. Staff interviews revealed confusion about responsibility for labeling food brought in from outside sources, contrary to facility policy.
A resident with an indwelling urinary catheter was observed in a hallway without a privacy bag covering the urinary collecting device, despite care plan instructions and physician orders requiring privacy measures. A nurse confirmed the privacy bag should have been in place but could not explain why it was missing.
Surveyors found that several residents were seated in wheelchairs without tables and were not served meals while others at tables were eating. Staff confirmed that meals are always served on trays, and some residents experienced delays in receiving food. The charge nurse was unaware of the reason for the delay, and no dining policy was provided upon request.
A resident with severe cognitive and physical impairments was observed using a pelvic positioning belt in a wheelchair without a physician's order or OT recommendation. The resident was unable to remove the belt independently, and facility policy defines such a device as a physical restraint. Despite recent assessment indicating the belt was not appropriate, it continued to be used without proper documentation.
A resident with a history of fracture, cognitive impairment, and substance abuse did not receive pain management according to provider orders. Staff failed to document non-pharmacological interventions before administering PRN pain medication, gave narcotic pain medication for a pain level of 0, and did not follow required medication administration intervals. The EHR lacked documentation codes, and staff did not use progress notes as directed by the DON.
The facility did not consistently implement or document required interventions to prevent pressure ulcers, including failure to apply pressure-relieving boots and perform regular turning and repositioning for a resident at high risk, and did not complete Braden Scale risk assessments as required for two other residents with skin breakdown risk. Staff were unaware of specific physician orders, and care plans lacked necessary preventative measures.
Oxygen, eye washing, and soiled linen rooms on a secured unit were found unlocked and accessible to residents, despite having coded locks that were not used. Staff entered these rooms without using codes, and residents were observed in the vicinity, with one using a door for support. Leadership confirmed these areas should have been secured.
A resident with diabetes and Adult Failure to Thrive experienced significant weight loss over several months, but staff did not reassess or document the resident's food preferences despite variable oral intake and ongoing nutritional risk. Only after three months did the dietician discuss food preferences with the resident, who then identified specific foods they would eat, highlighting a failure to follow facility policy for individualized nutrition care.
Expired stock medications, including Aspirin, ear drops, and Heparin Flush IV syringes, were found in medication rooms on two units. The process for checking expiration dates relied on Central Supply Office staff and nurses, but there was no set schedule or process for regular review, resulting in expired medications not being removed as required by facility policy.
A resident with multiple medical conditions lost their dentures, and the facility failed to identify the loss as an emergency dental issue or document it in the grievance log as required. Nursing staff did not communicate or follow up on the missing dentures, and the facility's policies did not adequately address denture care or ensure proper documentation and investigation of lost personal items.
Food items, including open and partially consumed products, were found stored in a room containing clean linen for the overnight shift. The clean linen was kept in open carts and on shelves alongside these food items. Both the Infection Control Nurse and the Director of Laundry/Housekeeping confirmed that food should not be stored with clean linen, and facility policies required food and drinks to be consumed only in designated areas.
Two residents did not receive required annual education on influenza vaccines or have proper documentation of informed consent. One resident with cognitive impairment lacked both vaccination and consent records for the current season, while another resident's record did not show that education on vaccine benefits and side effects was provided to the resident or their conservator.
A resident with moderate cognitive impairment and diabetes was found with their bed placed against the wall, lacking the required three-foot clearance on the side and foot of the bed. The facility did not have a current waiver for this arrangement, nor a policy on bed clearance, and could not provide documentation of a room audit to confirm compliance in other rooms.
The facility did not maintain sufficient surety bond coverage for resident trust accounts, with account balances frequently exceeding the bond amount. The Administrator was unaware of the discrepancy, and there was no regular monitoring to ensure the bond matched the highest account balances, resulting in a failure to secure all resident personal funds as required.
Six residents with Alzheimer's disease or dementia were admitted to a secured unit, but their care plans were not updated to reflect this placement. Despite clinical records and observations confirming their residence on the secured unit, care plans only addressed general cognitive and behavioral interventions. The DON stated that secured unit placement did not need to be included in care plans, which was inconsistent with facility policy requiring comprehensive, updated care plans.
Six residents with dementia or Alzheimer's disease were placed on a secured unit without documented clinical assessments or consent for their placement. Records showed no evidence that required criteria were evaluated or that residents or their representatives were involved in the decision-making process, despite facility policy requiring such steps.
A resident with a Stage III pressure ulcer and other chronic conditions was subjected to physical and verbal abuse by an LPN during a wound dressing change. The LPN was reported to have been aggressive, did not follow the physician's wound care orders, and dismissed the resident's input, resulting in the procedure being performed roughly and not as prescribed. Facility documentation and interviews confirmed the resident's account, and video review showed the LPN did not spend adequate time to complete the ordered care.
Evening Medication Pass Not Completed for Multiple Residents on One Unit
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors when scheduled medications were not administered during a specific evening shift on the 3CD unit. Review of clinical records and March 2026 Medication Administration Records (MARs) for twenty residents showed that none of them received their ordered evening medications on 3/22/26. These residents had multiple serious diagnoses, including seizure disorders, atrial fibrillation, CHF, COPD, DM, liver disease, schizophrenia, depression, dementia, paraplegia, and malnutrition, and were prescribed a wide range of medications such as antiepileptics (Levetiracetam, Depakote, Lacosamide), anticoagulants (Eliquis, Apixaban), antihypertensives (Atenolol, Amlodipine, Metoprolol, Hydralazine, Propranolol, Clonidine, Carvedilol), insulin (Lantus), psychotropics (Risperidone, Quetiapine, Clozapine, Olanzapine, Ziprasidone), pain medications (Oxycodone, Tramadol, Gabapentin, Lyrica), GI medications (Protonix, Omeprazole, Famotidine, Lactulose), and other treatments including tube feedings (Jevity) and eye drops. The MARs documented that the scheduled evening doses for these medications were not administered on that date. The events leading to the missed medications centered on staffing and handoff failures during the 3–11 PM shift on the 3CD unit. LPN #6 was scheduled to work from 3–7 PM on 3/22/26 and was asked by the nursing supervisor, RN #7, to stay for the entire shift. LPN #6 reported that she informed RN #7 she could not stay the full shift but could stay a little longer. According to LPN #6, when she was preparing to leave between approximately 8:30–9:00 PM, she told RN #7 that she had not finished the medication pass and asked if she should stay until the oncoming nurse arrived. LPN #6 stated that RN #7 declined, instructed her to punch out, and told her that the oncoming nurse would complete the medication pass. LPN #6 indicated it was her understanding that another nurse was scheduled to take over the unit once she left. However, there was no nurse who actually assumed responsibility for completing the evening medication pass on the 3CD unit after LPN #6’s departure. Later that night, the 11 PM–7 AM charge nurse, LPN #8, who had been working another unit on the 3–11 PM shift, came to the 3CD unit and was informed by a night-shift nurse aide that several residents reported not receiving their evening medications. LPN #8 attempted to locate the previous evening nurse, found that LPN #6 had already left, and discovered that no one had come to cover the unit after LPN #6’s departure. LPN #8 then spoke with the residents who reported missing medications and contacted the supervisor, RN #7, who, according to LPN #8, initially suggested that the medications might simply not have been signed off. A facility medication error report dated 3/22/26 documented that one resident reported not receiving scheduled evening medications, and the facility’s subsequent review identified that potentially twenty-six residents on the 3CD unit had not received their evening medications that shift. The DON later stated there was no written medication administration policy beyond the general expectation that medications be given as ordered and that supervisors are responsible for ensuring medication passes are completed before a nurse ends a shift, and acknowledged conflicting accounts about whether LPN #6 had informed RN #7 that the medication pass was incomplete before leaving. The facility’s own policy titled “Medication Administration,” last revised 5/1/24, directed staff to follow written instructions from the prescriber and to adhere to the five rights of medication administration (right resident, right medication, right dose, right time, and right route). Despite this policy, the documented MARs for the twenty residents show that the ordered evening medications were not administered on the identified date. The combination of LPN #6 leaving before completing the medication pass, the lack of a nurse to assume responsibility for the 3CD unit for the remainder of the evening shift, and the failure of supervisory oversight to ensure completion of the medication pass directly led to the residents not receiving their scheduled medications during that shift.
