Civita Care Meadowbrook
Inspection history, citations, penalties and survey trends for this long-term care facility in Granby, Connecticut.
- Location
- 350 Salmon Brook Street, Granby, Connecticut 06035
- CMS Provider Number
- 075367
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Civita Care Meadowbrook during CMS and state inspections, most recent first.
A non‑ambulatory, cognitively impaired resident, fully dependent on staff and a Hoyer lift for transfers, was care planned and ordered for two‑person mechanical lift transfers and bed‑level ADL and toileting care. During morning care, the resident suddenly screamed in pain when socks were applied, and staff notified LPNs but proceeded with Hoyer lift transfers to and from a wheelchair, reporting no issues and administering scheduled acetaminophen. The next day, the resident exhibited increased body and lower extremity pain, with a swollen, tender left leg, and was again observed in a wheelchair before being returned to bed for further assessment. Imaging subsequently showed displaced proximal tibia/fibula fractures and a right femur fracture requiring surgery; providers reported no known trauma or falls and, based on the resident’s dependence and injury pattern, one APRN identified the probable cause as related to mechanical lift transfers, while the medical director noted possible osteoporosis‑related fragility fractures potentially associated with lift use.
A resident with advanced dementia and schizoaffective disorder, who had severely impaired cognition (BIMS score of 0) and was rarely/never understood, had documented needs for emotional support, care coordination, and advocacy, as well as care plan interventions for expression of thoughts and feelings and provision of psychiatric services. However, required SW documentation was missing, including quarterly progress notes for an eight-month period and an annual assessment for over a year, with the sole SW acknowledging these were missed due to oversight and no SW documentation/assessment policy provided when requested.
Two residents experienced deficiencies in care due to failures in medication reconciliation and adherence to physician orders. One resident received medications not included in their hospital discharge instructions because of incorrect transcription and lack of proper verification by nursing staff. Another resident did not receive timely administration of a prescribed bowel regimen following a syncopal episode and signs of constipation, with significant delays in following the facility's bowel protocol. These events occurred despite established facility policies intended to prevent such errors.
A resident admitted after a hospital stay with elevated kidney function labs did not have hydration needs properly assessed or documented. Required intake and output (I&O) monitoring was incomplete, estimated fluid needs were not consistently recorded, and no hydration or nutritional assessment was completed after admission or following a syncopal episode. Staff interviews confirmed that facility policy for hydration assessment and documentation was not followed.
A resident with a history of diabetes, hypertension, and dementia was admitted with a rib fracture, but the facility failed to develop a baseline care plan addressing this condition. Despite hospital documentation indicating a rib fracture, the facility did not document or manage the resident's pain effectively, nor did they inform the rehabilitation department. The resident experienced falls, and staff interviews revealed an expectation for a care plan that was not met, highlighting a lapse in the facility's care planning policy.
A resident receiving IV therapy for recurrent UTIs had critical lab values that were not communicated to the physician in a timely manner. The lab results, which included elevated BUN, creatinine, and Vancomycin trough levels, were reported to the facility but not acted upon until 28 hours later. The delay resulted in the resident being transferred to the hospital with acute kidney failure related to Vancomycin toxicity. The facility lacked a specific policy for reporting critical lab results, and the responsible staff failed to notify the physician as required.
A resident with multiple diagnoses, including a methicillin-resistant staphylococcus aureus infection, did not receive IV Vancomycin as ordered, with doses administered outside the prescribed time frame. Additionally, Vancomycin was not discontinued as per new physician orders, with evidence suggesting a potential extra dose was given. The facility lacked a policy on IV administration, contributing to the deficiency.
A resident with multiple health conditions was not properly monitored for intake and output (I & O) as required by physician orders. The facility failed to provide I & O records for several days, and on the days records were available, the resident's fluid intake was significantly below the estimated daily needs. Despite this, a dehydration evaluation was not conducted as required by the facility's policy. Interviews with the DON and ADON revealed a lack of awareness and adherence to the facility's hydration policy.
