Harbor Village North Health And Rehabilitation Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in New London, Connecticut.
- Location
- 78 Viets St Extension, New London, Connecticut 06320
- CMS Provider Number
- 075196
- Inspections on file
- 27
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harbor Village North Health And Rehabilitation Cen during CMS and state inspections, most recent first.
A resident with COPD, seizures, bradycardia, visual impairment, weakness, and a cognitive communication deficit, who required substantial assistance for transfers and used a wheelchair, experienced an unresponsive episode while seated on a bench in the supervised smoking area. After a NA reported the resident might not be breathing, an RN assessed the resident as breathing but nonverbal with abnormal skin color, then left the resident with two NAs and instructed them not to move the resident while she went inside to call a code and EMS, leaving no licensed nurse at the scene. During her absence, an LPN arrived, found the resident leaning forward and responsive, and, without RN direction, assisted with transferring the resident to a wheelchair and transporting the resident inside, before the RN’s assessment was completed. EMS later documented that staff could not provide a clear, consistent account of the incident, including whether a fall or head strike occurred, reflecting that the resident was moved and the event was not fully or accurately assessed and documented in accordance with facility policies for change in condition and accidents.
A resident with COPD, seizures, visual impairment, weakness, and documented dependence on a wheelchair for mobility was allowed by staff to walk with a rollator to a supervised smoking activity, despite physician orders limiting ambulation to therapy and a care plan requiring wheelchair use and assist for transfers. A CNA did not check the resident care card and relied on an RN, who did not verify orders or the care plan, before permitting the resident to walk without a wheelchair following. During the smoking session, two CNAs were supervising about twelve residents when the resident, seated on a bench, became slumped and unresponsive to verbal cues. One CNA, aware that two staff were required to remain outside, panicked and ran inside to get the RN instead of using required communication devices, leaving only one staff member with the group. A wheelchair was not readily available at the smoking area, requiring staff to search for one after the resident became unresponsive, and the resident was later transported to the hospital for acute hypoxemic respiratory failure.
The facility failed to prevent physical abuse when two residents with dementia and documented behavioral issues, including prior aggression and a history of anger and yelling, were placed together as roommates despite known personality incompatibilities. During a disagreement over room temperature, one resident reported that the other grabbed their neck, and the alleged aggressor admitted to putting hands on the peer and justified the action based on the peer’s language. A roommate witness confirmed seeing hands placed on the victim’s shoulders and an altercation occurring. This incident occurred in the context of existing care plans and staff knowledge that both residents had behavioral and mood-related risks, contrary to the facility’s zero-tolerance abuse policy.
A resident with dementia, cognitive impairment, and Parkinson’s disease with dyskinesia, who required extensive assistance with ADLs and mechanical-lift transfers, was found seated at the nurse’s station with an unwitnessed hematoma on the forehead. Staff assumed the resident had struck their head on the bed’s headboard due to dyskinesia, but no one observed the event and the cause was not confirmed. The ADNS interviewed only two NAs from the prior shift and did not interview the unit nurse who had recently interacted with the resident, despite facility policy requiring a broader 72-hour inquiry for injuries of unknown source. After the ADNS relayed an assumed explanation to a regional RN, the event was not reported to the State Agency as an injury of unknown origin, contrary to the facility’s abuse and reporting policy.
A resident with dementia, cognitive deficits, and Parkinson's disease with dyskinesia, who was dependent on staff for most ADLs and required two-person mechanical lift transfers, was found with an unwitnessed hematoma on the forehead while seated at the nurse’s station. No staff witnessed the incident, and only two NAs from the prior shift were interviewed, whose statements were inconclusive and based on an assumption that the resident hit their head on the bed’s headboard due to dyskinesia. The ADNS did not follow policy requiring a 72-hour look-back and broader staff interviews, did not interview the unit nurse who had interacted with the resident minutes before the injury was noted, and, after discussing with a regional RN, did not report the event to the State Agency as an injury of unknown origin based on the unverified assumption of cause.
The facility failed to conduct thorough investigations into multiple resident-to-resident abuse incidents. In one case, a resident with schizophrenia struck another with dementia, but staff statements were missing. Another incident involved a resident with intellectual disabilities threatening their roommate, yet staff documentation was incomplete. A third case saw a resident with schizoaffective disorder being punched, but again, staff statements were not obtained. The DNS acknowledged the investigations were incomplete, contrary to facility policy.
The facility failed to provide timely social services support to residents involved in abuse incidents. A resident with paranoid schizophrenia was not met by social services until a day after an incident, with follow-ups lacking. Another resident with vascular dementia had no documented social worker interaction regarding the incident. Similar deficiencies were noted for other residents, with social workers failing to meet within 24 hours and not following up daily for 72 hours.
