Autumn Lake Healthcare At Windsor
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor, Connecticut.
- Location
- 581 Poquonock Ave, Windsor, Connecticut 06095
- CMS Provider Number
- 075011
- Inspections on file
- 31
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 48
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Windsor during CMS and state inspections, most recent first.
A resident with heart failure, anxiety, depression, and moderate cognitive impairment alleged that a man from their past entered the room at night, touched their ankles, and attempted to rape them, prompting an urgent psych APRN telehealth evaluation that documented differing accounts and significant confusion. Social services interviewed other residents on the unit and provided a written statement, but there was no nursing note documenting the psych consult request, no incident/accident report, and no complete facility investigation found. The Administrator, former DON, and acting DON acknowledged awareness of the allegation, characterized it at one point as non-reportable, and were unable to locate investigation files or staff statements, and the event was not reported to the State Agency within the facility’s required 2-hour timeframe, but only months later.
A resident with heart failure, anxiety, depression, and moderate cognitive impairment alleged that a man entered the room at night, touched the resident’s ankle and leg, and attempted rape. A psychiatric APRN was urgently consulted and documented differing versions of the event, ultimately concluding it was most likely a nightmare or delusion, while social services documented the allegation and interviewed two other residents about any male presence or screaming. Despite these reports, the facility did not complete a formal incident report or a thorough abuse investigation; instead, unsigned and partially unidentified staff statements were kept in informal files, and there was no comprehensive review of statements or clinical notes as required by the facility’s abuse and incident policies.
A resident with heart failure, anxiety, depression, and moderate cognitive impairment reported an incident in which a man entered the room, touched the resident’s ankle and leg, and was believed to be attempting rape; the account later varied, and a psychiatric APRN ultimately assessed the episode as most likely a nightmare or delusion. The resident’s care plan was updated to include trauma history and interventions such as 1:1 social service visits and emotional support, and the facility received an Ombudsman allegation of rape. However, the last social service note predated the incident, there was no social service documentation addressing the allegation or the delusion, and the SW, though directed by the DNS to speak with the resident and obtaining a statement, did not document the visit or provide additional follow-up or support visits, contrary to facility policy requiring emotional support and counseling during and after abuse investigations.
Failure to Protect Residents from Roommate Abuse: Two roommate situations involved repeated verbal and physical mistreatment that staff knew about but did not fully address. In one case, a resident with serious mental health diagnoses reported ongoing yelling, unwanted advances, hitting, kicking, and shoving by a roommate, while staff documented altercations and redirection attempts but did not separate the residents until later. In another case, two roommates with psychiatric and cognitive diagnoses had frequent verbal conflicts that escalated to grabbing a leg or foot, with staff confirming the ongoing disputes and incomplete documentation of the incident.
Inaccurate PBJ staffing data was submitted to CMS, resulting in a one-star staffing rating because no RN hours and no 24-hour licensed nurse coverage were reported on multiple days. Facility Daily Staffing records showed RN and licensed nurse coverage was actually present, and the Regional Administrator/DON stated the PBJ submission had been completed by the previous owner and she could not speak to its accuracy.
A nurse aide was reassigned to accompany another resident to a medical appointment and left without notifying the charge nurse or other staff, leaving three dependent residents without bathing and incontinent care for several hours. At observation, the residents were still in bed, in johnny coats, and wet with urine. The residents had significant care needs, including cognitive impairment, incontinence, and assistance with bed mobility, transfers, bathing, and toileting.
Missing nursing competency documentation was identified for 5 nurse aides and 2 LPNs. Personnel files did not show annual competency verification from the prior survey period or for 2025, and interviews confirmed that education and competency records from the prior owner were unavailable. Staff later completed mandatory in-service education after the ownership change, but the deficiency centered on the absence of documented competency evaluation for nursing staff.
Missing Annual Performance Evaluations for Nurse Aides: The facility failed to maintain annual performance evaluations for 5 nurse aides. Personnel files did not show required written evaluations within the review period, and the DNS stated the evaluations had been completed but could not be located after a change of ownership. Facility policy required formal employee performance evaluations and regular in-service training for nurse aides.
Medication administration errors exceeded the allowed rate, with surveyors observing 3 errors across 35 opportunities for error. An LPN gave a resident Levothyroxine with an iron product instead of the ordered Ferrous Sulfate oral solution, despite directions to separate Levothyroxine from iron and mineral supplements and give it on an empty stomach, and another LPN omitted an ordered Cholecalciferol dose for a different resident.
Medication carts were not maintained in a clean and sanitary manner in 4 of 4 carts observed. Surveyors found loose pills and/or blister pack back covers in the bottom drawer of each cart, and the LPNs present said they were not aware of the debris. The DNS stated she was not aware the carts were not being cleaned, and the facility policy required drugs and biologicals to be stored in a safe, secure, orderly manner with medication storage and preparation areas kept clean, safe, and sanitary.
A resident reported that water pitchers were being reused daily instead of routinely cleaned, and staff observations showed pitchers being filled from an ice cooler on a hall cart with no clean pitchers available. Nursing and dietary staff said pitchers were only cleaned or replaced when requested, not on a routine basis, and the FSD acknowledged pitcher and lid shortages and that existing pitchers were cleaned only if nursing asked. Facility policy required pitchers to be collected at least weekly and sanitized in the dish machine.
Lack of Standardized Infection Surveillance and Antibiotic Stewardship Review: The facility did not have an antibiotic stewardship program with a standardized infection surveillance tool or periodic review of antibiotic use and infection data during the period before ownership changed. An LPN and the DNS stated there was no full-time ICN, no documentation of McGeer or other standardized criteria being used, and no evidence that antibiotic utilization patterns, infection rates, or antibiotic ordering data were routinely reported to the IDT or used to educate staff and prescribers.
The facility failed to designate a qualified IP to oversee the IPCP. Review of records and interview with the Administrator showed no assigned IP had been in place for an extended period, with staff only intermittently assisting, including an LPN and the DNS. Documentation also showed limited recruitment activity and no records demonstrating designated time for IPCP oversight.
The facility failed to verify that 5 nurse aides had completed the required annual 12 hours of in-service education. Personnel files lacked documentation of the required training, and the MDS Coordinator, DNS, and HR Director stated that prior education records could not be located after the change in ownership. The facility policy required annual in-service training for nurse aides, including dementia care and abuse prevention.
Two residents were not treated with dignity when staff failed to respond appropriately to requests for a blanket and a bedpan. One resident with dementia and incontinence reported that a blanket was delayed until the next morning and that staff said bedpans were not used, while another resident with blindness, falls, and incontinence reported being told to use a brief instead of receiving a bedpan and later soiled the brief. The DNS had not reviewed or investigated either grievance, and the record showed the allegations were not addressed in the documentation.
A resident with schizoaffective disorder and dementia repeatedly requested a room change because of ongoing conflict with a roommate, including loud TV, profanity, and a verbal altercation. The facility did not honor the request, and the roommates later had a resident-to-resident altercation. Staff documented that the residents did not get along, but no other room options were explored to meet the resident’s request.
The facility failed to notify the MD and resident representative about repeated verbal and physical abuse between two roommates, including yelling, kicking, slapping, and a written allegation of daily abuse. The record also showed a resident with severe obesity, DM, hypothyroidism, and celiac disease had a rapid, significant weight gain that was documented by the dietitian, but the MD and resident representative were not notified in a timely manner.
Failure to Report Resident Abuse Allegations: A resident with schizophrenia, dementia, and anxiety disorder was documented yelling at and physically assaulting a roommate, yet no incident report or state report was completed. Another resident later submitted a grievance and letter describing daily verbal abuse and being hit by the same roommate, but the allegation was still not reported to the state agency. Interviews confirmed staff and leadership were aware of ongoing resident-to-resident conflict, while the incident reports and reporting portal showed no required reporting.
