Candlewood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Milford, Connecticut.
- Location
- 30 Park Lane East, New Milford, Connecticut 06776
- CMS Provider Number
- 075416
- Inspections on file
- 22
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Candlewood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, vascular dementia, restlessness, and agitation, and severely impaired cognition had a care plan identifying combative behaviors with an intervention to stop care and reapproach later if the resident became aggressive or resistive. On one shift, during incontinent care, the resident became combative while two NAs attempted to provide care, and a family member assisted by holding the resident to prevent hitting staff so care could be completed. Staff interviews, including with an RN, confirmed that care was continued instead of stopping and reapproaching as directed by the care plan, resulting in a failure to provide care in accordance with the individualized plan.
The facility failed to maintain a secure environment in a memory care unit, as several doors, including 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were not fully closed, latched, or locked. The 'Shower' door was also unlocked. Interviews revealed that moisture prevented proper door closure, and the Director of Maintenance was unaware of the locking requirement. No facility policy for a safe environment was provided.
The facility failed to properly store and label medications, as observed in four medication carts. A resident's medication was not refrigerated as required, and two residents' medications were not labeled correctly on the Apple Blossom Unit. Additionally, an expired medication was found in the Dogwood unit. Staff interviews revealed a lack of adherence to facility policy, which mandates proper storage, labeling, and expiration checks.
The facility failed to maintain cleanliness in the laundry room, with vents and a smoke detector covered in debris. The Laundry Supervisor was unsure of the last cleaning date, and cleaning logs were not readily available. The IP/LPN confirmed that vents should be cleaned weekly, but the policy was not followed. A review of logs showed specific cleaning dates in May, but the June log lacked a specific date, only stating cleaning occurred on the surveyor's inquiry day.
Two residents experienced a lack of dignity and respect from a nurse aide (NA) who delayed assistance with toileting and raised her voice when addressed. One resident, with COPD and respiratory failure, reported the incident, but the facility failed to document a thorough investigation. The other resident, requiring total assistance due to hemiplegia, was left waiting for help, contrary to facility policy.
A resident with acute kidney failure and duodenitis experienced recurring diarrhea after admission to a facility. Despite the symptoms, the nursing staff failed to notify the physician in a timely manner. Interviews revealed communication lapses, with an LPN assuming the condition was documented and not reporting it to a supervisor or physician. The Medical Director was not informed of the recurrent episodes until later, contrary to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment was struck in the chest by another resident with similar conditions in an unprovoked altercation. The incident was witnessed by an LPN, who confirmed no prior signs of agitation. The facility's policy requires intent to harm for abuse classification, but the incident was reported, and the involved resident was placed under observation and sent for evaluation.
A resident with Alzheimer's and insomnia was not administered medications as prescribed, as pills were found in their nightstand drawer. Despite no swallowing disorders, the resident was at risk for aspiration and required a ground diet. Staff interviews revealed that oral checks to confirm medication ingestion were not consistently performed, although it was a standard practice learned during nursing education.
A resident with acute kidney failure and duodenitis experienced diarrhea and gastric upset after eating shrimp, but the nursing staff did not report the change of condition to a supervisor or physician. Additionally, the resident had a nosebleed that was not followed by a documented nursing assessment. The facility lacked a policy for RN assessments, leading to a deficiency in care.
A resident with multiple health conditions, including diabetes and cancer, developed new pressure wounds, but the facility failed to reassess their nutritional status. Despite weekly discussions with the interdisciplinary team, the Dietitian was unaware of the new wounds and did not conduct a reassessment, contrary to the facility's policy on pressure injury management.
Two residents experienced deficiencies in respiratory care due to improper storage of equipment. A resident with COPD had a nebulizing mouthpiece left uncovered, while another with sleep apnea had a CPAP mask and oxygen tubing improperly stored. Staff interviews confirmed the equipment should have been stored in bags, but the facility's policy was not provided.
