Civita Care Center At Newington
Inspection history, citations, penalties and survey trends for this long-term care facility in Newington, Connecticut.
- Location
- 240 Church St, Newington, Connecticut 06111
- CMS Provider Number
- 075286
- Inspections on file
- 36
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 42 (1 serious)
Citation history
Health deficiencies cited at Civita Care Center At Newington during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and a history of aggressive behavior was removed from their room for an extended cleaning and placed in a common area without an individualized supervision plan. During this time, NAs were distributing lunch trays and an LPN was performing blood glucose checks, leaving the resident inadequately monitored. The resident entered another resident’s room, struck that resident, and was then pushed, resulting in a fall and facial injuries, including a laceration and a maxillary sinus fracture. A prior incident had occurred months earlier in which the same aggressive resident stepped out of their doorway on a secured memory care unit and punched another cognitively impaired, wandering resident in the face, causing facial swelling. These events occurred despite care plans and facility policies identifying the need for monitoring, redirection, and protection from abuse.
A resident with dementia, schizoaffective disorder, and adjustment disorder, identified as severely cognitively impaired and living on a secured memory care unit due to behavioral issues, struck another resident, causing facial swelling. After this incident, the resident was moved from a secured to a non-secured unit and continued on 1:1 monitoring, but the existing RCP—developed when the resident was on the secured unit and addressing psychotropic use, refusal of care, paranoia/delusions, hitting, and need for redirection—was not revised to reflect the room change. The DON confirmed the move and lack of RCP updates, and a SW stated the IDT normally meets to adjust the plan of care around room changes, which did not occur, contrary to the facility’s comprehensive care planning policy requiring measurable, data-driven care plans.
A resident with dementia, schizoaffective disorder, severe cognitive impairment, and a history of aggressive and resident-to-resident altercations was involved in an unwitnessed physical altercation with another resident, resulting in a fall, facial laceration, and a closed fracture. The resident was sent to the hospital for evaluation and then readmitted, but the hospital discharge paperwork did not include the expected psychiatric evaluation or harm clearance. The admitting RN did not obtain psychiatric clearance or a no-harm letter at the time of readmission, and the resident was not evaluated by a psychiatric provider until nearly eight hours later. Facility leadership acknowledged that the readmitting RN was responsible for identifying missing documentation and that there was no specific policy for psychiatric evaluations or 1:1 assignments following physical altercations.
Staff failed to safely open double doors to a secured unit, resulting in a cognitively impaired, ambulatory resident with dementia and osteoarthritis being struck by the door and falling. The resident, who frequently paced near walls and was care planned as a fall risk, was standing near the corner by the unit entrance when a CNA opened the door from the hallway side without adequately ensuring the area was clear, despite the presence of glass windows in the doors. The door hit the resident, causing a fall, nosebleed, and subsequent diagnosis of a closed nasal bone fracture after hospital evaluation.
A resident with multiple complex conditions, including contractures and a history of wrist surgeries, had documented orthopedic evaluation and wrist procedures, as well as a grievance alleging lack of PT. Facility records noted the resident’s return from wrist surgery and referenced specialized therapy needs and difficulty arranging outside therapy, and stated the resident was not appropriate for therapy pending splint removal. However, the clinical record lacked therapy notes related to the wrist surgery, documentation of the orthopedic procedure, and outside consult records for an extended period, and the facility could not produce any therapy documentation for that time frame, contrary to its own charting policy and expectations stated by the APRN and DON.
A resident with severe cognitive impairment and a history of wandering exited a secured memory care unit and the facility unsupervised during a period of high visitor traffic. Staff did not maintain required supervision at exit doors, allowing the resident to leave unnoticed and be found by police offsite.
A resident with dementia and Parkinson's disease experienced a fall, but staff did not complete the required Morse Fall Scale assessment afterward as mandated by facility policy. The next fall risk assessment was not conducted until several months later, despite the expectation that such assessments occur after each fall.
A resident who was dependent on staff for personal hygiene and had cognitive impairment was found with dirty linen and a soiled incontinent brief left on furniture surfaces in their room. The assigned nurse aide stated the items were left due to an unavailable soiled linen cart, and acknowledged they should have been bagged and removed. An LPN confirmed that proper infection control procedures were not followed, and the facility could not provide a relevant policy when asked.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
Staff did not consistently provide care in accordance with physician orders or the resident’s stated preferences and goals, resulting in treatment that was not individualized or aligned with the resident’s needs.
Two residents with severe cognitive impairment and known wandering behaviors were not adequately supervised, resulting in one resident entering another's room and sitting on their lap with undergarments lowered, while the other resident attempted to push them away. Staff were unaware of the residents' locations at the time, despite care plans and facility policy requiring close monitoring and redirection.
A resident with chronic venous ulcers and a history of accusatory behaviors alleged that a nurse punctured their leg during a dressing change. The nurse did not immediately report the allegation to facility leadership as required by policy, resulting in a delay of two days before the DON was notified.
Multiple residents with psychiatric and cognitive disorders experienced verbal and physical abuse from another resident with a history of aggressive behavior. Despite requests for room changes and ongoing verbal altercations, staff failed to document or act on concerns, leading to physical assaults and psychological trauma. Inadequate supervision and lack of timely interventions allowed repeated incidents involving both residents and staff.
The facility did not ensure that physician visits were conducted at the required intervals for several residents with various chronic conditions, resulting in missed or delayed evaluations as mandated by state regulations and facility policy.
Two residents were affected when staff failed to implement a care plan intervention requiring a stop sign banner on a doorway following a physical altercation. Despite the care plan directive, the stop sign was not in place, and staff confirmed responsibility for its maintenance, resulting in a deficiency.
Two residents did not receive care as ordered: one did not receive the full prescribed dose of a psychiatric medication due to missed labwork required for dispensing, and another did not receive daily wound care for a Stage III pressure ulcer, with no documentation or explanation for the missed treatment.