Failure to Investigate Resident Abuse Allegations and Resident-to-Resident Conflict A resident with schizophrenia, dementia, and anxiety disorder was documented yelling at and physically assaulting a roommate, yet the facility did not complete a thorough abuse investigation or document protection from further abuse. Another resident later reported daily verbal and physical abuse by the same roommate, including being hit and shoved, but the Administrator was unaware of the allegations and the letter was not reviewed. The report also described repeated verbal and physical altercations between two other residents with psych and mood disorders, with no thorough investigation or clear documentation of how they were separated and protected from each other.
Failure to notify the Ombudsman of resident hospital transfers. Four residents with diagnoses including Parkinson's disease, schizophrenia, diabetes, and pleural effusion were transferred or sent to the hospital, but the facility could not provide documentation that the Ombudsman was notified. The SW confirmed the monthly transfer-to-hospital forms were not sent for the reviewed period, and the DON was unaware the notifications were not being completed.
PASARR Reassessment Not Completed After Suspected Mental Illness Identified: A resident admitted with dementia and a history of schizoaffective disorder had psychiatric documentation showing ongoing schizoaffective disorder, auditory hallucinations, and psychotropic medication management. Although the resident’s Level I PASARR had not identified a major mental illness, facility staff confirmed the State-designated authority should have been notified when the diagnosis was recognized to determine whether a Level II PASARR reassessment was required, but it was not completed.
Failure to revise a resident’s care plan after repeated aggression toward a roommate. A resident with schizophrenia, dementia, and anxiety disorder had ongoing verbal outbursts, yelling, and physical aggression toward a roommate, including an incident where staff observed the resident kicking the roommate and later episodes of yelling all night despite redirection. Behavioral health log entries and an APRN note documented escalating behaviors and unsuccessful redirection, but the care plan did not reflect new interventions or revisions related to the repeated incidents.
Levothyroxine was not administered according to ordered timing and manufacturer directions for a resident with hypothyroidism. An LPN gave the medication with vitamin and iron supplements and at a later morning time, despite the blister pack stating it should be taken on an empty stomach and at least 4 hours before iron or vitamin/mineral supplements; staff also could not explain why the administration time had been changed from the earlier morning schedule.
A resident-to-resident altercation was witnessed when one resident yelled, then kicked and slapped a roommate, but the RN assessment and incident documentation were not completed as required. Separately, a resident with a heel wound was repeatedly observed in bed with both heels resting on the mattress despite an order to offload the heels, and another resident with an AICD did not receive the ordered cardiology battery-check consult. Interviews and record review showed missing assessments, incomplete documentation, and delayed follow-through on ordered care.
A resident with a new stage 3 pressure ulcer did not receive a timely nutrition assessment after the wound was identified, despite a wound care note recommending optimized nutrition. Two other residents had significant weight changes that were not addressed in a timely manner: one had ongoing weight loss with limited dietary follow-up, and another had a large weight gain with a delayed reweight and delayed notification to the MD/APRN and family.
Missing Controlled Drug Count Signatures: The facility failed to ensure shift-to-shift controlled drug counts were consistently completed for a medication cart on the South unit. The controlled drugs count record was missing 4 signatures across 2 shifts, and the DNS stated she was unaware of the omissions until the review. The facility policy required the oncoming and offgoing nurses to count controlled drugs together and document any discrepancies.
A resident with DM, schizophrenia, and dementia had impaired cognition, broken or loose dentures, and cavities or broken teeth. The physician ordered an oral surgeon consult for extractions, and dental records documented multiple damaged teeth still being used for chewing. Although the care plan addressed dental care coordination and noted possible refusal behaviors, the chart lacked documentation of refusal, and the appointment was not scheduled in a timely manner because staff had difficulty reaching the dental office.
Failure to implement EBP for two residents with wounds. One resident had a stage 3 pressure ulcer with drainage and received wound care without barriers or PPE beyond gloves. Another resident had a left foot wound related to GVHD/skin breakdown, refused some wound treatments, and was observed with the wound open to air and no EBP signage or PPE outside the room. Staff interviews showed uncertainty about EBP requirements, despite facility policy calling for gown and glove use during high-contact care for residents with wounds.
Two residents with significant chronic conditions and impaired cognition were not kept current on pneumococcal vaccination. One resident had a pneumococcal vaccine documented only after a long delay, while the other had no pneumococcal vaccine identified in the record. Staff reported fragmented vaccine documentation, missing logs from prior ownership, and delays related to outbreaks and staffing changes.
A facility failed to timely administer COVID-19 booster vaccines to multiple residents with varying cognitive and medical conditions, including dementia, CHF, DM2, COPD, and HTN. Although several residents had signed consent forms agreeing to the booster, their records showed they were not up to date on COVID-19 vaccination, and the facility’s vaccination documentation was fragmented between EHR and paper records. Staff reported that an audit was delayed by recent influenza and COVID-19 outbreaks, a change in ICN staffing, and competing projects, and that booster appointments were only being scheduled after surveyor inquiry.
Failure to Provide Required Medicare Denial Notices: The facility did not provide the required NOMNC and, in one case, could not produce the SNF ABN for residents whose Medicare Part A coverage ended with benefit days remaining. An LPN who had recently started beneficiary notification duties stated she could not find the notices for several residents, and one resident had signed an ABN but still did not receive the NOMNC explaining appeal rights.
Inaccurate MDS Coding of ADLs: A resident with dementia, paranoid schizophrenia, and major depressive disorder had multiple quarterly and annual MDS assessments that inaccurately coded ADL status, including eating, oral hygiene, bathing, dressing, footwear, toileting hygiene, and personal hygiene. The MDS coordinator and Administrator stated a recent MDS audit identified that prior ADL assessments had been inaccurately coded.
Failure to Document Provider Notification for Out-of-Range Blood Glucose Readings: Two residents with DM and dementia had repeated FSBS readings outside ordered parameters, but the clinical record did not show that the APRN/physician or resident representative was notified. One resident had multiple BG readings above 200 mg/dl and the other had multiple BG readings above 300 mg/dl, yet nurse notes lacked documentation of provider notification or related follow-up.
A nurse aide used profane and derogatory language toward a resident with dementia and hearing impairment, in the presence of other staff, constituting verbal abuse. Although the resident did not hear the remarks, the incident was witnessed and documented, violating the facility's zero-tolerance policy for abuse.
Failure to Timely Report and Investigate Allegation of Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the State Agency and to complete and maintain an investigation and related documentation. Resident #1, who had diagnoses including heart failure, anxiety, and depression, had a care plan identifying an ADL self-care performance deficit and interventions such as encouraging discussion of feelings and use of the call bell. A quarterly MDS showed moderate cognitive impairment with a BIMS score of 12/15, dependence in multiple ADLs, and no documented behaviors in the prior seven days. On 12/31/2025, a psychiatric APRN was urgently consulted via telehealth after the resident alleged that a man the resident grew up with came into the room on a gurney, touched the resident’s ankle and leg, and the resident thought he was trying to rape them. The APRN note documented differing versions of the event, significant confusion, and a clinical impression that the resident most likely had a nightmare or delusion. A social services note dated 12/31/2025, provided by the Administrator, documented that the resident alleged a man from their past came into the room at night, tried to rape them, and touched their ankles, causing the resident to scream. The social worker interviewed two other residents on the unit to ask if they had seen any males in the hallway or heard any screaming, and later provided a written statement to the DNS. However, review of the clinical record did not identify a nursing note regarding the request for the psychiatric evaluation, and review of facility documentation failed to identify an incident report or a complete facility investigation for the allegation. The State Agency’s FLIS system did not show that the allegation had been reported, and the facility could not locate staff statements or an incident/accident report related to the allegation. Interviews with the current Administrator, acting DNS #2, and former DNS #1 revealed that no formal facility investigation was conducted and that the allegation was not reported to the State Agency when first known on 12/31/2025. Former DNS #1 stated that social services and psychiatry were involved and that, based on the psychiatric evaluation and input from a covering Administrator and a corporate RN, the incident was characterized as a non-reportable allegation. The Administrator later acknowledged awareness of the allegation, stated she had directed DNS #1 to notify the State Agency, and confirmed that this did not occur. The Administrator and acting DNS #2 reported uncertainty about the existence or location of any investigation files or incident reports, and soft files in their offices contained statements dated 12/31/2025. The State Agency was ultimately notified on 4/14/2026 at 7:19 PM, well beyond the facility’s Abuse, Neglect and Exploitation Policy requirement to report all alleged violations to the Administrator and State Agency immediately, but not later than two hours after the allegation is made.