Inadequate Protection of Dependent Resident During Mechanical Lift Transfers Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate protection from injury for a non‑ambulatory, cognitively impaired resident who was totally dependent on staff and a mechanical lift for transfers. The resident had dementia with severely impaired cognition (BIMS score of 0), was always incontinent, and was care planned and ordered for Hoyer lift transfers with assist of two staff, and assist with ADLs and toileting at bed level. The resident’s care plan and orders specified non‑ambulatory status, total lift use, and a customized wheelchair with headrest and bilateral leg rests. Prior to the incident, an APRN documented baseline confusion, no pain, movement of all extremities, and bilateral knee contractures, and a skin check shortly before the event showed no new skin impairments. On one day, a nursing assistant reported that during morning care when applying socks, the resident suddenly began screaming, prompting the NA to stop care and notify the night‑shift LPN and the day‑shift LPN. The resident, who had baseline lower extremity edema but no noted discoloration or bruising the prior day, was nonetheless transferred with a Hoyer lift and two‑person assist to a wheelchair and later back to bed, with staff reporting no issues during the transfers and that the resident appeared comfortable after receiving scheduled acetaminophen. The following morning, the charge nurse was notified that the resident had increased generalized body pain, including lower extremity pain, and was uncomfortable during personal care. At that time, the resident’s left leg was noted to be swollen and painful to touch, though the skin was intact, and the resident was observed in the dining room in a wheelchair appearing uncomfortable. Subsequent assessment by an APRN led to orders for a Doppler ultrasound to rule out DVT and an x‑ray of the lower left extremity. Imaging revealed displaced, angulated, recent‑appearing proximal tibial and fibular fractures, and the resident was transferred to the ED, where additional right femur fracture was identified, requiring surgical intervention. The physician and APRNs noted there was no known trauma or recent falls, and one APRN stated that, given the resident’s dependence and lack of reported falls, the injuries were unlikely to have occurred from rolling in bed or an unwitnessed fall, and identified the probable cause of injury as related to use of the Hoyer lift during transfers. The medical director, after reviewing hospital documentation, stated there was no clear etiology but that the injuries could represent osteoporosis‑related fragility fractures potentially associated with mechanical lift transfers.
Failure to Provide and Document Required Social Work Services
Penalty
Summary
The facility failed to provide and document medically-related social services for a resident with dementia and schizoaffective disorder. The resident had a POA for health decisions and was documented in an annual social work (SW) assessment as being primarily alert to self with cognitive deficits related to place and time, as well as confusion. The annual assessment noted that the SW was available for emotional support and for concerns or complaints. A subsequent SW quarterly assessment documented that the resident continued to have severe cognitive impairment due to advanced dementia, with stable mood, calm and friendly affect, and poor insight and judgment, and stated that the SW would remain available for ongoing support, care coordination, and advocacy for the resident’s needs and comfort. The resident’s MDS showed severely impaired cognition with a BIMS score of 0 and that the resident was rarely or never understood. The resident’s care plan identified long-term care needs and psychiatric diagnoses of schizoaffective disorder and bipolar disorder, with interventions including encouraging the resident to express thoughts and feelings, providing support and validation as needed, and providing psychiatric services within the facility. Despite these identified needs and planned interventions, the clinical record lacked required SW documentation. There were no SW quarterly progress notes for an eight-month period following the last note dated 7/2/25, and no SW annual assessments for a period of one year and four months following the last annual assessment dated 11/13/24. The DNS confirmed there were no additional SW notes in the resident’s record. In an interview, the sole facility SW acknowledged that the resident’s annual and quarterly progress notes had been missed due to an oversight, noted that the electronic medical record did not prompt her to document, and stated that progress notes should be completed at least quarterly and annually. When requested, the facility did not provide a SW documentation and assessment policy.