A resident with severe cognitive impairment and multiple diagnoses did not have their activities of daily living (ADLs) consistently documented each shift, as required by facility policy. Staff failed to record essential information such as support provided for eating, meal intake, and toileting, partly due to agency nurse aides lacking access to the electronic charting system.
Failure to Supervise Aggressive Resident During Room Maintenance Leads to Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and safety planning for a resident with known aggressive behaviors during a scheduled room maintenance activity that required removal from the resident’s room. Resident #1 had diagnoses including dementia, schizoaffective disorder, depressive type, and adjustment disorder, and was identified on the MDS as severely cognitively impaired. The resident’s care plan documented psychotropic medication use, a history of refusal of care, paranoia/delusions, hitting, and prior resident-to-resident altercations, with interventions that included keeping the resident in a visible area when out of bed and monitoring for behaviors such as hitting and paranoia. Despite these identified risks and interventions, the resident was displaced from his/her room for a thorough cleaning and placed in a common area without an individualized, established supervision plan specific to this situation. On the day of the incident, housekeeping staff stripped the floors and washed the walls of Resident #1’s room, requiring the resident to be removed from the room from before 10:00 AM until between 3:00 PM and 4:00 PM. The Assistant Director of Nursing stated that the plan was for Resident #1 to attend activities from 10:00 AM to 11:30 AM, then sit in a chair outside the room for lunch, and then return to activities after lunch. LPN #3 reported that Resident #1 was moved into the hallway while cleaning took place and was to be monitored by NAs assigned to that wing. However, during the time of the incident, NAs were passing lunch trays and LPN #3 was performing blood glucose monitoring, and therefore was unable to monitor Resident #1. Resident #1, who preferred to stay in his/her room and was not known to wander, was not continuously observed during this period. During this lapse in supervision, Resident #1 entered another resident’s room (Resident #2). Resident #2, who had diagnoses including disorganized schizophrenia, schizoaffective disorder, and generalized anxiety disorder, was moderately cognitively impaired and independent with activities of daily living, with a care plan addressing mood and behavior issues such as agitation and yelling. A reportable event documented that Resident #2 reported being struck by Resident #1 and then pushed Resident #1, causing Resident #1 to fall. Staff responded after hearing commotion in Resident #2’s room and found Resident #1 on the floor, bleeding from a laceration to the right eyebrow. Resident #1 was later found to have sustained a laceration to the right eye and a closed fracture of the right maxillary sinus. This sequence of events demonstrates that the facility did not implement adequate supervision or a specific safety plan for Resident #1 during the room maintenance displacement, resulting in a resident-to-resident altercation with injury. The report also describes a prior incident involving Resident #1 and another resident, Resident #5, on a secured memory care unit. Resident #1’s care plan at that time identified severe cognitive impairment, psychotropic medication use, dementia diagnosis, and behaviors requiring staff intervention and redirection for safety, including wandering, exit seeking, and intrusive behaviors. Resident #5 had vascular dementia, schizoaffective disorder, bipolar type, and an unspecified head injury, was severely cognitively impaired, dependent with bathing, toileting, and personal hygiene, and able to ambulate independently, with a care plan directing staff to intervene and redirect when wandering or when behaviors became intrusive or affected other residents. On the day of that earlier event, NA #1 observed Resident #5 walking down the hallway on the side of Resident #1’s room; as Resident #5 approached the doorway, Resident #1 stepped out and punched Resident #5 in the face under the eye. Resident #5 sustained mild facial swelling, and staff removed Resident #5 from the area and notified the nurse. This prior altercation further reflects that Resident #1 had a documented history of aggressive behavior toward other residents that required close supervision and redirection, which was not effectively implemented during the later room maintenance event. The facility’s own policy on residents’ right to freedom from abuse, neglect, and exploitation stated that residents have the right to be free from abuse and that the facility has zero tolerance for abuse of any kind. Despite this, Resident #1, with a known history of hitting and resident-to-resident altercations, was not provided with adequate supervision or a clearly defined, individualized supervision plan during the extended period out of his/her room for cleaning. The lack of effective monitoring and failure to ensure that staff were available and actively supervising during a known high-risk situation directly preceded the resident’s unsupervised entry into another resident’s room and the resulting altercation and injuries.
Care Plan Not Updated After Room Change Following Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s comprehensive, person-centered care plan after a significant change in room assignment from a secured memory care unit to a non-secured unit following a resident-to-resident physical altercation. The resident had diagnoses including dementia, schizoaffective disorder (depressive type), and adjustment disorder, and was identified on a quarterly MDS as severely cognitively impaired with a BIMS score of 00, dependent for bathing, requiring substantial assistance with toileting and personal hygiene, and able to ambulate with supervision or touch assistance. The existing Resident Care Plan, dated 8/16/25, documented that the resident received psychotropic medications related to dementia, depression, schizoaffective disorder, anxiety, and insomnia, and had a history of refusal of care, paranoia/delusions, and hitting. It also identified the resident as living on a secured memory care unit due to behaviors requiring staff intervention and redirection for safety, with interventions to monitor for depression and intervene and redirect for wandering, exit seeking, or intrusive behaviors affecting other residents. A Reportable Event Form dated 10/11/25 documented that another resident was struck in the face by this resident, resulting in mild swelling to the other resident’s face. Following this incident, the resident was moved from the secured unit to a non-secured unit on 10/11/25. A nurse’s note by the Assistant DON on 10/12/25 indicated the resident continued on one-to-one monitoring, appeared to be adjusting to the room change, and to continue with the plan of care. However, review of the Resident Care Plan showed no revisions after the move from the secured to the non-secured unit. The DON confirmed the room change date and the lack of care plan revisions, and the social worker reported that the IDT would typically meet to discuss needs and develop a plan of care prior to a room change, or as soon as practicable after a safety-related move, which did not occur for this resident. This was inconsistent with the facility’s Comprehensive Care Planning policy requiring development and implementation of a comprehensive care plan with measurable objectives and timetables based on data gathering and clinical decision making.