Failure to Notify Provider of Repeated Refusals of Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to notify the APRN/physician in a timely manner when a resident repeatedly refused ordered daily wound treatments. The resident had peripheral vascular disease, paraplegia, depression, and was identified as alert and oriented with a BIMS score of 15. A care plan noted the resident was resistive to care, refused care including wound care, and was at risk for skin breakdown related to PVD, paraplegia, and weakness, with interventions to provide wound treatment as ordered and explain care and procedures. A physician order directed that a right shin wound be cleansed with normal saline, followed by calcium alginate and a dry clean dressing every day shift. During wound rounds on 3/19/2026, the APRN observed that the dressing on the resident’s right lower extremity was dated 3/15/2026, indicating the ordered daily treatment had not been performed for three days. The APRN stated that staff were required to notify her or the medical APRN whenever a treatment was refused and that she had not been notified of any refusals on 3/16, 3/17, or 3/18/2026, despite the resident frequently refusing wound treatments. The DON reported that, upon interview, the LPN assigned to the resident stated the resident had refused dressing changes on those three days but acknowledged she had forgotten to notify the APRN/physician of the refusals. Facility policies on Skin Integrity and Wound Management, Treatment Refusal, and Change in Condition/Notification directed staff to collaborate with the provider regarding conditions affecting healing, notify the physician of treatment refusals, and provide timely notification about changes relevant to the patient’s condition. These policies were not followed when the resident’s repeated refusals of wound care and the resulting lapse in daily wound treatment were not reported to the APRN/physician.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, fully dependent resident from sexual abuse by a roommate who exhibited sexually inappropriate behavior. Resident #11 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, epilepsy, unspecified mood disorder, and unspecified psychosis. A quarterly MDS identified moderately impaired cognition and total dependence on staff for all ADLs. The care plan documented impaired and declining cognitive function and impaired decision-making, with interventions focused on monitoring cognitive changes, assisting with decision-making, and providing a structured routine. Despite this vulnerability, Resident #11 was exposed to sexually inappropriate comments and behavior from the roommate, Resident #12. Resident #12 had diagnoses including dementia with agitation, adjustment disorder with anxiety and depression, and mild neurocognitive disorder. The quarterly MDS identified Resident #12 as cognitively intact and independent with bed mobility and transfers, but the care plan also noted impaired and declining cognitive function, short/long-term memory loss, and impaired decision-making. On one occasion, nursing documentation identified that Resident #12 made an inappropriate verbal request for Resident #11 to touch him/herself, with no physical contact observed. Staff pulled the privacy curtain and assessed both residents, and Resident #11 initially declined a room change. The DON later stated that an investigation was not initiated and the incident was not reported to the state agency because it was viewed as “just sexual talk” and not verbal or sexual abuse, despite the facility’s policy defining sexual abuse to include sexual harassment and coercion. A subsequent incident further demonstrated the facility’s failure to ensure freedom from abuse and to fully document and investigate alleged sexual abuse. A nurse reported finding Resident #12 sitting at the end of Resident #11’s bed, hearing Resident #12 ask if Resident #11 enjoyed last night, and observing Resident #11’s brief pulled down to the side in a way Resident #11 could not do independently. Another nurse supervisor reported that Resident #12 was observed fondling him/herself at the end of Resident #11’s bed and verbalizing sexual comments. Although Resident #11 was moved to another room for safety, the clinical records for both residents lacked documentation of the 3/1 incident beyond the room change, and the social worker was not informed of the earlier 2/25 incident until after the later event. The DON and administrator acknowledged the sexual comments and behavior but maintained that there was no touching of Resident #11 and that the events did not meet their interpretation of sexual abuse, despite facility policy defining sexual abuse as including sexual harassment and non-consensual sexual contact of any type. The facility’s own abuse prohibition policy defined verbal abuse as any oral, written, or gestured language that willfully includes disparaging and derogatory terms within a resident’s hearing, regardless of age, ability to comprehend, or disability, and defined sexual abuse as any non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault. Staff interviews confirmed that making a sexual statement toward another resident would be considered abuse and should be reported immediately. Nonetheless, the facility did not initiate an abuse investigation or report the initial allegation to the state agency, did not fully document the later incident in the clinical records, and did not consistently recognize the sexually inappropriate comments and behaviors toward Resident #11 as abuse under its own policy. These actions and omissions resulted in a failure to ensure that Resident #11 was free from sexual abuse by Resident #12.
Failure to Report Alleged Neglect and Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and fully disclose allegations of neglect related to incontinent care, and failure to report allegations of resident-to-resident sexual abuse to the State Agency, as required by policy and regulation. Multiple residents with significant mobility limitations, incontinence, and risk for pressure ulcers were involved in an allegation that they had not received timely incontinent care on the night shift. A reportable event submitted for one resident stated that several residents were found soaked with urine and some with feces, but the report did not identify the time rounds were conducted or which additional residents were affected. The facility did not initially identify all involved residents to the State Agency and delayed notification until several hours after the DON was informed of the allegation. Residents with conditions including polyneuropathy, traumatic brain injury, dementia, multiple sclerosis, paraplegia, peripheral vascular disease, and incontinence had care plans directing frequent turning, repositioning, and observation of skin for breakdown. A nursing assistant reported that at the start of the 7 AM–3 PM shift, she found several assigned residents with saturated pads, wet briefs, night clothes, and top sheets, leading her to believe that the night shift had not provided care on the last rounds. She did not immediately report this to the DON, instead discussing it with another staff member during a break, who then helped her report the concern later that morning. The DON acknowledged being notified of the allegation involving six residents but chose to report only one resident to the State Agency, omitting the others from the reportable event and stating she believed there was no harm in not notifying the State Agency of the additional allegations, despite facility policy requiring immediate reporting of suspected neglect. The deficiency also includes the facility’s failure to report to the State Agency two separate incidents in which one resident made sexually inappropriate comments and engaged in sexually suggestive behavior toward a cognitively impaired roommate. Documentation showed that the roommate had moderately impaired cognition and was dependent for all ADLs, while the other resident was cognitively intact but had documented behavioral and cognitive issues. Nursing notes described an incident where the cognitively intact resident requested the roommate to touch themself, and a subsequent incident where the same resident was again making inappropriate sexual comments. Later, a nurse observed the resident sitting at the end of the roommate’s bed, asking if the roommate enjoyed the previous night, and noted the roommate’s brief was pulled down, which the roommate could not do independently. The DON and administrator acknowledged they were aware of sexual comments and behavior but did not initiate an abuse investigation or report these incidents to the State Agency, stating they did not believe the events met the definition of verbal or sexual abuse, despite facility policy directing immediate reporting and investigation of suspected abuse, including resident-to-resident abuse. The facility’s Abuse Prohibition policy defined neglect as failure to provide necessary care and required anyone witnessing suspected abuse or neglect to report it immediately to a supervisor, with the supervisor then immediately notifying the administrator or designee and other officials in accordance with state law. The policy also required the administrator or designee to report allegations involving abuse not later than two hours after the allegation is made and specified that staff must identify events that may constitute abuse, including resident-to-resident abuse. In practice, the nursing assistant delayed reporting the neglect allegation, the DON delayed notifying the State Agency and did not include all affected residents in the report, and the DON and administrator did not report or investigate the sexual comments and behaviors as abuse allegations, contrary to the written policy requirements.
Failure to Reposition and Provide Timely Incontinent Care per Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to implement care plans requiring regular turning and repositioning for multiple residents at risk for pressure ulcers. Resident #4, with polyneuropathy, traumatic brain injury, depression, incontinence, and dependence for bed mobility and toileting, had a care plan dated 3/11/2026 directing staff to turn and reposition every two hours and observe the skin for breakdown. Resident #5, with dementia, diabetes, depression, incontinence, and dependence for bed mobility and toileting, had a care plan dated 3/18/2026 requiring turning and repositioning every one to two hours while in bed and skin observation. Resident #8, with PVD, paraplegia, altered mobility, compromised circulation, and contractures, had a care plan dated 1/2/2026 directing repositioning every two hours and as needed. NA care cards for all three residents reflected the need for assistance with turning and repositioning at least every two hours, as the residents allowed. A facility reportable event dated 3/27/2026 documented an allegation that several residents did not receive timely incontinent care on the 11 PM to 7 AM shift ending 3/27/2026, and that during rounds several residents were found soaked, with some also having feces on them. The report did not specify the exact time of the rounds or identify all of the affected residents. A subsequent summary reiterated that on morning rounds staff reported several residents had not received timely incontinent care and were soaked, with some having feces on them. Resident #8 was interviewed and reported no care issues and that care was provided timely, and other residents interviewed also reported no issues; however, the reportable event and staff interviews documented that multiple residents were found saturated. NA #2 reported that at the start of the 7 AM to 3 PM shift on 3/27/2026, during initial rounds beginning at 7:00 AM, she found Residents #3, 4, 5, 6, 7, and 8 with saturated pads, wet briefs, wet night clothes, and wet top sheets, and she believed the night NA had not provided care on the last rounds before 7 AM. The DON confirmed that NA #1 reported completing first rounds at about 1:15 AM and second rounds by 5:15 AM, with no additional rounds reported, and acknowledged that some of the residents identified by NA #2 had care plan interventions requiring repositioning every one to two hours. The DON also stated that video monitoring from the 11 PM to 7 AM shift showed NA #1 sleeping during the shift and that records showed NA #1 failed to document care provided. RN #11, the charge nurse on that shift, stated she saw NA #1 asleep in the hallway after first rounds around 1:30 AM, woke her multiple times, and only observed her get up to complete second rounds around 5:15 AM, and did not notify a supervisor that NA #1 was sleeping. These actions and inactions resulted in residents not being repositioned and checked in accordance with their care plans.
