Gardner Heights Health Care Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Connecticut.
- Location
- 172 Rocky Rest Road, Shelton, Connecticut 06484
- CMS Provider Number
- 075368
- Inspections on file
- 21
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Gardner Heights Health Care Center, Inc during CMS and state inspections, most recent first.
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 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.
A resident with diabetes, severe cognitive impairment, and high risk for skin breakdown developed a darkened area with a small open wound on the right great toe. Nursing staff measured only the open area and did not fully measure or classify the entire darkened area, and the wound was not evaluated by the wound APRN. Subsequent APRN assessment focused only on a wound on the left second toe, and the wound nurse, unaware of the right great toe issue, deleted the existing treatment order for that site when entering a new order for the left toe. As a result, there was no active treatment order or weekly wound documentation for the right great toe for a period of time, despite facility policy requiring weekly assessment and documentation of skin areas until healed.
The facility failed to meet state 3.0 PPD staffing requirements and its own facility assessment staffing ratios on multiple days, with combined RN/LPN and NA hours falling short of what was required for the census and specific shifts. The secured unit operated with fewer NAs than indicated by the facility’s own NA-to-resident ratios, despite a near-full census. Accident and incident logs documented numerous unwitnessed falls and injuries during the reviewed months, including events on the secured unit on days when staffing was below required levels. Administrative staff, including HR and the scheduler, reported relying on corporate direction and the administrator for staffing decisions and did not calculate or track required PPD hours, while NAs reported caring for more than 10 residents at times and expressed that additional NA support would be helpful.
Surveyors found that the facility’s required assessment of resources did not include its secured dementia unit or the building’s wander guard system, despite the presence of a locked, camera-monitored unit with coded entry/exit doors and a capacity of 35 residents. Documentation showed criteria for admission to the secured dementia unit based on dementia diagnoses and wandering or elopement behaviors, and the assessment identified numerous residents with dementia, impaired cognition, and behavioral health needs, with staff trained in dementia care. However, the physical environment section of the assessment omitted any reference to the secure unit or wander guard system, which the Administrator later acknowledged as an oversight.
A resident with dementia, osteopenia, and osteoarthritis, who required moderate assistance and a rolling walker for transfers, was moved from a chair to a bed by a nurse aide without the prescribed adaptive device. The aide used a stand and pivot transfer without the rolling walker, which had not been present in the room for some time. After the transfer, the resident was found to have a fractured left tibia and fibula.
The facility failed to maintain proper dishwasher temperatures in the Dietary Department, as the wash cycle was consistently below the manufacturer's guidelines of 150 degrees Fahrenheit. The temperature logs incorrectly stated that 140 degrees was acceptable, leading to oversight by staff. Neither the Dietary Manager nor a Dietary Aide noticed the manufacturer's guidelines, resulting in the deficiency.
The facility failed to provide a dignified dining experience, as staff were observed feeding residents while standing over them, contrary to policy. Additionally, some residents were isolated during meals, seated alone despite available space at other tables. The facility's feeding policy required staff to sit while feeding residents, but this was not consistently followed, and there was no policy on seating arrangements.
The facility failed to report injuries of unknown origin for two residents to the State Agency within the required timeframe. One resident with dementia and congestive heart failure had unexplained bruises and discoloration, while another with dementia and COPD had discolored areas and bruises. The DNS was unaware of the need to report such injuries unless they involved significant harm, leading to a compliance deficiency.
Three residents with significant weight loss did not receive their prescribed fortified cereal due to failures in dietary order processing and communication. Despite being listed on dietary rosters, the supplements were not served, and records inaccurately documented their consumption. This highlights deficiencies in the facility's coordination and adherence to dietary orders.
The facility failed to maintain the personal hygiene of three residents, who were observed with long facial hair despite requiring assistance with ADLs. Weekly body audits did not identify this issue, and staff interviews revealed a lack of documentation for care refusals. The facility's policy required individualized assistance, including shaving if needed.
A facility failed to monitor a resident's blood pressure before administering lisinopril, as required by a physician's order. The resident, diagnosed with dementia and hypertension, had a care plan that included taking vital signs before medication administration. However, staff did not consistently follow this directive over a 24-month period. An LPN admitted to not checking the blood pressure, believing the order did not require it, and the DNS confirmed the responsibility lay with the floor nurse. An APRN noted the resident was stable but highlighted the risk of administering the medication without prior blood pressure monitoring.
A resident with Alzheimer's and other health conditions developed a new heel ulcer due to the facility's failure to offload heels and follow hospice recommendations. Observations showed inconsistent heel offloading, and hospice recommendations were not reviewed by a provider, leading to inadequate wound care.
