Complete Care At Kimberly Hall North
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor, Connecticut.
- Location
- 1 Emerson Dr, Windsor, Connecticut 06095
- CMS Provider Number
- 075279
- Inspections on file
- 27
- Latest survey
- April 10, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Complete Care At Kimberly Hall North during CMS and state inspections, most recent first.
Two cognitively impaired residents on a locked dementia unit, both with severely impaired BIMS scores and care plans noting dementia-related cognitive decline, were left unsupervised for about 15–20 minutes after breakfast while staff assisted other residents. During this interval, staff discovered the two residents in a bed, prone and partially unclothed, with one on top of the other and lower garments removed or unfastened. Both residents were documented as not responsible for themselves, had no prior sexual disinhibition behaviors, and later demonstrated lack of recall or misperception of the event. The facility’s sexual expression policy applied only to residents with intact decision-making capacity, and there was no prior consent from responsible parties for sexual activity, resulting in a failure to protect these residents from sexual abuse through adequate supervision and interventions.
A resident with seizure disorder, dementia, and multiple comorbidities experienced repeated failures in timely medication administration and documentation. Required scheduled doses of gabapentin and acetaminophen were not documented as given at the ordered time, despite an RN later stating they had been administered. On another day, an RN documented a set of 9:00 AM medications, including anticonvulsants, antihypertensives, anticoagulant, antidepressant, and laxative, more than four hours late, while another RN administered evening anticonvulsant, analgesic, muscle relaxant, anticoagulant, sleep aid, antidepressant, and neuropathy medications more than two to three hours earlier than scheduled. One RN reported routinely delaying electronic documentation until after completing the full med pass due to EMR issues and workload, contrary to the facility’s one-hour administration window and immediate documentation standard.
A resident with dementia and dysphagia, fully dependent on staff for feeding, was not fed in a dignified manner. Video evidence showed a nursing assistant feeding the resident rapidly with large spoonfuls of food, not allowing time to swallow between bites, and letting food drip onto the resident's chin. Staff interviews confirmed the feeding did not follow the care plan or facility policy, which required slow, attentive feeding and ensuring swallowing between bites.
A nurse aide failed to follow proper feeding techniques for a resident with dementia and dysphagia, providing large spoonfuls of food too quickly and not ensuring the resident had swallowed before offering more, despite documented competency and clear care plan instructions. Video evidence and staff interviews confirmed the feeding was too rapid and did not adhere to protocols for safe feeding of residents with swallowing difficulties.
A resident with severe cognitive and physical impairments was subjected to abuse when a nursing assistant forcefully fed them despite clear signs of resistance, contrary to the care plan that required redirection and postponement of care. The incident was captured on video and confirmed through facility documentation and interviews.
A resident with dementia, dysphagia, and severe cognitive impairment, who was dependent on staff for eating, did not receive appropriate feeding interventions as outlined in their care plan. Video evidence showed a nursing assistant disregarding the resident's attempts to block feeding, continuing to feed, and failing to use redirection or re-approach techniques, resulting in improper care.
A resident with dementia and abnormal gait, who was independent with ambulation, tripped over an electrical cord stretched across a hallway while housekeeping was cleaning. Despite caution signs being present, the resident fell and sustained a laceration to the lip requiring sutures. Facility policy prohibited cords from crossing open areas, but this was not followed, resulting in the incident.
A resident with severe cognitive impairment and total care needs did not receive the required two-person assistance for bed mobility, as specified in their care plan and aide Kardex. Instead, a nurse aide provided care alone during an overnight shift, despite being aware of the two-person requirement. The resident was later found to have a right shoulder dislocation, and facility documentation confirmed the care plan was not followed.
The facility failed to protect residents from physical mistreatment, as evidenced by incidents involving two residents who were physically abused by other residents. One resident, diagnosed with Alzheimer's and anxiety disorder, was hit by another resident with a history of aggressive behavior. Another resident, diagnosed with dementia and anxiety, was bitten and knocked down by a resident with impulse disorder. The facility's policies and procedures were insufficient in preventing these incidents, highlighting a failure to ensure a safe environment.