Medication Reconciliation Failure Leads to Tacrolimus Overdose
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medication orders were accurately reconciled and transcribed upon a resident’s readmission, resulting in a significant dosing error. The resident, who had a history of kidney transplant and was care planned as being at risk for impaired kidney function and transplant-related complications, had been receiving Envarsus XR (Tacrolimus) 4 mg, one tablet daily prior to a hospital transfer. After a six-day hospitalization for abnormal lab values, the resident was readmitted with a hospital W-10 order for Tacrolimus XR 24-hour tablets, six 1 mg tablets daily for a total daily dose of 6 mg. An APRN note documented that admission orders and the hospital discharge summary were reviewed, and medication reconciliation was initiated, including Tacrolimus XR 6 mg by mouth daily. When entering the readmission orders into the EMR, RN #1 used the resident’s prior EMR medication list as a starting point and attempted to reconcile it with the hospital W-10. RN #1 changed the number of Tacrolimus tablets from one to six but failed to change the tablet strength from 4 mg to 1 mg, resulting in an EMR order for Envarsus XR 4 mg, six tablets once daily (a total of 24 mg instead of the intended 6 mg). RN #1 later stated she did not realize the tablet strengths were different and that she must have misread the tablet strength on the W-10, focusing only on changing the number of tablets. The incorrect order remained active in the EMR and matched a medication already available on the unit from the prior admission. The facility’s double-check system for new admissions and readmissions was not followed as intended. The DON reported that the process required a supervisor to review the W-10 with the APRN/MD and enter the orders, followed by a second supervisor performing a repeat reconciliation to verify accuracy. RN #1 entered the orders, but RN #2 did not complete the second reconciliation, reportedly due to being busy with other incidents. LPN #1 administered the Tacrolimus dose as it appeared in the EMR, stating that she relied on the fact that two supervisors had reconciled the orders and that the medication was available in the cart, and therefore did not question the dose. As a result, the resident received 24 mg of Tacrolimus instead of the ordered 6 mg before the error was identified through a pharmacy medication review.
Incomplete Documentation of Wound Care Refusals and Incontinent Care Rounds
Penalty
Summary
The deficiency involves failures to maintain complete and accurate medical records regarding wound care refusals and documentation of care provided during shift rounds. One resident with peripheral vascular disease, paraplegia, and depression had a care plan identifying resistance to care and risk for skin breakdown, with interventions including providing ordered wound treatment and explaining procedures. A physician order directed daily dressing changes to a right shin wound. A facility reportable event later identified that during wound rounds the resident’s dressing was found dated three days earlier, and the resident was described as self-responsible and having refused right shin wound treatments. However, the nurse did not notify the physician or APRN of these refusals. Record review showed that wound care on the Treatment Administration Record was documented as refused on one date and as completed on the following two dates, while a facility investigation and DON interview revealed the LPN reported the resident had refused dressing changes on all three days. Additional review failed to identify documentation in the medical record of the refusals on any of those dates, beyond the single TAR entry, and the DON stated she expected staff to document all refusals. This discrepancy between the LPN’s report, the TAR entries, and the absence of corresponding documentation in the clinical record demonstrated incomplete and inaccurate recording of the resident’s wound care and refusals. The deficiency also includes missing documentation of incontinent care and rounds for multiple residents at risk for skin breakdown. Several residents with conditions such as polyneuropathy, traumatic brain injury, dementia, multiple sclerosis, PVD, paraplegia, limited mobility, incontinence, and contractures had care plans directing turning and repositioning, incontinent care, and skin observation at specified intervals. A reportable event was submitted for an allegation that several residents did not receive timely incontinent care on an overnight shift and were found soaked, with some also soiled with feces. Although a subsequent facility summary stated that video surveillance showed the aide provided care and completed rounds as described, record review for the identified residents failed to show documentation of first and second rounds care provided. The DON confirmed that the aide reported completing rounds at specific times but did not document the care in the medical record, contrary to facility policy requiring nursing documentation to accurately reflect the resident’s condition and care provided.
Failure to Complete Required Resident Care Conferences and 72-Hour Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to complete Resident Care Conferences (RCCs) within required timeframes, including 72-hour admission conferences and at least quarterly reviews, as required by facility policy and regulatory expectations. For a resident with mild cognitive impairment, dysthymic disorder, left foot drop, and moderate protein calorie malnutrition, the record showed a care plan meeting held in early May 2025 with the resident and conservator, but no subsequent RCCs were scheduled or held from early May 2025 through mid-January 2026. Following a quarterly MDS dated in mid-January 2026, which documented intact cognition (BIMS 15) and dependence on staff for personal hygiene, bed mobility, and transfers, there was no evidence of an RCC being scheduled or held through the resident’s discharge in early February 2026. Another resident with Alzheimer’s disease (late onset), age-related macular degeneration, and major depressive disorder had an RCC documented in late September 2025 with the conservator present, but the record contained no evidence of any subsequent RCC being scheduled or held after a quarterly MDS completed in early December 2025, despite the MDS showing severely impaired cognition (BIMS 4) and dependence on staff for bed mobility and transfers; an RCC signature sheet for this resident was not available. A third resident with major depressive disorder, chronic kidney disease, and generalized abdominal pain had a quarterly MDS indicating intact cognition (BIMS 15) and independence with bed mobility, transfers, and ambulation, yet the clinical record from admission in mid-May 2025 through early March 2026 showed no 72-hour care plan meeting or any RCC scheduled or held, and no RCC signature sheet was obtained. The DON stated that RCCs should occur within 72 hours of admission and at least quarterly, and the Director of Social Services reported that staffing challenges contributed to inconsistent completion of 72-hour, change-in-condition, and quarterly RCCs, contrary to the facility’s Person-Centered Care Plan policy requiring invitations and documentation of care plan meetings via a Care Plan Meeting note.
Failure to Notify Provider and Representative of Change in Condition and Refusal of Podiatry Care
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a change in condition and refusal of care for one resident reviewed for allegations of neglect. The resident had diagnoses including mild cognitive impairment, dysthymic disorder, left foot drop, moderate protein calorie malnutrition, PVD, neuropathy, onychomycosis, and dermatophytosis. A quarterly MDS showed intact cognition with dependence on staff for personal hygiene, bed mobility, and transfers. A podiatry note documented that all ten toenails were thick, yellow, brittle, with subungual debris, and that aseptic debridement was performed with a plan for follow-up in 6–8 weeks. However, from the date of that podiatry visit through early the following year, the clinical record did not show that the provider or the resident’s conservator had been notified of the toenail condition or the need for follow-up. Subsequent podiatry service lists over several months identified that the resident was due for follow-up for tinea unguium, but visits were repeatedly rescheduled without documented reasons, and the resident was not seen. A later podiatry service list showed that the resident refused a scheduled podiatry visit. Nursing notes for the days following this refusal did not contain documentation of the refusal, any assessment of the refusal, or notification to the provider or the resident’s conservator. A facility reportable event later documented receipt of a complaint alleging neglect due to the appearance of the resident’s legs and stated that the resident had been seen by podiatry and wound personnel but refused treatments and had since been discharged. The resident’s conservator reported being present at the admission assessment at the receiving facility and observed that the resident’s toenails were so thick and long they were curling, and stated shock at their condition. The conservator stated that the facility had never notified them of podiatry issues or refusals of treatment and that they would have advocated for care if informed. The DON and APRN both stated they had not been notified of the condition of the toenails or the refusal of podiatry care and indicated that nursing staff should have documented the podiatry visit, ongoing toenail condition, and refusal, and notified the provider and conservator. Facility policies on notification of change in condition, refusal of treatment, and foot care required timely notification of the physician and healthcare decision maker, assessment and documentation of refusals, and appropriate referral and follow-up for residents with complicating disease processes requiring foot care, which were not followed in this case.