The facility failed to apply positioning devices as ordered for three residents with limited ROM. A resident with rheumatoid arthritis was observed without a required elbow splint, while another with cerebral infarction lacked a palm guard despite staff signatures indicating compliance. A third resident with a history of CVA was found without a palm guard due to staff citing combative behavior. These deficiencies were contrary to physician orders and care plans.
A resident with hemiplegia was involved in an incident during a transfer using a mechanical lift when the lift pad became unclipped, causing the resident to be lowered to the floor. The pad had a chipped clip and was part of a recalled batch due to its tendency to dislodge. The facility had been notified of the recall but failed to remove the pad from use, and the required pre-use inspection by staff was not effectively conducted.
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.
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.
Failure to Assess, Monitor, and Maintain Treatment Orders for Toe Wound
Penalty
Summary
The deficiency involves the facility’s failure to assess and monitor a resident’s toe wound according to professional standards and facility policy, and to maintain appropriate treatment orders. The resident, admitted with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, and muscle weakness, had severely impaired cognition and was dependent on staff for most ADLs, with care plans identifying diabetes and risk for skin breakdown due to decreased mobility and incontinence. On 4/1/26, the ADNS documented a darkened area with a small open area on the right great toe, measuring only the open area (0.3 x 0.1 x 0.1 cm) and not the entire darkened area, and obtained an order to cleanse with normal saline, apply bacitracin, and cover with a dry dressing daily for 10 days. The clinical record did not show that the darkened area on the right great toe was fully measured at the time of discovery, only the small open area, and there was no evidence that the wound was classified by nursing or the APRN at that time. The Wound Care APRN’s initial evaluation on 4/7/26 addressed only a diabetic foot ulcer on the left second toe and did not document any evaluation of the right great toe. During observations on 4/22/26 and 4/24/26, staff identified a discolored area with a scab on the right great toe, which they described as the same area first seen on 4/1/26, now appearing lighter. On 4/24/26, the wound nurse measured multiple components of the discolored area on the right great toe, but the ADNS acknowledged she had not originally measured both the open and darkened areas when first identified. The facility also failed to ensure ongoing weekly monitoring and a continuous physician order for the right great toe wound. The weekly wound documentation did not show thorough weekly assessment or monitoring of the right great toe from 4/1/26 through 4/22/26, despite facility policy requiring weekly documentation of skin areas until healed and weekly review at risk meetings. The wound nurse stated she was unaware of the right great toe area and therefore did not complete weekly documentation or monitoring. Additionally, the physician orders between 4/7/26 and 4/22/26 did not include a treatment for the right great toe wound because the wound nurse deleted the existing right great toe treatment order when entering a new order for the left second toe, later acknowledging this was a mistake. This resulted in a lack of an active treatment order and weekly monitoring for the right great toe wound during that period.
Failure to Meet 3.0 PPD and Facility-Defined Staffing Ratios
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet Connecticut Public Health Code minimum staffing requirements of 3.0 PPD and to follow its own facility assessment staffing ratios. On multiple reviewed days, the facility’s actual worked hours for licensed nurses and nurse aides (NAs) between 7:00 AM and 9:00 PM were below the required combined and licensed PPD hours for the census. For a census of 112 residents on a Saturday, the facility provided 238 combined PPD hours instead of the required 243.04, resulting in a 5.04-hour shortfall. On a Sunday with the same census, the facility provided 232 combined PPD hours instead of 243.04, with an 11.04-hour combined shortfall and a 1.84-hour shortfall in licensed hours alone. On a Monday with a census of 108 residents, the facility provided 216 combined PPD hours instead of the required 234.36, with a 5.56-hour shortfall in licensed hours and an 18.36-hour shortfall in combined hours. The facility also failed to meet its own staffing compliance grid and facility assessment ratios for specific shifts and units. For census ranges of 110–114 and 100–104, the facility’s staffing compliance guidelines required specific numbers of RN/LPNs and NAs on the 7 AM–3 PM and 3 PM–11 PM shifts, but the reviewed schedules showed shortages of NAs and RN/LPNs on several of those shifts. On the secured unit, which had a capacity of 35 and a daily census of 34, only 3 NAs were assigned, whereas the facility assessment’s NA-to-resident ratio (1:8–10 on days, 1:10–15 on evenings, 1:20–25 on nights) would have required 4 NAs for that census, resulting in a shortage of 1 NA on that unit. The facility assessment also called for 1 RN supervisor on each shift and licensed nurse-to-resident ratios of 1:30–35 on days and evenings and 1:40 on nights. Incident and interview data further reflected the staffing concerns and how staffing decisions were made. Accident and incident tracking showed multiple unwitnessed falls or injuries in the months reviewed, including 10 unwitnessed falls in November (with one on the secured unit on the cited Saturday), 20 unwitnessed incidents in January (with 3 before 9 PM on the cited Sunday, including one on the secured unit), and 14 unwitnessed incidents in April (with 1 on the cited Monday). On one of the understaffed days, the ADNS and DNS were pulled from their administrative roles to staff units, but the DNS time sheet still recorded the day as DNS hours rather than RN supervisor hours, and the DNS could not recall her main duties that day. The HR director, responsible for PBJ submissions, acknowledged low weekend staffing in prior months but could not state whether the facility was currently short-staffed and did not provide the updated staffing form. The scheduler reported that she filled schedules based on the administrator’s direction and did not calculate staffing based on PPD requirements or know the required hours per resident. The administrator stated awareness of the 3.0 staffing requirement but was not familiar with the specific hours-per-resident requirements and relied on corporate guidance, and nursing assistants reported that their assignments sometimes exceeded 10 residents per NA and that they could use additional NAs.