A facility failed to re-evaluate the use of PRN Lorazepam for a resident with anxiety disorder, Major Depressive Disorder, and vascular dementia. Despite the resident's behavioral records showing no change, the medication was administered without documented review or justification. Staff interviews revealed inconsistencies in managing PRN psychotropic medications, and the facility's policy did not address medication use requirements.
The facility failed to honor the food preferences of two residents, leading to deficiencies in care. One resident, with diverticulitis and atherosclerosis, wanted eggs and hash browns more often than provided, but the facility did not consistently accommodate this preference. Another resident, with macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite indicating a dislike for it. The facility's dietary policy and Residents' Rights emphasize accommodating preferences, yet these were not consistently followed.
A facility failed to provide a resident's medical records within 48 hours as required. The resident, who had cognitive impairment and required assistance with daily activities, had a family member request discharge paperwork. The social worker miscommunicated the process, directing the family to the acute care facility for records. Additionally, the medical records staff could not recall or find documentation of the request, violating the facility's policy for timely access to records.
A resident's family member was overcharged for copies of medical records, with inconsistencies in the rates quoted by facility staff. The facility's administrator was unaware of the overcharge, which exceeded the state statute and facility policy limits.
Failure to Follow Care Plan Interventions for Combative Resident During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care in accordance with an existing care plan and to follow care plan interventions when a resident became combative and resistive to care. Resident #1 had diagnoses including Alzheimer’s disease, vascular dementia, restlessness, and agitation, and a quarterly MDS showed a BIMS score of 1, indicating severely impaired cognition, dependence for ADLs, and no documented behaviors in the prior seven days. The resident’s care plan, dated 2/2/26, identified combative behaviors and directed staff that if the resident became aggressive or resistive to care, they were to leave the resident if safe to do so and reapproach later. Facility policy on care planning directed development of an appropriate and individualized plan of care for residents. On 4/4/26, a nursing note documented that Resident #1 was combative with incontinent care at the start of the shift. During surveyor interviews, NA #1 reported that around 3–4 PM that day, Resident #1 was combative while NA #1 and NA #3 attempted to provide incontinent care, and that a family member assisted by helping to hold the resident to prevent the resident from hitting staff so that care could be completed. Interview with RN #1 confirmed that the resident was combative during care around 4 PM and that staff should have stopped care and reapproached later when the resident became combative. The DON and Administrator acknowledged the resident had a history of being combative during care and stated that if the resident was combative, staff should ensure the resident’s safety, leave, and attempt to reapproach later. These accounts show that staff did not follow the care plan intervention to stop and reapproach when the resident became combative.
Failure to Secure Doors in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe and secure environment on a locked memory care unit for residents with special needs. During an observation, it was found that several doors, including those labeled 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were unable to be fully closed, latched, and locked. Additionally, the 'Shower' door was not locked. Although there were no accessible sharps or hazardous materials in these rooms and no residents were in the immediate area, the doors were expected to remain securely locked. Interviews with the Director of Nursing Services confirmed that the doors should have been locked, and the Director of Maintenance identified moisture as the reason for the doors not closing properly. The Director of Maintenance was not previously aware of the requirement for the doors to be locked. The facility did not provide a policy for ensuring a safe and secure environment when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to professional standards and facility policy, as observed in four out of seven medication carts. On the Elm Tree unit, a medication prescribed to a resident was not stored in the refrigerator as required after opening, and the Licensed Practical Nurse (LPN) was unsure of when it was opened. The medication was last administered the previous evening, and the LPN acknowledged that medications should be stored according to directions, with the last nurse responsible for proper storage. On the Apple Blossom Unit, two residents' medications were not labeled correctly. One resident's inhaler was not labeled at all, and another resident's medication lacked a date indicating when it was opened. The Registered Nurse (RN) interviewed was unable to explain the labeling issue and stated that the pharmacy is responsible for labeling, while staff should check orders before administration. Additionally, in the Dogwood unit's medication room, a resident's medication was found to be expired. The LPN interviewed confirmed that expired medications should be reviewed and discarded, and nurses are responsible for checking expiration dates. The facility's policy requires medications to be stored in pharmacy-labeled containers, with opened medications dated and refrigerated if necessary.