The facility failed to maintain a clean kitchen environment and did not discard expired foods. Observations included dust-covered fans, dirty walls, and expired food items in storage. The Food Service Manager, new to the position, had not yet updated the cleaning schedule or checked expiration dates. The Administrator was aware of the issues and had made some improvements.
The facility failed to resolve cleanliness issues in the kitchen identified during environmental rounds from January to June 2024. The ICN noted these issues, but there was no evidence of resolution within the required 10-day period. Additionally, significant lint debris was observed in the laundry area, with no documentation of recent cleaning. The Laundry Manager, temporarily covering the position, could not provide cleaning records, indicating a failure to maintain cleanliness as per policy.
The facility failed to notify the physician of significant changes in the conditions of two residents. One resident with multiple co-morbidities experienced worsening symptoms, including abdominal pain and labored breathing, without timely assessment or physician notification, leading to hospitalization and eventual death. Another resident with congestive heart failure gained 35.1 pounds over two weeks without re-weighing or physician notification, potentially contributing to lower leg edema. Staff interviews revealed gaps in monitoring and documentation, highlighting deficiencies in care processes.
The facility failed to assess, care plan, and obtain consents for residents on a secured dementia unit. Observations showed restricted access requiring a code, with no criteria for placement or physician's orders. Clinical records lacked consent and documentation of the least restrictive setting, and care plans did not reflect secured unit placement.
A resident with paraplegia experienced pain due to long, thickened, and brittle toenails, despite regular podiatrist visits. The facility failed to provide specific foot care beyond shower care, and the podiatrist did not prescribe anti-fungal treatment due to the resident's age and co-morbidities. The facility's foot care policy and healthcare service agreement required appropriate care, but the resident's toenail condition persisted, indicating a deficiency.
Two residents reported dissatisfaction with the food quality and preparation at the facility. One resident, with dementia and other conditions, noted a lack of variety and flavor, while another resident with spinal cord injury and paraplegia expressed similar concerns. Observations confirmed issues such as undercooked pork, mushy zucchini, and raw quiche crust. The food service manager attributed some problems to the use of frozen vegetables and a late delivery. The facility's policy on cooking temperatures did not ensure food safety during plating and transport.
The facility failed to maintain a pest-free environment, with fruit flies observed in resident rooms and the hallway of the Northeast wing, and rodent droppings found in the kitchen's emergency food storage area. Despite previous pest control treatments, the issues persisted, indicating inadequate pest management and sanitation practices. Interviews with staff revealed a lack of awareness and documentation regarding pest control efforts.
A resident with cognitive impairments was exposed to the hallway during morning care due to an open door, and was spoken to disrespectfully by a nursing assistant. The incident was witnessed by a surveyor, and staff interviews confirmed the failure to maintain privacy and dignity, contrary to facility policy.
A resident with dementia and other conditions was not provided privacy during morning hygiene care, as observed by a surveyor. The resident was exposed to the hallway with the door open, and the care plan's privacy interventions were not followed. Staff interviews confirmed the expectation of privacy, aligning with the facility's policy on resident dignity.
The facility failed to monitor and assess two residents for changes in their health conditions. A resident with multiple co-morbidities experienced worsening symptoms without proper assessment or physician notification, leading to an emergency hospital transfer and subsequent death. Another resident with CHF had a significant weight gain, indicating potential fluid overload, but was not reassessed or reported to a physician in a timely manner. Staff interviews revealed communication lapses and protocol failures.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident's PRN Miralax order lacked frequency clarification despite agreement from the APRN, while another resident's Seroquel prescription required orthostatic BP monitoring, which was not conducted. Communication lapses between the pharmacy consultant, DNS, ADNS, and APRN contributed to these oversights.
A medication error occurred when an LPN crushed and administered medications to a resident, despite instructions not to crush enteric coated and extended-release medications. The resident, who was severely cognitively impaired, received Aspirin EC, Bupropion HCl ER, and Metoprolol Succinate ER in crushed form, leading to a facility medication error rate of 12%. The LPN admitted to not fully reading the medication instructions, and the RN Supervisor confirmed the error.
A facility failed to maintain complete medical records for a resident with GERD, bipolar disorder, and COPD. Signed pharmacist recommendations from several months were missing from the resident's chart, contrary to facility policy. Interviews revealed inconsistencies in the handling and filing of these documents, leading to incomplete records.
A facility failed to prevent altercations between two residents, one with dementia and behavioral disorders and another with moderate cognitive impairment. Despite known risks and previous incidents, interventions such as a Velcro cloth stop sign were not consistently implemented, leading to physical altercations. The oversight resulted in a deficiency related to abuse prevention.