Failure to Include Secured Dementia Unit and Wander Guard System in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to include its secured dementia unit and associated wander management system in the required facility-wide assessment of resources needed to care for residents during routine operations and emergencies. Surveyors observed over multiple days that the building contained a secured unit on the right side of the facility, accessible only by doors requiring numeric codes to enter or exit, with additional coded exits leading to an internal courtyard and the exterior rear of the building, as well as a vestibule with coded doors and an interior entrance button. The unit had three hallways with cameras feeding to a monitor at the secured unit nurses’ station and a capacity of 35 residents. Sensors for a wander guard system were observed throughout the building, including near exit doors, and the system was confirmed to be operational. Review of facility documentation showed that the facility had established criteria for admission to a secured dementia unit, requiring a dementia diagnosis and behaviors such as elopement or wandering that necessitated closer supervision. The facility assessment identified 130 licensed beds and common diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, impaired cognition, and other behaviors requiring intervention, with an average of 36 residents having behavioral symptoms and cognitive performance issues and 36 residents receiving special treatments for behavioral health needs. The assessment also stated that all staff receive competency training on caring for residents with dementia, Alzheimer’s disease, and cognitive impairments. However, in the section addressing physical environment and building/plant needs, the assessment did not identify the wander guard system or the existence of the secure unit. In an interview, the Administrator confirmed there was a secured dementia unit policy, acknowledged that the secure unit was not included in the facility assessment and stated this was an oversight, and also confirmed the facility’s capacity as 120 beds.
Failure to Follow Physician's Order for Transfer with Adaptive Device
Penalty
Summary
A deficiency occurred when a resident with dementia, osteopenia, osteoarthritis, anxiety, and muscle weakness, who was assessed as requiring moderate assistance with transfers and the use of a rolling walker, was not transferred according to the physician's order. The resident's care plan and physician's order specified that transfers should be performed with the assistance of one staff member and a rolling walker. However, a nurse aide transferred the resident from a chair to a bed using a stand and pivot technique without the rolling walker and without additional staff present. The nurse aide also reported that the rolling walker had not been in the resident's room for some time and had not been used for transfers recently. Following this transfer, the resident was found to have swelling, pain, and bruising in the left lower leg, with decreased range of motion and guarding behavior. An x-ray revealed a fracture of the left tibia and fibula shaft, and the resident was subsequently sent to the emergency department. Interviews with facility staff confirmed that the transfer was not performed in accordance with the physician's order, and the required adaptive device was not used.