A resident with severe cognitive impairment was admitted with a stage 3 pressure ulcer, which deteriorated to stage 4 after admission. The facility failed to update the care plan to reflect this change, incorrectly indicating the ulcer was present on admission. Staff interviews confirmed the ulcer was facility-acquired, highlighting a deficiency in care planning.
A resident with dementia and Alzheimer's was not provided with a Kennedy cup as required by their care plan during mealtime. Despite the care plan and meal ticket indicating the need for adaptive equipment, the resident was observed using a regular cup. Interviews revealed that the kitchen was responsible for providing the equipment, but it was not included on the tray until after surveyor inquiry.
A facility failed to monitor behaviors for a resident on psychotropic medications, leading to undocumented administration. Another resident with a knee brace order was not wearing it due to improper documentation and lack of care planning for refusal. Additionally, a resident with edema did not receive prescribed Ace wraps due to oversight and lack of supplies, with no documentation of refusals.
A facility failed to provide adequate supervision during dining for six residents with cognitive impairments, leaving them unsupervised while eating. Observations and staff interviews confirmed that an LPN left the dining area to administer medications, resulting in residents being unattended. The ADNS acknowledged the lapse in supervision, which was contrary to the residents' care plans requiring assistance.
The facility failed to ensure staff competencies for IV therapy and the use of Low Air Loss (LAL) mattresses. Seventeen licensed staff lacked documented IV therapy competencies, and a resident's LAL mattress was incorrectly set due to inadequate staff training. The ADNS confirmed the absence of in-service training or facility policy on the specific LAL mattress used, leading to confusion among staff.
A resident with dysphagia was served a dinner roll despite being on a chopped diet, contrary to dietary guidelines. Staff interviews revealed a lack of understanding and communication about dietary restrictions, and the facility's policy to inspect food trays was not effectively implemented.
A resident with dementia and other health issues was served a meal that did not match their dietary preferences as indicated on their lunch ticket. Staff interviews revealed that dietary trays were served without verifying the meal against the ticket, contrary to facility policy. The Director of Dietary confirmed that a staff member is supposed to ensure meals meet dietary restrictions and preferences, but this was not done.
A facility failed to follow infection control procedures during wound care for a resident with a stage 4 pressure ulcer. An LPN handled wound supplies with dirty gloves and placed a trash bag on a nonsterile surface. Enhanced barrier precautions were not followed, as staff did not wear gowns and were unaware of the requirement, despite a sign outside the resident's door. PPE carts were located in the hall, shared among residents, but not immediately available near the resident's room.
The facility did not provide a homelike dining environment for memory unit residents, serving meals on dietary trays to prevent food sharing, as observed and confirmed by the Administrator.
A resident with severe cognitive impairment experienced a breach of dignity when a medical doctor made an inappropriate comment about a disciplinary sign in the resident's room. The comment, although not directed at the resident, was overheard by staff and considered unprofessional. The facility's policy on resident rights was not upheld, leading to a deficiency in maintaining the resident's dignity.
A resident with anxiety and depression was verbally abused by a nursing assistant (NA) who accused them of being a troublemaker and lying. The incident was confirmed by a facility investigation, which found that the NA's actions constituted verbal abuse as per the facility's policy. The NA's employment was subsequently terminated.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to protect two cognitively impaired residents from sexual abuse by not ensuring adequate supervision and interventions on a locked dementia unit. One resident had Alzheimer’s dementia with behavioral disturbance, was oriented only to self, and had a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. This resident’s care plan identified impaired cognitive function and thought processes related to dementia, with interventions focused on assisting with decision-making, using cues, and redirecting as needed. The other resident had frontotemporal neurocognitive disorder and dementia, a conservator of person, and a BIMS score of 6, also indicating severely impaired cognition. This second resident’s care plan identified risk for elopement and wandering, as well as impaired cognitive function, with interventions including engagement in tailored activities, redirection when wandering or intrusive, and communication strategies adapted to cognitive deficits. On the day of the incident, both residents were on a locked dementia unit and were described as not responsible for themselves. Breakfast was served on the unit, and one resident ate in the dining room while the other ate in their room. After breakfast trays were picked up, there was an interval of approximately 15–20 minutes between the last observation of the residents and the discovery of the incident. During this time, staff were engaged in feeding and assisting other residents. A nursing assistant entered one resident’s room to feed that resident and found the two residents lying prone in bed, partially clothed, with one resident on top of the other. Clothing for both residents was displaced or removed from the lower body. Staff statements and clinical evaluations documented that both residents had severe cognitive impairments and limited orientation, with no prior documented sexual disinhibition behaviors. The assistant and a certified occupational therapy assistant both described finding one resident on top of the other, with pants and undergarments removed or unfastened. Subsequent interviews with clinical staff indicated that one resident did not recall the incident, and the other misidentified the peer as someone from their past and believed they were rekindling a relationship. The facility’s policy on sexual expression specified that it applied to individuals with intact cognitive decision-making capacity, and there was no indication that either resident had such capacity or that consent for sexual activity with other residents had been obtained from their responsible parties prior to the incident. The combination of severe cognitive impairment, lack of capacity to consent, and the lapse in supervision on the locked dementia unit led to the failure to protect these residents from sexual abuse.