Failure to Maintain Licensed Nurse Presence and Prevent Movement After Unresponsive Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing services met professional standards of quality during and after an unresponsive episode of unknown origin involving Resident #1. Resident #1 had multiple diagnoses, including COPD, myoclonus, seizures, bradycardia, macular degeneration, weakness, and a cognitive communication deficit, and required substantial assistance for transfers, used a wheelchair for locomotion, and was a supervised smoker per the care plan. On the morning in question, a nurse documented that the resident went to the smoking area using a rolling walker with assistance, instead of the usual wheelchair. Shortly thereafter, the nursing supervisor (RN #3) was notified by a nursing assistant (NA #1) that the resident was outside, possibly not breathing, and unresponsive. When RN #3 went to the smoking area, she observed the resident hunched over on a bench, breathing but nonverbal, not moving, with pale/abnormal skin color and eyes closed, and she assessed vital signs and neurological signs as normal. RN #3 instructed NA #1 and NA #2 to stay with the resident and not to move the resident while she returned inside to call a code, notify the charge nurse (RN #4), and contact EMS. During this time, no licensed nurse remained with the resident. When RN #3 finished the calls and returned her attention to the situation, she observed that LPN #1 was already pushing the resident in a wheelchair down the hallway toward the resident’s room, indicating the resident had been moved from the bench before RN #3 completed her assessment and without her direction. LPN #1 later reported that when she responded to the code in the smoking area, the resident was on a bench leaning forward, breathing, and answering questions appropriately, and that no RNs were present at that time. LPN #1 stated she sat the resident up, obtained a wheelchair, and, with the assistance of NA #1 and NA #2, transferred the resident to the wheelchair and transported the resident inside to the room. EMS documentation indicated they were notified that the resident had sustained a fall, was unconscious, not breathing, and possibly in cardiac arrest, but upon arrival found the resident in bed, conscious but in an altered state, and staff were unable to provide an accurate, consistent description of the incident or confirm whether a head strike occurred. The facility’s policies on change in condition and accidents required licensed nurses to complete and document assessments of changes in condition and to provide supervision and a safe environment, but there was no specific policy for unresponsive episodes provided, and RN #3 acknowledged she did not remain with the resident or document staff reports about the resident leaning forward and falling back on the bench.
Failure to Follow Mobility Orders and Emergency Procedures During Supervised Smoking
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and appropriate use of assistive devices to prevent accidents during a supervised smoking activity. The resident involved had multiple diagnoses, including COPD, myoclonus, seizures, bradycardia, macular degeneration, weakness, and a cognitive communication deficit. A physician’s order directed assist of one for all transfers with a rollator and specified that the resident was to ambulate with therapy only. The admission MDS documented that the resident required substantial assistance for transfers, did not ambulate, used a wheelchair, and was dependent on staff for mobility. The resident’s care plan identified the resident as a current smoker with ADL self-care, mobility, and performance deficits due to failure to initiate, weakness, and impaired vision, and required supervision for smoking at all times, assist of two for transfers, wheelchair use for locomotion, and monitoring for altered respiratory status. On the day of the incident, a nurse’s note documented that the resident went to the smoking activity using a rolling walker with staff assist because the resident wanted to walk rather than use the wheelchair. NA #6 reported that she had initially assisted the resident into a wheelchair for the smoking activity, but when the resident requested to walk with a rolling walker, she did not reference the resident care card and instead asked RN #4 if the resident could walk. RN #4 told her it was fine and that the resident could use the exercise, without checking physician’s orders or the care plan. NA #6 then walked alongside the resident, without a wheelchair following, as the resident used the rolling walker down the hallway to the dining room, where the resident was seated to wait for the outside smoking activity. NA #6 then left the resident and returned to the unit. During the supervised smoking activity, NA #1 and NA #2 were responsible for supervising approximately twelve residents, including the resident involved. NA #1 stated that the resident walked outside independently with a rolling walker and sat on a bench. About fifteen minutes into the activity, NA #1 observed the resident slumped forward and to the right, appearing faint and unresponsive to verbal cues. NA #1 reported that she panicked and ran inside to locate RN #3, leaving NA #2 alone with the resident and the other residents, despite knowing that two staff were required to remain outside during the smoking activity. The facility’s smoking policy required that walkie-talkies or electronic devices be brought out with the smoking cart and used to contact the supervisor in case of emergency, but NA #1 reported that walkie-talkies were not utilized and she did not think to call the facility main line. RN #3 documented that she was notified in person by NA #1 that the resident might not be breathing, and upon going outside, she observed the resident hunched over on a bench, breathing but nonverbal, not communicating, and with pale/abnormal skin color. RN #4 documented that when informed by the nursing supervisor that the resident was slumped over in the smoking area, she went to check and found the resident unresponsive with abnormal skin color and initiated a sternal rub. She then went back into the building to obtain oxygen, and when she returned, the resident was responsive and in a wheelchair being brought toward the room by another nurse. Oxygen was applied in the hallway, and the resident had one episode of vomiting as EMS arrived to transport the resident. Interviews with the Director of Rehab and the DON confirmed that the resident was unsafe to ambulate with nursing staff, required a wheelchair within reach at all times due to unpredictable weakness and balance, and that NA #6 and RN #4 failed to verify and follow the resident’s ambulation and transfer orders. The DON also stated that staff supervising smoking were responsible for having a cell phone to contact the nursing supervisor and that NA #1 should not have left the smoking area with only one staff member present. The facility’s accident and incidents policy required the provision of appropriate assistive devices and supervision to prevent avoidable accidents, but staff did not follow these requirements, and a facility policy for following physician’s orders was not provided when requested.