Failure to Thoroughly Investigate Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a timely and thorough investigation after a resident alleged mistreatment of a sexual nature. The resident had diagnoses including heart failure, anxiety, and depression, and a care plan identifying an ADL self-care performance deficit with interventions to encourage expression of feelings and use of the call bell for assistance. A quarterly MDS showed moderate cognitive impairment with a BIMS score of 12/15, dependence in multiple ADLs, and no documented behaviors such as hallucinations or delusions in the prior seven days. On one date, a psychiatric APRN was urgently consulted via telehealth after the resident reported that a man they grew up with came into their room on a gurney, touched their ankle and leg, and that they believed he was trying to rape them. The APRN note documented that the resident described a male, in his 40s with short black hair, entering the room, touching the resident’s ankle, telling the resident not to scream, and running his hand up the resident’s leg. The APRN documented that this account differed from the original report and concluded, after evaluation, that the resident most likely had a nightmare or delusion, with significant confusion noted but mild, stable anxiety. The clinical record did not contain a nursing note documenting the request for the psychiatric evaluation related to this allegation. Social services documented that the resident alleged a man they grew up with came into the room at night, tried to rape them, touched their ankles, and that the resident screamed. Social services interviewed two other residents on the unit to ask if they had seen any males in the hallway or heard any screaming. However, facility documentation did not show that an incident report or a complete investigation was initiated in response to the allegation. The former DNS acknowledged recalling the allegation and stated that no facility investigation was completed, and that social services and psychiatry were involved and it was determined by administrative and corporate nursing staff that the resident was having a dream. Later, when the Administrator and current DNS were notified of the allegation via an Ombudsman email, they each had separate soft files containing unsigned staff statements dated the day of the allegation, some without staff names and none with signatures. There was no evidence of a formal incident report or a thorough investigation consistent with the facility’s Accident and Incidents Policy and Abuse, Neglect and Exploitation Policy, which require immediate investigation, identification and interviewing of all involved persons, and complete documentation of the investigation.
Failure to Provide Timely Social Services After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medically-related social services and emotional support following an allegation of abuse. Resident #1, who had diagnoses including heart failure, anxiety, and depression, had a BIMS score of 12/15 indicating moderate cognitive impairment and required extensive assistance with ADLs, transfers, wheelchair use, and bed mobility. A psychiatric APRN note documented that Resident #1 urgently reported that a man he/she grew up with came into the room on a gurney, touched the resident’s ankle and leg, and that the resident believed he was trying to rape him/her. The resident later described the alleged perpetrator as another resident, a man in his 40s with short black hair, who came into the room, touched the resident’s ankle, told the resident not to scream, and ran his hand up the resident’s leg. The APRN noted significant confusion, mild but stable anxiety, and concluded after evaluation that the resident most likely had a nightmare or delusion. The resident’s care plan was updated to reflect a history of childhood trauma and to include interventions such as social service 1:1 visits as needed for support and reassurance, encouraging family involvement and support, encouraging verbalization of feelings, and offering psych services as needed. However, record review showed the last social service note was dated 12/23/2025, with no social service documentation related to the 12/31/2025 allegation or the delusion documented by the psychiatric APRN. The facility received an Ombudsman email alleging that Resident #1 was raped, and the DNS requested that the social worker speak with the resident. Social Worker #1 confirmed speaking with the resident about the incident but acknowledged not writing a social service note and not providing additional follow-up or support visits. Interviews with DNS #2 and the Administrator confirmed that social services saw the resident after the allegation and obtained a statement, but there was no explanation for the lack of documentation or additional support visits, despite the facility’s Abuse, Neglect and Exploitation Policy directing emotional support and counseling during and after such investigations.
Failure to Protect Residents from Roommate Abuse
Penalty
Summary
The facility failed to protect residents from abuse in two separate roommate situations. One resident with diagnoses including schizophrenia, psychosis, and adjustment disorder was placed in a room with another resident with schizophrenia, dementia, and anxiety disorder. The first resident’s record showed repeated concerns about the roommate, including a room change request and a grievance letter stating the roommate verbally abused and had hit the resident. The resident later reported that the roommate made unwanted romantic advances, became more aggressive after rejection, yelled overnight, and at times hit, kicked, and shoved the resident into a closet door. The resident also stated that staff were told about the behavior but only advised the resident to tell the roommate to stop, and no room change was offered until the resident requested one. Facility documentation also showed multiple incidents involving the same roommate that were not effectively addressed. A nurse documented a verbal altercation and observed the roommate kicking the other resident in the hallway, and later documented the roommate yelling at the resident overnight and not responding to redirection. The care plan was not revised to address the altercation documented after the physical incident. Interviews with staff showed that several employees were aware of ongoing aggressive behavior between the two residents, that the behavior had continued for months, and that staff often attempted redirection but did not separate the residents until the later room change. The administrator, DNS, and medical director were not aware of key incidents or the resident’s written allegation of daily verbal and physical abuse. A second resident-to-resident abuse situation involved two roommates with diagnoses including schizoaffective disorder, dementia, stroke, and major depressive disorder. Both residents reported frequent verbal altercations, including name-calling and yelling over room issues such as TV volume and perfume. One resident reported that during an argument, the other grabbed a leg or foot, and the other resident reported the incident to nursing staff. Staff interviews confirmed repeated verbal conflicts between the two residents, with some staff separating them and notifying social services. The director of social services acknowledged that when the verbal mistreatment was first identified, the required measures were not fully implemented and the incident was not completely documented in the clinical record.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to ensure accurate staffing data was entered in the Payroll Based Journal (PBJ) using payroll and other verifiable, auditable data during FY Quarter 4 2025. Review of the PBJ Staffing Data Report identified that the facility triggered a one-star staffing rating because no RN hours were reported and licensed nurse coverage for 24 hours per day was not reflected on multiple dates, including 9/19/25, 9/20/25, 9/22/25 through 9/27/25, and 9/29/25 through 9/30/25. However, review of the facility’s Daily Staffing documents for those same dates showed that RN coverage and licensed nurse coverage 24 hours a day were present. During interview, the Regional Administrator/DON stated that the PBJ data for FY Quarter 4 had been completed by the previous owner and that she could not speak to the process or accuracy of the submission prior to the change of ownership on 11/1/25. The facility’s PBJ policy states that the Administrator, HR director, and DON are responsible for verifying the accuracy of staffing data submitted to CMS using facility audit forms and/or payroll vendor reports.