Laundry Room Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the laundry room, as observed during a tour on June 5, 2024. Two vents and a smoke detector were found covered in gray debris, with one vent located in the dirty laundry area and the other in the clean laundry area near a folding table. The smoke detector was also in the clean laundry area. During an interview, the Laundry Supervisor admitted uncertainty about the last cleaning date and mentioned that cleaning logs were not readily available in the laundry area. The Infection Preventionist (IP)/LPN confirmed that the vents should be cleaned weekly by the laundry aide and that cleaning logs exist, but was unsure why the policy was not followed. A review of the cleaning logs for May and June 2024 revealed that the vents were cleaned on specific dates in May, but the June log lacked a specific date, only stating that the vents were cleaned on the day of the surveyor's inquiry. The facility's policy, dated February 20, 2024, directed that vents be cleaned weekly, which was not adhered to.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the actions of a nurse aide (NA #1) towards two residents. Resident #23, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), emphysema, and chronic respiratory failure, required supervision and assistance with activities of daily living (ADL). Despite being cognitively intact and able to make needs known, Resident #23 reported that NA #1 raised her voice when asked to assist another resident, Resident #30, who needed to use the bathroom. This incident was reported to the nursing supervisor (RN #2), but there was no documented investigation attached to the grievance report. Resident #30, diagnosed with weakness, hemiplegia, and hemiparesis, required total assistance with toileting and was non-ambulatory. On the day of the incident, Resident #30 requested assistance from NA #1 to use the bathroom. NA #1, who was busy clearing trays, told Resident #30 to wait and did not inform another staff member to assist. It was only after Resident #23 intervened that NA #1 assisted Resident #30, approximately 15 minutes after the initial request. This delay in assistance and the manner in which NA #1 responded to the residents were not in line with the facility's policy to treat residents with care, courtesy, and respect. The facility's grievance policy requires a prompt and thorough investigation of all grievances, which was not adhered to in this case. The nursing supervisor acknowledged the incident as a customer service issue but failed to document the investigation properly. The lack of documentation and the failure to prioritize resident needs, such as toileting assistance, contributed to the deficiency in maintaining resident dignity and rights.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in status for Resident #427, who was exhibiting recurring symptoms of diarrhea. Resident #427, who had been diagnosed with acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing loose stools and requested medication for relief. Despite these symptoms, there was no documentation of how the change in condition was addressed, and the physician was not notified in a timely manner. Interviews with various nursing staff revealed a lack of communication and reporting regarding the resident's condition. LPN #6, who was on duty during the episodes of diarrhea, did not report the change of condition to a nursing supervisor or physician, believing it was already documented in the APRN communication book. The Medical Director was not informed of the recurrent episodes until later, and the Director of Nursing Services expected that any change of condition should be reported. The facility's policy directed that significant changes in status should be reported to the Nursing Supervisor, which was not followed in this case.
Resident-to-Resident Altercation in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse during a resident-to-resident altercation. Resident #48, who has Alzheimer's disease and severe cognitive impairment, was struck in the chest by another resident, Resident #75, who also has Alzheimer's disease and severe cognitive impairment. The incident occurred while Resident #48 was walking in the hallway with another person. Resident #75, who had no prior history of aggression, unexpectedly hit Resident #48 and yelled profanities. The altercation was witnessed by LPN #4, who confirmed that there was no provocation or signs of agitation from either resident prior to the incident. The facility's policy defines resident-to-resident altercation as a physical or verbal act between two residents, regardless of injury. The policy also states that cognitively impaired residents must possess intent to harm for an act to be considered abuse. Despite this, the incident was reported, and the supervisor, physician, and police were notified. Resident #75 was placed on 1:1 observation and sent to the hospital for evaluation following the altercation.