Medication Administration Timing and Documentation Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered within acceptable time frames and documented at the time of administration for a resident with seizure disorder, anxiety, and dementia. The resident was identified as severely cognitively impaired and required assistance with activities of daily living. The resident’s care plan noted risk for seizure activity with interventions to medicate as ordered and monitor for effectiveness and side effects. Physician orders included gabapentin every eight hours for neuropathy and acetaminophen every eight hours for pain. On one date in March, the Medication Administration Record showed that the resident’s scheduled 2:00 PM doses of gabapentin and acetaminophen were not documented as given. The nurse supervisor for that shift stated in interview that these medications were administered at 2:00 PM but acknowledged failing to document the administration, despite facility policy requiring documentation at the time medications are given. Additional deficiencies were identified when review of the March Medication Administration Record showed that multiple scheduled medications were administered significantly outside the facility’s standard one-hour before to one-hour after window. On one date, a nurse documented a group of 9:00 AM medications, including brivaracetam, ferrous sulfate, baclofen, carvedilol, losartan, apixaban, amlodipine, duloxetine, senna, and lorazepam, as administered at 1:32 PM, more than four and a half hours late. On the same date, another nurse administered 9:00 PM medications, including brivaracetam, diclofenac gel, baclofen, melatonin, apixaban, mirtazapine, lorazepam, and acetaminophen, between 6:32 PM and 6:33 PM, over two hours early, and a 10:00 PM gabapentin dose at 6:34 PM, more than three hours early. One nurse reported documenting medications only after all assigned residents had received their medications, citing electronic record issues and workload, which conflicted with the facility’s standard of practice and policy requiring immediate documentation and adherence to the one-hour administration window.
Failure to Feed Dependent Resident in a Dignified Manner
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for all activities of daily living, including eating, was not fed in a dignified manner. The resident had significant medical conditions, including dementia, dysphagia, mood disorder, and lack of coordination, and was on a dysphagia puree diet with nectar thick liquids. Care plans and physician orders specified that the resident should be fed slowly, with small bites and sips, and that staff should ensure the resident swallowed each mouthful before offering more food. However, video evidence showed that a nursing assistant fed the resident rapidly, placing multiple heaping spoonfuls of oatmeal into the resident's mouth without waiting for the resident to swallow, and allowed food to drip onto the resident's chin before using the spoon to remove it. Interviews with facility staff confirmed that the feeding was not performed according to the resident's care plan or facility policy, which emphasized slow feeding and ensuring swallowing between bites. The nursing assistant acknowledged not realizing how quickly she was feeding the resident and recognized that she should have paused between spoonfuls. The Director of Nursing Services also confirmed that the feeding was too fast and did not meet the required standards for dignified care. Facility documentation and policies reviewed supported the expectation for dignified, slow, and attentive feeding practices for residents with similar needs.