Failure to Prevent Resident-to-Resident Physical Abuse Between Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by allowing two residents with known behavioral issues to be placed together as roommates, which led to a physical altercation. Resident #15 had diagnoses including vascular dementia with behaviors, schizophrenia, and paranoid personality disorder, with a care plan noting potential for behaviors related to dementia, paranoia, delusions, a history of physical aggression, and a prior resident-to-resident altercation. Resident #40 had diagnoses including unspecified dementia, bipolar II disorder, and anxiety, with a care plan identifying risk for mood and behavioral issues such as rummaging, anger, yelling at staff, increased delusions, and confusion. Despite these documented behavioral risks, the residents were roomed together. Prior documentation showed that Resident #15 had a past reportable event involving an alleged altercation with a roommate, where words were exchanged and there was an allegation that Resident #15 grabbed the roommate’s arm, though both residents later denied physical contact and no injuries were found. Nursing and psychiatry notes following that earlier event did not identify ongoing resident-to-resident altercations, and subsequent notes up to the time of the later incident did not document further altercations. However, the care plan for Resident #15 continued to reflect a history of physical aggression and a prior resident-to-resident altercation. On the date of the cited incident, Resident #40 reported to a nurse aide that Resident #15 grabbed them around the neck after Resident #40 adjusted the room thermostat. Resident #15 admitted to putting hands on Resident #40 and justified the action by stating that the other resident had a foul mouth and deserved it. A roommate witness reported seeing Resident #15 place hands on Resident #40’s shoulders and confirmed that an altercation occurred. Staff interviews described Resident #40 as someone who could get mad, loud, and unpleasant with others and as having a feisty personality, and Resident #15, usually quiet, was identified as the aggressor who grabbed Resident #40’s neck during a disagreement over room temperature. The facility’s abuse prohibition policy required a zero-tolerance environment free from abuse, but the placement of these two residents together, despite known behavioral histories and personality incompatibility, led to a physical abuse incident in which Resident #15 grabbed Resident #40 around the neck.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by policy and regulation. One resident with dementia with agitation, cognitive communication deficit, and Parkinson’s disease with dyskinesia had significant ADL and mobility deficits and required extensive staff assistance, including two-person assist and a mechanical lift for transfers. The resident’s care plan reflected these needs. On the morning of 2/18/26, while the resident was seated in a wheelchair at the nurse’s station, an LPN observed a hematoma on the left side of the resident’s forehead. No one had witnessed how the injury occurred, and the cause was unknown at the time it was discovered. Staff concluded that the resident had likely hit their head on the bed’s headboard earlier in the morning due to intermittent dyskinesia. The Assistant Director of Nursing (ADNS) consulted with the Regional Director of Clinical Services (RN #3) and reported that the injury could be explained by dyskinesia, leading RN #3 to determine that the event did not need to be reported as an injury of unknown origin within the 24-hour reporting window. The ADNS did not follow the facility’s abuse policy requirement to conduct a complete investigation by interviewing all staff with access to the resident in the prior 72 hours; instead, only the two NAs from the previous shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. The facility’s policy defined an injury of unknown source as one not observed or not explainable by the resident and suspicious due to its extent or location, and directed reporting of such events to the State Agency within specified time frames. Because the investigation was incomplete and the source of the injury remained unwitnessed and unexplained, the injury met the facility’s definition of an injury of unknown origin, but it was not reported to the State Agency.
Failure to Thoroughly Investigate Resident Head Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for Resident #47, who had dementia with agitation, cognitive communication deficit, and Parkinson's disease with dyskinesia. The resident had moderate cognitive impairment and required extensive assistance, including two-person assist with a mechanical lift for all transfers and dependence for most ADLs. On the morning of 2/18/26, staff observed an unwitnessed hematoma on the left side of the resident’s forehead while the resident was seated in a wheelchair at the nurse’s station. No one had witnessed how the injury occurred, and the two NA statements were inconclusive, only assuming the resident had hit his/her head on the bed’s headboard earlier in the morning due to dyskinesia. The ADNS reported that, after conferring with the Regional Clinical Director (RN #3) and indicating the cause was believed to be related to dyskinesia, it was determined the injury did not need to be reported to the State Agency as an injury of unknown origin within the 24-hour reporting window. The ADNS acknowledged not following the facility’s abuse policy requirement to conduct a thorough investigation, including going back 72 hours and interviewing all staff with access to the resident; instead, only the two NAs from the prior shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. RN #3 stated she believed a complete and thorough investigation had been done and that the cause was known, and that she would have had the injury reported as an injury of unknown origin had she known the investigation was incomplete. The facility’s abuse policy required a thorough investigation of alleged abuse or neglect by the Administrator and/or DON to determine if conduct violated standards of care, which was not carried out in this case.