Failure to Ensure Proper Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #48, was administered medications as prescribed by the physician and in accordance with professional practice standards. Resident #48, who had diagnoses including Alzheimer's disease and insomnia, was found to have severe cognitive impairment and required assistance with personal hygiene and dressing. Despite having no swallowing disorders, the resident was at risk for aspiration and was on a ground diet consistency. The care plan included administering psychotropic medications as ordered and monitoring the resident's behaviors and sleep. However, an internal investigation revealed that pills, which were supposed to be administered to the resident at bedtime, were found in the resident's nightstand drawer. These pills included Melatonin, paroxetine, donepezil, quetiapine, and memantine. Interviews with staff indicated that the pills were identified by their appearance and imprints, and it was suspected that the resident may have had the pills in their mouth and spit them out. The facility acknowledged that ensuring cognitively impaired residents take their medications completely is part of the standard of practice. Despite this, it was noted that oral checks to confirm medication ingestion were not consistently performed. An LPN confirmed that checking if a resident swallowed their medications properly was a standard practice learned during nursing education. Observations during a medication pass showed that oral checks were performed, but not all staff had participated in the in-service training on oral checks, highlighting a gap in consistent practice across the facility.
Failure to Conduct Nursing Assessment for Change of Condition
Penalty
Summary
The facility failed to ensure a nursing assessment was completed for a resident experiencing a change of condition. Resident #427, who had diagnoses including acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing symptoms of diarrhea and gastric upset after consuming shrimp. Despite the resident's request for medication to address these symptoms and documentation in the APRN communication book, the nursing staff did not report the change of condition to a nursing supervisor or physician. Interviews revealed that the nursing staff believed the symptoms were food-related and did not require further reporting or assessment. Additionally, the resident experienced an episode of epistaxis, which was noted in the shift report but not followed by a documented nursing assessment. The Director of Nursing Services indicated that any change of condition should be reported and assessed, but this protocol was not followed. The lack of a policy for RN assessments was noted, and interviews with nursing staff confirmed that the change of condition was not communicated to the appropriate personnel, leading to a deficiency in care.
Failure to Reassess Nutritional Needs for Resident with New Pressure Wounds
Penalty
Summary
The facility failed to reassess the nutritional status and needs of a resident with newly identified pressure wounds. Resident #103, who had diagnoses including type II diabetes mellitus, obstructive sleep apnea, and malignant neoplasm of the urethra/bladder, was identified as being at risk for pressure ulcers. Despite the presence of unhealed pressure ulcers and the development of new wounds on the left ankle, sacrum, right hip, and right knee, there was no documented reassessment of the resident's nutritional status following these developments. The resident was receiving palliative care, and while some nutritional interventions were noted, such as the addition of liquid protein, the lack of a formal reassessment was a significant oversight. Interviews with the Dietitian and the Director of Nursing Services (DNS) revealed that wounds were discussed weekly with the interdisciplinary team, including the Dietitian. However, the Dietitian was unaware of the new wounds and had not conducted a reassessment of the resident's nutritional needs. The facility's policy for Pressure Injury Prevention and Management required that residents at high risk for pressure injuries or with existing pressure injuries receive appropriate interventions, and that the plan of care be revised as necessary. The failure to reassess the nutritional needs of Resident #103 following the identification of new wounds was a deviation from this policy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for two residents, leading to deficiencies in respiratory care. Resident #71, diagnosed with chronic obstructive pulmonary disease and essential hypertension, was observed with a nebulizing mouthpiece left uncovered on top of the nebulizing equipment. Despite having a care plan that included nebulizer treatments, the mouthpiece was not stored in a bag after use, as confirmed by a registered nurse who admitted to the oversight. The Director of Nursing Services and the registered nurse both acknowledged that all respiratory equipment should be stored in a bag when not in use. Resident #103, who has obstructive sleep apnea, was found with a CPAP mask placed on top of the machine without a cover and oxygen tubing labeled with an outdated date. The resident used the CPAP during the night and oxygen during the day, but the equipment was not stored properly when not in use. Interviews with a nurse aide and the Director of Nursing Services confirmed that the CPAP mask and oxygen tubing should have been stored in a bag and changed weekly, respectively. The facility's policy for storage guidelines was not provided, contributing to the deficiency.