Failure to Maintain Proper Dishwasher Temperatures
Penalty
Summary
The facility failed to identify and address low dishwasher temperatures in the Dietary Department, which were below the manufacturer's guidelines. During an observation, it was noted that the wash cycle temperature of the high-temperature dishwashing machine was only reaching 141 degrees Fahrenheit, whereas the manufacturer's guidelines required it to be above 150 degrees Fahrenheit. The temperature logs from multiple days showed consistent recordings of 140 degrees Fahrenheit, but no follow-up actions were documented to address these low temperatures. The discrepancy arose because the temperature log sheet incorrectly stated that a minimum temperature of 140 degrees Fahrenheit was acceptable, leading to the oversight. Interviews with the Dietary Manager and a Dietary Aide revealed that neither had noticed the manufacturer's guidelines posted on the dishwasher, which specified the correct wash temperature. The Dietary Manager assumed the paper log was correct as it had been in use since her employment began, and the Dietary Aide did not recognize the low temperatures due to the incorrect information on the log sheet. This lack of awareness and adherence to the correct temperature guidelines resulted in the deficiency identified by the surveyors.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents in the Laurel dining room. Observations revealed that staff members, including nursing assistants and licensed practical nurses, were feeding residents while standing over them, rather than sitting at eye level as per facility policy. This practice was noted with multiple residents who were severely or moderately cognitively impaired and required assistance with eating. Despite the availability of chairs, staff members chose to stand, citing personal preference or lack of awareness of the policy. Additionally, the report highlights instances where residents were isolated during meals. Two residents were observed seated alone against a wall, separated from other residents who were dining together at tables. This was despite the availability of space at other tables and no documented reason for their isolation. Interviews with staff indicated a lack of awareness regarding the need for these residents to be seated with others, and it was noted that one resident's wheelchair did not fit under the dining tables, contributing to their isolation. The facility's feeding policy, dated December 7, 2023, explicitly directed staff to provide assistance during feeding in a dignified and respectful manner, which included not standing while feeding residents. However, interviews with staff, including the Director of Nurses and the MDS Coordinator, revealed a lack of adherence to this policy. The report also noted the absence of a facility policy regarding the placement of residents at dining tables, which may have contributed to the observed deficiencies.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report incidents of unknown origin involving two residents to the State Agency within the required 24-hour timeframe. Resident #23, who had diagnoses including dementia and congestive heart failure, was found with a bruise on the left shoulder and discoloration on the fingers and leg. Despite investigations, the facility could not determine the cause of these injuries and did not report them to the State Agency. Similarly, Resident #29, diagnosed with dementia and chronic obstructive pulmonary disease, was found with discolored areas on the finger and bruises on the forearm. Again, the facility was unable to identify the cause and failed to report these injuries. The Director of Nursing Services (DNS) admitted during an interview that he did not report these incidents because he was unaware of the requirement to report injuries of unknown origin unless they involved fractures or significant injuries. The facility's policy mandates that any injuries of unknown origin should be reported to the Department of Public Health within 2 hours if they involve abuse or serious bodily injury, or within 24 hours if they do not. This oversight led to a deficiency in the facility's compliance with reporting requirements.
Failure to Provide Nutritional Supplements to Residents
Penalty
Summary
The facility failed to provide a nutritional supplement for three residents with known weight loss, leading to deficiencies in their nutritional care. Resident #30, diagnosed with type 2 diabetes mellitus, dysphagia, and chronic kidney disease, experienced significant weight loss and was ordered to receive fortified cereal as a supplement. However, during an observation, it was noted that the fortified cereal was not served with the resident's breakfast, despite being listed on the Dietary Roster. The dietary aide admitted to the oversight, and the resident expressed a desire for the cereal, which was eventually provided after surveyor inquiry. Resident #53, with Alzheimer's disease and adult failure to thrive, also experienced weight loss and was recommended to receive fortified cereal. However, the dietary slip indicating this requirement was not properly processed, resulting in the resident not receiving the supplement. The dietary roster was not updated, and the fortified cereal was not included in the resident's breakfast. Despite this, the Medication Administration Record inaccurately documented that the resident had consumed the cereal, highlighting a discrepancy in record-keeping and communication between departments. Resident #105, suffering from severe protein-calorie malnutrition, anxiety, and chronic obstructive pulmonary disease, was also ordered to receive fortified cereal. However, the dietary roster did not reflect this order, and the resident did not receive the supplement with breakfast. The Medication Administration Record falsely indicated that the resident had consumed the cereal, pointing to a failure in the facility's process to ensure accurate documentation and delivery of nutritional supplements. These deficiencies demonstrate a lack of coordination and adherence to dietary orders, impacting the nutritional care of the residents.