Incomplete Investigations into Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into multiple incidents of resident-to-resident abuse involving five residents. In one incident, a resident with paranoid schizophrenia and antisocial personality disorder struck another resident with vascular dementia and behavioral disturbances. The facility's reportable event documentation lacked statements from staff who witnessed the incident, and the acting Director of Nursing Services (DNS) was unable to explain why these statements were not obtained. The nursing supervisor on duty did not have a clear list of caregivers assigned to the involved residents, which contributed to the incomplete investigation. Another incident involved a resident with severe intellectual disabilities threatening to harm their roommate, who had dementia and schizophrenia. Although the residents were separated and emergency services were notified, the facility's documentation did not include statements from the staff responsible for the residents' care during the incident. The DNS acknowledged the lack of complete documentation and was unsure why the necessary statements were not collected. A third incident involved a resident with schizoaffective disorder being punched by another resident. The nursing supervisor documented the physical injuries sustained by the victim but failed to obtain statements from staff present during the altercation. The DNS admitted that the investigations into these incidents were incomplete due to missing staff statements and a lack of documentation regarding the residents' status before the incidents. The facility's policy required a thorough investigation by the DNS or Social Services department, which was not fulfilled in these cases.
Failure to Provide Timely Social Services Support After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide timely social services support to residents involved in resident-to-resident abuse incidents. Five residents were reviewed for such incidents, and it was found that the facility did not ensure that social services met with the residents within the required timeframe. For instance, Resident #1, diagnosed with paranoid schizophrenia and other disorders, was involved in an incident on 8/7/24 but was not met by social services until the following day. Subsequent follow-ups were also lacking, as there were no social service notes from 8/9/24 through 8/11/24 and from 8/13/24 through 8/20/24. Resident #2, who has vascular dementia and other behavioral issues, was also involved in the same incident on 8/7/24. However, there was no documentation of any social worker interaction with this resident regarding the incident throughout the entire month of August. Social Worker #1 admitted to not remembering meeting with the resident, which resulted in the absence of documentation. This lack of timely intervention and documentation was a recurring issue for other residents involved in similar incidents. Residents #3, #4, and #5 also experienced deficiencies in social services follow-up after incidents of resident-to-resident abuse. For example, Resident #3 was involved in an incident on 8/30/24, but follow-up documentation was missing from 9/1/24 through 9/8/24. Similarly, Resident #4, involved in the same incident, had no further social service documentation after the initial meeting on 8/30/24. The facility's social workers failed to consistently meet with residents within 24 hours of incidents and did not follow up daily for the required 72 hours, as confirmed by interviews with the social workers and the facility administrator.
Deficiencies in Kitchen Cleanliness and Food Expiration Management
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not discard expired foods, as observed during a tour of the Dietary Department. The inspection revealed a ceiling fan covered with dust blowing over washed silverware and mugs, walls in the dishwashing area coated with dust, and a foul odor emanating from the sink area due to grime and dirt accumulation. Additionally, the vent above the stove was dusty while food was being prepared, and the cleaning schedule did not include fans, walls, or ceiling tiles. The Food Service Manager, who had been in the position for four weeks, acknowledged the need for steam cleaning the kitchen and had reported the cleanliness issues in meetings. However, the cleaning schedule did not cover all necessary areas, and the responsibility for cleaning certain areas was unclear between the kitchen staff and the maintenance department. The Sanitarian had previously identified cleanliness issues during an inspection and noted that staff were cleaning the kitchen during a follow-up visit. Expired food items were found in the emergency food supply and the walk-in freezer, including cereal, pudding, canned fruits, and meats. The Food Service Manager admitted to not checking expiration dates yet and stated that it was the responsibility of the staff stocking the freezer. The Dietician noted that serving expired food could make residents ill. The Administrator was aware of the cleanliness issues and had made some improvements but acknowledged that the cleaning schedule needed updates.
