Ark Healthcare & Rehabilitation At St. Camillus
Inspection history, citations, penalties and survey trends for this long-term care facility in Stamford, Connecticut.
- Location
- 494 Elm St, Stamford, Connecticut 06902
- CMS Provider Number
- 075320
- Inspections on file
- 18
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Ark Healthcare & Rehabilitation At St. Camillus during CMS and state inspections, most recent first.
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 severe cognitive and physical impairments, requiring two-person assistance for bed mobility, was left unattended by a single nurse aide during incontinent care. The aide attempted to turn the resident alone, resulting in the resident falling from bed and sustaining a displaced spiral femur fracture that required surgical intervention. This occurred despite clear physician orders and care plan directives for two-person assistance and use of bed rails.
The facility failed to provide accessible contact information for the State Long-Term Ombudsman Program. Residents were unaware of the Ombudsman and where to find contact details. The information was posted high on elevator walls, inaccessible to wheelchair users and not visible to those facing forward. It was also absent from bulletin boards outside elevators and on units, violating facility policy.
The facility did not inform residents about the grievance process or ensure that grievance forms were accessible. Residents were unaware of how to complete a grievance or where to find the forms. A social worker could not locate the forms in the designated area and acknowledged they were not easily accessible. Despite a request, a copy of the grievance policy was not provided.
The facility failed to revise care plans for three residents, leading to deficiencies in managing physical limitations, skin integrity, and fall risk. A resident with hand deformities did not have a care plan update to manage the condition. Another resident with a stage 3 pressure ulcer lacked a care plan for offloading boots, despite recommendations. A third resident's care plan was not updated after a fall, missing necessary interventions.
A resident at risk for pressure ulcers developed a new DTI on the left heel due to the facility's failure to consistently document turning and repositioning. Despite recommendations from a wound physician, the facility did not obtain physician's orders for offloading boots, contributing to the ulcer's progression to stage 3. Interviews revealed a lack of communication and documentation regarding pressure-relieving interventions, indicating non-compliance with the facility's skin care management policies.
The facility failed to ensure timely evaluation and treatment for residents with limited mobility and contractures. A resident developed bilateral hand deformities without proper evaluation or treatment, while another experienced contractures post-stroke with delayed intervention. Additionally, a resident prescribed splints for contracture management did not receive them as ordered, with staff unaware of the requirements.
The facility's kitchen was found to be unsanitary, with issues such as dirty ceiling tiles, a broken dishwasher cover, and unlabeled food items. Temperature logs were incomplete, and a cook was not wearing a beard guard. The Dietary Manager acknowledged these deficiencies.
The facility failed to properly dispose of garbage and refuse, with numerous debris items found alongside the dumpsters, including mattresses, televisions, and broken furniture. The Dietary Director had informed the Maintenance Director about the need for cleanup two weeks prior, and the Maintenance Director confirmed the situation, stating that a company was scheduled to pick up the items.
The facility failed to investigate a missing item report for a resident, resulting in confusion about the item's recovery. Additionally, the facility environment was unsanitary, with a rusted medicine cabinet, dusty fan, and poorly maintained shower rooms. Maintenance staff were unaware of repair needs, and there was no documentation of maintenance rounds or cleaning policies.
A facility failed to ensure the accuracy of the MDS assessment for a resident with a serious mental illness. The resident, diagnosed with dementia and schizoaffective disorder, was incorrectly coded on the MDS as not having a PASRR related condition. An RN responsible for MDS coding admitted to the oversight, despite the RAI instrument directing that such conditions be coded under Section A 1500 PASRR related condition.
A resident with Type 2 diabetes and incontinence was given Lactulose syrup borrowed from another resident's supply due to a depletion of their own medication. The LPN admitted to routinely borrowing medications, contrary to facility policy, which states that medications should not be shared and the pharmacy should be contacted if a medication is unavailable.
A resident with heart failure, diabetes, and neuropathy was found with long, dirty fingernails despite being dependent on staff for personal hygiene. The resident had requested nail care but did not receive it, and there was no documentation of nail care being offered or refused. Staff interviews revealed no specific schedule for nail care, and the DNS stated that staff should proactively offer nail care. The facility's policy required daily cleaning and regular filing of nails.
A resident with Alzheimer's and wandering behavior was inadequately supervised, leading to unsupervised wandering and access to potentially hazardous items. Despite being on 15-minute checks, the resident was observed without supervision, entering another resident's room, and handling personal items, highlighting a failure in implementing the care plan and facility policy.