Failure to Maintain Residents' Personal Hygiene
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident #44, Resident #56, and Resident #85, were free of facial hair, which is a part of their personal hygiene care. All three residents had diagnoses including dementia and required assistance with activities of daily living (ADLs), including personal hygiene. Despite having care plans and physician orders in place that required weekly body audits by a licensed nurse, these audits did not identify any issues with facial hair. Observations on multiple days revealed that these residents had visibly long facial hair below the lower lip, indicating a lapse in the provision of personal hygiene care. Interviews with nursing staff, including a nurse aide and an LPN, revealed that while they were responsible for assisting residents with shaving, there were instances where residents were combative or refused care. However, there was no documentation to support that these residents had refused shaving. The Director of Nursing Services (DNS) confirmed that refusal of care should be documented in the residents' clinical records, and any concerns should be noted on the Body Audit Form. The facility's policy on AM care/ADLs emphasized individualized assistance and honoring residents' preferences, including shaving if needed, unless otherwise indicated.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that blood pressures were taken prior to the administration of an antihypertensive medication, lisinopril, for a resident diagnosed with dementia and hypertension. The resident's care plan included interventions such as administering medications and obtaining vital signs as ordered. A physician's order specifically directed staff to take the resident's blood pressure before administering lisinopril and to withhold the medication if the systolic blood pressure was less than 110 mmHg. However, a review of the medication administration records over a 24-month period revealed that staff did not consistently take the resident's blood pressure before administering the medication. An interview with an LPN revealed that he did not obtain the resident's blood pressure prior to administering lisinopril, as he believed the order did not require it. The LPN suggested that the directive to take blood pressure might have been omitted when the order was placed. The Director of Nursing Services confirmed that the floor nurse was responsible for obtaining blood pressures for residents with such orders but could not explain why the directive was not included in the medication order. An APRN noted that the resident was stable but acknowledged the risk of a further drop in blood pressure if lisinopril was administered without checking the blood pressure first.
Failure to Offload Heels and Address Hospice Recommendations
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with multiple health conditions, including Alzheimer's disease, Lupus, peripheral vascular disease, and diabetes. The resident was severely cognitively impaired and dependent on staff for mobility and care. The care plan required offloading of the heels and turning and repositioning according to nursing standards. However, observations revealed that the resident's heels were not consistently offloaded, and the care plan was not followed. The resident developed a new open area on the right heel, which was not addressed in a timely manner. Hospice recommendations for treatment were not reviewed by a provider, and there was a lack of physician orders for the newly identified wound. Despite recommendations to ensure heel booties were in place bilaterally, observations showed that only one bootie was used, and the resident's heels were often in contact with the mattress or wheelchair without proper offloading. Interviews with staff revealed a lack of communication and adherence to facility policies regarding hospice recommendations and wound care. The facility's positioning policy required repositioning every two hours, but this was not consistently implemented. Additionally, the hospice recommendation for the right heel wound was not communicated to the physician, resulting in a delay in appropriate treatment. The facility's failure to follow the care plan and address hospice recommendations contributed to the resident's pressure ulcer development and inadequate care.
Failure to Apply Positioning Devices as Ordered
Penalty
Summary
The facility failed to apply positioning devices according to physician orders and rehabilitation plans for three residents with limited range of motion. Resident #8, diagnosed with osteoarthritis, contractures, rheumatoid arthritis, and PTSD, was observed without a left elbow splint on multiple occasions despite physician orders to wear it after morning care. The DNS acknowledged the splint was not applied due to a new nurse aide's difficulty with the task, which was contrary to the care plan and physician orders. Resident #33, with cerebral infarction and left-side hemiplegia, was also found without the required left hand palm guard on several occasions. Despite staff signatures on the MAR indicating compliance, the palm guard was not in place, and staff were unaware of its necessity. The OT confirmed the importance of the palm guard for maintaining functional positioning and noted the lack of documentation or notification regarding its absence. Resident #46, with a history of CVA and left-hand contracture, was observed without a left palm guard, which was supposed to be applied after morning care. The palm guard was found on the nightstand, and staff cited the resident's combative behavior as a reason for non-compliance. The LPN admitted to not verifying the palm guard's placement, and the PT highlighted the potential for worsened contractures if the device was not used as directed.
Failure to Ensure Safe Transfer with Mechanical Lift
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a mechanical lift, leading to an incident where the resident was lowered to the floor due to a mechanical lift pad becoming unclipped. The resident, who had left-sided hemiplegia and hemiparesis following a stroke, was non-ambulatory and required total dependence for transfers. The physician's order specified the use of a total mechanical lift for transfers, and the resident's care plan identified them as a fall risk. During a transfer, the mechanical lift pad's clip became loosened, causing the resident to be slowly lowered to the floor. Interviews with the nurse aides involved revealed that the pad had a chipped opening in one of the clips, which was not noticed before the transfer. The Director of Nursing Services examined the pad post-incident and found it intact, but it was removed from circulation as a precaution. Further investigation revealed that the mechanical lift pad used had gray clips, which had been recalled years prior due to their tendency to become dislodged. The facility had been notified multiple times about the recall, but the pad was still in use. The facility's policy required nursing assistants to inspect the integrity of slings before use, but this was not effectively implemented, contributing to the incident.
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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