Ark Healthcare & Rehabilitation At Branford Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in Branford, Connecticut.
- Location
- 189 Alps Road, Branford, Connecticut 06405
- CMS Provider Number
- 075296
- Inspections on file
- 25
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Ark Healthcare & Rehabilitation At Branford Hills during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, onychomycosis, and toe pain did not receive timely podiatry follow-up after returning from a hospital stay. Surveyors observed the resident barefoot with extremely lengthy, thick toenails, and records showed the facility failed to notify the contracted podiatry provider that the resident had returned, delaying the resident’s foot care.
Dietary staff failed to date opened frozen, refrigerated, and dry food items, and several products were expired or lacked expiration dates. Surveyors also found an unidentified raw meat item, an uncovered onion, and a Clorox cleaner bottle stored in a cooler used for resident food. The FSD stated staff had been instructed to date items when opened and believed he had left the chemical in the cooler.
A resident on droplet/contact precautions for an undiagnosed respiratory illness was observed out of the room and in common areas without a mask, and the resident said he/she had not been told why precautions were needed. An RN performing g-tube care for a resident on EBP wore gloves but no gown during residual checks, flushing, and tube feeding. During a dressing change for a resident with two stage 3 pressure ulcers, an RN treated one wound and then the other without hand hygiene or changing gloves between wounds.
Incomplete ADL Care Plans for Shaving and Nail Care: Two residents with severe cognitive impairment and significant ADL needs had care plans that did not include their refusals or preferences related to shaving and fingernail trimming. One resident was repeatedly observed unshaven with an electric razor left at the bedside, and an NA reported frequent refusals and occasional combativeness. The other resident was repeatedly observed with extremely long, sharp fingernails, while the care plan did not reflect refusal of nail trimming or a preference for long nails.
A nurse was observed still completing the morning med pass late in the day, and two residents’ ordered meds were signed off several hours after the scheduled times. One resident with dementia, a pelvis fracture, and anxiety had multiple 8:00 AM and 9:00 AM meds documented around noon, including some doses given too close together, while another resident with dementia, HF, and anxiety had 8:00 AM meds documented at about 12:17 PM to 12:18 PM. The DNS and another RN were unaware the morning pass was still unfinished, and the nurse said the pass was heavy with meds for over 30 residents.
Failure to Provide Meal Cueing and Assistance: A resident with dementia and a recent pelvic fracture was repeatedly observed with meals placed in front of him/her but without timely cueing or effective feeding assistance. Staff often left the resident with untouched or nearly untouched trays, and the resident consumed little food during multiple dining observations. Records later documented poor PO intake and significant weight loss, while staff stated they had not been aware earlier that the resident was not eating well or might need feeding help.
Two residents had air mattresses that were not set according to MD orders, with LPNs documenting the pumps as correct even though survey observations showed the firmness and/or alternating settings did not match the orders. In another case, a resident with dementia and COPD had an APRN order for VS every shift for 3 days after a new abdominal/flank skin finding, but the VS log showed they were obtained only 3 of 9 shifts and an RN acknowledged the order was not completed as directed.
A resident at risk for pressure ulcers developed a coccyx skin issue that was documented on a weekly skin assessment, but the area was not staged and no treatment order was obtained when first identified. Two days later, an LPN found an open coccyx area with drainage and redness, and a treatment order was then placed. The RN said she normally documents skin issues after weekly checks or when staff identify them during care, and the wound MD stated treatment should have been ordered when the area was first noted.
A resident with COPD, bipolar disorder, and anxiety was found with an unsecured Albuterol inhaler at the bedside without an order for self-administration, and multiple residents were observed with bed wheels unlocked, partially locked, or broken so the beds could move freely. One resident with a fall risk care plan reported that an unlocked bed moved during an independent transfer and caused a large skin tear on the forearm. Other residents stated they often noticed their beds were unlocked and had nearly fallen when the beds moved.
Delayed Re-Weight and Weight Loss Recognition A resident with dementia, a pelvis fracture, and severe cognitive impairment had ordered weight monitoring, but staff did not obtain or document a timely re-weight after repeated refusals and a questionable low weight. An LPN struck out one weight, forgot to enter another re-weight, and did not document the significant weight loss or related notifications. The APRN and RN were not aware of the weight loss until the record was reviewed, and staff relied on aides to report poor intake.
A resident with a feeding tube, severe cognitive impairment, diabetes, dementia, and CHF had ordered enteral nutrition and flushes, but the RN did not start the tube feeding at the ordered time and later left it running beyond the scheduled stop time to reach the volume goal. The RN also failed to verify g-tube length before giving the feeding and flushes, and an additional ordered water flush was missed at the scheduled time.
A resident with a double lumen PICC line and IV antibiotics had no documented weekly arm circumference or external catheter length measurements to monitor the line. Staff interviews and record review showed the required orders were not obtained or implemented, and when the PICC was later removed, the APRN did not document that the line was fully intact.