Improper Feeding Technique for Dependent Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a nurse aide failed to use the proper feeding technique for a resident who was dependent on staff for feeding and had significant medical conditions, including dementia, dysphagia, and impaired cognitive and physical abilities. The resident was on a dysphagia puree diet with nectar thick liquids and required slow feeding with small bites, alternating solids and liquids, and monitoring for signs of aspiration. Despite documented competency validation and clear care plan instructions, video evidence showed the nurse aide feeding the resident too quickly, providing large spoonfuls of food without ensuring the resident had swallowed before offering more, and not pausing between bites as required. Interviews with facility staff, including the nurse aide, speech and language pathologist, and director of nursing, confirmed that the feeding was performed too rapidly and did not follow the established protocols for safe feeding of residents with swallowing difficulties. The facility's competency validation form also specified the need to ensure the resident's mouth was empty before the next bite, which was not followed in this instance. The facility was unable to provide a specific policy for feeding residents when requested.
Failure to Protect Resident from Abuse During Feeding
Penalty
Summary
A deficiency occurred when a resident with dementia, dysphagia, mood disorder, and severe cognitive and physical impairments was not protected from abuse during mealtime assistance. The resident required total assistance with eating and was to be fed slowly, with cues and redirection if resistive. During a breakfast meal, video footage showed a nursing assistant (NA) attempting to feed the resident, who raised their hands to block their face. Instead of stopping or redirecting as care plans directed, the NA moved the resident's hands away and forcefully placed a spoonful of oatmeal into the resident's mouth, causing the resident's head to jerk. The NA then verbally accused the resident of kicking, despite no evidence of such behavior, and abruptly ended the feeding by throwing the spoon and leaving the room. Facility documentation and interviews confirmed that the NA did not follow the resident's care plan, which required postponing and reapproaching care if the resident became resistive. The actions observed in the video were identified by facility leadership as mistreatment and not in accordance with established policies to prevent abuse. The incident was substantiated through direct observation and review of the resident's care requirements and staff responsibilities.
Failure to Implement Feeding Interventions for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to implement appropriate interventions for a resident who was dependent on staff for eating and had multiple diagnoses, including dementia, dysphagia, mood disorder, lack of coordination, and difficulty waking. The resident's care plan and Kardex directed staff to assist or feed as needed, use a slow approach with cues, encourage fluid intake, and, if the resident became resistive, to postpone care and re-approach after allowing time to regain composure. Physician orders specified a dysphagia puree diet with nectar thick liquids, and the resident was documented as having severely impaired cognitive skills, being dependent for all ADLs, and being non-ambulatory. On the date in question, video footage showed a nursing assistant feeding the resident and, when the resident attempted to block their face, the assistant moved the resident's hands away and continued feeding, ultimately pushing a spoon further into the resident's mouth and causing the resident's head to jerk. The assistant then abruptly ended the feeding and left the room. The Director of Nursing confirmed that the assistant should have stopped feeding, attempted redirection, and re-approached the resident as per the care plan. This failure to follow the established interventions and care plan led to the deficiency.
Resident Fall Due to Electrical Cord Hazard in Hallway
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's Disease and abnormal gait, who was independent with ambulation but had poor memory recall, tripped over an electrical cord that was stretched across a hallway. The resident was identified as being at risk for falls due to dementia, and the care plan included interventions to keep areas clutter-free and provide handheld assistance when redirecting. On the day of the incident, the resident was observed ambulating independently in the hallway, where four wet floor caution signs were present, and an electrical cord was running across the hall as housekeeping staff were buffing rooms. Despite the caution signs, the resident tripped over the cord and fell, sustaining a laceration to the inner lower lip that required sutures and hospital evaluation. Facility policy for floor care specifically directed staff not to stretch equipment cords across open common areas to prevent trip hazards. Interviews with staff confirmed that the cord was running across the hallway at the time of the fall, and the housekeeper acknowledged plugging the machine into a hallway outlet, causing the cord to cross the hall. The Director of Housekeeping confirmed that staff had previously been in-serviced on this policy, and the housekeeper involved had attended the training. The failure to follow facility policy and ensure the hallway was free from environmental hazards directly led to the resident's fall and injury.
