Havencare At Valerie Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrington, Connecticut.
- Location
- 1360 Torringford St, Torrington, Connecticut 06790
- CMS Provider Number
- 075332
- Inspections on file
- 37
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Havencare At Valerie Manor during CMS and state inspections, most recent first.
Three residents with pain and anxiety diagnoses had discontinued controlled medications (oxycodone and lorazepam) that went missing from narcotic lock boxes, along with the associated proof-of-use sheets. One resident with lumbar spine surgery and mood disorders had PRN oxycodone ordered and care planned for pain management, another resident with dementia had PRN oxycodone ordered and later discontinued, and a third resident with dementia and anxiety had PRN lorazepam ordered and discontinued. A drug audit revealed that multiple tablets of these discontinued medications, stored in the back of unit narcotic boxes for later destruction, could not be accounted for, and subsequent review showed that many nurses had access to the narcotic storage during the period between audits, with no staff member identified as responsible for the removal.
The facility failed to properly document, classify, and timely report an incident involving missing discontinued controlled medications belonging to three residents. An internal reportable event form noted that discontinued meds scheduled for destruction were missing but did not identify the affected residents or the specific drugs. Subsequent documentation showed that multiple tablets of Oxycodone and Lorazepam tied to these residents were unaccounted for, and disposition sheets were also missing. The event was reported to the State Agency 10 days after it was identified, was initially misclassified as a non-abuse event, and was not treated as potential misappropriation, despite facility policies requiring that alleged violations be reported promptly and that incident reports include the names of individuals involved and detailed event information.
The facility failed to maintain proper control and accountability of discontinued narcotic medications, resulting in missing Oxycodone and Lorazepam tablets for three residents with pain, dementia, and anxiety. Discontinued controlled drugs remained in unit narcotic lock boxes instead of being promptly removed to a secured nursing office lock box, and both the white proof-of-use sheets and matching medication packs went missing. An LPN’s narcotic audits did not include MAR review, discrepancies were adjusted to match proof-of-use sheets, and required dual nurse signatures for end-of-shift narcotic counts were missing on multiple dates. These actions and omissions violated the facility’s own controlled substance handling policy and led to unaccounted-for controlled substances.
Two cognitively impaired residents with a history of inappropriate sexual behaviors were allowed to spend time together in a common area with care plan restrictions limiting their contact to hand holding, as consented by their court-appointed conservators. Despite these restrictions, staff observed one resident with their chest exposed and the other in contact with the exposed area, constituting non-consensual sexual contact. Staff interviews confirmed awareness of the residents' relationship and care plan limitations, but inadequate supervision led to the incident, violating facility policy to protect residents from abuse.
Nursing staff administered medications as ordered but failed to document administration in the MAR at the time of delivery, instead recording doses hours later for multiple residents with complex medical needs. This practice was identified through an internal audit and confirmed by interviews, with facility leadership and policy requiring immediate documentation.
A resident with dementia and a history of falls suffered an unwitnessed fall resulting in bilateral femur fractures. Although the care plan was eventually updated to include a bolster mattress as a fall prevention measure, this intervention was not added or implemented until several days after the incident, indicating a delay in updating and executing care plan interventions following the injury.
A nurse aide verbally abused a resident with severe cognitive impairment by loudly confronting the resident in the dining room, using inappropriate language and aggressive gestures. Multiple staff witnessed the incident, and the aide admitted to making the statement out of frustration. The event caused the resident emotional distress and was substantiated as abuse according to facility policy.
Staff did not immediately report an incident where a resident with severe cognitive impairment was observed touching another resident inappropriately. An LPN initially reported only partial details, resulting in a delay of over 16 hours before the DON notified the State Agency, which was not in accordance with the facility's abuse reporting policy.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained unexplained right foot fractures. The facility failed to conduct a thorough investigation, as required by its abuse policy, by not obtaining complete staff statements or documentation for several shifts prior to the injury, and could not provide evidence that all relevant staff were interviewed.