A resident with COPD, respiratory failure, emphysema, and pneumonia was ordered continuous O2 at 2 L/min via nasal cannula, but surveyors observed the oxygen concentrator set at 3 L/min on two occasions. The concentrator was out of the resident’s reach, and an RN later confirmed the setting was incorrect and adjusted it. The charge nurse stated she signed the TAR without checking the setting and assumed it was correct from the prior shift.
Improper Storage and Labeling of Controlled Medications: The facility failed to store controlled substances under double lock and failed to keep medications properly labeled and secured. Multiple controlled meds were found in the DNS office under only one lock, and the office door was open while unattended; the Administrator stated others had keys to the office. An LPN was also observed discarding medication cups from a med cart, and surveyors found an unlabeled cup of meds plus a recapped syringe containing an unidentified substance in the top drawer. The LPN could not identify the syringe contents or the refusal procedure, while an RN stated meds should not be pre-poured or kept in the top drawer.
A resident with dementia, tremors, and poor coordination did not receive ordered red foam built-up utensils at meals. Staff observed the resident using regular utensils with difficulty, and an NA admitted forgetting to provide the adaptive equipment even though it was labeled and available on the unit. Interviews confirmed nursing staff were responsible for giving the utensils at mealtime.
Resident Council concerns about nursing staff using cell phones and ear buds during work were repeatedly raised by residents, but meeting minutes often did not show any discussion of what the facility did in response. Residents stated they did not know whether concerns brought to council were addressed and believed the issue kept happening without noticeable change. The Administrator and Interim Rec Director could not clearly identify why the follow-up and documentation were not consistently included in the council process.
Unclean and Poorly Maintained Shower Room: The second floor Ledgewood 2 shower room had chipped and cracked ceiling paint, a black/brown substance on the floors and walls, and a used wet washcloth on the shower floor. An LPN stated environmental rounds were done every other week and that the shower was not clean, and the Maintenance Director also confirmed the room was not clean. Environmental Rounds logs did not identify concerns for any of the 6 showers over the past 6 months.
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.
A resident with diabetes and other complex conditions missed four days of prescribed insulin after the facility failed to coordinate with the pharmacy to clarify and deliver the correct medication. The pharmacy did not fill the updated order, and nursing staff did not consistently notify supervisors or the pharmacy about the missed doses, resulting in a lapse in medication administration.
A resident with diabetes and other complex conditions did not receive prescribed Humulin-R insulin on multiple occasions due to the medication being unavailable. Documentation failed to show that the nursing supervisor, provider, or pharmacy were notified of the missed doses, as required by facility policy. Nursing notes only reflected notification and follow-up for one missed dose, with no documentation for other missed administrations.
A resident with dementia and known exit-seeking behaviors managed to elope from the facility, despite having a wander guard in place. The facility failed to conduct an elopement assessment, notify the family or APRN, and ensure regular checks of the wander guard's placement and function. Staff interviews revealed a lack of communication and understanding regarding the resident's elopement risk, leading to the resident being found 0.3 miles away from the facility. This resulted in a finding of Immediate Jeopardy.
A facility failed to notify a resident's family and APRN of a significant change in condition when a wander guard was applied due to exit-seeking behavior. Despite the resident's history of dementia and a hip fracture, staff did not follow the facility's policy to inform the necessary parties. Interviews revealed a lack of communication and adherence to notification procedures.
A resident with dementia and a history of hip fracture exhibited increased exit-seeking behavior, but the facility failed to update the care plan to reflect these changes or the application of a wander guard. The resident was later found 0.3 miles away from the facility, highlighting a deficiency in addressing the elopement risk. Staff interviews confirmed the care plan was not updated as required by the facility's policy.
Delayed Podiatry Services and Overgrown Toenails
Penalty
Summary
The facility failed to ensure timely podiatry services for a resident with Alzheimer’s disease, onychomycosis, and bilateral toe pain. The resident had agreed to facility-contracted podiatry services, and a prior podiatry consult documented painful, moderately aching toenails that were relieved by cutting the nails, with follow-up recommended in 2 to 3 months. The resident’s care plan identified a self-care deficit and included assistance with ADLs, nail care, and obtaining podiatry consults as needed for health and comfort. During observation, the resident was seated barefoot with extremely lengthy and thick toenails on both feet. The clinical record and interviews showed the resident had last been seen by podiatry on 3/20/25, and after returning to the facility from a hospitalization on 7/25/25, the resident did not receive another podiatry visit despite the podiatrist coming to the facility on a regular basis. The DNS stated nursing staff should have assessed the resident’s feet and placed the resident back on the podiatry list, and also identified that the facility failed to notify the consulting podiatry company that the resident had returned, which contributed to the delay in care.