Failure to Provide Required Two-Person Assistance for Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, osteoarthritis, and osteoporosis, who required total assistance for activities of daily living (ADLs), did not receive care in accordance with their established care plan. The resident's care plan and aide care card/Kardex both specified that two staff members were required to assist with bed mobility. Despite this directive, a nurse aide provided care and repositioned the resident alone during an overnight shift, as there was only one aide assigned to the unit at that time. The nurse aide was aware of the two-person assist requirement but proceeded without additional help. Subsequently, the resident was observed with facial grimacing and later diagnosed with a right shoulder dislocation. Facility documentation and interviews confirmed that the required two-person assistance was not provided during the relevant shift, and the LPN on duty did not assist or receive reports of pain from the aide. The facility's policy required the care plan to describe the services to be furnished, but the care plan was not followed, resulting in the resident not receiving the level of assistance specified.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical mistreatment, as evidenced by incidents involving Resident #76 and Resident #122. Resident #76, who was severely cognitively impaired and diagnosed with Alzheimer's disease and anxiety disorder, was hit in the back by Resident #139 while both were ambulating in the hallway. Resident #139, who had a history of aggressive behavior and was diagnosed with Alzheimer's disease, depression, and aphasia, was observed to be agitated and throwing objects prior to the incident. Despite being redirected by staff, Resident #139 managed to hit Resident #76, indicating a lapse in supervision and intervention. In another incident, Resident #122, who was severely cognitively impaired and diagnosed with dementia, anxiety, and depression, was physically abused by Resident #10. Resident #122 was bitten on the forearm by Resident #10 after holding onto Resident #10's wheelchair. Later, Resident #122 was knocked down by Resident #10, resulting in a bruise. Resident #10, diagnosed with dementia, schizoaffective disorder, and impulse disorder, was known to express frustration with other residents and had previously bitten Resident #122. The facility's failure to effectively supervise and redirect Resident #122, who exhibited wandering behaviors, contributed to these altercations. The facility's policies and procedures were insufficient in preventing these incidents of resident-to-resident abuse. Staff interviews revealed that Resident #139 and Resident #10 had histories of aggressive behavior, yet interventions to manage their behaviors were inadequate. The Director of Nursing Services acknowledged the challenges in redirecting Resident #139 and the ineffectiveness of stop signs in preventing Resident #122 from entering other residents' rooms. These deficiencies highlight the facility's failure to ensure a safe environment for its residents, free from abuse and mistreatment.
Failure to Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan for a resident with a pressure ulcer when there was a change in the wound's status. The resident, who was severely cognitively impaired, was admitted with a stage 3 pressure ulcer on the sacral region. The wound was initially assessed as unstageable due to necrosis and was debrided by a consulting wound physician. Subsequent evaluations revealed that the wound deteriorated to a stage 4 pressure ulcer. Despite these changes, the care plan was not updated to reflect the new status of the wound. The care plan, initiated after the wound was confirmed as stage 4, incorrectly indicated that the pressure ulcer was present on admission. Interviews with facility staff, including the ADNS and RN responsible for MDS assessments, confirmed that the wound had deteriorated from stage 3 to stage 4 after admission, making it a facility-acquired pressure ulcer. The failure to update the care plan to reflect the accurate status of the wound represents a deficiency in the facility's care planning process.
Failure to Provide Adaptive Equipment at Mealtime
Penalty
Summary
The facility failed to provide adaptive equipment at mealtime for a resident diagnosed with dementia, muscle weakness, and Alzheimer's disease. The resident was identified as severely cognitively impaired and required supervision with transfers and bed mobility but was independent with eating when provided with adaptive equipment. The care plan specified the use of a Kennedy cup to assist the resident in feeding themselves, which was also noted in the dietician's assessment and the meal ticket. On a specific observation date, the resident was found drinking from a regular cup instead of the prescribed Kennedy cup. Interviews with the nursing assistant and the Director of Dietary revealed that the kitchen was responsible for providing adaptive equipment, but the Kennedy cup was not included on the resident's tray. The following day, after inquiry by the surveyor, the resident was provided with the Kennedy cup. The facility's policy directed nursing staff to ensure assistive devices were available as needed, which was not adhered to in this instance.