Failure to Address Cleanliness Issues in Kitchen and Laundry Areas
Penalty
Summary
The facility failed to address cleanliness issues identified during monthly environmental rounds from January 2024 to June 2024. The Infection Control Nurse (ICN) and other staff were responsible for conducting these rounds, and they noted cleanliness issues in the kitchen. However, there was no evidence that these issues were resolved within the 10-day timeframe as required by the facility's policy. The ICN confirmed that the cleanliness of the kitchen remained an issue throughout this period, indicating a lack of follow-through on identified problems. Additionally, during an observation in the laundry area, significant lint debris was found on the back wall, ceiling wall, metal pipe, and floor where the washing machines were located. The Laundry Manager, who was temporarily covering the position, could not provide documentation of when these areas were last cleaned. This indicates a failure to maintain a clean laundry area, as required by the facility's Environmental Rounds Best Practice policy, which mandates that problem areas be resolved and documented within 10 days.
Failure to Notify Physician of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of two residents, leading to deficiencies in care. Resident #16, who had multiple co-morbidities including chronic anemia, cirrhosis, and heart failure, experienced a significant change in condition with symptoms such as abdominal pain, vomiting, and labored breathing. Despite these symptoms, there was a lack of timely and thorough assessment by the nursing staff, and the physician was not notified of the resident's worsening condition. This oversight resulted in the resident being sent to the hospital in a critical state, where they later expired. Resident #43, diagnosed with congestive heart failure, diabetes, and dementia, experienced a significant weight gain of 35.1 pounds over two weeks. The facility failed to re-weigh the resident or notify the physician of this significant change, as required by their weight policy. The oversight in monitoring and reporting the resident's weight gain potentially contributed to the resident's lower leg edema, which was noted in the clinical record. The lack of communication and follow-up on the resident's condition highlights a deficiency in the facility's care processes. Interviews with facility staff, including the ADNS, LPNs, and the dietician, revealed gaps in the monitoring and documentation of the residents' conditions. The staff acknowledged the failure to conduct thorough assessments and notify the physician of significant changes. The facility's policy on changes in a resident's condition or status was not adhered to, resulting in a lack of timely intervention and appropriate care for the affected residents.
Failure to Assess and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to properly assess, care plan, and obtain necessary consents for residents residing on a secured dementia unit. Observations during the survey period revealed that the secured unit required a code for entry and exit, and only staff were observed using the code. The facility assessment did not include criteria or specific functions for the unit, and interviews with facility staff confirmed that there were no established criteria for placing residents on the secured unit. The decision to place residents was based on diagnoses or family requests, without a formal assessment process or physician's orders. The clinical records of thirty-eight residents on the secured unit did not show evidence of consent from responsible parties, physician's orders, or documentation that the secured unit was the least restrictive setting. Care plans did not reflect the residents' placement on the secured unit or agreement from residents or their responsible parties. Interviews with the facility's administration and staff confirmed the lack of criteria for placement and the absence of reassessments to ensure the appropriateness of the secured unit for residents.
Deficiency in Toenail Care for Resident with Paraplegia
Penalty
Summary
The facility failed to provide necessary services for maintaining good grooming and personal care for a resident with paraplegia, specifically related to toenail care. The resident, who had intact cognition and used a wheelchair, experienced pain due to long toenails. Observations revealed that the toenails were thickened, yellowed, brittle, and had grown over the ends of the toes. Despite regular visits from a podiatrist, the resident's toenails remained problematic, and the facility did not provide specific foot care beyond shower care. The podiatrist's notes indicated that the resident had fungal nails that were debrided, but anti-fungal treatment was not prescribed due to the resident's age and co-morbidities. The facility's foot care policy stated that residents should receive appropriate care to maintain foot health, and those with foot disorders should be referred to qualified professionals. However, the resident continued to experience issues with toenail care, as the podiatrist did not recall the resident and did not make a referral for oral anti-fungal medication. The facility's healthcare service agreement with the podiatry group required care and treatment in accordance with professional standards, yet the resident's toenail condition persisted, indicating a deficiency in the facility's adherence to its own policies and agreements.
Deficiency in Food Preparation and Serving Standards
Penalty
Summary
The facility failed to provide food that was prepared in a manner to conserve nutritive value and in a palatable manner for two residents. Resident #20, who has diagnoses including unspecified dementia, major depressive disorder, and diabetes insipidus, reported that the food lacked variety and flavor, with an overuse of pasta. The menu review showed frequent repetition of pasta dishes over several weeks. An observation and taste test of a lunch meal revealed issues such as undercooked pork, mushy zucchini, and a raw quiche crust. The food service manager confirmed the issues with the quiche and zucchini, attributing the latter to the use of frozen vegetables and a late delivery truck. Resident #39, with diagnoses including unspecified injury to the lumbar spinal cord and paraplegia, expressed dissatisfaction with the food choices and preparation, noting that the food was sometimes overcooked or undercooked. During an observation, Resident #39 was seen pushing away his lunch tray, indicating he did not consume the meal. A test tray observation confirmed the issues with the meal, including overcooked zucchini and undercooked quiche. The food service manager acknowledged the substitution of zucchini for broccoli due to a late delivery and confirmed the quiche was undercooked. The facility's policy on proper cooking temperatures was reviewed, highlighting the importance of maintaining food outside the danger zone to prevent bacterial growth. However, the policy did not account for maintaining the appropriate temperature during plating and transport. The dietician noted that consuming undercooked or raw foods could cause gastrointestinal symptoms and that overcooking could lead to a loss of nutritional value. The facility's failure to adhere to proper food preparation and serving standards resulted in unpalatable and potentially unsafe meals for the residents.