Failure to Provide Morning ADL Care After Aide Reassignment
Penalty
Summary
The facility failed to provide basic ADL care, including bathing and toileting, for 3 of 3 residents reviewed who were unable to care for themselves. Resident #12 had diagnoses including stroke and dementia, was severely cognitively impaired, required two-person assistance with bed mobility, transfers, and toileting, and was incontinent of bowel and bladder. Resident #69 had diagnoses including spondylosis and difficulty walking, was cognitively intact, required one-person assistance with bed mobility, transfers, bathing, and toileting, and was frequently incontinent. Resident #79 had diagnoses including Parkinson’s disease and stroke, was moderately cognitively intact, required one-person assistance with bed mobility, transfers, and toileting, and was incontinent of bowel and bladder. During the morning shift, the nurse aide assigned to these residents began work at 7:00 AM but left the facility at 10:00 AM without completing resident assignments and without informing the charge nurse or other staff. RN #5, the nursing supervisor, reassigned the aide to accompany another resident to a community medical appointment when transportation arrived, but did not notify LPN #6 of the change. LPN #1 later identified that she was only learning of the reassignment and was adjusting aide assignments accordingly. NA #13 confirmed she left immediately after being told to accompany the resident to the appointment and did not notify the charge nurse or anyone else about the status of her assignment. At 1:00 PM, observation and documentation review showed Resident #12, Resident #69, and Resident #79 were still in bed, in johnny coats, and wet with urine. NA #8 stated she assisted with incontinent care for Resident #79 at 6:30 AM but provided no other care for the three residents until they were reassigned after 12:00 PM. NA #9 and NA #19 stated they had not provided care to the three residents before being assigned at 12:00 PM. The facility policy required daily ADL care and that each resident’s assistance needs be assessed, included in the care plan, and used when providing care.
Missing Nursing Competency Documentation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had demonstrated the competencies necessary to care for residents' needs for 5 of 5 nurse aides and 2 of 2 licensed nurses reviewed for sufficient and competent staffing. Review of personnel files for NA #8, NA #15, NA #16, NA #17, and NA #18 showed that each was hired in [DATE], but the files did not contain documentation that annual competencies had been demonstrated from the last standard survey [DATE]. After the facility changed ownership on [DATE], each of these nurse aides completed an in-service on the 2026-2027 mandatory education on [DATE]. Review of LPN #5's personnel file showed that he/she was hired in February 2024, but the file did not contain documentation that annual competencies had been demonstrated in 2025. Review of LPN #8's personnel file also showed that the file did not contain documentation that annual competencies had been demonstrated in 2025. After the facility changed ownership on [DATE], both LPNs completed an in-service on the 2026-2027 mandatory education on [DATE]. Interviews supported that documentation of nursing staff education and competency evaluations from the prior owner was not available. The MDS Coordinator/Interim Staff Development and Infection Control Nurse stated that when she began employment, there was no documentation of nursing staff education or competency evaluations available under the prior owner, and that a mandatory in-service/competency fair was later initiated for all nursing staff. The DNS stated that the annual mandatory education packet had been provided by Human Resources in 2025, but the documentation could not be located because the prior owner had removed or taken the nursing staff education records, and that there was no formal process for evaluating licensed nurses or nurse aides for competencies under the prior owner.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that 5 of 5 nurse aides (NA #8, 15, 16, 17, and 18) received a performance evaluation at least once every 12 months during the period from the last standard survey through 2/24/26. Review of each nurse aide’s personnel file showed no documentation that an annual performance evaluation had been completed within that timeframe. The personnel files reviewed identified that NA #8 was hired in August 202, NA #15 in October 2018, NA #16 in September 2007, NA #17 in [NAME] 2004, and NA #18 in October 2018. During interview, the DNS stated that performance evaluations for all nursing staff, including nurse aides, had been completed in 2025, but the evaluations could not be located after the change of ownership. The DNS explained that in 2025 the DNS evaluated RN supervisors, RN supervisors evaluated charge nurses, and charge nurses evaluated nurse aides, with completed evaluations placed in personnel files with HR. The DNS also stated that the prior company had taken most of the HR files and that since the change of ownership in 10/2025, the new company had started the annual evaluation process but had not yet implemented it. Facility policy required formal written employee performance evaluations, and the In-Service Training Program, Nurse Aide policy stated that all nurse aides shall participate in regularly scheduled in-service training classes.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. During the recertification survey from 2/24/26 to 2/27/26, surveyors observed 5 residents during medication administration and identified 35 opportunities for error, with 3 observed medication errors for an overall error rate of 8.57%. The report states that the facility’s medication administration policy required medications to be administered by licensed nurses or other authorized staff, compared against the MAR for resident name, medication name, form, dose, route, and time, and administered as ordered and in accordance with manufacturer specifications. For Resident #19, who was admitted in October 2020 and had hypothyroidism, the physician ordered Levothyroxine 112 mcg daily along with Vitamin C, Vitamin D, and Ferrous Sulfate oral solution. During observation, an LPN administered Levothyroxine, Vitamin C, an iron tablet instead of the ordered Ferrous Sulfate oral solution, and Vitamin D. The Levothyroxine packaging directed that it be taken at least 4 hours before iron or vitamin/mineral supplements and on an empty stomach, and RN #2 stated it should be given at 6:30 AM. For Resident #111, an LPN administered medications but omitted the ordered Cholecalciferol 1000 units.
Medication carts not kept clean and sanitary
Penalty
Summary
Medication carts were not maintained in a clean and sanitary manner in 4 of 4 carts observed. During observation of the Center South, Center North, North, and South medication carts, surveyors found accumulations of loose medication pills and/or blister pack back covers at the bottom of the fifth drawer in each cart. Each cart was observed with the DNS and nursing staff present, and the staff members interviewed at the time stated they were not aware of the loose pills and/or blister pack back covers in the medication drawers. The LPNs interviewed stated it was the responsibility of all nurses to keep the medication carts clean at all times and after themselves. The DNS stated she was not aware the medication carts were not being cleaned and identified the facility expectation that all nurses clean the medication carts at the end of their shift and/or keep them clean at all times. Review of the facility storage of medications policy stated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner, and that nursing staff are responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.
Failure to Routinely Clean and Sanitize Resident Water Pitchers
Penalty
Summary
The facility failed to ensure resident-designated water pitchers were cleaned and sanitized routinely. During interview, a resident reported that water pitchers were not routinely cleaned and were instead reused daily, and that a prior complaint to staff did not change the practice. Multiple observations found an ice cooler on a utility cart at the end of the hall with no clean water pitchers available, while staff used an ice scooper inside the cooler to obtain ice and fill pitchers before taking them to resident rooms. Staff were observed filling unmarked pitchers and returning to resident rooms, and on later observations the same cooler was still present with no clean pitchers available. Interviews with nursing and dietary staff showed that pitchers were being cleaned only when requested rather than on a routine basis. A nurse aide stated pitchers were not washed often and that staff had to ask for replacements, while another nurse aide said pitchers were cleaned or replaced upon resident request and not routinely completed. The Dietary Aide stated that the prior process of bringing pitchers to the kitchen for morning cleaning had not occurred for about five months, and the Food Service Director acknowledged shortages of pitchers and lids and said existing pitchers were cleaned only if nursing requested it. The Administrator stated clean pitchers were provided weekly and that audits were conducted, but no documentation of those audits was provided. Facility policy stated water pitchers were to be collected at bedside at least weekly, sanitized in the dish machine, and returned for redistribution.
Lack of Standardized Infection Surveillance and Antibiotic Stewardship Review
Penalty
Summary
The facility failed to ensure an antibiotic stewardship program was in place that included a standardized tool for infection surveillance and a system for periodic review from the last standard survey through the change of ownership. Review of the Antibiotic Stewardship binder with documentation dated 3/1/25 through 2/23/26 did not identify that, from 3/1/25 through 10/31/25, the facility was using a standardized tool when assessing residents for infection, and it did not identify that a feedback system was in place for educating prescribing practitioners on antibiotic utilization patterns and facility infection rates. Review of the November 2025, December 2025, and January 2026 monthly infection reports showed infection surveillance broken down by body systems and percentage rates, but this tracking was documented only after the change of ownership. During interview, the MDS Coordinator/Interim Staff Development and Infection Control Nurse stated she began working at the facility in November 2025 and that there had been no standardized tool in place for infection surveillance when she arrived; she said the facility later began using McGeer criteria. She also stated there was no documentation from the prior owner showing periodic review and reporting of antibiotic surveillance and infection surveillance to the interdisciplinary team, including medical providers and nursing staff, and no documentation of education to nursing staff about antibiotic stewardship before the change of ownership. The DNS stated that from her hire in March 2025 until the change of ownership, the facility was without a full-time ICN, the prior owner oversaw infection control, and there was no documentation that a standardized tool had been used or that infection and antibiotic surveillance data had been reported to the IDT. The DNS further stated that active infections were reported at Medical Staff meetings, but antibiotic reconciliation and provider antibiotic ordering data were not presented.
No Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist to be responsible for the infection prevention and control program. Review of the infection control program showed there was no designated IP, and interview and documentation review with the Administrator on 2/24/26 at 2:03 PM confirmed that no designated IP had been assigned since 1/19/23. The Administrator stated that various staff had intermittently assisted with infection control, including an LPN employed since November 2025 and the DNS who was recently certified on 2/7/26. The Administrator also reported ongoing efforts to recruit for the position, but facility documentation showed the position had been posted only once on 10/22/25. A candidate had been hired and was expected to start on 3/4/26, but the Administrator could not provide schedules or punch records showing designated time for management of the infection control program or oversight by the LPN. The facility policy required a qualified individual to be designated for the IPCP and employed at least part time, and the facility assessment identified an IP and IPCP with no formal hours detailed.
Missing Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that 5 of 5 nurse aides reviewed had sufficient and competent nurse aide training, including the minimum required 12 hours of annual in-service education. Personnel file reviews for NA #8, NA #15, NA #16, NA #17, and NA #18 showed no documentation that the required in-service education had been completed during the period from the last standard survey through the change of ownership. The records reviewed showed each nurse aide had been employed for years, but their files did not contain evidence of the required annual training hours for the identified time periods. Interviews with the MDS Coordinator/Interim Staff Development and Infection Control Nurse, the DNS, and the Human Resources Director confirmed that documentation of prior nursing staff education could not be located after the change of ownership. The interim staff development nurse stated that when she began employment, there was no documentation of nursing staff education available and she could not determine how many in-service hours the nurse aides had received under the prior owner. The DNS stated that an annual mandatory education packet had been provided, but the binder containing in-service documentation had been removed by the prior owner and she could not verify that nurse aides had received 12 hours of in-service education. The facility policy required annual in-service training for nurse aides, including training on resident care, cognitive impairment, dementia management, and abuse prevention, and the facility assessment also directed that in-service training be no less than 12 hours per year.
Failure to Provide Dignified Assistance and Respond to Resident Requests
Penalty
Summary
The facility failed to ensure two residents were treated in a respectful and dignified manner when their requests for toileting-related assistance and basic comfort needs were not handled appropriately. One resident, admitted with diagnoses including muscle wasting and atrophy, dementia, a history of falling, and CHF, had a care plan that included assistance with ADLs, toileting every 2 to 3 hours while awake, and routine incontinence checks. The resident’s grievance stated that a blanket requested in the afternoon was not provided until the next morning and that a bedpan request was met with a statement that bedpans were not used at the facility. The resident’s record showed intact cognition, frequent bowel and bladder incontinence, and need for assistance with toileting and transfers. A second resident, admitted with diagnoses including legal blindness, muscle wasting and atrophy, repeated falls, lumbar radiculopathy, and right knee osteoarthritis, had care plans and orders addressing incontinence, toileting assistance, and transfer support. The resident’s grievance stated that during the early morning hours the resident rang for a bedpan, but the nurse aide instructed the resident to use the brief instead, after which the resident soiled the brief and later received peri care. The grievance also documented that the nurse aide made a comment to the resident about sleeping at that time. The resident’s record showed intact cognition, occasional bladder incontinence, frequent bowel incontinence, and need for assistance with toileting and transfers. For both residents, the clinical record and facility documentation did not reflect that the allegations were addressed or investigated. The DNS stated she had not reviewed either grievance form and had not investigated the allegations. Interviews with staff identified that the facility had extra blankets and bedpans available, and one nurse aide acknowledged telling the resident to soil the brief because she did not think the transfer was safe, while also stating she did not notify the RN supervisor or floor nurse. The Administrator was aware of the grievances, and the record also showed that the customer service in-service could not be verified for several staff members.
Failure to Honor Resident Room Change Request
Penalty
Summary
The facility failed to honor a resident’s request for a room change after repeated negative interactions with a roommate, and the resident and roommate later had a resident-to-resident altercation. Resident #99 was admitted with diagnoses including schizoaffective disorder and dementia, and the quarterly MDS identified the resident as moderately cognitively impaired but independent with bed mobility, transfers, and ambulation. The care plan addressed mood problems related to dementia, schizoaffective disorder, and anxiety. A handwritten grievance note from the resident requested a room change because the resident and roommate “both hate each,” but the request was not acted on at that time. The record shows ongoing conflict between the roommates, including loud TV complaints, profanity, and a verbal altercation in which Resident #99 was relocated to another room for the night while management review was pending. Later documentation noted the resident again requested a room change due to roommate compatibility, but the change did not occur because the other resident’s responsible party did not agree and the facility was at capacity. Interviews confirmed the residents did not get along, had been socially separated after the altercation, and that no other room options were explored to honor the resident’s request. The facility policy stated room changes may be made when requested by the resident or representative and that incompatibility is a reason for a change.
Failure to Report Abuse and Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician and the resident representative of verbal and physical abuse involving two roommates. One resident had diagnoses including schizophrenia, dementia, and anxiety disorder and was documented as having moderately impaired cognition. Clinical notes described repeated overnight yelling at the roommate, a verbal altercation, and an incident in which the resident was observed kicking the roommate in the hallway. Another note later documented continued yelling and screaming at the roommate for no reason, and a behavioral health log also reflected ongoing disruptive behavior toward the roommate. The roommate, who had diagnoses including schizophrenia, psychosis, and adjustment disorder, was moved to a different room after reporting verbal abuse by the roommate. The resident wrote a letter to the administrative office stating that the roommate verbally abused and had hit the resident a few times, that the behavior happened every day when entering or leaving the room and when accessing the closet, and that the resident wanted a different room. Interviews with staff and the resident indicated the abuse and aggressive behavior had been ongoing for months, but the clinical record did not reflect notification of the physician or resident representative regarding the witnessed incidents, the later verbal altercation, or the written allegations of daily abuse. The facility also failed to notify the physician in a timely manner of significant weight gain for two residents. One resident with diagnoses including severe morbid obesity due to excess calories, diabetes, hypothyroidism, and celiac disease had a documented weight increase from 145.8 lbs. to 179.2 lbs. over 23 days, followed by a further increase to 181.8 lbs. The dietitian documented the weight gain and requested a recheck, but the record did not show that the weight was rechecked or that the physician and resident representative were notified during the period reviewed. Another resident was identified in the report as having a significant weight gain as well, with the deficiency statement indicating the facility failed to notify the physician of that change in a timely manner.