Dietary Storage and Labeling Deficiencies
Penalty
Summary
The dietary department failed to ensure food was stored, dated, and discarded in accordance with facility policy and professional standards. During a tour of the department, surveyors observed multiple opened frozen food items in the walk-in freezer that were undated when opened, including riblets, onion rings, pork chops, hamburger patties, fish cakes, meatballs, stuffed shells, and French toast sticks. In Reach in Cooler #3, surveyors found opened refrigerated items that were not dated, including sour cream, cottage cheese, butter, and mayonnaise, along with a 96-ounce container of sour cream that had expired on 12/22/25 and dressing containers with no expiration date. Surveyors also observed additional storage and labeling problems in the same cooler and other food storage areas. Reach in Cooler #3 contained an unidentified portion of pink raw meat wrapped in aluminum foil and an uncovered cut onion. In the dry goods storage area, opened packages of egg noodles, elbow pasta, and spaghetti were resealed but not dated. In the kitchen food prep area, several opened seasonings and other food items were either undated, expired, or lacked expiration dates, including lemon extract, cream of tartar, dill weed, poultry seasoning, bay leaves, black pepper, balsamic glaze, celery salt, ground cumin, granulated garlic, mashed potatoes, whole celery seed, imitation vanilla, powdered sugar, and Old Bay seasoning. A 32-ounce spray bottle of Clorox Clean-Up Cleaner with Bleach was also stored on a shelf in Reach in Cooler #3, and the Food Service Director stated he had instructed staff to date items when opened and believed he had left the cleaning chemical in the cooler.
Infection control failures during isolation, g-tube care, and wound dressing changes
Penalty
Summary
Resident #3 was placed on contact/droplet precautions for an undiagnosed viral respiratory illness after being seen for new onset cough, congestion, fatigue, and feeling generally unwell. The resident’s assessment noted nasal congestion, decreased breath sounds bilaterally, and an upper respiratory infection with cough and congestion. A physician order directed droplet/contact precautions for suspected viral illness for 7 days, and the facility policy stated that residents on contact/droplet precautions should be strongly encouraged to stay in their room and, if unable, wear a surgical mask. The resident was observed outside the room, in the hallway, on an elevator, in a lounge, and in a recreation room without a mask, and a visitor was also observed without a mask. The resident stated he/she was not aware of being on isolation precautions and had not been directed by staff to wear a mask when outside the room. Review of the clinical record and interviews with nursing staff and the Infection Preventionist failed to identify documentation that the resident had been informed of the reason and need for the precautions. Staff also acknowledged that the resident should have been educated and should not have been out of the room without a mask, but the resident was observed moving through common areas and another unit without one. Resident #124 had diabetes, dementia, congestive heart failure, and a feeding tube, and was on Enhanced Barrier Precautions related to the indwelling medical device. During observed g-tube care, the RN performed hand hygiene, entered the room with supplies, and donned gloves, but did not wear a gown while checking residual, returning residual, flushing the tube, and starting the tube feeding. The RN stated he had forgotten to put on the gown before entering the room, and the DNS confirmed that gown and gloves should have been worn for the feeding tube care under EBP. Resident #144 had stage 3 pressure ulcers to the coccyx and right buttock with physician-ordered wound treatments for each wound. During an observed dressing change, the RN treated the coccyx wound and then proceeded to treat the right buttock wound without performing hand hygiene or changing gloves between the two wounds. The RN acknowledged the error and stated the wounds should have been treated individually with hand hygiene and glove changes between them. The wound physician also stated that each wound needed to be treated individually to prevent contamination.
Incomplete ADL Care Plans for Shaving and Nail Care
Penalty
Summary
The facility failed to ensure the care plan was comprehensive for two residents with ADL needs. Resident #41 was admitted with diagnoses including Parkinson's disease, dementia, and anxiety, and was assessed as severely cognitively impaired and needing moderate assistance with personal hygiene. The resident care plan addressed general ADL assistance, toileting, transfers, meals, and fluctuating ability due to cognitive status, but it did not reflect the resident's refusals for shaving. Observations on multiple days showed the resident unshaven with about 1/2 inch of hair growth on the chin and cheeks, and an electric razor was seen on the bedside dresser during those observations. Resident #41's care flowsheet showed shower days scheduled weekly, and no refusals were documented for showers during the month reviewed. The DNS stated residents were shaved with ADL care and as needed, and refusals were to be documented by NAs. During review of the care plan, the corporate MDS Director confirmed that Resident #41 did not have a care plan for refusing shaving and stated the care plan should reflect refusals if the resident did not allow staff to shave him/her. A later interview with an NA indicated the resident often refused shaving and could become combative at times, and that the resident's electric razor was no longer functioning. Resident #58 was admitted with diagnoses including dementia, adjustment disorder, and generalized muscle weakness, and was assessed as severely cognitively impaired and requiring maximum assistance with ADLs. The resident care plan addressed toileting, incontinent care, oral hygiene, bed mobility, glasses, therapy, and transfers, but did not reflect the resident's refusal to have fingernails trimmed or the desire to have long fingernails. Observations on multiple days showed the resident's fingernails were extremely long, sharp, and pointed. The DNS stated fingernails were trimmed on shower days and as needed, and the corporate MDS Director confirmed the care plan did not include the resident's refusal or preference regarding fingernail trimming until after surveyor inquiry.