A resident with severe cognitive impairment and alcohol dependence was discharged home without adequate documentation, communication, or immediate support services in place. The facility did not ensure the responsible party was fully informed of the risks or that necessary discharge information was provided, resulting in the resident being hospitalized shortly after discharge.
A resident with severe cognitive impairment and multiple medical conditions was discharged from the facility with an inadequate plan, resulting in hospitalization within hours. Despite being medically cleared, the facility delayed readmission for eight days due to lack of a payer source and corporate approval, even though beds and staff were available. The resident was only readmitted after intervention from the LTC Ombudsman.
A resident with cognitive impairment and ongoing severe pain, as evidenced by daily pain reports and assessments, did not have a pain management care plan developed despite physician orders and facility policy requiring such interventions. The DON confirmed the absence of a care plan addressing the resident's pain.
A resident with multiple medical conditions was discharged home without proper medication reconciliation, resulting in the resident being sent home with medications belonging to other residents. Staff interviews confirmed that the required review and reconciliation process was not completed by the responsible LPN prior to discharge.
A resident with a biliary drain did not receive the required twice-daily flushing of the biliary tube with normal saline as specified in the hospital discharge summary. Facility documentation and physician orders only addressed cleansing and dressing the drain site, omitting the flushing procedure needed to maintain tube patency.
A resident with multiple medical conditions reported daily headaches and received Acetaminophen with inconsistent relief, but the facility did not conduct required pain evaluations or develop a care plan for pain management, as confirmed by the DON.
A resident with dementia and severe cognitive impairment, who required assistance for ambulation, was improperly restrained in a wheelchair using a gait belt by staff, restricting movement without a physician order or assessment. Staff accounts conflicted regarding who directed the restraint, but it was confirmed that the gait belt was used to prevent the resident from standing, contrary to facility policy and the resident's care plan.
A resident with severe cognitive impairment was improperly restrained in a wheelchair using a gait belt by a nursing assistant, following an LPN's direction. Another staff member witnessed the event but did not report it immediately, and the facility delayed notifying the State Agency after learning of the incident, exceeding required reporting timeframes.
The facility improperly used Resident Council funds for activities and services that should have been covered by the facility's budget, including music entertainment, art classes, and the beauty salon license fee. Residents felt obligated to vote for these expenditures, and the Administrator was unaware of the misuse, lacking oversight and a policy for fund management.
The facility failed to complete required background checks and obtain professional references for six staff members, including NAs, LPNs, and RNs, before they began working. The HR department was responsible for these tasks but did not adhere to the facility's policies, resulting in incomplete employee files and a deficiency noted during the survey.
The facility failed to change and label oxygen tubing weekly for residents requiring respiratory care, as per its policy. Several residents, including those with chronic respiratory conditions, had tubing that was not changed on schedule, and staff were unaware of the policy requirements. Observations revealed inconsistencies in documentation and improper handling of oxygen equipment.
The facility failed to conduct required performance evaluations for several nursing assistants, as outlined in their employee handbook. The HR Director acknowledged the backlog, with some evaluations missing for multiple years. The Administrator was informed of the issue, which involved incomplete employee records and unrecognized staff performance.
The facility failed to notify medical personnel of critical changes in two residents' conditions. One resident with diabetes had multiple high blood sugar readings that were not reported to the physician, despite care plan requirements. Another resident refused a medication due to its taste, but the refusal was not communicated to the physician or documented. The facility lacked a policy on medication refusal.
A facility failed to monitor vital signs for a resident with chronic conditions as per physician's orders, missing 91 out of 135 shifts. Additionally, after a resident with dementia was struck on the head, the required neurological monitoring was not conducted, with only 1 out of 20 checks documented. These deficiencies were confirmed through record reviews and staff interviews, indicating non-compliance with care protocols.