Failure to Obtain Timely Psychiatric/Harm Clearance After Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not obtaining a harm/psychiatric clearance prior to a resident’s return following a physical altercation. Resident #1, who had dementia, schizoaffective disorder (depressive type), adjustment disorder, severe cognitive impairment (BIMS of 4), dependence with toileting and lower body dressing, and a history of refusal of care, paranoia/delusions, hitting, and resident-to-resident altercations, was care planned to receive psychotropic medications and to be monitored for depression and aggressive behaviors. On 3/16/26, an unwitnessed incident occurred between Resident #1 and Resident #2 in which Resident #2 reported being struck by Resident #1 and then pushing Resident #1, causing Resident #1 to fall. Resident #1 was found lying on the floor, reported being struck in the face, and had a laceration to the right eyebrow. An APRN evaluated Resident #1 that afternoon and recommended transfer to the emergency department for evaluation. The hospital discharge summary documented that Resident #1 sustained a right eye laceration and a closed fracture of the right maxillary sinus but did not indicate that a psychiatric evaluation had been completed. Resident #1 returned to the facility at 11:30 PM on 3/16/26. Facility documentation did not show that a no-harm letter or psychiatric clearance was obtained for Resident #1 related to the altercation before or at the time of readmission. A subsequent note by an APRN at 7:25 AM on 3/17/26 documented that Resident #1 was evaluated after the altercation and was not considered a danger to self or others, but this occurred nearly eight hours after the resident’s return. Interviews with facility leadership confirmed that the readmitting RN was responsible for reviewing hospital paperwork and addressing missing documentation, and that the hospital had not completed the psychiatric evaluation as expected. The facility did not have a policy specific to psychiatric evaluations or one-to-one assignments for residents involved in physical altercations.
Resident Struck by Unit Door and Sustains Nasal Fracture
Penalty
Summary
Staff failed to safely open an access door to a secured resident unit, resulting in a resident being struck by the door and falling. The resident involved had diagnoses including Alzheimer's disease, dementia with behaviors, and osteoarthritis, and was care planned as a fall risk. A recent MDS assessment documented severe cognitive impairment, independent ambulation with set-up assistance, and no falls in the prior 90 days. On the evening of 1/14/2026, the resident was positioned near the corner of the wall and the double doors at the secured unit entrance when a nursing assistant opened the door from the hallway side. The door had a push bar and a clear glass window above it that allowed visibility into the area where the resident was standing. According to nursing documentation and facility incident reports, the nursing assistant did not recognize that the resident was behind the door when she opened it, and the door hit the resident, causing a fall. The resident was found with a nosebleed and facial discoloration but with range of motion at baseline and no reported loss of consciousness. The APRN ordered transfer to the hospital for facial x‑rays, and the resident was diagnosed with a closed nasal bone fracture. Interviews with the DNS, RN, and the nursing assistant confirmed that the resident often paced close to the walls, that multiple residents on the unit wandered or paced near doors, and that the nursing assistant either did not see or did not adequately identify the resident through the door window before pushing the door open, leading to the accident.
Failure to Maintain Complete Medical Record for Post‑Surgical Therapy and Orthopedic Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who had complex medical needs, including neurogenic bladder, a stage 4 sacral pressure ulcer, chronic pain, contractures, an indwelling catheter, an ostomy, a feeding tube, and dependence for all care. The resident’s MDS showed intact cognition with a BIMS score of 14, and the care plan identified the need for bilateral elbow extension splints and a custom tilt-in-space wheelchair with gentle range of motion and therapy screening as needed. An APRN progress note documented that the resident was seen by a bone/joint specialist for hand contractures and had a right wrist carpectomy without complications, with left wrist/hand surgery scheduled. A nursing note later documented the resident’s return from a surgical appointment with a left wrist dressing that was clean, dry, and intact and no acute distress. A grievance filed by the resident stated that he/she reported to a hospital bone and joint institute that physical therapy was not being received. The grievance response stated that after the wrist surgery, the required therapy was specialized and could not be completed at the facility, that attempts to arrange outside therapy were complicated by the resident’s special needs, and that therapy had thoroughly evaluated the resident and determined he/she was not appropriate for therapy pending removal of a wrist splint by the orthopedist. However, record review did not identify any therapy notes or records related to the wrist surgery, any documentation of the orthopedic procedure on the left wrist, or any outside consultations prior to a specified date. The facility was unable to provide any therapy documentation for 2021 or outside consultations before that date. In interviews, the APRN and DON both stated that documentation of the orthopedic procedure, therapy evaluations, any therapy provided, or reasons therapy was not provided, and orthopedic consultations/surgeries should have been included in the resident’s medical record, consistent with the facility’s Charting Documentation Policy requiring all services and changes in condition to be documented.
Failure to Prevent Elopement Due to Inadequate Supervision During High Visitor Volume
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and a known history of wandering was not adequately supervised during a period of increased visitor activity. The resident was independent with ambulation and transfers, and care plans identified wandering behaviors with interventions to redirect and provide structured routines. Despite these interventions, the resident was able to leave the secured memory care unit unsupervised while visitors were entering and exiting the unit in large groups. On the day of the incident, there were several out-of-state visitors unfamiliar with the facility, as well as ongoing construction and a social worker present, contributing to a busier environment than usual. Staff interviews revealed that the resident likely exited the secured unit alongside visitors when the door was opened for them. The staff member responsible for entering the secure door code did not remain at the door to ensure no residents exited, as required by facility policy. The resident then proceeded through two hallways and exited the main facility entrance without being noticed by the receptionist or other staff. The facility was unaware that the resident had left until notified by the police, who found the resident 0.4 miles away from the facility. Documentation and interviews confirmed that staff did not provide the necessary supervision or monitoring at exit points during peak visitor times, as outlined in the facility's elopement prevention policy. This lapse in supervision allowed the resident to leave the secured area and the facility without detection.