Deficiencies in Medication Monitoring, Assistive Device Application, and Edema Management
Penalty
Summary
The facility failed to monitor the behaviors associated with psychotropic medications for a resident diagnosed with major depressive disorder, history of suicidal ideation, and cerebral vascular disease. The care plan required behavior monitoring, but there were omissions in documentation on specific shifts, and psychotropic medications were administered without documented behaviors. Interviews revealed that the nursing staff did not document behaviors prior to administering medications, contrary to the facility's policy. Another deficiency involved a resident with polyosteoarthritis and dementia, who had a physician's order for a knee brace. Observations showed the resident was not wearing the knee brace on multiple occasions, and interviews indicated the resident frequently removed it. The care plan did not reflect the resident's refusal to wear the brace, and the order was not properly documented in the facility's system, leading to a lack of application. The facility also failed to manage edema for a resident with localized edema and hypertension. The resident was observed without Ace wraps on multiple occasions, despite physician orders to apply them daily. Nursing staff did not apply the wraps due to a lack of supplies and assistance, and there was no documentation of refusals or rationale for not applying the wraps. The Director of Nursing Services expected the staff to follow physician orders, but the task was not completed.
Inadequate Supervision During Dining
Penalty
Summary
The facility failed to provide adequate supervision during dining for six residents, all of whom had varying degrees of cognitive impairment and required assistance with eating. Observations revealed that these residents were left unsupervised in the dining room while still eating, contrary to their care plans which specified the need for supervision and assistance. For instance, Resident #9, who was severely cognitively impaired and required supervision for eating, was left alone with food items on the table. Similarly, Resident #116, who needed extensive assistance for eating, was observed holding a bowl of food without staff presence. The lack of supervision was confirmed by staff interviews, where an LPN assigned to supervise the dining room admitted to leaving the area to administer medications, leaving residents unattended. The ADNS acknowledged that residents should not have been left alone and mentioned a rotating schedule for supervising the dining room, which was not adhered to in this instance. The absence of staff during dining posed a risk to residents who required assistance, as evidenced by Resident #116's statement about needing to yell for help in an emergency.
Deficiencies in Staff Competencies for IV Therapy and LAL Mattress Use
Penalty
Summary
The facility failed to ensure that nursing staff had current competencies for the provision of Intravenous Therapy (IV) and the use of Low Air Loss (LAL) mattresses. A review of staff competencies revealed that 17 out of 47 licensed staff members did not have documented competencies for IV therapy. The Assistant Director of Nursing Services (ADNS) confirmed that competencies for IV therapy were reviewed with staff only when a resident was prescribed IV therapy, despite the facility's policy requiring these competencies to be completed upon hire and annually. Additionally, the facility did not ensure that staff were trained in the use, settings, and maintenance of LAL mattresses, as evidenced by the case of a resident with a stage 4 pressure ulcer. The resident's care plan required the LAL mattress to be set according to the resident's weight, which was 80 pounds. However, observations showed the mattress was incorrectly set at 260 pounds. Interviews with staff revealed confusion regarding the correct settings, and the ADNS admitted there was no in-service training or facility policy on the specific LAL mattress used. Manufacturer guidelines contradicted the care plan instructions, leading to further confusion among staff.