Medication Reconciliation and Bowel Regimen Protocol Failures
Penalty
Summary
The facility failed to ensure accurate medication reconciliation and adherence to physician orders for two residents. For one resident admitted with multiple fractures, delirium, glaucoma, GERD, depression, and dementia, the hospital discharge summary listed specific medications to be continued. However, during the admission process, two medications—gabapentin and senna-s—were incorrectly transcribed into the electronic physician's orders, despite not being included in the hospital discharge instructions. The resident subsequently received two doses of gabapentin and one dose of senna-s before the error was identified. The medication reconciliation process required a second nurse to verify the accuracy of transcribed orders, but this verification failed, allowing the error to proceed undetected until after administration. For another resident admitted with a cervical spine fusion, cognitive communication deficit, and weakness, the facility did not follow the prescribed bowel regimen as per physician order and facility policy. The resident, who was receiving scheduled oxycodone, had not had a bowel movement for several days. Although a bowel regimen was ordered after the resident experienced a syncopal episode and was found to have a firm, distended abdomen, the medications were not administered according to the protocol. There were significant delays between the ordering and administration of each step in the bowel regimen, with the first medication given 17 hours after the order and subsequent steps delayed further, contrary to the facility's bowel evacuation protocol. Interviews with nursing staff revealed lapses in the medication reconciliation and bowel regimen processes. The admitting nurse acknowledged accidentally transcribing incorrect medications, and the verifying nurse failed to catch the error. In the case of the bowel regimen, staff could not recall whether medications were administered as ordered, and documentation did not support timely administration. The facility's policies for medication reconciliation and bowel management were not followed, resulting in medication errors and delayed care.
Failure to Assess and Document Resident Hydration Needs
Penalty
Summary
A deficiency was identified regarding the facility's failure to adequately assess and document the hydration needs of a resident following admission. The resident, who had recently been discharged from the hospital with a noted increase in creatinine and BUN levels, was admitted with multiple diagnoses including cervical spine fusion, cognitive communication deficit, and weakness. Upon admission, the resident was alert and oriented, with normal abdominal findings and independence in eating. However, the medical provider's note did not specify fluid intake goals, and a physician's order was issued to monitor intake and output (I&O) every shift for 72 hours and document it on the appropriate flowsheet. Review of the I&O documentation revealed significant gaps. There was no I&O documentation for the day of admission, and incomplete records for the following day, with missing entries for several hours and no 24-hour estimated fluid needs recorded. Over the subsequent days, the resident's total fluid intake was consistently below the estimated needs, and the required estimated fluid needs were not documented until several days after admission. Additionally, there was no evidence of a nursing hydration assessment or a nutritional assessment after admission or following a syncopal episode and findings of constipation and abdominal distension. Interviews with facility staff confirmed that hydration assessments should be completed on admission and readmission, and that both nursing and dietary staff are responsible for calculating and documenting fluid needs. The dietitian acknowledged that she may not have assessed the resident due to her limited schedule and the resident's hospital stay. The facility's hydration policy requires at-risk residents to be reviewed and provided with interventions to promote hydration, and mandates that I&O be documented for each shift for 72 hours post-admission. These requirements were not met in this case, resulting in the identified deficiency.
Failure to Develop Baseline Care Plan for Resident with Rib Fracture
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident with fractured ribs. The resident, who had a history of diabetes, hypertension, metabolic encephalopathy, and dementia with behavioral disturbances, was admitted with a nondisplaced left posterior 10th rib fracture, pleural effusion, and suspected malignancy. Despite these conditions being identified in the hospital's discharge summary, the facility did not document or address the rib fracture in the resident's care plan, nor did they communicate this critical information to the hospital upon the resident's transfer. The resident's clinical records and staff interviews revealed that the facility did not adequately assess or manage the resident's pain related to the rib fracture. A handwritten note in the resident's file incorrectly identified a right rib fracture, and subsequent evaluations by medical staff failed to address the left rib fracture. The resident exhibited non-verbal signs of pain, and although Tylenol was administered, there was no comprehensive plan to manage the rib fracture or associated pain. The rehabilitation department was not informed of the rib fracture, which could have influenced the resident's therapy and care. The facility's failure to communicate and document the resident's rib fracture led to inadequate care planning and pain management. The resident experienced two falls while at the facility, and the lack of a care plan addressing the rib fracture meant that appropriate interventions were not in place. Interviews with facility staff, including the ADNS and RN, indicated that there was an expectation for a care plan to be developed, but this was not done. The facility's care planning policy requires an interim plan of care within 24 hours of admission, but this was not adhered to in this case.