Failure to Complete Post-Fall Risk Assessment
Penalty
Summary
A deficiency was identified when a resident with a history of falls, dementia with behavioral disturbances, and Parkinson's disease experienced a fall. The resident's care plan indicated interventions such as keeping the call light within reach, encouraging the resident to call for assistance, and providing help with bed mobility, transfers, and ambulation. After the fall, the resident was found sitting on the floor, assessed for injuries, and assisted back to bed. Documentation showed no injuries or distress following the incident. However, a review of the clinical record revealed that the required fall risk assessment, specifically the Morse Fall Scale, was not completed after the fall as mandated by facility policy. The next documented fall risk assessment occurred four months later. Interviews with the DON and Regional Nurse confirmed that the Morse Fall Scale should have been completed after the fall, in accordance with policy, but this was not done. Facility policy directs that a fall risk assessment must be completed and documented in the medical record after any fall.
Failure to Remove Soiled Linen and Incontinent Brief from Resident's Room
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for personal hygiene and activities of daily living was found to have dirty linen and a soiled incontinent brief left on top of the dresser and overbed table in their room. The resident had diagnoses including dementia with behavioral disturbances and Parkinson's disease, and was noted to have significant cognitive impairment, requiring substantial assistance for bed mobility, transfers, and was incontinent of bowel and bladder. Observations on the morning of the survey revealed that soiled items remained on furniture surfaces in the resident's room for at least ten minutes. During interviews, the assigned nurse aide explained that the soiled linen and brief were left on the furniture because the soiled linen cart was unavailable in the hallway, and acknowledged that the items should have been bagged and removed immediately. The Regional Nurse (LPN) confirmed that staff should never place dirty linens or incontinent briefs on furniture surfaces and that proper procedures were not followed. The facility was unable to provide a policy on infection control practices related to the disposal of soiled linens and incontinence supplies when requested.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.
Failure to Provide Adequate Supervision for Residents with Wandering Behaviors
Penalty
Summary
The facility failed to provide adequate supervision for two residents with known wandering behaviors, resulting in a resident-to-resident interaction. Both residents had diagnoses of dementia and severe cognitive impairment, with one also diagnosed with bipolar disorder and schizoaffective disorder. Care plans for both residents identified risks related to wandering and directed staff to redirect and encourage recreational activities as diversions. Despite these interventions, one resident was found in another resident's room, sitting on the lap of the other resident with their undergarment around their ankles, while the other resident attempted to push them away. Staff had last observed the residents separately less than half an hour before the incident, but were unaware of their whereabouts at the time of the event. Facility documentation and interviews confirmed that both residents had a history of wandering, and the incident occurred in a room equipped with a video camera. The facility's policy required staff to monitor for behaviors that could provoke reactions, including sexually aggressive behavior, and to take steps to protect residents from abuse. However, the report did not identify how the residents were able to access another resident's room without staff knowledge, indicating a lapse in supervision and monitoring as required by the residents' care plans and facility policy.
Failure to Timely Report Alleged Abuse
Penalty
Summary
A deficiency occurred when staff failed to report an allegation of abuse in a timely manner for a resident with chronic venous ulcers and a history of accusatory and manipulative behaviors. The resident, who was cognitively intact and independent in ADLs, alleged that a registered nurse punctured their leg with scissors during a dressing change. The nursing note documented the allegation and minimal bleeding, but no other signs of injury were observed at the time. Despite the facility's policy requiring immediate reporting of all alleged abuse to the administrator or designee, the registered nurse did not report the allegation on the day it was made. Instead, the Director of Nursing Services (DNS) was informed two days later, after the resident reiterated the accusation. Interviews confirmed the delay in reporting, with the DNS acknowledging that the nurse should have reported the allegation immediately, regardless of the presence or absence of injury.
Failure to Protect Residents from Abuse and Inadequate Intervention for Resident Altercations
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both physical and psychosocial abuse, as evidenced by several incidents involving altercations between residents. In one case, a resident with schizoaffective and bipolar disorder, who was cognitively intact and independent with ADLs, repeatedly made negative and racist remarks to a non-ambulatory roommate with a history of stroke and adjustment disorder. Despite the roommate's request for a room change due to feeling unsafe and uncomfortable, the social worker did not facilitate the move, citing a lack of available rooms, although rooms were in fact available. The ongoing verbal altercations were not documented, and the situation escalated to a physical assault, resulting in injury to the non-ambulatory resident. Another incident involved a resident with schizophrenia and anxiety disorder who was physically assaulted by another resident with a history of aggressive behavior. The aggressor, who had previously attacked both staff and residents, was able to break free from staff supervision and physically attack another resident, causing significant distress and ongoing psychological trauma. Staff interviews confirmed that the resident was not adequately supervised, and interventions to prevent further incidents were insufficient, as the resident was able to continue aggressive behaviors after returning from hospitalization. A third incident involved a resident with disorganized schizophrenia and impaired cognition who was physically attacked in the hallway by another resident. The altercation was witnessed by staff, and both residents were sent to the emergency room for evaluation. The facility's failure to implement and document effective interventions, as well as the lack of communication and follow-through on resident concerns, contributed to an environment where residents were not protected from abuse, in violation of facility policy and regulatory requirements.
Failure to Ensure Timely Physician Visits for Residents
Penalty
Summary
The facility failed to ensure that physician visits for seven of fifteen residents reviewed were conducted in accordance with state agency requirements and the facility's own policy. Specifically, the clinical record reviews revealed that several residents with diagnoses such as Alzheimer's Disease, seizure disorder, schizoaffective disorder, diabetes mellitus, anxiety, depression, heart failure, and other chronic conditions did not receive physician evaluations at the required intervals. For example, some residents were not evaluated by a physician every sixty days as mandated, and in some cases, there were gaps in documentation of physician visits for several months. Additionally, for newly admitted residents, the required monthly evaluations for the first ninety days were not consistently maintained. The facility's policy and the Connecticut Public Health Code require that each resident be examined by their personal physician at least once every thirty days for the first ninety days following admission, and at least every sixty days thereafter unless otherwise justified in the medical record. Despite these requirements, documentation for multiple residents showed missed or delayed physician visits, with some residents not being seen within the required timeframes. Interviews with facility staff confirmed that the standard of practice was not consistently followed, resulting in noncompliance with both facility policy and state regulations.