Late Medication Administration for Two Residents
Penalty
Summary
The facility failed to ensure medications were administered within the ordered time frame for two residents. For one resident with diagnoses including dementia, pelvis fracture, and anxiety, the care plan identified risk for malnutrition and the physician ordered multiple morning medications, including allopurinol, amlodipine, cranberry, ferrous sulfate, losartan, naloxegol, omeprazole, vitamin D, polyethylene glycol, acetaminophen, Seroquel, tramadol, and trazodone. On observation, the resident was sitting upright in bed while the medication administration record showed the 8:00 AM and 9:00 AM medications were not signed off until between 12:23 PM and 12:47 PM, several hours late. Some doses were also documented close to, before, or after other scheduled doses, including duplicate or closely spaced administrations of acetaminophen, Seroquel, tramadol, and trazodone. For the second resident, who had diagnoses including dementia, heart failure, and anxiety, the care plan identified risk for alteration in cardiopulmonary function and the physician ordered morning medications including acetaminophen, trazodone, vitamin B-12, vitamin D3, and artificial tears. The resident was observed sitting out of bed in a chair, and the medication administration record showed the 8:00 AM medications were not signed off until 12:17 PM to 12:18 PM. These medications were documented more than four hours late, including acetaminophen, trazodone, vitamin B-12, vitamin D3, and artificial tears. During observation, RN #3 was seen moving from room to room with the medication cart and looking at the computer attached to the cart before placing medications into cups and taking them into rooms. The same procedure had been observed during an earlier medication pass. At 12:20 PM, the DNS observed RN #3 still completing the morning medication pass and was unable to identify why the nurse was still passing morning medications at that time of day. RN #7 stated he believed RN #3 was passing 12:00 PM medications and was not aware the morning pass had not been completed. RN #3 stated the pass was late because it was heavy with medications for over 30 residents and that he had previously told the unit manager the pass took too long, but no change had occurred. The facility policy required medications to be administered within 1 hour before or after the ordered time.
Failure to Provide Meal Cueing and Assistance
Penalty
Summary
The facility failed to provide cueing and assistance with meals for a resident who was severely cognitively impaired, had dementia, and had a recent left pelvic fracture. The resident’s care plan identified risk for malnutrition, variable food intake, and the need to document meal consumption, notify the nurse if meals were refused, and offer alternative foods. Records also showed the resident had been receiving a regular diet with thin liquids and oral nutritional supplements, and later developed a significant weight loss from 123.4 lbs. to 108.6 lbs. During dining observations, the resident was repeatedly left with meals in front of him/her without effective cueing or assistance. On one occasion, the resident had a bowl of soup and a covered plate placed in front of him/her, picked up a spoon but did not bring food to the mouth, and was later only given one bite of chicken before staff walked away to assist another resident. The resident was then offered ice cream but did not eat it and was transported out of the dining room after consuming only one bite of food. On other observations, the resident was found in bed with breakfast or lunch trays untouched or nearly untouched, with no visible prompting to eat and no attempts by the resident to self-feed. Additional observations showed the resident sitting with food in front of him/her for extended periods, including stuffed shells, mixed vegetables, a cupcake, scrambled eggs, oatmeal, and applesauce, with little or no intake. In one instance, a NA attempted to assist after the meal had been present for over an hour and stated the resident only ate a couple bites even with assistance. Staff later acknowledged that the resident had been sleeping more since the fall and might ask for food later. The dietary record documented poor oral intake, intermittent refusals, and significant weight loss, while nursing and dietary staff stated they had not been aware earlier that the resident was not eating well or might need feeding assistance.
Air mattress settings and ordered vital signs not followed
Penalty
Summary
The facility failed to ensure that air mattresses were set according to physician orders for two residents. One resident had Alzheimer’s disease, COPD, anxiety, severe cognitive impairment, a Stage 4 coccyx pressure ulcer, and was dependent for eating, transfers, and bed mobility. The resident’s care plan directed use of a specialized mattress and every-shift checks of the air mattress function and setting. A physician order directed the mattress to be set at 80 and alternating, but survey observations on multiple occasions found the pump knob positioned between 80 and 120 and the static setting light illuminated instead of alternating. An LPN signed off in the EMR that the mattress was checked and matched the order, but when shown the pump and order, still identified the setting as correct despite the observed mismatch. A second resident had diabetes, dementia, congestive heart failure, severe cognitive impairment, and was dependent for eating, bed mobility, and chair/bed transfers. The resident’s care plan directed an air mattress set at 2 and alternating with every-shift checks. A physician order also directed the mattress to be set at 2 and alternating. Survey observations found the mattress pump with 3 lights lit for firmness instead of 2, while the alternating light was lit. An LPN again signed off in the EMR that the mattress was checked and matched the order, but during observation with the surveyor, identified the setting as correct even though it did not match the physician order. The unit manager later observed the mattress was still set at 3 lights lit and alternating, and the nursing supervisor stated the charge nurse should check and verify the settings each shift. The facility also failed to follow a physician order for obtaining vital signs for a resident with dementia, chronic thrombocytopenia, and COPD. After the resident developed a new large red raised area to the abdomen and right flank and reported discomfort, an APRN ordered monitoring of the area every shift for 5 days and vital signs every shift for 3 days. The physician order was entered, but the treatment and medication records did not identify the vital signs order, and the vital signs log showed that from the date of the order through the next several days, vital signs were obtained only 3 of 9 shifts. An RN later acknowledged that the resident’s vital signs were not completed every shift as ordered and that the floor nurse on each shift was responsible for ensuring physician orders were completed and documented.