A resident with multiple pressure injuries was not provided with proper air mattress care as the facility failed to adjust the mattress settings according to the resident's weight changes. Despite a physician's order and facility policy requiring specific settings, the air mattress was incorrectly set, contributing to inadequate pressure ulcer care.
A resident with a history of malnutrition experienced significant weight loss due to inconsistent weight monitoring and receiving burnt meals. Despite physician orders for weekly weight checks, the facility failed to document weights consistently. The resident's appetite was affected by the poor meal quality, confirmed by survey observations. Staff interviews revealed communication lapses and inadequate follow-up on weight monitoring and meal quality issues.
A resident with chronic respiratory issues was found with medication left on their bedside table, contrary to the facility's policy requiring nurses to ensure medications are taken immediately. Interviews confirmed that medications should not be left unattended, and the resident had not been evaluated for self-administration. This led to a deficiency in medication storage and administration.
The facility failed to provide palatable and presentable meals, as observed when cheese ravioli served to residents was blackened and hardened. The Dietary Director admitted the ravioli was overcooked and should not have been served. Additionally, the director did not inspect the meals before serving, and the facility lacked documentation of test tray monitoring.
Misappropriation of Discontinued Controlled Medications and Missing Narcotic Records
Penalty
Summary
Surveyors identified a deficiency related to misappropriation of resident property involving controlled medications for three residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. A second resident with dementia had an order for PRN oxycodone for moderate to severe pain, later discontinued, and was care planned as at risk for pain with interventions to administer pain medication as ordered. A third resident with dementia and anxiety had an order for PRN lorazepam for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that the second resident did not receive the ordered oxycodone. A facility reportable event documented that discontinued medications scheduled for destruction appeared to be missing, but initially did not identify which residents or which medications were involved. The incident was noted to have occurred in the afternoon, and the Medical Director and Consumer Protection were notified, but local law enforcement was not initially notified. Subsequent information identified that disposition sheets for controlled medications were missing and that the medications were last seen during a prior audit. The missing medications were quantified as 37 tablets of oxycodone 5 mg and 15 tablets of lorazepam 0.5 mg. Further facility documentation and interviews clarified that the missing controlled substances were discontinued medications belonging to the three residents: nine oxycodone tablets for the first resident, 28 oxycodone tablets for the second resident, and 15 lorazepam tablets for the third resident. The proof-of-use sheets and matching medication packs were missing from narcotic lock boxes on two different units, to which approximately 30 nurses had access during the period between two audits. The medications had been moved to the back of the narcotic lock boxes for later disposal, and the facility was unable to identify which nurse removed the medications or when they were removed. A memo from the Consumer Protection drug control division confirmed a significant loss of controlled substances, a procedural lapse in not segregating discontinued medications immediately, and the inability to reconcile inventory due to missing logs, while the medications were under the security of the narcotic lock boxes.
Failure to Properly Classify and Timely Report Missing Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to properly identify, document, classify, and timely report an allegation of misappropriation of controlled medications belonging to multiple residents. Resident #2 had diagnoses including lumbar spine fusion, bipolar disorder, and depression, with an order for PRN Oxycodone for pain and a care plan intervention to administer pain medication as ordered. Resident #3 had dementia with severe cognitive impairment, an order for PRN Oxycodone for pain that was later discontinued, and a care plan identifying risk for pain with an intervention to administer pain medication as ordered. Resident #4 had anxiety with severely impaired cognition, a care plan for anxiety with an intervention to administer anti-anxiety medication as ordered, and a PRN Lorazepam order that was later discontinued. A facility reportable event form dated 11/20/2025 identified that discontinued medications scheduled to be destroyed appeared to be missing, but the form did not identify which residents were affected or what specific medications were involved. Additional information later documented that disposition sheets for controlled medications were missing and that the medications were last seen during an audit, with missing quantities including 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility reportable event summary identified that a drug audit had found missing narcotics scheduled for collection as discontinued medications, specifying that 9 tablets of Oxycodone for Resident #2, 28 tablets of Oxycodone for Resident #3, and 15 tablets of Lorazepam for Resident #4 were missing. The facility’s incident report for the same event stated that discontinued medications scheduled to be destroyed appeared to be missing but again did not list any of the affected residents. The State Agency online portal showed that the reportable event was submitted on 11/20/2025 for an incident identified as occurring on 11/10/2025, resulting in a 10-day delay in reporting. The event was initially misclassified as a Class C (loss of heat/water/emergency systems or evacuation) before being changed to a Class B (abuse), and the DON reported that she did not classify the incident as misappropriation, instead selecting “other,” because the medications had been discontinued and should have been destroyed. Interviews with the DON and Corporate RN #1 confirmed that the medications and related documentation were identified as missing on 11/9/2025, that the State Agency was not notified of the resident names, and that they did not consider the situation a potential misappropriation despite facility policy defining misappropriation as the deliberate misplacement or use of a resident’s belongings without consent and requiring immediate reporting of alleged violations. The facility’s Accident and Incident Policy also required that incident reports include the names of individuals involved and a detailed description of the event and resident condition, which was not done in this case.