Failure to Implement Care Plan Intervention for Resident Safety
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a stop sign banner was in place on the doorway of a resident with diagnoses including paranoid schizophrenia, schizoaffective disorder, and chronic obstructive pulmonary disease. The resident was assessed as cognitively intact and independent with activities of daily living. Following a physical altercation in which another resident entered the room and was struck, the care plan was updated to include the placement of a stop sign banner across the resident's doorway as an intervention. However, during observation and interview, it was found that the stop sign banner was missing from the resident's door, and staff confirmed that all were responsible for maintaining its presence as directed by the care plan. The facility's care plan policy requires that interventions be implemented as described to address identified problem areas and prevent further incidents. Despite this, the intervention to place a stop sign banner was not followed, as confirmed by both staff observation and interview with the regional clinical consultant. This failure to implement the care plan intervention contributed to the deficiency cited during the review.
Failure to Administer Psychiatric Medication and Wound Care as Ordered
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, bipolar disorder, and schizophrenia did not receive their prescribed psychiatric medication as ordered. The resident was supposed to have monthly Absolute Neutrophil Count (ANC) bloodwork completed and faxed to the pharmacy to allow for the dispensing of clozapine. The required labwork was not completed as ordered, resulting in the pharmacy not dispensing the full prescribed dose of clozapine. As a result, the resident only received a partial dose of the medication until the labwork was completed and the medication was supplied. Documentation did not provide an explanation for the missed labwork, and the facility's policy required medications to be administered according to physician orders. Another deficiency was identified when a resident with neurocognitive disorder with Lewy bodies, anxiety, and major depressive disorder, who had a Stage III pressure ulcer, did not receive wound care as ordered. The resident's care plan and physician's order specified daily wound care to the coccyx, including cleansing with normal saline, application of Dakin's solution, and a foam dressing. On one occasion, the treatment was not signed off as administered, and facility staff could not identify why the wound care was missed. The facility's policy required pressure ulcer treatments to be administered in accordance with physician orders.
Failure to Document Activities of Daily Living Each Shift
Penalty
Summary
The facility failed to document activities of daily living (ADLs) for one of three residents reviewed, specifically for a resident with neurocognitive disorder with Lewy bodies, anxiety, and major depressive disorder. The resident was assessed as severely cognitively impaired and required substantial assistance with toileting, as well as support with dressing, hygiene, and bathing. The care plan directed staff to assist with turning, repositioning, skin care after incontinence, and ADLs as needed. However, review of the Point of Care History for May and June 2024 showed that staff did not consistently document the resident's ADLs each shift, including support provided for eating, meal consumption, toileting, and related care. Interviews revealed that the facility's practice was to document ADLs each shift, but agency nurse aides did not have access to the charting system, resulting in incomplete documentation.
Latest citations in Connecticut
A resident with dementia, urinary incontinence, and a toe wound had wound care recommendations from a physician that were not accurately transcribed into treatment orders. On two separate occasions, the wound care provider specified that topical treatments (first Bactroban, then Betadine) be applied only to the left great toe, but nursing staff entered physician orders directing application to both great toes. The MD later confirmed he intended treatment only for the left toe, and the DON acknowledged the entered orders did not match the wound care recommendations, contrary to facility policy requiring accurate implementation of physician orders.
A resident with Alzheimer’s dementia, urinary incontinence, and dependence for ADLs had a care plan directing staff to provide ADLs and mouth care, but ADL personal hygiene documentation was left blank on multiple shifts during a month. Review of the ADL task record and interview with the DON confirmed that hygiene care entries were missing on numerous day and one evening shift, despite the facility’s policy requiring all services provided to be documented in the medical record.
A resident with dementia and multiple psychiatric diagnoses relied on a family member, acting as Responsible Party and POA, to manage finances and deliver applied income checks to the facility. The routine process involved the receptionist placing these checks into an unsecured business office mailbox, a procedure known to a CNA who had previously covered the reception desk. One such check, made payable to the facility, never reached the business office; instead, it was later discovered to have been mobile-deposited into the CNA’s personal bank account, with the CNA’s verified signature on the back of the check. This constituted misappropriation of the resident’s funds in violation of the facility’s abuse policy, which prohibits wrongful use of a resident’s belongings or money without consent.
A resident with intact cognition and significant visual impairment was threatened by a roommate, who had dementia and mental health diagnoses, when the roommate placed a plastic knife to the resident’s neck after the resident called out for assistance. Following the incident, the DON instructed an LPN to move the victim rather than the aggressor, and the resident was relocated to a room at the end of a corridor four rooms away, with no alternate route of access, requiring the resident to pass the aggressor’s room to reach common areas. The resident reported feeling they had no real choice but to move and later expressed anger and ongoing nervousness about the situation. Interviews and census review showed that private rooms on another unit had been available for the aggressor, and facility leadership acknowledged that the victim was not offered the option to remain in the original room, despite resident rights policies guaranteeing notice and choice regarding roommate changes.
The facility failed to ensure physician orders were reviewed and signed at least every 60 days for three residents, including individuals with dementia, severe protein calorie malnutrition, chronic pulmonary disease, and a history of TIA who required assistance with ADLs and transfers per MD orders. All three were on a 60‑day review schedule, yet the last signed orders for two residents dated back several months, and the facility could not determine when the third resident’s orders were last signed. The DNS and a corporate RN acknowledged that orders should be signed every 60 days, noted that the MD was new to electronic signatures and had not signed the affected orders, and were unable to identify a facility process or provide a policy to ensure timely physician signatures.