Failure to Care Plan Left Foot Drop and Podiatry Conditions
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan to address a resident’s left foot drop, which was documented in hospital records as a past medical history diagnosis at the time of admission in 2022. Review of the resident care plan from admission through early February 2026 showed no identification of left foot drop and no interventions to treat or manage this condition. A physical therapist reported that the resident was admitted with significant left foot drop and that therapy attempted to use an AFO brace, but the resident refused, leading to discontinuation. The therapist stated that therapy reattempted AFO use and therapy services several times, but the resident refused to participate or get out of bed. The therapist also indicated that therapy communicated functional and ADL status updates to nursing, and that nursing was responsible for developing the resident care plan with appropriate interventions, including care planning for left foot drop and documenting refusals since admission. The facility also failed to care plan podiatry abnormalities identified during the resident’s stay. A podiatry note documented that the resident had thick, yellow, brittle toenails with subungual debris and diagnoses of PVD, neuropathy, onychomycosis, and dermatophytosis, and that aseptic debridement of all ten elongated, thick toenails was performed with a plan for follow-up. However, review of the resident care plan from the date of this podiatry visit through early February 2026 showed no care plan addressing nail disorders, infections, or foot and nail diagnoses to ensure proper treatment and prevent complications. The DON stated that the IDT should have care planned the left foot drop present on admission, initiated interventions, documented treatment refusals, and that licensed nursing staff or the IDT reviewing podiatry notes should have developed a podiatry care plan with interventions. The facility’s Person-Centered Care Plan policy required comprehensive, individualized care plans with measurable objectives and timetables, including services not provided due to the resident’s right to refuse treatment, to be developed and reviewed based on comprehensive assessments.
Failure to Ensure Ongoing Podiatry Care and Follow-Up for Foot and Nail Abnormalities
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing podiatry care and timely follow-up for a resident with documented foot and nail abnormalities. The resident had diagnoses including mild cognitive impairment, dysthymic disorder, left foot drop, moderate protein calorie malnutrition, PVD, neuropathy, onychomycosis, and dermatophytosis. A podiatry note documented on 9/22/25 described thick, yellow, brittle toenails with subungual debris and indicated that aseptic debridement of all ten toenails was performed, with a plan for follow-up in six to eight weeks. However, the resident’s care plan from 9/22/25 through 2/9/26 did not include podiatry abnormalities, nail disorders, infections, or foot and nail diagnoses to guide ongoing treatment and monitoring. From 9/22/25 to 2/9/26, the clinical record contained no further podiatry treatment notes or documentation of refusals of podiatry care for this resident. Nurse’s notes during this period did not address the condition of the resident’s feet or toenails or any refusals of podiatry services, and the TARs for September 2025 through February 2026 did not show any treatments or monitoring related to the resident’s feet or toenails. Podiatry Service Lists dated 11/10/25, 12/22/25, and 1/6/26 showed the resident was due for follow-up for tinea unguium, but each visit was rescheduled without a documented reason, and the resident was not seen. A Podiatry Service List dated 2/3/25 indicated the resident was due for follow-up and refused the visit, but there was no corresponding nursing documentation of this refusal in the nurse’s notes from 2/3/26 through 2/9/26. The resident’s conservator later reported being shocked by the condition of the resident’s toenails, describing them as so thick and long that they were curling, and stated that the facility had not notified them of podiatry issues or refusals of care. The Administrator acknowledged being unaware of the 9/22/25 podiatry note and was unsure how nursing staff became aware of podiatry recommendations, noting that podiatry notes were sent to Medical Records and communication with the podiatry group occurred by email. The DON stated that nursing staff should have followed up on the 9/22/25 podiatry visit for orders and recommendations, assessed and documented the toenail condition, and notified leadership to facilitate timely follow-up, but there was no designated nurse responsible for coordinating podiatry visits and no process to ensure specialty providers’ findings were communicated to nursing before leaving the facility. The DON also reported misinterpreting several Podiatry Service Lists as refusals and could not determine why the resident was not seen on those dates. The APRN reported she was never notified of the podiatry findings or the reported refusal and stated that nursing should have documented and notified her of the podiatry visit and ongoing issues so that monitoring and timely follow-up could have occurred.
Failure to Care Plan for Intrusive Behaviors in Resident With Dementia
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan to address a resident’s intrusive behaviors toward other residents. The resident had diagnoses of severe dementia with psychotic disturbances and an adjustment disorder with mixed anxiety and depressed mood, and the admission MDS showed severely impaired cognition with a BIMS score of 4 and a need for supervision with transfers and ambulation. The existing Resident Care Plan addressed distressed or fluctuating mood, impaired cognitive function related to dementia, and impaired communication due to hearing impairment, with interventions such as providing consistent caregivers, structured routines, simplified communication, reassurance, and referral to a behavioral health specialist as needed. However, the care plan did not identify or address intrusive behaviors toward other residents. Nursing notes documented specific incidents of intrusive behavior, including the resident entering another resident’s room and following that resident down the hallway, and a separate incident in which the resident was observed tugging the front collar area of another resident’s shirt in a brief, non-aggressive, non-threatening manner. Staff interviews indicated the resident frequently attempted to “help” others by obtaining plastic cups from nurse carts and passing out drinks, pushing other residents in wheelchairs, and at times following other residents, reflecting a belief that the resident was at work and enjoyed staying busy. The Director of Nursing acknowledged awareness of these behaviors and that the interdisciplinary team had discussed the need for a behavioral care plan after an incident, but the care plan was not updated to include intrusive behaviors or person-centered interventions, contrary to the facility’s Person-Centered Care Plan policy requiring individualized care plans that are reviewed and revised to reflect changing needs and goals.
Failure to Provide Required Social Services Follow-Up After Room Change
Penalty
Summary
The facility failed to provide ongoing medically-related social services monitoring during the 72-hour adjustment period following a room change for a resident with severe cognitive impairment and psychiatric diagnoses. The resident had severe dementia with psychotic disturbances and an adjustment disorder with mixed anxiety and depressed mood, with an admission MDS showing severely impaired cognition (BIMS score of 4) and a need for supervision with transfers and ambulation. The resident’s care plan identified that the resident was adjusting to a new memory care environment, with interventions including reminiscence, discussion of meaningful family relationships, and opportunities for quiet, one-to-one visits. On the day of the incident, an LPN documented that the resident was intrusive in another resident’s room and followed that resident down the hallway, after which the resident was redirected, separated, placed on 15-minute safety checks, and moved to a new unit. Social services were notified, and a social worker met with the resident to show the new room and documented that the resident was confused by the change but not agitated or behavioral. The following day, another social worker documented an assessment of the resident’s adjustment to the room change, noting that the resident was adjusting well with no signs of anxiety or distress and stating that she would follow up two more times per protocol. However, review of the clinical record from 1/17/26 through 1/21/26 revealed no further social services follow-up notes for the resident during the required 72-hour adjustment period. The Administrator confirmed that facility policy and practice required social services staff to follow up with a resident for 72 hours after a room change to ensure a smooth transition and that social services did not complete the required follow-up after the initial post-move visit. The Administrator also identified that the responsible social worker was reassigned after the 1/16/26 visit and that the follow-up was missed during the transition to a new social worker, contrary to the facility’s Room Change policy, which directed that social services assess and document how the resident is adjusting and address any issues after relocation.
Failure to Accurately Administer and Document Controlled Anxiolytic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors related to anxiolytic medications, including incorrect dosing and omitted doses. For one resident with vascular dementia, anxiety disorder, and depressive episodes, a physician’s order directed administration of Ativan 0.25 mg (½ of a 0.5 mg tablet) three times daily for anxiety. However, documentation on the Medication Administration Record (MAR) and the Controlled Substance Disposition Record showed that from 12/10/25 through 12/23/25, nurses repeatedly administered 0.5 mg per dose instead of 0.25 mg, resulting in double the prescribed dose on at least seventeen occasions. The Controlled Substance Disposition Record also showed that after a later order change to 0.5 mg three times daily, the resident received only 0.25 mg at several subsequent administrations, which was half of the ordered dose. Charge nurses, including LPNs and an RN, later stated they had misread the physician’s orders and failed to compare the electronic MAR with the medication blister pack label before administration. For a second resident with dementia, schizophrenia, anxiety, major depressive disorder, and epilepsy, a physician’s order directed lorazepam 0.5 mg by mouth every eight hours for anxiety and agitation. The January MAR indicated that lorazepam 0.5 mg was administered at scheduled times each day. However, review of the Controlled Substance Disposition Record did not show that the 5:00 AM dose on 1/3/26 was documented as administered, despite the MAR indicating it had been given. This discrepancy between the MAR and the controlled substance record demonstrated a failure to accurately document and verify administration of a controlled anxiolytic medication as ordered. For a third resident with dementia with behavioral disturbances, paranoid personality disorder, generalized anxiety disorder, and major depressive disorder, a physician’s order directed Xanax 0.5 mg by mouth three times daily for anxiety and agitation. The January MAR showed that Xanax 0.5 mg was signed out as administered at the scheduled times. In contrast, the Controlled Substance Disposition Record did not reflect administration of the medication for six specific scheduled doses, even though all six were signed off on the MAR as given. The psychiatric APRN stated that licensed nurses are expected to fully read orders, follow the five rights of medication administration, and clarify any uncertainties, and the DON stated that nurses are expected to compare the physician’s order with the blister pack label and to document medications at the time of administration so that the MAR and Controlled Substance Disposition Record match. The facility’s own Medication Administration and Medication Errors policies defined medication errors to include omissions and wrong doses and required staff to follow written provider instructions and verify doses, which did not occur in these cases. The psychiatric APRN also reported that no one contacted him to clarify or question the Ativan orders for the first resident until 12/24/25 and that he was not informed that any of the three residents had omitted doses of anxiolytic medications during the period in question. The APRN identified that all three residents had dementia and were at risk for increased anxiety, agitation, and impaired comfort when scheduled anxiolytic medications were omitted. The DON confirmed that licensed nurses did not follow expectations to fully read and verify orders and to ensure the five rights of medication administration, resulting in the wrong dose being given to one resident and undocumented or omitted doses for the other residents, and that the MARs should have matched the corresponding Controlled Substance Disposition Records but did not. Overall, the survey findings show that for three residents receiving controlled anxiolytic medications, the facility failed to administer medications in accordance with provider orders and failed to maintain accurate, consistent documentation between the MAR and the Controlled Substance Disposition Records. These failures included administering double the ordered dose, administering half the ordered dose, and omitting or failing to document scheduled doses, contrary to facility policy and provider expectations.