A facility failed to maintain a complete communication log for a resident receiving dialysis, missing critical information such as nurse names, access site conditions, vital signs, and meal times. Staff interviews revealed inconsistencies in understanding documentation requirements, leading to incomplete records despite the facility's policy for comprehensive communication with the treatment center.
A facility failed to ensure staff was knowledgeable about using electronic care cards, leading to a resident experiencing pressure on their feet and legs due to improper use of offloading booties. The RN supervisor could not find a physician order or care plan for the booties, and a nurse aide was unaware of their necessity due to a lack of available care cards and reliance on verbal reports. The process for reviewing assignments and documenting care on electronic tablets was not followed, and there was no documentation of the booties' implementation or effectiveness.
A resident's prescribed Lactulose medication was unavailable, leading an LPN to use another resident's medication, contrary to facility policy. The facility's policy prohibits borrowing medications and emphasizes timely reordering to ensure availability.
The facility's PBJ data for Quarter 3 of 2023 was found to be incomplete and inaccurate, with excessively low weekend staffing levels. Despite meeting state staffing requirements on certain dates, the HR Director could not explain the low weekend staffing trigger. Staffing data was compiled from payroll and agency invoices and submitted to CMS by an outside consultant.
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.
Failure to Provide Required Assistance with Bed Mobility Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to provide the required assistance with bed mobility for a resident with significant cognitive and physical impairments. The resident had diagnoses including Parkinson's disease, dementia, abnormal gait, and generalized muscle weakness, and was assessed as severely cognitively impaired and fully dependent for bed mobility and ADLs. Physician orders and the care plan specified that two staff members were required to assist with bed mobility, and that 1/4 bed rails should be used as an enabler during repositioning. Despite these directives, a nurse aide provided incontinent care to the resident alone, without seeking assistance, because other aides were busy and she believed she could manage by herself. During the process of turning the resident, the aide turned the resident onto their right side, at which point the resident's foot slid off the mattress and the resident fell out of bed onto the floor. Initial assessment did not reveal injuries, but swelling and deformity of the left leg were noted the following morning, and subsequent hospital evaluation confirmed a displaced spiral fracture of the left femur requiring surgical intervention. The Director of Nursing confirmed that the nurse aide did not follow physician orders, which were in place to prevent such falls, and the facility's fall prevention policy required individualized interventions to prevent falls.
Inaccessible Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that residents were provided access to the contact information for the Office of the State Long-Term Ombudsman Program in a manner that was accessible and understandable. During a meeting with eight residents, it was identified that they were unaware of who the State Ombudsman was and where to locate the contact information. An interview with a social worker revealed that the contact information was posted on bulletin boards located on each elevator. However, observations showed that the information was posted high on the back wall of the elevator, making it inaccessible to individuals in wheelchairs and not visible to residents facing the front of the elevator. Additionally, the information was not posted on bulletin boards outside the elevator doors or on the units, contrary to the facility's policy requiring such postings to be accessible and understandable to residents and their representatives.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to inform residents about the grievance process and ensure that grievance forms were accessible and available to residents and visitors. During a meeting with eight residents, it was revealed that they were unaware of how to complete a grievance or where to find the forms. An interview with a social worker indicated that the grievance forms were supposed to be located in the nursing office behind the nursing station on both floors. However, during an observation, the social worker was unable to locate the forms in the designated area and could not provide any other location for them. The grievance policy, which was reviewed, stated that forms should be easily accessible, especially for those wishing to remain anonymous. The social worker acknowledged that the forms were not easily accessible and mentioned that the location would be changed to better meet the residents' needs. Despite a request, a copy of the facility's grievance policy was not provided.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #13, who was identified with physical limitations of the hands. Despite the resident's left-hand deformity being noted in an interdisciplinary rehabilitation screen and bilateral hand contractures being documented in progress notes, the care plan did not include any interventions for managing these deformities to prevent progression. The Director of Nursing acknowledged that the care plan should have been revised once the physical limitation was identified. For Resident #98, the facility did not develop a care plan to address the resident's skin integrity to prevent further skin breakdown. The resident, who had a stage 3 pressure ulcer on the left heel, was recommended to use offloading boots by a wound physician. However, there was no physician's order for the boots, and the care plan was not updated to reflect this recommendation. The wound care nurse confirmed that the recommendation for offloading boots was overlooked, and the care plan did not include this intervention until after surveyor inquiry. Resident #54 experienced a fall, but the facility failed to revise the resident's care plan timely post-fall. Although the care plan indicated the resident was at risk for falls, it did not show updated interventions after the fall occurred. The Director of Nursing stated that staff are expected to update the care plan with new interventions to prevent injuries after a fall, but the care plan reviewed was the most updated version available, lacking any new interventions post-fall.