Delayed treatment order for coccyx pressure ulcer
Penalty
Summary
The facility failed to ensure timely treatment was ordered when a pressure ulcer was identified for Resident #144, who was admitted with diagnoses including elevated white blood cells, a terminal colon condition, and depression. On admission, the resident was cognitively intact, required moderate assistance with ADLs including bed mobility, and was identified as at risk for pressure ulcers with a Braden Scale score of 17. The care plan included skin monitoring, incontinent care, inspection during care, turning and positioning, and use of a pressure-reducing mattress. The admission MDS indicated the resident was at risk for pressure ulcers but did not have one on admission. A weekly skin assessment documented that the resident developed a skin issue on the coccyx, measuring 1.0 cm by 0.3 cm by 0.1 cm, but the area was not staged and no physician order for treatment was obtained at that time. Two days later, an LPN noted an open area on the coccyx measuring 0.5 cm by 0.5 cm by 0.1 cm with a small amount of serous drainage and surrounding redness, and a treatment order for Triad Paste with a dry, clean dressing daily and as needed for soiling was then obtained. The RN who completed the skin assessment stated she would normally document a skin issue in a nursing note after the weekly skin check or if staff identified an area during care, but could not explain why no treatment order or corresponding nursing note was completed when the coccyx area was first identified. The wound physician stated that if the area was noted on the coccyx, a treatment order should have been put in place when it was identified.
Unsecured Medication and Unlocked Bed Wheels
Penalty
Summary
The facility failed to ensure a resident’s medication was properly secured when a resident with COPD, bipolar disorder, and anxiety was observed with an unsecured Albuterol inhaler at the bedside without an order for self-administration. The resident’s care plan identified the resident as non-compliant and resistive to care and medication, and included interventions for staff to check the resident’s mouth after medication administration and to provide consistent caregivers. During observation, the inhaler was found at the bedside, labeled from the facility’s contracted pharmacy, and the resident stated it had been there for a while. An LPN stated the resident had not received the morning dose because the resident was sleeping, and an RN confirmed the resident did not have an order for self-administration and should not have medication at the bedside per facility policy. The facility also failed to ensure bed wheels were locked for multiple residents whose beds were observed in an unlocked or partially locked condition. Residents interviewed included individuals with diagnoses such as dementia, COPD, mild cognitive impairment, overactive bladder, cirrhosis, osteoarthritis, abnormal gait, muscle weakness, bipolar disorder, and a history of falling. Observations showed several beds were freely movable because the wheels at the foot of the bed were unlocked, partially locked, or broken. In one room, a resident was observed washing in the bathroom while one of the two locking wheels at the foot of the bed was unlocked; the resident stated housekeeping unlocks the wheels. In other rooms, staff observed beds with both foot-end wheels unlocked, one wheel partially locked, or a broken wheel that still allowed the bed to move easily. One resident with intact cognition and a fall risk care plan reported sustaining a skin tear after attempting to get out of bed independently when the bed moved because the wheels were unlocked. The resident stated the bed moved into the wooden footboard, causing a large skin tear on the left forearm, and later stated the bed had been found unlocked multiple times before. Other residents stated they often noticed their beds were unlocked and had nearly fallen because the beds moved, and one resident reported using the bed rail for transfers but noticing the entire bed moved when the wheels were not locked. The facility was unable to provide a policy specifically addressing bed locks and instead provided a general fall prevention and management policy.
Delayed Re-Weight and Documentation of Significant Weight Loss
Penalty
Summary
The facility failed to ensure a re-weight was obtained in a timely manner to identify a significant weight loss for a resident with dementia, a pelvis fracture, anxiety, and severe cognitive impairment. The resident’s care plan identified risk for malnutrition related to variable food intake, significant weight change, and advanced age, and included monitoring weights as ordered. The resident also had a left pelvis fracture, with interventions related to pain assessment, therapy, and transfers per MD orders. The resident’s weight history showed 127.2 lbs. on 12/4/25, 124.6 lbs. on 12/11/25, 127.8 lbs. on 12/18/25, and 123.4 lbs. on 12/25/25. A dietary assessment noted the resident’s intake was generally good, the resident received Boost daily, and the weight was stable for 6 months. Later, a nursing note documented that the resident had been refusing to get out of bed and refusing weights after the hip fracture, and that multiple attempts to obtain weights had been unsuccessful. The dietician and APRN were notified, but no new orders were in place at that time. Interview and record review showed that a weight of 108.6 lbs. was obtained but struck out because it was thought to be inaccurate, and a reweight of 104.6 lbs. had been obtained but not documented in the clinical record. Staff were unable to explain why the reweight was not obtained sooner or why the weight loss was not identified for several days. The LPN stated she forgot to enter the reweight and had not documented the significant weight loss or the notifications made to the speech therapist, dietician, MD/APRN, and responsible party. The APRN stated he had not been notified of the resident’s refusal of weights or of the significant weight loss until he reviewed the record, and the RN stated he was not aware of the weight loss because he had not seen a weight ordered on the day he worked and relied on nurse aides to report poor intake.