Failure to Report Allegation of Neglect Involving Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency when it was identified. A resident with epilepsy, multiple sclerosis, repeated falls, and an adjustment disorder had a BIMS score of 7/15, indicating they rarely or never made decisions regarding tasks of daily living. An SBAR note documented that the resident experienced a seizure and was transferred to the ED after receiving Ativan per provider orders. A subsequent nurse’s note, written by the former DON, recorded that the resident’s family reported to hospital staff their concern that the facility had withheld the resident’s anti-seizure medications prior to the seizure event. This allegation of neglect was not entered into the facility’s grievance book, and there was no Accident and Investigation (A&I) documentation related to the allegation. Review of the State Agency Reportable Events website showed no evidence that the allegation of neglect was reported to the State Agency around the time it was identified. The former DON acknowledged in interview that, despite documenting the family’s allegation in the nurse’s note and reviewing the Medication Administration Records, she did not report the allegation to the State Agency or fully investigate it. The Administrator stated that the former DON had only casually mentioned a medication issue and did not communicate that it was an allegation of neglect, and the Administrator was unaware of the nurse’s note. The facility’s Abuse Prohibition policy required immediate entry of allegations into the risk management portal, reporting to state and local authorities within specified time frames, and initiation of a documented investigation within 24 hours, but these steps were not carried out for this allegation.
Failure to Investigate and Report Allegation of Withheld Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an allegation of neglect related to a resident’s anti-seizure medication. The resident had diagnoses including epilepsy, multiple sclerosis, repeated falls, and adjustment disorder, and a BIMS score of 7/15 indicating significantly impaired decision-making for daily tasks. An SBAR note documented that the resident experienced a seizure and was transferred to the ED with new orders for IM Ativan. A subsequent nurse’s note by the former DON, based on the hospital record, stated that the resident’s family reported to hospital staff concerns that the facility had withheld the resident’s anti-seizure medications. The DON documented that she reviewed the resident’s October and November MARs. However, there was no corresponding grievance or documentation in the facility’s Grievance Book related to the family’s allegation that seizure medications were withheld, and no Accident and Investigation (A&I) report was available despite being requested. Review of the State Agency Reportable Events website showed no evidence that the allegation of neglect was reported to the State Agency. In an interview, the former DON acknowledged she did not report the allegation to the State Agency or fully investigate it beyond reviewing the MARs, explaining that the family had only reported the concern to hospital staff and not directly to the facility. The Administrator reported that the DON had only casually mentioned a medication issue and had not communicated that it was an allegation of neglect, and the Administrator was unaware of the DON’s nurse’s note. These actions and omissions were inconsistent with the facility’s Abuse Prohibition policy, which required prompt reporting to authorities and initiation of a documented investigation upon receiving information about suspected or alleged abuse or neglect.
Failure to Timely Refill and Properly Administer Anti-Seizure Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure anti-seizure medications were refilled in a timely manner and administered from the correct resident-specific supply, in accordance with professional standards and facility policy. Resident #1 had diagnoses including epilepsy, multiple sclerosis, repeated falls, and adjustment disorder, and had physician orders for levetiracetam 1000 mg twice daily and oxcarbazepine 300 mg twice daily for seizure control. The resident’s care plan identified seizure risk and included interventions to medicate as ordered and monitor for effectiveness and side effects. An SBAR note documented that on 11/10/25 the resident experienced a seizure, the provider was notified, Ativan 1 mg IM was ordered as a rescue medication, and the resident was transferred to the ED for further evaluation. Review of the October and November Medication Administration Records showed all scheduled doses of levetiracetam and oxcarbazepine at 9:00 AM and 9:00 PM were signed as administered, and a nurse’s note by the former DON stated there were no missed doses. However, pharmacy records and order audit reports showed repeated delays in reordering both medications, with multiple refills requested several days to two weeks after the prior 14‑day supply should have been exhausted. The pharmacist confirmed that both medications were dispensed in 14‑day supplies, that no STAT deliveries were requested for these drugs during the review period, and that levetiracetam was available in the Pyxis emergency supply while oxcarbazepine was not. A Pyxis report showed that levetiracetam had not been pulled from emergency stock for this resident during the relevant timeframe. Multiple nursing staff interviews revealed that when the resident’s levetiracetam and oxcarbazepine could not be located, nurses did not follow facility procedures for medication unavailability. A 3–11 PM RN reported that when she returned after days off, she frequently had to refill the resident’s anti-seizure medications and, if they were not available, she would obtain doses from other residents who were on the same medications rather than notify the supervisor, pull from Pyxis, or call the pharmacy for a STAT refill. Several LPNs similarly reported that when they could not find the medications on several occasions, they took doses from other residents’ anti-seizure medication supplies instead of contacting the supervisor, using Pyxis, or arranging refills through the pharmacy or eMAR. The DON confirmed that the medications had not been pulled from emergency stock for this resident, that charge nurses were responsible for reordering when two to three days of supply remained, and that nurses should not use other residents’ medications at any time. Facility policies on reordering medications and medication administration required timely communication with the pharmacy and adherence to the seven rights of medication administration, which were not followed in these instances.
Failure to Obtain Ordered Lab Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to obtain ordered laboratory tests for a resident receiving medication that required lab monitoring. The resident had diagnoses including vascular dementia with mood disturbances, anxiety disorder, and depressive episodes, and had a BIMS score of 15/15, indicating the resident was alert and oriented. A physician ordered Depakote sprinkles 125 mg, six capsules by mouth at bedtime for bipolar disorder, and the resident’s care plan identified risk for complications related to psychotropic medications, with interventions including monitoring for side effects and consulting the physician or pharmacist as needed. A subsequent physician’s order directed that a CBC, CMP, and Depakote level be obtained on the next laboratory draw day. Review of the clinical record from the date of the lab order through the survey date showed no documentation that the ordered bloodwork was obtained. The DON stated that routine lab days were Monday, Wednesday, and Friday, and that the resident’s bloodwork should have been drawn on the next scheduled lab day, but she was unable to find documentation that the lab draw occurred. The DON explained that when lab orders are entered into the EHR, the same shift is responsible for confirming the order and writing it in the lab book, and the 11 PM–7 AM shift is responsible for ensuring the order matches what is written in the lab book. The DON was unable to provide documentation that the lab orders were entered into the lab book or explain why the labs were not obtained, and facility policies for physician orders, transcription of orders, and obtaining bloodwork were not provided.
Failure to Inform Resident of New Diagnosis and Treatment Options
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident with multiple complex diagnoses, including type 2 diabetes mellitus, chronic heart failure, and end stage renal disease, of a new diagnosis of Clostridium Difficile. The resident, who was cognitively intact and dependent on staff for activities of daily living, was not notified of the diagnosis, was not offered available treatment options, and did not receive education regarding the risks of refusing treatment. Documentation showed that the resident had a history of refusing medications and was on hospice care, but there was no evidence that the resident was informed about the new diagnosis or the rationale for antibiotic therapy at the time the positive lab result was received. Interviews with facility staff confirmed that the standard practice would be to inform the resident of a new diagnosis, discuss treatment options, and provide education on the consequences of refusal. However, both the clinical record and staff interviews indicated that this process did not occur for the resident on the date of the positive Clostridium Difficile result. The facility's own policy required staff to explain the negative effects of refusing medications and to document refusals, but this was not followed in this instance.