Failure to Control and Account for Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate controls over narcotic medications, resulting in the misplacement and loss of controlled substances for multiple residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN Oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. Another resident with dementia had a PRN Oxycodone order for pain, and a third resident with dementia and anxiety had a PRN Lorazepam order for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that one resident did not receive the ordered Oxycodone. A reportable event documented that discontinued medications scheduled for destruction were missing, but the initial form did not identify which residents or which medications were involved. Later information identified that disposition sheets for controlled medications were missing and that the medications were last seen during an audit. The missing medications were specified as 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility summary further detailed that a drug audit identified missing narcotics that had been discontinued and last observed weeks to months earlier, including nine Oxycodone tablets for one resident, 28 Oxycodone tablets for another resident, and 15 Lorazepam tablets for a third resident. The investigation did not identify the person responsible for the missing medications, and the last recorded medication disposal before the loss was more than a month earlier. Interviews and documentation showed that the white controlled substance disposition records and matching medication packs were missing from the unit narcotic books and lock boxes. The medications had been moved to the back of the narcotic lock boxes on the medication carts for future removal for destruction instead of being removed immediately to a secured lock box in the nursing office, as required. The RN involved stated she did not know why the narcotics were not removed when discontinued. An LPN who conducted narcotic audits reported that her audits did not include review of the MAR and that when discrepancies were found, she adjusted counts to match the white proof-of-use sheets. Audit records showed a discrepancy in one resident’s Oxycodone count and missing required dual nurse signatures for end-of-shift narcotic counts on multiple dates and shifts. The facility’s own policy required immediate documentation of controlled substances, shift-change counts by two licensed nurses, and timely return of discontinued controlled drugs to a double-locked cabinet in the nursing office, but these procedures were not consistently followed, leading to the misappropriation of narcotics.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident incident involving inappropriate sexual contact. Two residents, both with severe cognitive impairment and court-appointed Conservators of Person (COP), were care planned to spend time together in the common area holding hands, as consented by their COPs. Both residents had a history of inappropriate sexual behaviors, and their care plans specifically prohibited intimate contact or being alone together in a room. Despite these interventions, staff observed one resident with their chest exposed and the other resident in contact with the exposed area in the common area. Staff interviews confirmed that the two residents were known to have a friendly relationship and often spent time together in the common area, holding hands as permitted. However, on the day of the incident, a nursing assistant witnessed inappropriate physical contact between the residents, which was not consented to by either the residents (due to their cognitive impairment) or their COP. The staff member intervened, and the resident involved became agitated and combative when redirected. Facility documentation and interviews with clinical staff, including the LPN, APRN, and Director of Nursing, confirmed awareness of the residents' cognitive limitations and the restrictions in place regarding their interactions. The facility's policy directed that residents be protected from abuse, including non-consensual sexual contact. Despite these policies and care plan interventions, the lack of adequate supervision allowed the incident to occur, resulting in a failure to protect the residents from abuse.