Surveyors found that the facility failed to complete, update, and accurately document elopement risk assessments for four residents with cognitive impairment, depression, dementia, and anxiety. One resident with severe cognitive impairment had no elopement assessment completed since admission, and another cognitively intact resident with fluctuating ADL function had no reassessment for several years despite prior documentation. A third resident identified as cognitively impaired and care-planned as at risk for elopement had only an incomplete assessment with no final risk determination, and no assessment since admission. A fourth resident with dementia, care-planned for wandering and elopement risk and using a wander guard, had no current documented elopement risk assessment in the clinical record.
A resident with moderate cognitive impairment, an unsteady gait requiring walker assistance, and on Apixaban was inaccurately assessed as not being at risk for elopement, with the facility’s evaluation stating the resident lacked cognitive impairment and physical ability to leave. The resident’s care plan identified fall risk and need for assistance with transfers and ambulation, yet the resident exited through the alarmed front lobby door, which opened via a 15‑second egress mechanism. A therapeutic recreation assistant heard the door alarm, immediately silenced it without checking inside or outside the door and without notifying a supervisor, assuming it was related to a scheduled smoke break. The resident walked to a nearby hospital ED, where staff found the resident confused and documented disorientation and risk for elopement, while facility staff remained unaware of the resident’s absence for an extended period and had no written policy for staff response to exit door alarms, despite having multiple other residents identified as elopement risks.
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with bipolar disorder, anxiety, moderately impaired cognition, and documented behavioral issues was care planned for staff to leave and return later if the resident became abusive. On one occasion, a CNA and a student entered the resident’s room to care for the roommate while the resident was in the bathroom. According to the student, the CNA ignored the resident’s demand not to enter, opened the bathroom door, argued with the resident, called the resident a “crazy bitch,” and, after the resident threw a soiled brief and kicked the CNA, kicked the resident back, pushed the wheelchair, scratched the resident’s arm, and held the resident’s arm down against the wheelchair armrest while the room door was closed. Subsequent skin assessments documented new abrasions and bruises on the resident’s arm and leg, and the CNA acknowledged not leaving when asked, not calling for help, and managing the escalating situation without seeking assistance, contrary to the facility’s abuse policy defining verbal and physical abuse, including kicking and use of disparaging language.
A resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an altercation with another moderately cognitively impaired resident with dementia, psychosis, and mood disorder. An LPN observed the second resident block the first resident’s path with a chair in the dining area; when the first resident attempted to move the wheelchair and questioned the obstruction, the second resident slapped the first resident hard on the left side of the face. The first resident reported immediate, severe jaw, ear, and neck pain, rated the pain 10/10, described seeing stars and briefly losing balance, and was later documented by an APRN as having a contusion to the left jaw and was treated in the ED for a closed head injury. This incident occurred despite a facility abuse policy requiring residents be free from abuse and treated with kindness, compassion, and dignity.
Inaccurate Transcription of Wound Care Physician Orders for Toe Treatment
Penalty
Summary
The deficiency involves the facility’s failure to accurately transcribe and implement wound care physician recommendations for a resident with Alzheimer’s dementia, urinary incontinence, and dependence in ADLs. The resident’s care plan identified a toe wound with interventions to observe for infection and provide treatments and dressing changes as ordered. On 5/23/23, a nursing note documented that a physician assessed both great toes, noting ingrown nails on both, purulent drainage from the left great toe, and discoloration without drainage on the right great toe, and that Mupirocin treatment was ordered. The wound care provider’s note from the same date specified a recommendation to apply Bactroban to the wound base of the first left lateral toe with a dry clean dressing daily. However, the corresponding physician order entered on 5/23/23 directed staff to apply Mupirocin to both great toes every day for 14 days and to cleanse both great toe wounds with normal saline, despite no documentation that the wound physician had ordered treatment for both toes. On 5/30/23, a nursing note documented that the same physician again assessed the resident’s bilateral great toes, noting they were dry with no purulent drainage, swelling, or erythema, and that treatment was changed to Betadine. The wound care provider’s note that day recommended painting only the first left lateral toe with Betadine daily and leaving it open to air. In contrast, the physician order entered on 5/30/23 directed staff to apply Betadine to both great toes daily for seven days. During interviews, the physician stated that on both dates he intended treatment only for the left toe and that nursing should have followed his wound care recommendations, and the Director of Nursing acknowledged that the wound care orders for both dates did not match the wound care physician’s recommendations and could not explain why the orders were entered incorrectly. The facility’s Physician Order Policy required staff to assure treatment orders are implemented accurately and in accordance with regulations.
Failure to Maintain Complete ADL Hygiene Documentation in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record, specifically documentation of personal care provided for a resident with Alzheimer’s dementia and urinary incontinence. The resident’s quarterly MDS identified short- and long-term cognitive deficits and dependence for ADL care, and the resident’s care plan documented a self-care deficit with interventions directing staff to provide ADLs and mouth care. Review of the Personal Hygiene ADL task record for May 2023 showed missing (blank) documentation on 16 shifts throughout the month. Interview and record review with the DNS confirmed that ADL hygiene documentation was absent on 15 day shifts and one evening shift, and the DNS stated that staff would have provided the care and should have documented it, but she did not know why staff failed to do so. The facility’s Charting and Documentation Policy required that all services provided to residents be documented in the medical record, which was not followed in this case.
Misappropriation of Resident Applied Income Check by Staff Member
Penalty
Summary
A resident with dementia, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, and muscle weakness had a family member designated as Responsible Party and Power of Attorney who managed the resident’s finances and routinely brought applied income checks to the facility. The resident’s assessment and care plan documented poor memory recall and a need for cues, reminders, prompting, and redirection. The facility’s usual process was for the family member to give the applied income check to the receptionist, who would then place it in an unsecured business office mailbox slot for later collection by the business office. A nurse aide who had previously covered the reception desk was familiar with this procedure. An applied income check from the resident, made payable to the facility and dated 3/9/26, was dropped off by the family member but did not reach the business office as intended. Subsequently, the family member reported to the business office manager that the check was missing and had been deposited via mobile deposit. After the family member provided a copy of the check, the business office manager observed a signature on the back that was identified and verified as belonging to the nurse aide. Further review determined that the bank account numbers associated with the deposited check matched the nurse aide’s personal banking account. The facility’s abuse policy, which prohibits misappropriation of resident property and defines misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent, was not followed when the resident’s applied income check, intended as payment to the facility, was wrongfully deposited into a staff member’s personal account.