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently provide evidence of turning and repositioning a resident, leading to the development of a pressure ulcer. The resident, who was at risk for pressure ulcers due to paraplegia, diabetes mellitus, and incontinence, developed a new Deep Tissue Injury (DTI) on the left heel. Despite having a care plan that included interventions to prevent pressure ulcers, there were multiple instances of missing documentation for turning and repositioning the resident, which is a fundamental practice to prevent pressure ulcers. Additionally, the facility did not obtain physician's orders for recommendations made by a consulting wound physician, which contributed to the further decline of the pressure ulcer. The wound physician recommended the use of offloading boots to prevent further injury, but there was no physician's order for their use, and the care plan did not reflect this intervention. The resident's pressure ulcer progressed from a DTI to a stage 3 pressure ulcer, indicating a lack of timely and appropriate intervention. Interviews with staff revealed that there was a lack of communication and documentation regarding the use of offloading boots and other pressure-relieving interventions. The facility's policies on skin care management and prevention of pressure injuries were not adequately followed, as evidenced by the missing documentation and lack of physician's orders for recommended treatments. This deficiency highlights the need for consistent documentation and adherence to care plans to prevent the development and worsening of pressure ulcers.
Failure to Address Mobility and Contracture Needs
Penalty
Summary
The facility failed to ensure timely evaluation and treatment for residents with newly identified limited mobility and contractures. Resident #13, who was admitted with mild cognitive impairment and other conditions, developed bilateral hand deformities over time. Despite multiple screenings and observations indicating the presence of contractures, a full evaluation to determine the extent of the limitations and appropriate treatment was not conducted until after surveyor inquiry. The lack of timely intervention and preventative measures potentially contributed to the progression of the contractures. Resident #97, diagnosed with cerebral infarction and hemiplegia, also experienced a lack of timely evaluation and intervention for contractures. Initial therapy sessions identified impairments and recommended services to increase functional activity tolerance. However, after discharge from therapy, no further recommendations were made to prevent further loss of mobility. Subsequent screenings noted increased tone and contractures, but no evaluations or interventions were conducted until prompted by surveyor inquiry. The absence of a documented physician's order for a recommended splint further delayed necessary treatment. Resident #86, with a history of hemiplegia and cerebral infarction, was prescribed splints for contracture management. However, the facility failed to ensure the application of these splints as per physician's orders. Observations revealed that the resident was not wearing the prescribed splints, and staff interviews indicated a lack of awareness and communication regarding the splint application. The facility's failure to adhere to its own policies and procedures for splint application and staff training contributed to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour of the Dietary Department. Several issues were identified, including ceiling tiles with a brown substance, a broken and discolored dishwasher cover, and black substances around the dishwasher edges and on the tiles in the kitchen and dishwasher room. The floor throughout the kitchen was dirty with debris and food, and the second-floor nourishment refrigerator had a red substance inside. Additionally, the baking oven and cooktop were covered with a brown substance, and the ceiling vent in the main kitchen had a brown substance around it. The facility also failed to ensure proper food labeling and storage, with numerous items in the dry goods storage area and freezer found unlabeled or undated. The temperature logs for the freezer and refrigerator were missing several evening readings, and the day cook was not wearing a beard guard as required by policy. Interviews with the Dietary Manager revealed that staff were responsible for labeling and dating items, and that hair coverings, including beard guards, were to be worn around food. The Dietary Manager acknowledged the issues and identified that the facility had hired a company to steam clean the kitchen, but it was not as clean as expected.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed by surveyors. During an inspection with the Dietary Director, numerous debris items were found alongside the dumpsters and facility, including discarded mattresses, old televisions, a nightstand, a tire, broken pieces of wood, and chairs. The Dietary Director acknowledged that the area was not well-kept or cleaned and mentioned that these items were from maintenance, not dietary-related. He had informed the Maintenance Director about the need for cleanup two weeks prior, and noted that the dumpsters are emptied twice a week. The Maintenance Director confirmed that the Dietary Director had spoken to him about the debris on June 29, 2024. He identified the items beside the dumpsters and stated that a company was scheduled to pick them up on the day of the inspection. He also acknowledged his responsibility for maintaining the cleanliness of the dumpsters and surrounding area, and stated that the area had only been in that condition since June 29, 2024.