Failure to Document Controlled Substance Administration and Removal
Penalty
Summary
The facility failed to properly document the removal and wasting of controlled substances on the Controlled Substance Distribution Record (CSDR) for one resident, and failed to record the administration of controlled medications on the Medication Administration Record (MAR) for two residents. Specifically, for one resident with diagnoses including Type 2 Diabetes Mellitus, chronic heart failure, and End Stage Renal Disease, the CSDR did not indicate that Fentanyl patches administered on two occasions were removed or wasted according to facility policy. Additionally, a 100 microgram/hour Fentanyl patch administered to the same resident was not documented as removed or wasted, despite policy requiring two licensed professionals to destroy and document the destruction of controlled substances. For the same resident, the MAR did not reflect the administration of a 100 microgram/hour Fentanyl patch, even though the CSDR showed it was given. Another resident, with a history of diabetes, chronic heart failure, and chronic pain syndrome, was administered Tramadol as documented on the CSDR, but this administration was not recorded on the MAR. Facility policy requires that nurses document the administration of medications on both the MAR and CSDR at the time the medication is given. Interviews with the Interim Director of Nurses confirmed that the facility's policy mandates documentation of both the administration and removal/wasting of controlled substances, with two nurses required to sign off on the removal/wasting. The review of facility policies and records demonstrated that these procedures were not consistently followed for the residents in question.
Failure to Administer Controlled Medications per Provider Orders
Penalty
Summary
A deficiency was identified in the administration of controlled medications for one of three residents reviewed for medication administration. The resident, who had diagnoses including type 2 diabetes mellitus, chronic diastolic heart failure, and end stage renal disease, required total assistance with activities of daily living and was noted to have refused medications at times. On one occasion, a physician's order directed the application of two 50 microgram/hour Fentanyl patches every three days for chronic pain. Documentation inconsistencies were found: the Medication Administration Record (MAR) indicated two patches were administered at 8:00 AM, while the Controlled Substance Distribution Record (CSRD) only documented one patch given at 12:00 PM. The assigned LPN could not confirm whether the correct dose was administered at the correct time. The Director of Nursing (DON) confirmed that the patches should have been administered as ordered and that the five medication rights were not followed. In a separate incident, a physician's order for a 100 microgram/hour Fentanyl patch was received at 7:45 PM, but the CSRD showed the patch was administered at 3:00 PM, several hours before the order was obtained. The DON acknowledged that the medication was given prior to receiving the provider's order and reiterated the importance of following the five medication rights, including administering medications at the correct time. Facility policy required staff to follow written provider instructions and document medication administration at the time it occurred, which was not adhered to in these cases.
Misappropriation of Narcotic Medication by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, specifically an agency LPN, removed a narcotic medication, oxycodone 5 mg, from the medication cart for personal use, violating facility policy and procedures. The incident involved a resident with diagnoses including generalized abdominal pain, interstitial pulmonary disease, chest pain on breathing, and anxiety, who was alert and oriented. The resident had a physician's order for oxycodone 5 mg to be administered as needed for pain, and the medication was documented as received and partially administered prior to the incident. On the day of the incident, the LPN arrived late for her shift and did not participate in the required narcotic count with the outgoing nurse, instead taking the keys without following protocol. Throughout her shift, surveillance footage captured the LPN engaging in suspicious behavior around the medication cart, including handling the narcotic log binder out of camera view, shuffling papers, and being observed placing medication cups to her mouth on multiple occasions. The narcotic count logs were found to have been altered, and a significant quantity of oxycodone tablets, along with the disposition record, went missing from the cart and could not be located despite a thorough search. Interviews with staff confirmed that the required two-nurse narcotic count was not performed at shift change, and that the LPN in question appeared anxious and fidgety during her shift. The DON and other staff members identified discrepancies in the narcotic count and documentation, and the LPN was observed ingesting medication at the cart. The facility's abuse prohibition policy, which defines misappropriation of resident property as the wrongful use of a resident's belongings without consent, was not followed in this instance, resulting in the misappropriation of the resident's narcotic medication.
Failure to Accurately Administer and Document Narcotic Pain Medication
Penalty
Summary
A deficiency occurred when a resident with chronic pain and diabetic polyneuropathy, who was alert and oriented, did not receive narcotic pain medication as ordered by the physician. The resident was prescribed oxycodone 5 mg to be administered three times daily for pain management. On a specific date, the Medication Administration Record (MAR) indicated that the 2:00 PM dose was signed off as administered by an LPN, but the Controlled Substance Disposition Record did not show that the medication was dispensed at that time. The disposition record only reflected administration at 6:00 AM and 10:00 PM. During interviews, the LPN could not recall the specific resident or event but stated that if the medication was not signed out on the disposition record, it was not administered, and she was unsure why it was marked as given on the MAR. The Director of Nursing confirmed that an audit of the records could not verify whether the 2:00 PM dose was actually given. Facility policy required staff to follow provider instructions and document medication administration accurately, which was not done in this instance.
Failure to Perform Two-Nurse Narcotic Shift Count and Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to ensure that the required shift count of controlled substances was conducted by two licensed nurses during the handoff of narcotic keys, and did not maintain complete, accurate, and unaltered documentation on the Controlled Drug Inventory Sheets. On the date in question, a charge nurse discovered that both a blister pack of oxycodone 5 mg and its corresponding disposition record sheet were missing from the medication cart and narcotic count book. Despite searching the medication cart and room, the missing medication and documentation could not be located. The incident was reported, and statements were obtained from all staff with access to the medication cart. Interviews revealed that an agency LPN, who was scheduled for the day shift, arrived late and did not perform the required narcotic count with the outgoing nurse. Instead, the narcotic keys were handed over without a count, contrary to facility policy. Later, another LPN reported being rushed during the shift change and did not count the total number of disposition sheets or physical blister cards as required. The Controlled Medication Shift Change Log showed alterations, with numbers crossed off and changed, and missing disposition sheets for the relevant period. Staff interviews confirmed that the required two-nurse count was not performed at multiple shift changes, and documentation was altered or incomplete. Facility policy requires a complete count of all controlled substances at each shift change, performed by two licensed nurses, and mandates accurate recordkeeping. The investigation found that these procedures were not followed, resulting in missing medication, altered documentation, and a lack of reconciliation between narcotic cards and disposition sheets. The failure to adhere to these protocols led to the deficiency cited in the report.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's well-being.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Include Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that residents were included in the development and updating of their person-centered care plans and were not provided with advanced notification of changes to their care plans. For three residents reviewed, documentation and interviews revealed that care plan meetings were either not held as scheduled or residents were not invited to participate, despite being cognitively intact and able to contribute to their care planning. In several instances, care plan meetings were documented as attended only by staff or conservators, with no evidence that the residents themselves were notified or included. One resident with end stage renal disease, supplemental oxygen dependence, and a right leg amputation was found to have been informed about care plans only after decisions were made, and had not been invited to participate in care plan meetings for several years. Another resident with peripheral vascular disease, hemiplegia, and chronic pain syndrome, who had a court-appointed conservator, was also not notified or included in care plan meetings, despite facility policy requiring both the conservator and the resident to be involved. A third resident with a femur fracture, history of falls, and benign prostatic hyperplasia, also with a conservator, had no documentation of care plan meetings or invitations to participate, even though the resident was cognitively intact. Interviews with facility staff, including the Director of Social Services and the Director of Nursing Services, confirmed that both MDS Coordinators and Social Services were responsible for scheduling care plan meetings and inviting residents. However, they were unable to provide reasons for the lack of documentation or resident involvement. Review of facility policy confirmed that residents have the right to participate in care planning and to be informed in advance of changes, but these requirements were not met for the residents reviewed.
Failure to Update and Document Resident Care Plans and Involvement
Penalty
Summary
The facility failed to ensure that care plans were consistently developed, updated, and revised to reflect the changing needs and preferences of residents, as well as to document resident involvement and provide advance notice of care plan meetings. For several residents, care plans did not include necessary interventions or reflect current physician orders. For example, one resident with a history of malnutrition, vascular disease, and amputation developed a deep tissue injury, but the care plan lacked interventions for turning and repositioning, and there was no consistent documentation of offloading or repositioning prior to the injury. Another resident utilizing a pelvic positioning belt did not have a care plan or physician order reflecting the use or rationale for the belt, and the care plan was only updated after inquiry, not in real time with the resident's needs. Additionally, a resident receiving intravenous hydration therapy did not have this intervention reflected in the care plan, despite physician orders and staff acknowledgment that it should have been included. Another resident undergoing discharge planning did not have a discharge care plan initiated, even though social service notes indicated active efforts to arrange a transfer to another facility. These omissions demonstrate a lack of timely and accurate care plan updates in response to significant changes in residents' conditions or care needs. The facility also failed to provide advance notice of care plan meetings, document that meetings were held, or ensure that care plan revisions reflected resident involvement for multiple residents. Documentation was missing for several scheduled care plan meetings, and interviews with residents and staff confirmed that residents were not consistently invited or involved in the care planning process. Facility policy required resident participation and advance notification, but these requirements were not met, as evidenced by missing sign-in sheets, lack of meeting notes, and resident reports of not being informed or involved.