Pest Infestation in Resident Rooms and Kitchen Storage
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of fruit flies in several resident rooms and the hallway of the Northeast wing. Observations revealed fruit flies in rooms 15, 18, and 20, with significant infestations noted on overbed tables, side tables, and beds. The presence of food items, such as cups of orange juice and sandwiches, contributed to the infestation. Despite previous pest control treatments, the issue persisted, indicating inadequate pest management and sanitation practices. In addition to the fruit fly issue, the facility's kitchen food storage area showed signs of rodent infestation. Observations identified chewed markings and fecal droppings on emergency food supplies, including cans of diced peaches, carrots, and corned beef hash. The flooring beneath the storage racks was also coated with fecal droppings. Interviews with the Food Service Manager and review of pest control invoices revealed that the facility had a history of rodent issues, with treatments conducted twice monthly. However, the presence of droppings indicated that these measures were insufficient. Interviews with facility staff, including the Administrator and DNS, highlighted a lack of awareness and documentation regarding pest control efforts. The Administrator admitted to changing pest control companies due to unsatisfactory results, while the DNS mentioned that treatments for fruit flies were conducted outside, as the chemicals could not be used indoors. The facility's failure to effectively address pest issues in both resident areas and food storage environments demonstrates a significant deficiency in maintaining a sanitary and safe environment for residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident #33, during morning hygiene care. Resident #33, who has diagnoses including unspecified dementia, a history of traumatic brain injury, and Asperger's syndrome, was observed in a vulnerable state with the door to their room open, exposing their naked body to the hallway. The resident, who has moderately impaired cognition and requires assistance with daily activities, was subjected to undignified treatment by a nursing assistant (NA#1). NA#1 responded to the resident's repeated comments about a smell with a disrespectful and inappropriate remark, which was repeated multiple times. This interaction was witnessed by a surveyor, prompting NA#1 to close the door belatedly. Interviews with staff, including NA#1, LPN#1, and RN#1, confirmed that the resident's privacy should have been maintained by closing the door or drawing the curtain during care. NA#1 acknowledged the failure to provide privacy and admitted that the comment made to the resident was inappropriate. LPN#1 identified the incident as verbal abuse and emphasized the importance of reporting such behavior immediately. The facility's policy on dignity, which mandates respectful communication and the protection of resident privacy, was not adhered to in this instance.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy for Resident #33 during personal care, as observed by a surveyor. Resident #33, who has diagnoses including unspecified dementia, a history of traumatic brain injury, and Asperger's syndrome, was observed receiving morning hygiene care with the door open, exposing the resident's naked body to the hallway. The care plan for Resident #33, which includes interventions for privacy during care, was not followed. NA#1, who was providing the care, responded inappropriately to the resident's repeated comments about a smell, using the resident's first name in a frustrated manner. It was only after noticing the surveyor that NA#1 closed the door. Interviews with NA#1, LPN#1, and RN#1 confirmed that privacy should have been maintained by closing the door or drawing the curtain during care. The facility's policy on Quality of Life Dignity, revised in 2009, directs staff to promote and protect resident privacy during personal care and treatment procedures. The failure to adhere to these policies and procedures resulted in a deficiency related to the privacy and dignity of Resident #33.
Failure to Monitor and Assess Changes in Residents' Conditions
Penalty
Summary
The facility failed to consistently monitor and assess two residents for changes in their health conditions, leading to deficiencies in care. Resident #16, who had multiple co-morbidities including chronic anemia, cirrhosis of the liver, and heart failure, experienced an acute onset of nausea and vomiting. Despite orders for close monitoring and assessments, the facility's nursing staff did not document complete assessments or notify the attending physician of significant changes in the resident's condition, such as altered mental status, shortness of breath, and labored breathing. The resident's condition worsened, leading to an emergency transfer to the hospital, where the resident later expired. Resident #43, diagnosed with congestive heart failure, diabetes, and dementia, experienced a significant weight gain of 35.1 pounds over a short period. The facility failed to reassess the resident or notify the physician of this significant change, which could indicate fluid overload due to CHF. The weight gain was not addressed until much later, despite the potential for contributing to the resident's lower leg edema. Interviews with facility staff, including LPNs, RNs, and the APRN, revealed a lack of communication and failure to follow protocols for monitoring and reporting changes in residents' conditions. The facility's policy required prompt notification of changes to the attending physician and detailed assessments by nursing staff, which were not adhered to in these cases. The deficiencies highlight a failure in the facility's processes for managing residents' health changes effectively.