Deficiencies in Resident Safety and Facility Maintenance
Penalty
Summary
The facility failed to thoroughly investigate a report of a missing item for a resident diagnosed with morbid obesity, heart failure, and an above-the-knee amputation. The resident, who was cognitively intact, reported a missing Apple watch, which was initially documented as recovered by a social worker. However, subsequent interviews revealed that the watch had not been located, and there was confusion about whether the resident actually possessed the watch. The facility's policy for missing items was not followed, as there was no detailed investigation or conclusion documented regarding the missing watch. The facility environment was found to be unsanitary and not homelike, with a rusted medicine cabinet without doors and disconnected light bulb sockets in a bathroom. Maintenance staff were unaware of how long the cabinet had been in disrepair, and there was no documentation of repair requests or maintenance rounds. Additionally, a resident with chronic obstructive pulmonary disease had a fan in their room that was covered in dust, which had not been cleaned for at least six months. The facility lacked a policy for cleaning fans, and the housekeeping/maintenance director was unsure of the cleaning procedures. The facility's shower rooms were observed to be in poor condition, with chipped and cracked paint, black substances on floors and walls, torn wallpaper, and rusty shower curtain rods. The director of housekeeping/maintenance acknowledged the need for repairs but failed to document any concerns in the environmental rounds logs. The facility did not provide a maintenance policy or documentation of maintenance rounds, indicating a lack of oversight and attention to maintaining a safe and sanitary environment for residents.
Inaccurate MDS Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident identified with a serious mental illness. This deficiency was identified during a review of clinical records, facility policy, and interviews. Specifically, for one of the sampled residents, the facility did not accurately code the Preadmission Screening and Resident Review (PASRR) related condition on the MDS. The resident in question was admitted with diagnoses including dementia and schizoaffective disorder, and a PASRR level II outcome had previously identified the resident as meeting criteria for a serious mental illness. However, the Annual MDS assessment incorrectly indicated that the resident did not have a PASRR related condition for serious mental illness or intellectual disability. An interview with a Registered Nurse (RN) revealed that she was responsible for MDS coding and acknowledged that the PASRR should be coded on the MDS upon admission, annually, and with significant changes. Despite this, the RN entered incorrect information on the MDS due to an oversight, even though social services were responsible for coding the MDS for residents with serious mental illness. The Resident Assessment Instrument (RAI) used for MDS coding directs that all conditions related to serious mental illness or intellectual disability be coded under Section A 1500 PASRR related condition.
Medication Borrowing Leads to Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality during medication administration for a resident diagnosed with Type 2 diabetes mellitus and incontinence. The resident had a physician's order for Lactulose Oral Solution to be administered daily for constipation. However, during an observation, it was noted that the Lactulose syrup administered to the resident was borrowed from another resident's supply because the resident's own supply was depleted. The LPN involved admitted that it was their usual practice to use other residents' medications when a resident's supply was unavailable. The facility's policy clearly states that medications prescribed for one resident should never be administered to another resident, and if a medication cannot be located, the pharmacy should be contacted. Despite this policy, the LPN did not adhere to the guidelines, leading to the deficiency. The RN Unit Manager confirmed that the facility's practice is not to borrow medications and emphasized the importance of reordering medications to ensure availability for residents.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that a resident's fingernails were clean and cut, as observed in the case of a resident with diagnoses including heart failure, diabetes mellitus, and neuropathy. The resident was cognitively intact and required substantial assistance for personal hygiene. Despite being dependent on staff for bathing and personal hygiene, the resident's fingernails were observed to be long with a black and brown substance underneath. The resident reported having requested nail care about a week prior but could not recall the staff member they spoke to. The medical records from the relevant period did not document any offer or refusal of nail care. Interviews with staff revealed that there was no specific schedule for cutting residents' fingernails, although nurse aides were expected to notice and address long or dirty nails during routine care. The Director of Nursing Services (DNS) indicated that staff should proactively ask residents if they would like their nails cut, rather than waiting for residents to request it. The facility's policy on fingernail care emphasized daily cleaning and regular filing to prevent infection, but this was not adhered to in the case of the resident in question.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with Alzheimer's disease, disorientation, wandering, unspecified dementia, and unspecified psychosis. The resident was identified as cognitively impaired and at risk for elopement, with a care plan that included frequent safety checks and supervision when off the unit. Despite these interventions, the resident was observed wandering without supervision, entering another resident's room, and handling personal items, which posed a safety concern. On the morning of the incident, the resident was seen walking in the hallway without undergarments and later wandering in socks without shoes. The resident was redirected by staff but continued to wander unsupervised, eventually obtaining a bowl of applesauce from a medication cart and entering another resident's private room. The resident handled items such as shaving cream and a bottle of sterile water and attempted to drink from a used coffee mug before being assisted by a nurse aide. The facility's policy on wandering and elopements aimed to prevent harm while maintaining a least restrictive environment. However, the resident's frequent checks were not adequately documented or executed, as evidenced by the resident's unsupervised wandering and access to potentially hazardous items. The Director of Nursing Services acknowledged the safety concerns and indicated that the resident was on 15-minute checks, but the checks were not effectively implemented, leading to the observed deficiencies.