Failure to Report Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the state agency according to regulatory requirements and its own policy. One resident with schizophrenia, dementia, and anxiety disorder was documented on 7/7/25 as being involved in a verbal altercation with a roommate, with a nurse noting that the resident was observed yelling and was seen by three staff members kicking the roommate in the hallway. The record review identified that no accident and incident report was completed and the allegation of abuse was not reported to the state agency. A psychiatric evaluation the next day noted no delusions, hallucinations, agitation, or aggression, and no changes were recommended. The same resident was later documented on 10/21/25 as yelling all night at the same roommate, with the nurse noting that redirection was unsuccessful. Review of the facility’s incident reports and state agency reporting portal again showed no accident and incident report and no report of verbal abuse to the state agency. A behavioral health follow-up log also documented that the resident was up all night yelling at the roommate and accosting the roommate for coughing. A later APRN note described recent escalation in behaviors, including yelling and screaming at the roommate during the night and being disruptive, with an increase in Risperdal ordered. A second resident, admitted with schizophrenia, psychosis, and adjustment disorder, later submitted a grievance and letter requesting a room change due to verbal abuse by the same roommate. The letter stated that the roommate abused the resident verbally and had hit the resident a few times, with daily incidents when entering or leaving the room and when accessing the closet. The grievance form documented that the room was changed and that things were better afterward, but it also identified that local law enforcement was not notified and that the grievance did not result in a state agency reportable event. Review of the incident reports and reporting portal showed no report of the alleged verbal and physical abuse. Interviews with the resident, staff, the DNS, the Administrator, and the Medical Director confirmed that staff were aware of ongoing yelling and aggression between the residents, that the incidents were not reported, and that no incident reports were completed for the events described.
Failure to Investigate Resident Abuse Allegations and Protect Residents from Further Harm
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident abuse and failed to ensure residents were protected from further abuse. Resident #41, who had diagnoses including schizophrenia, dementia, and anxiety disorder and was noted to have moderately impaired cognition, was documented on 7/7/25 as yelling at a roommate and being observed by staff kicking that roommate in the hallway. Facility documentation showed no completed investigation and no documentation that the roommate was removed from the room or otherwise protected from future abuse. A psychiatric evaluation the next day noted no delusions, hallucinations, agitation, or aggression, and no changes were recommended. A second incident involving Resident #41 was documented on 10/21/25, when the resident was observed yelling all night at the same roommate, Resident #93, and not responding to redirection. Facility records again showed no investigation and no documentation that Resident #93 was removed from the room or protected from future abuse. A behavioral health log also noted Resident #41 was up all night yelling at the roommate and accosting him/her for coughing. Later documentation noted staff reported an escalation in behaviors, including yelling and screaming at the roommate during the night, and that Risperdal was increased. Resident #93, who had diagnoses including schizophrenia, psychosis, and adjustment disorder, later submitted a grievance and letter requesting a room change and describing daily verbal abuse and physical abuse by Resident #41, including being hit a few times and shoved into a closet door. The Administrator stated she did not read the letter because she could not read the handwriting and was unaware it contained abuse allegations. Interviews with Resident #93, nursing staff, the DNS, and the Medical Director identified that the incidents had been ongoing for months, were known to some staff, and were not thoroughly investigated or reported as required. The report also identified a separate failure involving Resident #23 and Resident #99, both of whom had repeated verbal altercations and at least one physical altercation, yet the facility did not complete a thorough investigation or document how the residents were protected from each other. Resident #99 had diagnoses including schizoaffective disorder and dementia, and Resident #23 had diagnoses including stroke and major depressive disorder with mood disturbances.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when residents were transferred to the hospital. Review of the clinical record and facility documentation identified four residents involved in hospital transfers: Resident #3, who had diagnoses including Parkinson's disease, was transferred to the hospital multiple times; Resident #8, who had schizophrenia, was transferred to the hospital; Resident #74, who had diabetes, was transferred to the hospital; and Resident #107, who had pleural effusion, was sent to the hospital and also left the facility for a physician appointment and did not return on the first shift before later being reported as transferred from the oncology clinic. The Administrator stated she was unable to provide documentation showing the Ombudsman had been notified when these residents were transferred to the hospital. The review of hospitalizations showed the State Long-Term Care Ombudsman was not notified of residents transferred to the hospital between November 1, 2025, and January 31, 2026. The Administrator stated Social Services was responsible for notifying the Ombudsman monthly, and SW #1 confirmed she did not send the monthly transfer-to-hospital forms for November 1, 2025, through January 31, 2026, and could not provide documentation for the earlier period reviewed. The facility policy stated the Social Services Director or designee would provide copies of notices for emergency transfers to the Ombudsman and maintain evidence that the notice was sent.
PASARR Reassessment Not Completed After Suspected Mental Illness Identified
Penalty
Summary
The facility failed to ensure a PASARR reassessment was completed after a suspected mental illness was identified for one resident. The resident was admitted in August 2019 with diagnoses that included schizoaffective disorder and dementia. A Level I PASARR completed during hospitalization before admission stated the resident did not have a diagnosis of a major mental illness and that no further Level I screening was required unless a serious mental illness or intellectual disability was later suspected and there was a significant change in treatment needs. Psychiatric consultations beginning in November 2019 documented schizoaffective disorder, including a history of auditory hallucinations previously treated during hospitalization, with ongoing medication management and supportive psychotherapy. The annual MDS identified the resident as not considered by the state Level II PASARR to have a serious mental illness or intellectual disability, while also noting an active diagnosis of schizophrenia and psychotropic medication use. Interviews with Social Services, the DNS, and the LPC confirmed the resident had a primary diagnosis of schizoaffective disorder and that the State-designated authority should have been notified to determine whether a PASARR reassessment was required, but this reassessment had not been completed when the diagnosis was identified.
Failure to Revise Care Plan After Repeated Resident-to-Resident Aggression
Penalty
Summary
The facility failed to revise Resident #41’s care plan and implement additional interventions after repeated resident-to-resident altercations and ongoing verbal aggression toward a roommate. Resident #41 had diagnoses including schizophrenia, dementia, and anxiety disorder, and had physician orders for behavior monitoring and Risperdal. The annual MDS identified moderately impaired cognition, continence of bowel and bladder, and need for assistance with bathing, eating, and lower body dressing. On 7/7/25, an LPN documented that Resident #41 was observed in a verbal altercation with roommate Resident #93, continued yelling despite redirection, yelled at other residents in the hallway, and was then observed kicking the roommate in the hallway by three staff members. The note stated the supervisor was notified and a psychiatry referral was placed. Review of the care plan did not identify revisions or interventions related to this incident. On 10/21/25, the same LPN documented that Resident #41 was up all night yelling and screaming at Resident #93 for no reason, and that redirection was unsuccessful. The clinical record did not identify additional interventions related to these behaviors. A Behavioral Health Visit Request/Follow Up Log entry for that date noted Resident #41 was yelling at the roommate and accosting him/her for coughing, but the entry did not identify who placed it and did not show psychiatric provider review or sign-off. The care plan again did not reflect revisions or interventions related to the ongoing verbal behaviors. A psychiatric evaluation on 10/29/25 documented increased paranoia and agitated behaviors, with a treatment plan to increase Risperdal to 2 mg twice daily. An APRN note on 10/31/25 documented staff reports of recent escalation in yelling and screaming at the roommate, disruptive behavior, and unsuccessful redirection. The care plan still did not identify revisions or interventions related to these behaviors. A grievance dated 11/12/25 showed the roommate requested a room change due to verbal abuse and reported being verbally and physically abused daily. The facility documentation also reflected that the roommate was moved and reported things were better after the change.
Levothyroxine Given at Incorrect Time With Interacting Supplements
Penalty
Summary
The facility failed to administer Levothyroxine according to professional standards for one resident with bipolar disorder and hypothyroidism. The resident had a physician’s order for Levothyroxine 112 mcg daily, and the February MAR showed it was given at 6:30 AM from 2/1/26 through 2/19/26. After the resident returned from the hospital on 2/21/26, the physician again ordered Levothyroxine 112 mcg daily along with Vitamin C, Vitamin D, and Ferrous Sulfate, and the February MAR showed Levothyroxine was then administered at 9:00 AM with those other medications from 2/22/26 through 2/25/26. During observation of medication administration on 2/26/26 at 10:04 AM, an LPN administered Levothyroxine 112 mcg together with Vitamin C 500 mg, an iron tablet, and Vitamin D 25 mg. The Levothyroxine blister pack directions stated the medication should be taken at least 4 hours before iron or vitamin/mineral supplements and preferably 1/2 to 1 hour before breakfast on an empty stomach. Interview with staff identified that the resident had previously received Levothyroxine at 6:30 AM before hospitalization, but the reason for the change to 9:00 AM was not known. An RN stated the medication should be administered at 6:30 AM.