Failure to Implement Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to implement pharmacy review recommendations for two residents, leading to deficiencies in medication management. For one resident with diagnoses including GERD, bipolar disorder, and COPD, the pharmacist recommended clarifying the frequency of a PRN Miralax order on multiple occasions. Despite the APRN agreeing to the recommendation, the order was not updated in the resident's medical record, and the facility's policy requiring action within 30 days was not followed. Interviews revealed communication issues between the pharmacy consultant, DNS, ADNS, and APRN, contributing to the oversight. Another resident with diagnoses of unspecified dementia, psychosis, and Asperger's syndrome was prescribed Seroquel, which can cause orthostatic hypotension. The pharmacist recommended monitoring orthostatic blood pressures, and the physician agreed to this recommendation. However, the facility failed to implement the order, as no orthostatic blood pressures were recorded in the resident's medical record. Similar communication lapses were noted, with the APRN and DNS not ensuring the recommendation was acted upon. The facility's policy on Medication Regimen Review and Reporting requires that recommendations be communicated to the DNS or designee and acted upon within 30 days. However, the facility did not adhere to this policy, resulting in unaddressed pharmacy recommendations for both residents. The lack of follow-through on these recommendations highlights a breakdown in the facility's processes for managing medication regimens and ensuring resident safety.
Medication Administration Error Due to Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an incident involving a resident with diagnoses including hypertension, depression, repeated falls, and anxiety. The resident was severely cognitively impaired and required assistance with personal hygiene, bed mobility, transfers, and supervision with eating. On a specific date, an LPN prepared and administered medications to the resident by crushing and mixing them in applesauce, despite pharmacy directions indicating that the medications should not be crushed. The medications included Aspirin enteric coated (EC), Bupropion Hydrochloride (HCl) extended release (ER), and Metoprolol Succinate ER, all of which have specific release mechanisms that are compromised when crushed. The LPN, who was not the regular nurse for the unit, admitted to not fully reading the medication administration record and instructions, leading to the error. The RN Nursing Supervisor confirmed that the administration orders should have been followed. The Pharmacy Consultant explained the potential effects of crushing these medications, such as faster release and potential irritation. The facility's total medication error rate was reported to be 12%, and the facility's policy required medications to be administered according to orders, with staff verifying the right resident, medication, dose, time, and method before administration.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to ensure that medical records for a resident were readily accessible and complete, as required by professional standards. The resident in question had diagnoses including gastro-esophageal reflux disease (GERD), bipolar disorder, and chronic obstructive pulmonary disease (COPD). The facility's deficiency was identified during a clinical record review, which revealed that signed copies of pharmacist recommendations from December 2023 to February 2024 were missing from the resident's medical records. These recommendations were supposed to be part of the resident's medical chart, but they were not filed appropriately, as confirmed by interviews with the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS). The facility's policy on medication monitoring and regimen review required that findings be communicated to the director of nursing or designee and documented in the resident's chart. However, the process was not followed correctly, as the recommendations were found outside the medical chart and not filed under the pharmacy tab as expected. Interviews with the former DNS and medical records personnel revealed a lack of clarity and consistency in the handling and filing of these documents, contributing to the incomplete medical records for the resident.
Failure to Prevent Resident Altercations
Penalty
Summary
The facility failed to protect two residents from mistreatment, resulting in a deficiency related to abuse prevention. Resident #1, who had diagnoses including dementia and behavioral disorders, was known to exhibit behaviors such as wandering and intruding into others' spaces. Despite being identified as an elopement risk and having a history of altercations, the facility did not effectively prevent Resident #1 from entering Resident #2's room, leading to a confrontation. Resident #2, who had moderate cognitive impairment and a potential for mood disorders, was found in a physical altercation with Resident #1, which was not prevented by the facility's interventions. On two separate occasions, Resident #1 entered Resident #2's room, leading to incidents of yelling and physical altercations. The first incident occurred when Resident #1 was found next to Resident #2's bed, causing Resident #2 to yell for Resident #1 to leave. Although a Velcro cloth stop sign was placed across Resident #2's doorway as a deterrent, it was not documented as being in place during a subsequent incident. During the second incident, both residents were observed punching each other, resulting in red marks on their faces, indicating a failure to maintain a safe environment. The facility's documentation and interviews revealed that the interventions to prevent Resident #1 from entering Resident #2's room were not consistently implemented. Despite the known behaviors of Resident #1 and the previous altercations, the Velcro cloth stop sign was not in place during the second incident, allowing Resident #1 to enter the room and engage in a physical altercation with Resident #2. This oversight contributed to the deficiency in ensuring residents were free from mistreatment and abuse.
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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