Incomplete Dialysis Communication Log for Resident
Penalty
Summary
The facility failed to consistently maintain a communication log for a resident receiving specialized dialysis treatment. The resident, diagnosed with end-stage kidney disease, dementia, and Parkinson's disease, required dialysis three times a week. The care plan highlighted the risk of dehydration and fluid deficit, necessitating close monitoring of intake, output, and vital signs. However, the communication log, which was supposed to document the resident's status and treatment details, was found to be incomplete on several occasions. Missing information included the nurse's name, the condition of the specialized access site, the resident's last vital signs, and the time of the last meal. Interviews with facility staff revealed discrepancies in understanding the documentation requirements. The nurse unit manager expected the log to include vital signs, weight, and access site status, while an LPN believed only vital signs were necessary. The facility's policy required comprehensive communication between the long-term care facility and the specialized treatment center, but this was not consistently followed. The specialized treatment center did not have access to the resident's electronic medical record, relying instead on the communication log and telephone updates, which were not adequately maintained.
Failure to Ensure Staff Knowledge on Electronic Care Card Use
Penalty
Summary
The facility failed to ensure that staff was knowledgeable about using the electronic care card to provide resident care according to the plan of care. During an observation and interview, it was found that a resident was experiencing pressure on various parts of their feet and legs while seated in a wheelchair. Although there was an indication that offloading booties were ordered for the resident, the RN supervisor could not find a physician order or care plan for their use. The RN supervisor also could not explain how licensed nurses were supposed to monitor for pressure on the resident's feet and heels while out of bed. Additionally, a nurse aide who had not worked on the resident's unit for some time was unaware of the need for pressure-relieving booties, as there were no care cards available in the resident's room or at the nurse's station. The nurse aide relied on verbal reports from the outgoing aide and the resident's own instructions for care. The RN supervisor identified that the process for reviewing assignments and documenting care on electronic tablets was not followed, as the nurse aide did not review the assignment at the beginning of the shift. Furthermore, there was no documentation of the implementation, consistent use, or evaluation of the effectiveness of the booties, and the nurse aide had not received prior education on using the electronic documentation system.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's supply of Lactulose medication was available for administration as per the physician's orders. Resident #45, who has a diagnosis of Type 2 diabetes mellitus and incontinence, was prescribed Lactulose Oral Solution to be administered daily for constipation. During a medication administration observation, it was found that the Lactulose syrup intended for Resident #45 was depleted, and the Licensed Practical Nurse (LPN) used medication prescribed for another resident instead. This action was contrary to the facility's policy, which prohibits borrowing medications from other residents. The incident was observed during a medication administration session, where the LPN admitted to using another resident's medication due to the unavailability of Resident #45's supply. The LPN stated that an order had been sent to the pharmacy the previous day. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed, using the Five Rights, and explicitly states that medication for one resident should never be administered to another. The RN Unit Manager confirmed that the facility's practice is to ensure medications are reordered in a timely manner to prevent such occurrences.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to ensure that its Payroll-Based Journal (PBJ) data for Quarter 3 of 2023 was complete and accurate. A review of the facility's PBJ submissions for this period revealed excessively low weekend staffing levels. Despite meeting minimum state staffing requirements on specific dates, such as May 21 and June 10, 2023, the overall data indicated inconsistencies. The Human Resource (HR) Director explained that staffing data was compiled from the facility's payroll provider and agency staffing invoices, which were then sent to an outside consultant for submission to the Centers for Medicare and Medicaid Services (CMS). However, the HR Director could not account for the low weekend staffing trigger in the PBJ data, suggesting fluctuations in staffing levels that were not accurately reflected in the submissions.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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