Deficient Kitchen Sanitation, Equipment Maintenance, and Food Labeling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not ensure that kitchen equipment was operating properly. Observations revealed water and food debris accumulating on the floor under the prep sink area due to missing drain strainers, causing dirty water to drain directly onto the kitchen floor. Tiles were missing in the prep sink area as a result of repeated water buildup, and the kitchen floor would require excavation and plumbing to correct the drainage. Additionally, a coffee maker's overflow grate drained fluid directly onto the floor, which then flowed several feet to a floor drain in a high-traffic area. The Dietary Manager acknowledged these issues and indicated that efforts were made to avoid fluid overflow, but the problems persisted. Temperature monitoring and food labeling practices were also found to be inconsistent. Broken thermometers were observed in both the walk-in refrigerator and a stand-alone refrigerator/freezer, with missing temperature logs for the freezer over a 17-day period. The Dietary Manager confirmed that the wrong temperature log was posted and that no freezer temperatures had been recorded during that time. Furthermore, food items in a kitchenette refrigerator were found to be unlabeled or labeled only with resident names and room numbers, lacking required dates. Staff interviews revealed uncertainty about responsibility for labeling and dating food items brought in from outside sources, despite facility policy assigning this responsibility to the dietary department.
Failure to Maintain Resident Dignity During Catheter Use
Penalty
Summary
A resident with diagnoses including obstructive and reflux uropathy, moderate dementia, mood disturbance, anxiety, and a urinary tract infection was observed in the hallway near the nursing station with an indwelling urinary catheter that was not covered by a privacy bag. The resident's care plan specified the use of privacy bags and leg bags as appropriate to maintain privacy and comfort, and a physician's order directed catheter care as needed. Despite these directives, the resident was seen without a privacy bag in a public area, and a registered nurse confirmed that the resident should have had a privacy bag in place but could not explain the omission.
Failure to Provide Homelike Dining Experience
Penalty
Summary
Surveyors observed that the facility failed to provide a homelike dining experience for residents in one of its dining rooms. During a meal service, several residents were seated in wheelchairs without access to dining tables, facing other residents who were eating at tables. Some residents at tables had not been served food while others at the same tables were eating. All residents in the dining room were served their meals on trays. Staff interviews confirmed that meals are always served on trays, and there was no explanation provided for why some residents had not received their meals while others had begun eating. Further, the charge nurse present in the dining room was unaware of the reason for the delay in meal service to certain residents. The facility was unable to provide a policy or procedure for resident dining on the nursing units when requested. The observations and staff interviews indicated a lack of coordination and inconsistency in meal service, resulting in some residents not receiving their meals in a timely or homelike manner.
Failure to Ensure Resident Is Free from Physical Restraints
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Alzheimer's disease, paranoid schizophrenia, and hypertension was observed using a pelvic positioning belt in a wheelchair, which was not supported by a physician's order or occupational therapy (OT) recommendation. The resident's Minimum Data Set (MDS) assessment indicated severe impairment and a need for maximal assistance with mobility and hygiene, but did not document the use of restraints. The care plan referenced the use of a custom wheelchair but did not specify the use of a pelvic positioning belt, and the physician's orders did not include this device. Observations on multiple occasions confirmed the resident was using the pelvic positioning belt, and interviews with nursing and OT staff revealed that the resident was unable to remove the belt independently. The facility's policy defines a physical restraint as a device that the resident cannot remove easily and that restricts movement. Despite recent OT assessment determining the belt was not appropriate for this resident, the device continued to be used without proper documentation or orders, resulting in the resident not being free from physical restraints as required.
Failure to Follow Pain Management Orders and Documentation Requirements
Penalty
Summary
The facility failed to follow physician's orders for pain management for one resident with a history of left femur fracture, liver disease, hypertension, moderate cognitive impairment, and a history of substance abuse. The resident's care plan required monitoring for pain, use of non-pharmacological interventions before administering PRN pain medication, and documentation of these interventions and their effectiveness every shift. Despite multiple reports of pain over several days, there was no documentation of non-pharmacological interventions in the electronic health record or on paper. Additionally, the facility's electronic health record system was missing codes for documenting these interventions, and staff did not document them in progress notes as expected by the Director of Nursing Services. Further review revealed that pain medications were not administered according to physician orders. Oxycodone, a narcotic pain medication, was given for a pain level of 0 and for mild pain when acetaminophen should have been used first, as per orders. There were also instances where Oxycodone was administered at intervals shorter than the prescribed four hours. Interviews with nursing staff and the APRN confirmed that pain medication should not be given for a pain level of 0 and that non-pharmacological interventions should be attempted first. The facility's pain management policy required documentation of non-pharmacological interventions and their effectiveness, which was not done for this resident.
Failure to Prevent Pressure Ulcers and Inconsistent Risk Assessments
Penalty
Summary
The facility failed to prevent the re-occurrence of a pressure injury and did not consistently implement or document required interventions for residents at risk for pressure ulcers. For one resident with multiple risk factors, including protein calorie malnutrition, peripheral vascular disease, amputation, and dementia, staff did not consistently apply a pressure-relieving boot as ordered, nor did they consistently turn and reposition the resident, despite the resident being dependent on staff for mobility. Documentation showed that turning and repositioning was not performed or recorded for several weeks prior to the development of a deep tissue injury (DTI), and the care plan lacked specific interventions for these preventative measures. Additionally, the pressure-relieving boot was not applied while the resident was out of bed, contrary to physician orders, and staff were unaware of the full requirements of the order. For two other residents at risk for pressure ulcer development, the facility did not consistently conduct or document Braden Scale risk assessments according to facility policy. One resident had only two Braden assessments completed upon admission, with no further assessments documented, despite ongoing risk factors and actual skin breakdown. The other resident had Braden assessments completed at irregular intervals, not aligning with the policy requirement for weekly assessments during the first month after admission. Both residents had care plans indicating risk for skin breakdown, but the required risk assessments and documentation were not consistently performed. Interviews with facility staff, including the DNS and regional director, confirmed that the process for scheduling and completing Braden Scale assessments was not consistently followed. The facility's policy required risk evaluations on admission/readmission, weekly for the first month, quarterly thereafter, and with any change in condition. However, these assessments were not completed as required, and preventative interventions such as turning, repositioning, and use of pressure-relieving devices were not consistently implemented or documented for residents at risk.
Unsecured Storage Areas Accessible to Residents
Penalty
Summary
The facility failed to ensure that the oxygen room, eye washing room containing medical supplies, and soiled linen room on a secured unit were properly locked, allowing residents access to these areas. Observations revealed that the oxygen room, which contained four oxygen tanks, as well as the eye washing and soiled linen rooms, were not locked despite having coded locks that were not utilized. Staff were observed entering these rooms without using the codes, and residents were seen wandering the hall and using the eye washing room door for support. Interviews with the DNS and Regional Clinical Director confirmed that these storage areas should not be accessible to residents and that the Maintenance Department is responsible for ensuring the locks are functional.
Failure to Assess and Honor Food Preferences for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a nutritional assessment included a resident's food preferences for a resident at risk for malnutrition and experiencing significant weight loss. The resident, who had diagnoses including diabetes mellitus and Adult Failure to Thrive, was admitted with a nutritional assessment that did not specify any particular food preferences. Although the resident was cognitively intact and able to communicate, the facility did not document or update the resident's food preferences after a significant weight loss was identified. Over several months, the resident experienced a notable weight loss, with weights dropping from 138.7 lbs to 123.8 lbs within one month, representing a 10.7% loss. Despite this, interventions such as dietary supplements and medication adjustments were implemented without reevaluating or discussing the resident's food preferences. The care plan included honoring food preferences and offering alternatives if less than 50% of a meal was consumed, but there was no evidence that the resident's preferences were reassessed during this period of weight loss and variable oral intake. It was not until three months after the initial significant weight loss that the dietician met with the resident to discuss food preferences, at which point the resident expressed a strong preference for peanut butter and jelly sandwiches and pasta. Observations confirmed the resident consistently consumed these preferred foods. Staff interviews and documentation review revealed that food preferences were not obtained or updated as required by facility policy, and the only documented preferences were entered months after the weight loss began.