Failure to Honor Resident Room Choice After Resident-to-Resident Threat
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choose whether to remain in their room and to receive appropriate notice before a room change following a resident‑to‑resident altercation. One resident with intact cognition, muscle weakness, type II diabetes mellitus, and absolute glaucoma was dependent on staff for bed mobility and required assistance with transfers and ambulation. This resident ambulated independently with a rolling walker in the room and throughout the facility and enjoyed walking out of the room, socializing with friends, and going to the dining room for meals. Another resident, who had Alzheimer’s disease, major depressive disorder with psychotic symptoms, generalized anxiety disorder, and moderately impaired cognition, had a care plan identifying poor impulse control, lack of safety awareness, potential for manipulative behaviors, and a history of making accusatory statements, with interventions including the use of plastic utensils and staff support for coping and behavior. On the date of the incident, the cognitively intact resident reported that the dinner cart was outside the room and began calling out “hello” for help. The roommate became aggravated, approached the resident’s side of the room, told the resident to use the call bell, and then placed a plastic knife to the resident’s neck and moved it across. The victim reported that the roommate cursed, called names, and threatened that if the resident did not “shut up” it would be worse next time. Staff documentation and interviews confirmed that the victim was removed from the room to the hallway, assessed with no acute injury noted, and that the aggressor was placed on one‑to‑one observation and sent to the ED for evaluation. The victim was described as calm but slightly anxious and later expressed being upset and worried about the aggressor returning. Following the altercation, the DON directed staff to move the victim to a different room, despite the aggressor being the one who initiated the threatening behavior. The LPN asked the victim if they were agreeable to the move and proceeded with the room change without offering the option to remain in the original room. The new room was located at the end of a hallway four rooms away from the aggressor’s room, with no alternate route of exit or access, requiring the victim to routinely pass the aggressor’s room to reach common areas and the dining room. The victim later reported feeling they had no real choice but to move in order to feel safe, expressed anger that the aggressor ended up with a private room, and continued to feel nervous about having to walk past the aggressor’s room. Interviews with facility leadership acknowledged that the victim should have been offered the choice to remain in the original room, that the aggressor should have been moved instead, and that private rooms on another unit had been available at the time. The facility’s Residents’ Bill of Rights policy stated that residents have the right to notice before a roommate is changed, to be treated equally with other residents, and to be free from abuse, but there was no specific policy available for room transfers following resident‑to‑resident altercations.
Failure to Obtain Timely Physician Signatures on 60‑Day Order Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician or designee orders were reviewed and renewed at least every 60 days for three residents. For one resident with dementia and delusional disorders, a quarterly MDS showed moderate cognitive impairment and a need for assistance with ADLs, while the care plan identified an alteration in ADL function with interventions to assist as needed. This resident was on a 60‑day schedule for review and renewal of physician orders, but the last signed orders were dated September 2025, and there were no signed physician orders from October 2025 through February 2026, either on paper or electronically. A second resident with severe protein calorie malnutrition, chronic pulmonary disease, and a history of transient ischemic attack had a quarterly MDS indicating no cognitive impairment but a need for assistance with ADLs, and a care plan directing assistance with ADLs and transfers per MD orders. This resident was also on a 60‑day schedule, yet the last signed orders were dated September 2025, with no signed orders from October 2025 through February 2026. A third resident with dementia, severe cognitive impairment, and dependence in ADLs had a care plan noting altered ADLs and interventions to assist as needed and transfer per MD orders; this resident was likewise on a 60‑day schedule, but the facility could not identify when the orders were last signed, and they were not signed in September 2025. Interviews with the DNS and a corporate RN confirmed that orders should be signed at least every 60 days, that the physician was new to electronic signatures and had not signed the orders for these residents, and that there was no identified facility process to ensure timely signing of orders. The facility did not provide a policy related to physician orders or electronic signatures when requested.
Failure to Complete and Update Elopement Risk Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that elopement risk assessments were completed, accurate, and performed at appropriate intervals for four residents reviewed for quality of care. For one resident with mild cognitive impairment and anxiety, whose care plan documented impaired memory, recall, and decision-making and whose MDS showed a BIMS score of 3/15 indicating severe cognitive impairment, no elopement risk assessments were completed at any time since admission two years earlier. A nursing re-admission assessment showed that an elopement risk assessment had been initiated but not completed. Another resident with depression, cognitively intact per a BIMS score of 15/15, and care-planned for fluctuating ADL function due to cognitive status, had no elopement reassessment for more than three years; the last completed assessment was dated in 2022. A nursing re-admission assessment referenced a prior assessment indicating no elopement risk, but there was no evidence that a new elopement risk assessment was completed upon re-admission. A third resident with adjustment disorder and anxiety had cognitive impairment documented on a nursing assessment, and an elopement risk assessment was initiated but not completed, including omission of the final risk determination section. The care plan identified this resident as at risk for elopement due to a tendency to wander and included interventions such as placement on a secured unit and use of a wander guard with checks each shift, but there was no completed elopement assessment since admission 68 days earlier. A fourth resident with dementia and adjustment disorder had cognitive impairment documented on admission and was care-planned as at risk for wandering and elopement, with interventions including a wander guard and staff escort if seen near exits. The clinical record showed that the most recent completed elopement risk assessment for this resident was dated, but no current or recent assessment was documented in relation to the resident’s identified elopement risk.