Failure to Serve Correct Diet to Resident
Penalty
Summary
The facility failed to ensure that food was served in the correct form for a resident on a mechanically altered diet. The resident, who had diagnoses including Alzheimer's disease, dysphagia, and hypertension, was prescribed a regular diet with chopped texture and thin consistency. Despite this, during a lunch meal observation, the resident was served a dinner roll, which was not allowed on a chopped diet. The resident's care plan and dietary guidelines clearly indicated the need for a chopped diet, yet the dietary staff did not adhere to these requirements. Interviews with staff revealed a lack of understanding and communication regarding dietary restrictions. A nursing assistant admitted to not knowing which foods were allowed on a chopped diet and assumed the food on the tray was correct. The Food Service Director acknowledged that a dinner roll was not appropriate for a chopped diet and was unsure why the resident received incorrect food items. The Speech Language Pathologist confirmed that a dinner roll should not have been served and expected staff to be aware of dietary needs. The facility's policy required food trays to be inspected to ensure correct meals were provided, but this was not effectively implemented.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preference, as observed during a dining review. Resident #90, who has diagnoses including dementia, hypertension, and muscle weakness, was identified as severely cognitively impaired but independent with eating. The resident's care plan included providing food and beverage choices, and a physician's order specified a regular diet with regular texture. However, during an observation, the resident was served an egg salad sandwich and macaroni salad instead of the assorted cold cereals indicated on their lunch ticket. Interviews with staff revealed that Nurse Aides served dietary trays as they were received from the kitchen without verifying the meal against the ticket. The Director of Dietary stated that a staff member is responsible for ensuring meals meet dietary restrictions and preferences before being placed on meal trucks. Despite this, the facility's Food and Nutrition Services policy, which requires inspection of food trays to ensure correct meals are provided, was not followed. The Nutrition Assessments policy also mandates interviews with residents or families to assess food preferences, which was not adhered to in this instance.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control procedures during wound care for a resident with a stage 4 pressure ulcer on the sacral region. The resident, who was severely cognitively impaired, was observed receiving wound care where the charge nurse, an LPN, placed the old dressing on the resident's top sheet before discarding it into a trash bag. The LPN then handled the resident's wound supply bag with dirty gloves, prompting the unit manager, an RN, to instruct the LPN to wash hands and apply new gloves. Despite this intervention, the LPN placed the trash bag on a television stand on top of an open nonsterile package of 4x4 dressings before washing hands. Additionally, the facility did not follow enhanced barrier precautions as required for the resident. The ADNS/IP/wound nurse noted that a gown should have been worn during the procedure, but the staff did not see the sign indicating enhanced barrier precautions outside the resident's door. The PPE carts were located in the hall, shared among residents requiring PPE, but no cart was outside the room. The facility's policy on hand hygiene and enhanced barrier precautions was not followed, as gowns and gloves were not immediately available near the resident's room, and the staff was unaware of the need for a gown during the procedure.
Failure to Provide Homelike Dining Environment in Memory Unit
Penalty
Summary
The facility failed to provide a homelike environment for residents in the memory unit during meal times. Observations on multiple occasions revealed that 30 residents were served their lunch meals on dietary trays. This practice was intended to act as a barrier to prevent residents from taking food from others, as confirmed by an interview with the Administrator.
Failure to Maintain Resident Dignity Due to Unprofessional Staff Comments
Penalty
Summary
The facility failed to ensure that staff comments within the hearing of a resident were respectful, which led to a deficiency in honoring the resident's right to a dignified existence. The incident involved a resident with severe cognitive impairment and dementia, who was admitted with diagnoses including loss of movement on both sides of the body after a stroke. The resident's care plan included interventions to explain procedures clearly and slowly, using short phrases that required yes or no answers. However, a grievance was filed by the resident's conservator after observing a video where a medical doctor (MD) made an inappropriate comment in the resident's room. The comment was related to a sign about camera usage and potential staff discipline, and although it was not directed at the resident, it was deemed unprofessional. The incident occurred when the MD noticed a sign in the resident's room that mentioned disciplinary actions for staff if the camera was obstructed. The MD found the sign offensive and made a comment to a vendor outside the room, questioning whether the discipline would involve a thrashing or spanking. This comment was overheard by staff who laughed, and although the MD provided care to the resident afterward without any noted unusual behaviors, the comment was considered unprofessional and inappropriate for the setting. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, which was not upheld in this instance.
Verbal Abuse Incident Involving Resident
Penalty
Summary
The facility failed to protect Resident #2 from verbal abuse by a nursing assistant (NA #1). Resident #2, who was admitted with anxiety and major depression, reported an incident where NA #1 accused them of being a troublemaker and making up stories. This incident occurred after a disagreement about a linen hamper and was witnessed by another staff member, LPN #1. The facility's investigation confirmed that NA #1 made disparaging remarks to Resident #2, which constituted verbal abuse as defined by the facility's policy. The facility's investigation revealed that NA #1 had a confrontation with Resident #2, during which NA #1 accused the resident of lying and causing trouble. This interaction was distressing for Resident #2, who was already identified as at risk for mood disturbances due to their mental health conditions. The facility's policy on abuse, neglect, and misappropriation clearly defines verbal abuse as the use of language that includes disparaging and derogatory terms, which NA #1's actions met. As a result of the investigation, NA #1's employment was terminated.
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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