Expired Medications Found in Stock Rooms Due to Lack of Review Process
Penalty
Summary
Surveyors observed expired stock medications in medication rooms on two separate units, including bottles of Aspirin 325 mg, Carbamide Peroxide ear drops, and Heparin Flush IV syringes, with expiration dates ranging from August to December of the previous year. The process for ensuring medications are not expired involved Central Supply Office staff checking expiration dates when stocking and rotating stock, as well as nurses checking dates before placing medications on carts. However, there was no established process or set frequency for reviewing stock medications, which led to expired medications remaining in storage areas. Facility policy required expired, discontinued, or contaminated medications to be removed and disposed of, but this was not consistently followed.
Failure to Provide Emergency Dental Services After Loss of Dentures
Penalty
Summary
A deficiency occurred when the facility failed to identify and provide emergency dental services for a resident who lost their dentures. The resident, who had diagnoses including vascular dementia, left-sided hemiplegia and hemiparesis, and chronic pain syndrome, was care planned for oral health risks and required assistance with oral hygiene and eating. Despite documentation in the dental note that the dentures were missing and staff were instructed to search for them, there was no evidence that the loss was entered into the grievance log or that appropriate follow-up actions were initiated. The resident reported the loss to staff, but the dentures remained missing, and the incident was not documented as required by facility policy. Interviews with nursing staff revealed a lack of communication and follow-through regarding the missing dentures, with responsibilities for reviewing dental notes and logging lost items not being fulfilled. The Director of Nursing Services confirmed that, in the absence of an Assistant Director of Nursing Services, nurse managers were responsible for reviewing specialty provider notes, but this process was not completed. Additionally, the facility's oral health policy did not address denture care and maintenance, and the personal property policy required documentation and investigation of lost items, which did not occur in this case.
Improper Storage of Food Items in Clean Linen Room
Penalty
Summary
During a tour of the facility's laundry area with the Infection Control Nurse, food items such as an empty can of orange soda, an empty bag of crackers, aluminum foil with yellow residue, a can of cashews with crumbs, an open mayonnaise packet, a piece of candy cane, plastic forks with residue, unopened tea bags, a cough drop, and a sugar packet were found stored in a room containing clean linen for the overnight shift. The clean linen, including incontinence pads, towels, curtains, and a fitted sheet, was stored in open, partially filled carts and on shelves in the same room as these food items. The Infection Control Nurse and the Director of Laundry/Housekeeping both confirmed that food items should not have been stored with clean linen, and the Director was unaware of who placed the items there. The facility's linen handling policy did not address the storage of food in linen rooms, but the employee handbook specified that food and drinks may only be consumed in designated areas and not in work areas.
Failure to Provide Annual Influenza Vaccine Education and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure that residents received annual education on influenza vaccines and that annual informed consent was obtained, as identified through clinical record reviews and staff interviews for two residents. One resident with severe cognitive impairment did not have documentation of receiving the influenza vaccine for the current season, nor was there evidence of written consent or refusal for the vaccine. The Infection Control Nurse was unable to provide a reason for the absence of vaccination or consent documentation for this resident. Another resident, who had a Conservator of Person as the responsible party and was moderately cognitively impaired, received influenza vaccinations over multiple years. While there was documentation of consent and provision of a Vaccination Information Sheet (VIS) in previous years, for the most recent vaccination, there was no indication that the resident or their conservator received education on the benefits and potential side effects of the vaccine. Nursing notes confirmed the administration of the vaccine but did not document the provision of required education.
Failure to Maintain Required Bed Clearance in Resident Room
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Type 2 diabetes mellitus, who was moderately cognitively impaired and independent with bed mobility and transfers, was observed with the left side and foot of their bed positioned directly against the wall. This arrangement did not maintain the required three-foot clearance around the bed. The issue was confirmed during multiple observations, including one with the facility Administrator present, who acknowledged the bed's placement and discussed the lack of current waivers for the room size. Further review revealed that the facility did not have a policy regarding bed clearance and could not provide documentation of a room audit that was reportedly conducted to ensure compliance in other rooms. The Administrator referenced previous waiver requests from 2019 and explained that the room's size necessitated the bed's placement to accommodate wheelchair access to the bathroom. However, no current waivers were in place, and the facility failed to ensure the required clearance for the resident's bed.
Inadequate Surety Bond Coverage for Resident Trust Accounts
Penalty
Summary
The facility failed to ensure adequate coverage of resident personal funds deposited with the facility, as required for the security of resident trust accounts. Review of the Resident Trust Account (RTA) balances over several months revealed that the account balances frequently exceeded the $100,000 surety bond coverage in place from June 3, 2024, through June 3, 2025. Specifically, during the period from July 1, 2024, through July 31, 2024, the RTA balance reached as high as $304,637.38, far surpassing the bond coverage. Other months also showed balances well above the $100,000 limit, with amounts ranging from over $100,000 to nearly $190,000 at various times. Interviews and documentation review indicated that the facility did not regularly monitor the adequacy of the surety bond coverage in relation to the fluctuating RTA balances. The Administrator acknowledged being unaware that the resident trust account regularly exceeded the bond coverage limit and confirmed that there was no routine process in place to ensure the bond amount matched or exceeded the highest RTA balances. The facility's policy required all resident funds entrusted to the facility to be covered by the surety bond, but this was not consistently achieved during the review period.
Failure to Update Care Plans for Residents on Secured Unit
Penalty
Summary
The facility failed to ensure that the care plans for six residents were reviewed and revised in a timely manner to include their placement on a secured unit. Each of these residents had diagnoses such as Alzheimer's disease or dementia, with varying levels of cognitive impairment as documented in their Minimum Data Set (MDS) assessments. Despite being admitted to a secured unit, their Resident Care Plans (RCPs) did not reflect this placement, nor did they include interventions or documentation specific to residing on a secured or locked unit. Clinical record reviews confirmed that all six residents were admitted to the secured unit on specific dates, yet their care plans lacked any mention of this significant aspect of their care environment. Observations during the survey verified that these residents resided on the secured unit, which required a code for entry and exit, accessible only to staff. The care plans instead focused on general interventions related to cognitive loss, behavioral health, and support, without addressing the unique needs or considerations associated with living on a secured unit. An interview with the Director of Nursing (DON) revealed that, although individualized care plans were developed for each resident, the DON did not believe that residing on a secured unit needed to be included in the care plans. Review of the facility's care plan policy indicated that care plans should be comprehensive, person-centered, and updated to reflect changes in the resident's needs and environment, including after each assessment. However, the care plans for these residents were not updated to include their placement on the secured unit, contrary to facility policy and regulatory expectations.
Failure to Assess and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to ensure that six residents placed on a secured unit were properly assessed for clinical criteria requiring such placement and did not obtain consent for their placement. Clinical record reviews for all six residents revealed that there was no documentation of an assessment being completed or consent being obtained prior to their admission to the secured unit. The residents involved had diagnoses including Alzheimer's disease and dementia, with varying levels of cognitive impairment as indicated by their BIMS scores and care plans. Some residents were noted to be severely cognitively impaired, while others were cognitively intact, yet all were admitted to the secured unit without the required documentation. Observations during the survey confirmed that these residents resided on a secured unit where access and egress were controlled by a keypad code known only to staff. Additional record reviews failed to identify documentation of the clinical criteria used for placement on the secured unit by the physician or the interdisciplinary team prior to a specified date. There was also no evidence that residents or their representatives were involved in the decision-making process for placement in the secured unit prior to that date. Interviews with facility staff confirmed that, although there was a policy outlining criteria for admission to the secured dementia unit, the facility was unable to provide documentation of assessments or consents for residents placed on the unit before a change in facility ownership. The facility's policy required a medical diagnosis, evidence of functional decline, behavioral changes, and a medical assessment confirming the need for specialized care in a secure environment, but there was no documentation that these criteria were met or that consent was obtained for the residents in question.
Failure to Protect Resident from Physical and Verbal Abuse During Wound Care
Penalty
Summary
A deficiency occurred when a resident with a Stage III pressure ulcer, type 2 diabetes, and chronic pain syndrome was not protected from physical and verbal abuse by a staff member. The resident, who was cognitively intact and required moderate assistance with activities of daily living, reported that a charge nurse was aggressive during a dressing change, did not follow the physician's wound care orders, and made dismissive comments when the resident attempted to provide input on their care. Documentation and interviews confirmed that the nurse told the resident not to instruct her on how to do her job and performed the dressing change in a manner the resident described as rough and uncomfortable. The nurse did not apply the soaked gauze as ordered and completed the dressing change in a time frame inconsistent with the prescribed procedure. Facility records, including nurse and social service notes, corroborated the resident's account of the incident, noting the resident's preference for how care was provided and the staff member's failure to listen and adhere to the care plan. The Director of Nursing's review of video footage further indicated that the nurse was not in the room long enough to perform the wound care as ordered. The facility's policies require prevention of abuse and respect for resident rights, but these were not upheld in this instance, resulting in the resident experiencing both physical and verbal mistreatment during a necessary medical procedure.
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A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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