Failure to Timely Notify Physician of Critical Lab Values
Penalty
Summary
The facility failed to notify the physician of critical lab values in a timely manner for a resident receiving intravenous therapy for recurrent urinary tract infections. The resident had several diagnoses, including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician order required weekly lab work, including a Vancomycin trough, to be conducted on Mondays. On a Monday, the resident's lab results showed critical values, including a BUN of 77, creatinine of 4.1, and a Vancomycin trough greater than 50. These results were reported to the facility but not acted upon until 28 hours later. The facility's documentation and interviews revealed that the critical lab results were not communicated to the physician or the infectious disease office in a timely manner. The RN supervisor was responsible for handling incoming lab results, but there was no documentation that the physician was notified before 1 PM the following day. The facility was unable to verify who received the lab results, as the person named in the report did not exist in their records. The infectious disease office was unaware of the critical lab values until contacted by an external person, who then informed the facility. The delay in notifying the physician resulted in the resident being transferred to the hospital with acute kidney failure related to Vancomycin toxicity. The facility's Physician Notification Policy required lab results to be reported to the physician, but there was no specific policy for reporting critical lab results. Interviews with the ADON and DON confirmed that the physician should have been contacted regarding the critical lab values, but no explanation was provided for the delay.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer IV antibiotics to a resident in accordance with physician orders, leading to a deficiency in the quality of care provided. The resident, who had diagnoses including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression, was receiving Vancomycin IV therapy for recurrent UTIs. The physician's order specified that Vancomycin should be administered every 18 hours. However, the electronic medication administration record (eMAR) showed that the doses were not administered within the prescribed time frame, with one dose being an hour late and another being administered one hour and 47 minutes early. The Director of Nursing (DON) confirmed that medications should be administered within one hour before or after the scheduled time but could not explain the discrepancies. Additionally, there was a failure to discontinue Vancomycin as ordered by the physician. Despite a new order to discontinue Vancomycin and start Daptomycin, an empty Vancomycin IV bag was found labeled with a date six days after the discontinuation order. Interviews with the Assistant Director of Nursing (ADON) and the DON revealed uncertainty about whether an extra dose was administered, but the presence of labeled IV bags suggested a potential error. The facility did not provide a policy regarding IV administration, further highlighting the deficiency in adhering to physician orders and ensuring proper medication management.
Failure to Monitor Resident Hydration
Penalty
Summary
The facility failed to ensure proper monitoring of intake and output (I & O) for a resident with multiple health conditions, including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician's order required monitoring of I & O every shift for 72 hours upon admission or readmission, with documentation on an I & O paper flowsheet. However, the facility did not provide I & O records for several days, and on the days records were available, the resident's fluid intake was significantly below the estimated daily needs. Despite these deficiencies, the facility did not conduct a dehydration evaluation as required by their policy when a resident's intake is below the estimated needs for three consecutive days. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's policy did not include performing a dehydration risk evaluation upon admission. Instead, nursing staff used other assessment measures to determine dehydration risk. The DON was unaware of the missing I & O flowsheets and could not explain why the low intake levels were not addressed. The facility's Hydration Policy required residents at risk for dehydration to be on I & O monitoring until adequate hydration status is achieved, but this was not followed for the resident in question.
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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