Delayed Tube Feeding and Failure to Verify G-Tube Placement
Penalty
Summary
The facility failed to ensure a tube feeding was initiated on time and failed to ensure gastric-tube (g-tube) length was verified before administration of tube feeding per physician orders for one resident with a feeding tube. The resident had diagnoses including diabetes, dementia, and congestive heart failure, was severely cognitively impaired, and received 51% or more of total calories through the feeding tube. The care plan identified the feeding tube was in place to assist with maintaining nutritional status due to inadequate oral intake, and interventions included checking tubing placement as ordered and providing nutrition and flushes via the feeding tube per physician orders. A physician order directed Jevity 1.5 to be administered at 67 ml/hr for 18 hours starting at 12:00 PM and ending at 6:00 AM or when the volume goal of 1206 ml was reached. On observation, the tube feeding was not in place at the ordered start time, and the nurse did not begin the feeding until 3:00 PM. The nurse stated he attempted to hang the tube feeding late because he could not do everything at the exact time it was ordered for. The nurse also stated he would have the night nurse leave the tube feeding on for an extra hour, and the next morning the feeding was still running with 1031 ml delivered. The dietician stated the volume goal was the amount that should be administered and that the feeding should only be stopped at 6:00 AM if the full 1206 ml had been reached. The facility also failed to follow the physician order to verify g-tube length prior to administration of tube feeding, flushes, or medications. The order required checking the g-tube length each shift, but it did not identify the proper length. During observation, the nurse prepared the feeding, checked residual, administered a 150 ml water flush, and then started the tube feeding without verifying the tube length first. The nurse acknowledged he had forgotten to administer an additional ordered 200 ml flush at 12:00 PM and said he would give it later. He stated that because he obtained 10 ml of residual, he did not need to check the g-tube length before the flushes or feeding and would measure it later. Another nurse stated placement was checked by verifying the securement piece had not migrated and checking for residual, and that if residual was present, visualization of tube placement was not necessary.
Failure to Measure and Document PICC Line Length and Arm Circumference
Penalty
Summary
The facility failed to measure and document the arm circumference and external catheter length for a resident with a double lumen PICC line receiving IV antibiotics. Resident #13 had diagnoses including osteomyelitis of the left ankle and foot, severe sepsis, and bacteremia, and was admitted with a left basilic vein PICC line inserted at the hospital. Physician orders addressed PICC dressing changes and IV antibiotics, and the resident’s care plan later identified the PICC line and included weekly measurement of the left arm circumference and external catheter length with dressing changes. During record review and staff interviews, the DNS stated that for a resident with a PICC line, catheter length and arm circumference measurements were to be taken weekly and documented, but the clinical record did not show orders were in place or that the measurements were documented. The APRN who removed the PICC line later noted that the resident tolerated removal, but she did not measure the line or document that it was fully intact. Facility staff stated the admitting nurse or supervisor should have obtained the physician’s orders for the weekly PICC measurements, and the facility policy directed that upper arm circumference be measured on admission and weekly and that external catheter length be monitored on admission and weekly.
Oxygen Concentrator Set Above Ordered Flow Rate
Penalty
Summary
The facility failed to ensure oxygen was set at the physician-ordered rate for a resident with COPD, respiratory failure with hypercapnia, emphysema, and pneumonia. Physician orders directed oxygen at 2 liters per minute via nasal cannula, and the resident’s care plan also directed continuous oxygen at 2 liters per minute. The resident was moderately cognitively impaired and dependent for toileting, transfers, and bed mobility, and the MDS indicated the resident was receiving oxygen therapy. During observations, the resident was found in bed with oxygen via nasal cannula while the oxygen concentrator was running and set at 3 liters per minute on two separate occasions. The concentrator was out of the resident’s reach and positioned with the front facing the wall, making it inaccessible to the resident. A nursing note later documented no respiratory or cardiac distress and oxygen at 2 liters per minute continuously. RN #2 confirmed the concentrator was set incorrectly and adjusted it to 2 liters per minute, and LPN #7, the charge nurse, stated she had signed the TAR without checking the setting and had assumed it was correct from the previous shift. The DNS stated it was the charge nurse’s responsibility to check the oxygen concentrator every shift and ensure the correct setting.