Failure to Supervise and Respond to Exit Alarm Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a resident with moderate cognitive impairment and an unsteady gait who was receiving Apixaban, a blood thinner. On admission, the nursing assessment documented that the resident required assistance for transfers, had an unsteady gait with poor trunk control, and was at risk for falls, with the resident care plan directing supervision for transfers and ambulation with a walker. An admission MDS identified a BIMS score of 9, indicating moderate cognitive impairment, and a need for partial assistance with bed mobility and transfers. Despite these findings, the facility’s elopement risk evaluation concluded that the resident was not at risk for wandering or elopement, stating that the resident did not have cognitive impairment, had the capacity to make informed decisions about leaving, and did not have the physical ability to leave the facility. On the day of the incident, the resident had a recent APRN remote visit for moderate bright red blood with stool while on Apixaban, with a plan to monitor for bleeding. That evening, the resident was last seen by an LPN at approximately 6:05–6:08 PM when medications were administered. Security video later reviewed by the DON showed the resident exiting the front lobby door at 6:07 PM, activating the 15‑second egress mechanism and door alarm. The front entrance door, which is locked after the receptionist leaves at 6:00 PM, is an egress door that unlocks after 15 seconds when pushed, and an alarm sounds when it is opened. A therapeutic recreation assistant, located near the lobby, heard the front door alarm, went to the door, and immediately deactivated the alarm using the staff code. She reported that she believed the alarm had been triggered for a scheduled supervised smoke break and did not realize it was around 6 PM. She did not look outside or inside the vicinity of the door for residents, did not search for any resident, and did not notify the nurse or supervisor that the alarm had sounded. The nursing supervisor later received a call from the hospital ED at 7:50 PM stating that the resident had arrived at 6:20 PM, appeared confused, believed they were in Texas, and reported living in elderly housing across the street. Hospital discharge documentation listed diagnoses including disorientation and at risk for elopement from a healthcare setting. The facility’s reportable event summary identified that staff were unaware the resident was out of the facility for one hour and 45 minutes, and the DON confirmed there was no written policy governing staff response to exit door alarms, while six additional residents had been identified by the facility as at risk for elopement. These failures were determined to have placed the resident and the six additional at‑risk residents in Immediate Jeopardy beginning on the date of the elopement.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Protect Resident From Physical and Verbal Abuse by Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired, conserved resident with bipolar and anxiety disorders from physical and verbal abuse by staff. The resident’s MDS identified moderately impaired cognition, verbal behaviors directed toward others, and the need for substantial/maximal assistance with toileting, while being independent in standing and using a wheelchair for mobility. The resident’s care plan noted a risk for altered mood and behaviors, including yelling at staff, with an intervention to leave the resident alone and return later if the resident was abusive toward staff. Prior to the incident, weekly skin observations documented no skin issues, and nursing notes indicated the resident was refusing care and refusing staff entry into the room, even for care of the roommate. On the date of the incident, a nursing assistant student and a nurse aide entered the room to provide care to the resident’s roommate while the resident was in the bathroom. According to the student’s statement, the resident yelled from the bathroom not to come in, but the nurse aide opened the bathroom door, and an argument ensued. The student reported that the nurse aide called the resident a “crazy bitch,” after which the resident threw a soiled brief at the nurse aide. The student further stated that the nurse aide attempted to close the bathroom door on the resident, continued calling the resident a “crazy bitch,” and when the resident began kicking the nurse aide’s legs, the nurse aide kicked the resident back on the legs, pushed the resident’s wheelchair, scratched the resident’s left arm, and restrained the resident by holding the resident’s arm down against the wheelchair armrest. The main door to the room was closed, and the student was not aware of anyone else hearing the incident. Subsequent clinical documentation identified new skin injuries consistent with the reported physical contact. A full body audit documented an abrasion on the resident’s left arm and an abrasion on the right leg, and a later weekly skin observation noted fading bruises and abrasions on the right leg, left forearm, and right upper arm. The nurse aide involved acknowledged that the resident threw a soiled diaper, was kicking and cursing, and that the aide did not leave the room when the resident told the aide to get out, did not ring the call bell, and did not call for help while the resident was agitated, with the room door closed. The aide denied using derogatory language, kicking the resident, or pushing the resident’s arms down, but the Director of Nursing Services noted that the student had nothing to gain from a false accusation and that the resident’s injuries had no other clear cause. The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing and physical abuse as including kicking and similar acts, which were implicated by the reported conduct.
Resident-to-Resident Altercation Resulting in Physical Abuse and Injury
Penalty
Summary
The facility failed to protect a resident from abuse when a resident-to-resident altercation occurred resulting in physical harm. One resident with bipolar disorder, anxiety disorder, and dementia, who was moderately cognitively impaired and ambulatory, was involved in an incident with another resident diagnosed with dementia, unspecified psychosis, and mood disorder, who was also moderately cognitively impaired and used a walker and wheelchair. Both residents had care plans dated 10/11/24 noting involvement in a resident-to-resident altercation, with interventions to notify the MD/APRN and provide psychiatric and social work support. On 10/10/24, an LPN witnessed the second resident place a chair in front of the first resident, blocking the path in the dining room. When the first resident attempted to grab the handles of the second resident’s wheelchair and questioned why the path was blocked, the second resident slapped the first resident on the left side of the face. Following the slap, the first resident reported severe pain in the jaw, ear, and left side of the neck, described the slap as “hard as hell,” and stated it caused them to see stars and briefly lose balance, with pain rated 10 out of 10. A nurse’s note documented these complaints, and an APRN progress note identified a contusion to the left jaw and concern that the jaw might be broken, leading to transfer to the hospital emergency department. The hospital report documented treatment for a closed head injury and jaw pain. The facility’s abuse policy states that all residents are to be treated with kindness, compassion, and dignity, and defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Despite this policy, the resident experienced physical abuse from another resident, and the Director of Nursing Services acknowledged that all residents should be free from abuse.
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