Failure to Assess Assault, Offload Heel Wound, and Complete Cardiology Consult
Penalty
Summary
The facility failed to complete an RN assessment and related incident response after a witnessed resident-to-resident altercation involving two roommates. One resident was observed yelling, continuing disruptive behavior despite redirection, and then kicking and slapping the roommate in the hallway while three staff members were present. The nurse documented that the supervisor was notified and that a psychiatry referral was placed, but the record did not contain an RN assessment of the resident who was struck, nor did it contain the incident documentation described in facility policy. The record and interviews also showed that the resident who was struck later reported ongoing verbal abuse, physical aggression, and fear of the roommate, including yelling overnight and being shoved into a closet door when trying to access the closet. The resident stated that staff had been told about the behaviors multiple times and had advised the resident to tell the roommate to stop, but the behaviors continued. The DNS stated that after the incident the residents should have been separated, the resident should have had a physical assessment, the physician, psychiatric provider, resident representatives, and social work should have been notified, and an investigation should have been started immediately with witness statements. The facility also failed to ensure a resident with a left heel pressure ulcer had the heels offloaded as ordered. The resident had a physician order to offload the heels while in bed every shift, and the care plan included heel offloading. Multiple observations showed the resident in bed with both heels directly on the mattress and no offloading in place. The wound was initially documented as a stage 3 pressure ulcer and later reclassified as vascular, but the clinical record did not contain documentation that the resident was noncompliant with offloading or that the care plan addressed refusal of the intervention. In addition, the facility failed to complete a cardiology consultation for a resident with an implanted AICD despite physician orders for a battery check and a faxed request for consultation. Review of the record from the order date through the survey date did not identify that the cardiology consult had been completed. Interviews showed the appointment had not been scheduled in a timely manner, the scheduling process had not been documented, and staff were unsure of the status of the consult.
Delayed nutrition assessment and weight-change follow-up
Penalty
Summary
The facility failed to provide timely nutritional assessment and follow-up for a resident with a newly identified stage 3 pressure ulcer. The resident had multiple chronic conditions, including impaired cognition, incontinence, and limited mobility, and the care plan identified fragile skin and limited mobility as skin integrity risks. After a new facility-acquired pressure ulcer was identified on the plantar surface of the left foot/heel, the wound care physician documented the wound and recommended optimizing nutrition, but the clinical record did not show that a nutritional assessment or evaluation was completed at that time. The dietitian stated she was not aware of the new wound when it was identified and explained that she had relied on wound lists being provided to her. She later reviewed the wound list and acknowledged that the resident had a facility-acquired pressure ulcer, stating she had missed it and would see the resident that day. A nutritional progress note was then entered after surveyor inquiry, documenting that the resident was eating over 75% of meals and had snacks, but the assessment had not been completed when the wound was first identified. The facility also failed to timely address significant weight changes for two other residents. One resident with diabetes and anemia had a 10% weight loss over 90 days, followed by additional documented weight loss after hospitalization, but the record did not show timely dietary intervention or documentation addressing the continued loss when it was identified. Another resident with obesity and diabetes had a 33.4-pound weight gain over 23 days; the dietitian requested a reweight, but the record did not show that the reweight or follow-up occurred for about 2 weeks, and the physician and resident representative were not notified during that period.
Missing Controlled Drug Count Signatures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure shift-to-shift controlled drug counts were consistently completed for 1 of 4 medication carts. During observation of the South unit medication cart, the February 2026 controlled drugs shift count record was reviewed and found to be missing 4 signatures on 2 shifts on 2/24/26, covering the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts. The DNS stated she was not aware of the missing signatures until the review and identified that it was the responsibility of all nurses to sign the controlled drugs count record at the beginning and end of each shift when the count is completed. The facility controlled substances policy stated that nursing staff must count controlled drugs at the end of each shift, that the nurse coming on duty and the nurse going off duty must make the count together, and that discrepancies must be documented and reported to the DON.
Delayed Oral Surgery Scheduling for Resident With Dental Problems
Penalty
Summary
The facility failed to ensure timely dental services with an oral surgeon for a resident who had diagnoses including type 2 diabetes mellitus, schizophrenia, and dementia. The resident’s quarterly MDS identified moderately impaired cognition, a broken or loosely fitting full or partial denture, and obvious or likely cavities or broken natural teeth. The care plan addressed oral/dental health problems related to cavities and included coordinating dental care and transportation, as well as monitoring and reporting oral/dental problems. It also identified behaviors of refusing medications or medical appointments, including self-scheduling and canceling outside medical appointments, with social services support as needed. A physician’s order directed the facility to arrange an outpatient oral surgeon for dental extraction, and a dental consultation documented multiple teeth with cavities and/or fractures that the resident was still using for chewing. The consulting dental group later documented a referral to an oral surgeon for extraction of multiple teeth and noted that there was a wait, making prompt calling beneficial. However, review of nurse’s notes and APRN notes did not identify documentation that the resident refused dental care, and the administrative assistant responsible for scheduling appointments stated that the resident had not yet been seen by an oral surgeon. She also stated she had been playing phone tag with the dental office, and the resident was not scheduled for the oral surgery appointment until after surveyor inquiry.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for two residents with wounds. Resident #57, who had moderately impaired cognition and required substantial assistance with toileting, dressing, and transfers, developed a new facility-acquired stage 3 pressure ulcer on the left heel/plantar foot. The wound was documented as open with drainage, and physician and wound care notes described ongoing treatment with honey, calcium alginate, and protective dressings. The physician orders reviewed did not identify EBP in place after the wound was identified, and during observation the resident’s wound care was performed without barriers between the resident and the open wound and without PPE other than disposable gloves. Resident #90, who had type II diabetes and GVHD, had a left foot wound that was described as an abrasion/chronic wound with drainage and later required wound consults and dressing orders. Nursing notes documented refusal of wound treatments at times, with the resident stating the wound should remain open to air. Observations showed the resident with the wound open to air, including while out of the room, and there was no signage on the door and no PPE located outside or nearby. Staff interviews reflected uncertainty and disagreement about whether EBP was required, with some staff stating the resident should have been on EBP because of the wound and the DNS initially agreeing that EBP should have been in place. The facility policy for Enhanced Barrier Precautions directed use of gowns and gloves during high-contact resident care for residents with wounds, including pressure ulcers and any skin opening requiring a dressing. The policy also directed that EBP be used until the wound resolved. Despite this policy and the wound care documentation for both residents, the observations and interviews showed EBP was not implemented for either resident during wound care and related resident care activities.
Delayed Pneumococcal Vaccination Documentation and Administration
Penalty
Summary
The facility failed to ensure pneumococcal vaccination was administered in a timely manner for 2 of 5 residents reviewed for immunizations. Resident #4 was admitted in April 2023 with diagnoses including heart failure, dementia, and hypertension. The quarterly MDS identified severely impaired cognition and noted the resident was not up to date on the pneumococcal vaccination, which had been offered and declined. The immunization record later showed Pneumococcal-Historical Type Unknown was administered on 3/20/24, and a Resident Pneumonia Vaccine Education Document Form signed on 2/5/26 showed the resident agreed to receive PCV 20. Resident #6 was admitted in January 2022 with diagnoses including dementia, type 2 diabetes mellitus, and COPD. The annual MDS identified moderately impaired cognition and noted the resident was not up to date on the pneumococcal vaccination, which had been offered and declined. Review of the immunization report did not identify any pneumococcal vaccine administered while the resident was at the facility or historically, and a Resident Pneumonia Vaccine Education Document Form signed on 2/11/26 showed the resident agreed to receive PCV 20. During interviews, staff stated the prior owner did not maintain a vaccination log, documentation was fragmented between the EHR and paper records, and an audit was needed to identify eligible residents; staff also stated the audit and consent collection were delayed by influenza and COVID-19 outbreaks and staffing changes.