Improper Storage and Labeling of Controlled Medications
Penalty
Summary
The facility failed to ensure medications were stored and labeled according to professional standards and failed to ensure controlled narcotic medications were stored under double lock at all times. Review with the DNS identified multiple controlled medications, including Morphine Sulfate, Lacosamide, Ativan, Morphine, Tramadol, Valium, Ritalin, Oxycodone, and Oxycontin, stored in the DNS office under one flip-type lock in a file cabinet credenza made of particleboard material, with a sliding window accessible from ground level. The DNS stated she considered her office door the second lock because she was the only one with a key and kept the office locked when unoccupied, but observation found the office door open without the DNS or staff present. The Administrator stated maintenance had extra keys to all offices, including the DNS office, and he also had a key to the DNS office. The facility also failed to ensure medications were properly handled on the medication cart. An LPN was observed removing two medication cups from the top drawer of the BH medication cart and discarding them before surveyor review; the cups contained an unidentified number of medications and were identified as being discarded due to resident refusals. Further review of the cart found a third medication cup containing 11 medications and a recapped syringe containing 20 cc of an unidentified substance, both in the top drawer without labels. The LPN could not identify the substance in the syringe, when it was prepared, or who prepared it, and could not identify the policy or procedure for resident refusals. An RN stated it was against facility policy to pre-pour medications or keep prepared medications in the top drawer, and that refusals should be reapproached and the supervisor and provider notified.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils at mealtime for a resident with dementia, essential tremor, and unspecified lack of coordination. A physician’s order directed red foam on utensils during all meals, and the resident’s nutritional assessment, MDS, and care plan identified the resident as needing meal assistance, setup, and red foam built-up utensils. The care plan also included interventions to provide the red foam built-up utensils and assist with cutting up foods. During observations, the resident was seen eating meals with a regular fork and difficulty cutting and picking up food, without the ordered adaptive utensils. On one occasion, a NA served and set up the resident for lunch without the red foam built-up utensils, later stating she had forgotten to provide them. The NA then located the resident’s labeled utensils from a clear bin on the beverage cart and gave them to the resident. Interviews with the FSD, DNS, and OT confirmed the adaptive utensils were prepared and sent to the unit, and that nursing staff were responsible for passing them to the resident at mealtime.
Resident Council Concerns About Staff Cell Phone and Ear Bud Use Were Not Properly Followed Up
Penalty
Summary
The facility failed to provide follow-up to residents attending Resident Council meetings regarding concerns raised about nursing staff using cell phones and ear buds during work and care, and it failed to attempt alternative measures when the same issue kept recurring. During the 1/29/26 Resident Council meeting, 7 residents attended and stated that if they brought concerns to staff at council meetings, they would not know whether the concern was addressed and assumed it was not. Residents reported that nursing staff using phones and ear buds during care was so widespread that they no longer identified specific staff members, and they stated the issue had been brought up multiple times without noticeable change or feedback from the facility. Review of Resident Council minutes from January 2025 through January 2026 showed repeated concerns about staff on cell phones and using ear buds. In February 2025, a resident raised concern about 3:00 PM to 11:00 PM staff wearing ear buds during working hours, and a grievance form documented that concern. In March 2025, residents again reported nurse aides working with headphones in their ears and talking on phones while working. In December 2025 and January 2026, residents again reported staff members being on cell phones too often and observed ear buds and phone use on the 3rd floor during the 3:00 PM to 11:00 PM shift. Several meeting minutes did not document discussion of actions taken by the facility in response to the concerns raised at prior meetings. Interviews with the Interim Recreation Director and the Administrator showed the meeting process and follow-up were not consistently carried out as described in policy. The Interim Recreation Director stated he would reference prior minutes, document concerns, report them to the Administrator, and follow up during the meeting to ensure concerns had been addressed. The Administrator stated follow-up to Resident Council concerns was kept in a binder and that he received the minutes monthly, but he could not identify what was reviewed in the meetings. The facility policy required Resident Council minutes to include residents in attendance, discussions and actions taken, and to retain copies of resolutions addressing concerns, but the minutes reviewed did not consistently document those discussions or actions.
Unclean and Poorly Maintained Shower Room
Penalty
Summary
The facility failed to keep the second floor Ledgewood 2 shower room clean and in good repair. During an initial tour, the shower room ceiling was observed with chipping and cracked paint, a black/brown substance was present on the floors and walls, and a used white wet washcloth was on the shower floor. An LPN later identified that environmental rounds were completed every other week and stated the black substance on the floors and walls was dirt, grout, or caulk, and that the grout or caulk needed to be replaced because the shower was not clean. The Maintenance Director also observed that the ceiling needed repainting and that the brown/black substance was glue for the baseboard that should be cleaned off, and confirmed the shower room was not clean. Review of the Environmental Rounds logs did not identify concerns for any of the 6 showers in the facility for the past 6 months.
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 care and well-being.