Failure to Re-evaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the re-evaluation of a psychotropic medication for a resident diagnosed with anxiety disorder, Major Depressive Disorder, and vascular dementia. The resident, who was cognitively impaired and required maximal assistance with daily activities, had a physician's order for Lorazepam to be administered every four hours as needed for restlessness and agitation. Despite the medication being prescribed on a PRN basis, the facility did not provide documentation or rationale for the continued use of this medication. The resident's behavioral flow records indicated no change in behaviors, yet the PRN Lorazepam was administered without a documented review or justification. Interviews with facility staff revealed inconsistencies in the management and documentation of PRN psychotropic medications. An RN indicated that PRN orders should be reevaluated every 14 days, while an LPN noted that targeted behaviors and interventions should be documented when psychotropic medications are used. However, the facility's policy on psychotropic medication did not address the requirements for medication use, and there was no rationale provided for the continued PRN order for Lorazepam. The facility's DNS mentioned that psychotropic medications are not usually prescribed as PRN, highlighting a lack of adherence to the facility's usual practices.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to deficiencies in their care. Resident #121, who has diagnoses including diverticulitis and atherosclerosis, expressed a preference for eggs and hash browns more frequently than the once-weekly offering. Despite communicating this preference to the dietary staff, the Food Service Director stated that eggs could not be provided more often due to preparation constraints, and hash browns were not consistently set aside for the resident. The Director of Nursing Services acknowledged the resident's numerous preferences and expected reasonable accommodations, but the facility did not ensure these preferences were consistently met. Resident #52, with diagnoses including macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite expressing a dislike for it and indicating this preference on meal tickets. The Kitchen Supervisor acknowledged the issue, attributing it to confusion among new staff, which led to the resident receiving incorrect meals. The facility's dietary notice policy and the Residents' Rights emphasize the importance of accommodating individual preferences, yet these were not adhered to, resulting in the residents' preferences being overlooked.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide copies of a resident's medical record within the required 48-hour timeframe. This deficiency was identified during a review of the clinical records, facility policy, and staff interviews for a resident who was admitted with multiple diagnoses, including metabolic encephalopathy and cognitive impairment. The resident required substantial assistance with daily activities, as noted in their care plan. A family member, identified as the resident's emergency contact, requested a copy of the resident's discharge paperwork. However, the social worker informed the family member that they could not provide the paperwork and directed them to the acute care facility for the records. Further investigation revealed inconsistencies in the facility's handling of the request. The social worker later clarified that the request was for medical records from the acute care facility, not the discharge paperwork from the facility, and stated that the facility's policy required the family to obtain records from the outside facility. Additionally, a staff member from the medical records department could not recall receiving any request for copies of the resident's medical record and found no documentation of such a request. The facility's policy allows residents or their legal representatives to access and purchase copies of their records within two working days of the request, which was not adhered to in this case.
Inappropriate Charges for Medical Record Copies
Penalty
Summary
The facility failed to charge the appropriate amount for copies of a resident's medical records, leading to a deficiency in compliance with applicable laws and regulations. Resident #432, who was admitted with diagnoses including metabolic encephalopathy, essential hypertension, muscle weakness, hypothyroidism, and dysphagia, was identified as cognitively impaired and required substantial assistance with activities of daily living. The resident's family member, who was the emergency contact, requested copies of the medical records and was charged 75 cents per page and an additional 30 dollars for document retrieval. Interviews with facility staff revealed inconsistencies in the charges for medical record copies, with different staff members quoting different rates per page, none of which aligned with the Connecticut general state statute. The facility's administrator acknowledged that residents or family should not be charged more than 65 cents per page and was unaware of the reason for the overcharge. The facility's policy stated that the cost for copies should not exceed prevailing community rates, indicating a failure to adhere to their own policy and state regulations.
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.