Delayed COVID-19 Booster Vaccination for Multiple Residents
Penalty
Summary
The facility failed to ensure COVID-19 booster vaccines were administered in a timely manner for 4 of 5 residents reviewed for immunizations. Resident #4 was admitted with heart failure, dementia, and hypertension; the quarterly MDS identified severely impaired cognition and that the resident was not up to date on COVID-19 vaccination, with the most recent SARS-COV-2 vaccine documented on 1/26/24. Resident #6 was admitted with dementia, type 2 diabetes mellitus, and COPD; the annual MDS identified moderately impaired cognition and that the resident was not up to date on COVID-19 vaccination, with Dose 2 documented on 11/3/24. Resident #8 was admitted with hypertension and COPD; the quarterly MDS identified intact cognition and that the resident was not up to date on COVID-19 vaccination, with the last SARS-COV-2 vaccine documented on 12/7/21. Resident #99 was admitted with type 2 diabetes mellitus and dementia; the quarterly MDS identified moderately intact cognition and that the resident was up to date on COVID-19 vaccination, with the last SARS-COV-2 vaccine documented on 12/18/24. The Resident Covid Vaccine Education Document Forms for these residents showed consent to receive the COVID-19 booster vaccine, signed between 1/6/26 and 2/12/26. During interview, the MDS Coordinator/Interim Staff Development and Infection Control Nurse and the Regional Clinical Leader stated that the prior owner did not maintain a vaccination log and the facility’s vaccination documentation was fragmented between the EHR and paper records. They also stated that an influenza outbreak occurred from 12/26/25 to 1/28/26 and a COVID-19 outbreak occurred from 1/7/26 to 1/28/26, and that a vaccination audit was needed. The MDS Coordinator stated that a part-time Nursing Supervisor began the audit in the last week of January and completed it on 2/12/26. She further stated that, after surveyor inquiry, Residents #4 and #6 were scheduled for the COVID-19 booster on 3/16/26, Resident #8 was scheduled for 3/3/26, and Resident #99 would be scheduled. The DNS stated that prior to the change of ownership only influenza vaccines had been administered, most recently in October 2025, and that the facility was conducting an audit of vaccination status and planning a vaccination clinic for eligible, consenting residents.
Failure to Provide Required Medicare Denial Notices
Penalty
Summary
The facility failed to provide the required Medicare denial notices to 4 of 4 residents reviewed for beneficiary notification when their Medicare Part A covered stays ended with benefit days remaining. The residents identified in the review were Resident #38, Resident #68, Resident #79, and Resident #110. Surveyors requested the facility complete SNF Beneficiary Protection Notification Review forms and explain how the Part A service termination was determined and whether the SNF ABN CMS-10055 and NOMNC CMS-10123 were provided, but none of the requested forms were completed by facility staff. Resident #38 was admitted with Medicare Part A as the payor source and remained in the facility during the standard survey. A SNF ABN form showed that beginning on 1/30/26 the resident may have to pay out of pocket for physical therapy, occupational therapy, and daily skilled nursing care, and the resident signed the form on 1/28/26 choosing not to receive the listed care. However, the NOMNC CMS-10123, which explains the right to appeal the Medicare Part A denial and how to request an immediate appeal, was not provided. LPN #6 stated she had just started doing beneficiary notification work the prior month and was being trained by a regional nurse, and she identified that no other notice had been provided to Resident #38. Resident #68 was discharged home with benefit days remaining, but a NOMNC CMS-10123 was not provided. Resident #79 was discharged from Medicare Part A coverage and remained in the facility, yet the facility could not provide either the SNF ABN or the NOMNC. Resident #110 was on Medicare Part A covered services and was discharged home with benefit days remaining, but a NOMNC CMS-10123 was not provided. For Residents #68, #79, and #110, LPN #6 stated she could not find the required notices and did not provide any other information about the beneficiary notification.
Inaccurate MDS Coding of ADLs
Penalty
Summary
The facility failed to ensure that Resident #6’s activities of daily living were accurately coded in the MDS assessments. Resident #6 was admitted in January 2022 with diagnoses including dementia, paranoid schizophrenia, and major depressive disorder. The quarterly MDS dated [DATE] identified the resident as having moderately impaired cognition and coded the resident as needing set up or clean-up assistance with eating, oral hygiene, shower/bath, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene, which was identified as inaccurate. A later quarterly MDS dated [DATE] identified the resident as having moderately impaired cognition and coded the resident as independent with eating, oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene, and as needing supervision or touching assistance with shower/bath, which was also identified as inaccurate. The annual MDS dated [DATE] identified the resident as having severely impaired cognition and coded the resident as needing set up or clean-up assistance with eating, supervision or touching assistance with oral hygiene, shower/bath, and personal hygiene, and as dependent with toileting hygiene, upper body dressing, lower body dressing, and putting on/taking off footwear. During interview, the MDS coordinator stated a previous MDS coordinator had been responsible in November 2025 and that a recent MDS audit identified inaccurate ADL coding. The Administrator also stated the facility had recently conducted an MDS audit and identified that residents’ ADL assessments had been inaccurately coded.
Failure to Document Provider Notification for Out-of-Range Blood Glucose Readings
Penalty
Summary
The facility failed to ensure the medical record accurately documented that blood glucose readings outside ordered parameters were reported to the physician for 2 residents reviewed for unnecessary medications. Resident #6, admitted with COPD, type 2 diabetes mellitus, and dementia, had a physician order to monitor blood sugars twice daily three times per week and to notify the physician if blood sugar was less than 70 or greater than 200 before breakfast. Review of the blood sugar summary showed multiple readings above 200 mg/dl between 12/1/25 and 12/24/25, including values of 203, 216, 255, 243, 213, 210, 201, and 218 mg/dl. The nurse's notes did not identify that the medical provider was notified of blood sugars greater than 200 before breakfast and did not address whether the morning blood sugars were obtained before breakfast. During interview, facility leadership could not identify that the provider or responsible party had been notified when the blood sugars were above 200. Resident #99, admitted with type 2 diabetes mellitus and dementia, had a physician order to check blood sugar twice daily and notify the APRN if the FSBS was less than 70 or greater than 300. Review of the blood sugar summary showed multiple readings above 300 mg/dl between 2/1/26 and 2/27/26, including 321, 336, 319, and 333 mg/dl. The nurse's notes did not document that the medical provider was notified of the blood sugars greater than 300, and clinical record review with facility leadership failed to identify that the provider or conservator had been notified. The resident's A1C was 9.7%, and the facility's Change in a Resident's Condition or Status policy directed prompt notification of the resident, attending physician, and representative for changes in condition or status.
Staff Member Used Profanity Toward Resident, Violating Abuse Policy
Penalty
Summary
A staff member failed to protect a resident from verbal abuse when a nurse aide used profanity and derogatory language towards the resident during an interaction. The resident, who had diagnoses including vascular dementia, anxiety, depression, and right-sided weakness from a previous stroke, required supervision for personal hygiene and toileting and was hard of hearing. Multiple staff members, including another nurse aide and an LPN, witnessed the incident in which the nurse aide told the resident, using profane language, to get away from her and continued to curse as she walked down the hall. The resident did not hear the abusive language due to hearing impairment and later confirmed to police that nothing was heard. The facility's policy maintains zero tolerance for any form of abuse, including verbal abuse defined as disparaging or derogatory language directed at or within hearing distance of residents, regardless of their ability to comprehend. Despite the resident's lack of awareness of the incident, the event was witnessed by several staff members and documented in the clinical record, constituting a failure to protect the resident from verbal abuse as required by facility policy and regulatory standards.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