Failure to Ensure Timely Insulin Delivery Due to Poor Pharmacy Collaboration
Penalty
Summary
A deficiency occurred when the facility failed to collaborate effectively with the pharmacy to ensure a new admission received prescribed insulin, resulting in the resident missing four days of medication. The resident, who had diagnoses including type 2 diabetes mellitus, end stage renal disease, and morbid obesity, was discharged from the hospital with an order for Humulin R U-500 insulin. Upon admission, a physician's order was entered for this medication, but due to its unusual concentration, the pharmacy required clarification before filling it. Subsequently, the order was changed to Humulin-R 100 units/mL, but the pharmacy did not fill this new order, and the medication was not available for administration on multiple days. Review of the Medication Administration Record (MAR) showed that the insulin was not administered on four separate days, and there was no documentation that nursing supervisors, providers, or the pharmacy were notified of the missed doses. Interviews revealed that the pharmacist was unaware of the new order and did not fill it, while the Director of Nursing stated that nursing staff should have followed up with the pharmacy each time the medication was unavailable. The lack of communication and follow-up led to the resident missing critical doses of insulin.
Failure to Document Missed Insulin Doses and Notifications
Penalty
Summary
The facility failed to document in the clinical record when a prescribed medication, Humulin-R insulin, was not available for a resident with diagnoses including type 2 diabetes mellitus, end stage renal disease, and morbid obesity. The resident was admitted with orders to receive Humulin R U-500 insulin, which was later changed to Humulin-R insulin 100 units/mL, 40 units subcutaneously every evening. The Medication Administration Record (MAR) showed that the Humulin-R insulin was not administered on several dates, and notes indicated the medication was on order or not available. However, there was no documentation that the nursing supervisor, provider, or pharmacy were notified of the missed doses on these dates. Nursing notes indicated that on one occasion, after being unable to locate the insulin, the Advanced Practice Registered Nurse (APRN) was updated and directed staff to hold the dose, follow up with the pharmacy, and monitor blood sugars. Despite this, subsequent MAR notes for other missed doses did not reflect any notification to supervisory staff, providers, or the pharmacy. The facility's documentation policy requires nursing staff to complete documentation reflecting all care and services provided, including missed medications and related interventions, but this was not followed in the instances identified.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with known exit-seeking behaviors, resulting in the resident being able to exit the facility without staff knowledge. The resident, who had a history of dementia and was at risk for falls, was found 0.3 miles away from the facility after eloping. Despite having a wander guard in place, the resident managed to remove it, and the facility did not have proper documentation or monitoring in place to prevent this incident. The facility's records showed that the resident had increased exit-seeking behavior, but there was no documentation of an elopement assessment or notification to the family or psychiatric nurse practitioner prior to the placement of the wander guard. Additionally, the facility failed to ensure that the wander guard's placement and function were checked regularly, as required by their policy. Staff interviews revealed a lack of communication and understanding regarding the resident's elopement risk and the use of the wander guard. The facility's policy on elopement prevention was not followed, as evidenced by the lack of a physician order for the wander guard, failure to notify the family and APRN, and absence of tracking for placement and function checks. The facility's documentation also failed to include education for staff on responding to alarms and ensuring wander guard placement and function checks. This oversight contributed to the resident's ability to elope from the facility, resulting in a finding of Immediate Jeopardy.
Failure to Notify Family and APRN of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the family and the Advanced Practice Registered Nurse (APRN) of a resident's change in condition, specifically the application of a wander guard due to exit-seeking behaviors. The resident, who had diagnoses including dementia and a history of hip fracture, was initially assessed as not being an elopement risk. However, on a subsequent date, the resident was transferred to a different floor with a wander guard in place due to increased exit-seeking behavior. Despite this significant change, there was no documentation that the resident's family or physician were informed of the application of the wander guard or the change in behavior. Interviews with facility staff, including the Administrator, Registered Nurses (RNs), and the Director of Nursing (DON), revealed a lack of communication and adherence to the facility's policy regarding notification of significant changes in a resident's condition. The staff involved could not recall placing the wander guard or notifying the necessary parties, and the facility's policy clearly directed that the resident's physician and representative should be made aware of any significant changes. This oversight in communication and policy adherence led to the deficiency identified in the report.
Failure to Update Care Plan for Resident with Wandering Behaviors
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with known wandering behaviors. The resident, who was admitted with dementia, a history of hip fracture, and malnutrition, was initially assessed as not being an elopement risk. However, subsequent nursing notes indicated increased exit-seeking behavior, and a wander guard was applied. Despite these observations, the care plan was not updated to reflect the resident's wandering behaviors or the application of the wander guard. On a later date, the resident was found 0.3 miles away from the facility, indicating a failure to address the elopement risk adequately. Interviews with staff, including the Director of Nursing, revealed that the care plan was not updated to include the resident's wandering behaviors or the use of the wander guard. The facility's care planning policy requires that care plans be comprehensive and updated to reflect changes in a resident's status, which was not adhered to in this case.
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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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