Failure to Timely Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that clinical records accurately reflected the timing of medication administration for four residents reviewed. In each case, medications were administered according to physician orders, but documentation in the Medication Administration Record (MAR) was completed significantly after the actual administration time. This pattern was identified through an internal medication administration audit, which flagged late documentation for medications scheduled primarily around 9:00 A.M., with entries often made between 10:00 A.M. and 2:00 P.M. This issue affected approximately 80 residents across various units. For the residents involved, all had significant medical conditions such as dementia, failure to thrive, hypertension, diabetes, and behavioral disturbances. The MARs for these residents showed that medications, including supplements, psychotropics, and other daily treatments, were documented as being administered hours after the scheduled time. Interviews with nursing staff revealed that the delay in documentation was due to workload and the practice of signing off on the MAR after completing medication rounds for all assigned residents, rather than at the time of administration. Facility leadership, including the DON and regional nurse, confirmed that their expectation was for medications to be documented in the MAR at the time they are administered. The facility's own policy also required immediate documentation following administration. Despite the delayed documentation, there were no reports of negative outcomes or missed doses for the residents involved, as confirmed by the medical director and facility incident summaries.
Delayed Implementation of Fall Prevention Interventions After Resident Injury
Penalty
Summary
The facility failed to ensure timely implementation of care plan interventions following a resident's fall with injury. A resident with diagnoses including anxiety, dementia, history of falls, weakness, and insomnia, and with moderately impaired cognition, experienced an unwitnessed fall resulting in fractures to both femurs. Prior to the fall, the care plan identified the resident as at risk for falls and directed staff to place the call bell within reach and provide assistance with bed mobility. However, after the fall, the care plan was not promptly updated with new interventions to prevent further falls. Although pain management was added to the care plan after the incident, an intervention to use a bolster mattress was not included until two days after the fall, and the mattress itself was not applied until four days after the incident. Interviews with facility leadership confirmed that the care plan should have been updated and interventions implemented sooner, but no explanation was provided for the delay. The deficiency centers on the lack of timely care plan revision and delayed implementation of fall prevention measures following a significant injury event.
Verbal Abuse of Resident by Nurse Aide
Penalty
Summary
A deficiency occurred when a nurse aide (NA) verbally abused a resident with severe cognitive impairment, including dementia, depression, adjustment disorder, and anxiety. The resident required moderate assistance for personal hygiene and had a care plan directing staff to use a calm, gentle approach and avoid known triggers. On the morning of the incident, multiple staff members observed the NA approach the resident in the dining room, point her finger, and loudly state she would tell her supervisor to have the resident leave her "the hell alone." The NA admitted during the facility's investigation that she had become frustrated with the resident and intentionally made the statement in response to feeling targeted by the resident. Witnesses, including other nurse aides and a nursing supervisor, confirmed the NA's aggressive behavior and inappropriate language directed at the resident. The facility's policies defined such conduct as verbal and mental abuse, which is prohibited. The incident caused the resident initial emotional distress, although the resident did not recall the event later in the day. The facility's investigation substantiated the abuse based on staff interviews and documentation.
Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents with severe cognitive impairment. One resident, diagnosed with Wernicke's encephalopathy and mild cognitive impairment, was observed by an LPN with their hand on another resident's thigh and later with their hand resting against the other resident's upper chest area. Both residents had documented behavioral issues, including sexually inappropriate behavior and swearing at staff. The LPN separated the residents but did not immediately report the full extent of the incident, specifically that the hand was on the other resident's breast. The incident occurred during dinner and was documented in the nursing notes and a reportable event form. However, the State Agency was not notified until over 16 hours after the incident, contrary to the facility's policy requiring immediate reporting, but not later than two hours after an allegation of abuse. The delay in reporting was confirmed during an interview with the DON, who stated that the LPN initially reported only partial information about the incident, leading to the late notification to authorities.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an injury of unknown origin sustained by a resident with multiple complex medical conditions, including severe cognitive impairment, non-ambulatory status, and total dependence on staff for transfers and activities of daily living. The resident was found to have bruising and multiple fractures in the right foot, with no clear explanation for the injuries. The resident's care plan required two-person assistance and use of a mechanical lift for transfers, and the injury was discovered during a physician evaluation, which led to urgent imaging and hospital evaluation. Facility documentation indicated that a reenactment was performed to hypothesize possible causes, such as improper foot positioning during a mechanical lift transfer or entrapment with equipment attached to the bed. However, the facility was unable to produce a complete investigative record. Specifically, there was a lack of written staff statements and documentation covering five shifts within the 72-hour period prior to the identification of the injury, and it was unclear whether all relevant staff, including agency staff, were interviewed. The investigation did not provide information about the resident's care during several key shifts, and the responsible staff could not recall or explain why the investigation was incomplete. The facility's own Abuse Prohibition policy required that all allegations of abuse, including injuries of unknown origin, be thoroughly investigated, including interviewing all available witnesses and completing the investigation within five days. Despite this policy, the investigation into the resident's injury was not comprehensive, and the facility failed to meet its own standards for investigating potential abuse or neglect.
Failure to Ensure Safe and Documented Discharge for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that required discharge information was documented and communicated to the responsible party to ensure a safe and effective discharge for a resident with severe cognitive impairment and a history of alcohol dependence. The resident, who was admitted for short-term rehabilitation, had multiple diagnoses including metabolic encephalopathy, Wernicke's encephalopathy, brain atrophy, and severe cognitive impairment. The care plan indicated the resident would be discharged home after therapy, but the resident was assessed as needing 24-hour care and was noted to be disoriented, forgetful, and at risk for wandering and substance use. Despite these significant needs, the facility did not adequately document or communicate the resident's mental status, activities of daily living, or discharge instructions in the nursing discharge summary. The responsible party was not clearly informed of the risks associated with the resident returning home alone, nor was there evidence that the facility ensured immediate support or assistance would be available upon discharge. Interviews revealed that both the psychiatric APRN and the responsible party were not fully informed or involved in the discharge planning, and the responsible party expressed concerns about the resident's ability to safely return home, which were not addressed by the facility. The facility also failed to provide evidence that options for the resident to remain at the facility until additional services were available were explored or communicated. The discharge occurred without ensuring that the resident had a primary care physician or that home care services would be immediately available. As a result, the resident was discharged home alone, was later found wandering and confused, and was hospitalized approximately four hours after discharge. The facility's actions and lack of communication and documentation led to an unsafe discharge process.
Failure to Permit Timely Readmission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, following an inadequate discharge plan that resulted in the resident being hospitalized shortly after discharge. The resident, who had multiple diagnoses including metabolic encephalopathy, alcohol dependence, brain atrophy, Wernicke's encephalopathy, adjustment disorder, anxiety, depression, diabetes, and hypothyroidism, was admitted for short-term rehabilitation with plans for discharge home. The care plan included discharge planning meetings and involvement of family, but documentation shows ongoing concerns about the resident's cognitive status, substance use, and lack of a long-term payer source. Despite these concerns, the facility proceeded with discharge, and the resident was found lost and disoriented on the street within hours, leading to hospital admission. Hospital documentation indicated that the resident was discharged from the facility to an unsafe situation, with the facility aware of the resident's cognitive impairment and risk factors. The hospital case manager attempted to coordinate the resident's return, but the facility initially refused readmission, citing the absence of a legal decision maker and a long-term payer source. The facility had available beds and staff to provide care, but required corporate approval for readmission due to payment concerns, resulting in delays. As a result, the resident remained in the hospital for an additional eight days after being medically cleared for return to the facility. The facility eventually readmitted the resident after intervention from the Long-Term Care Ombudsman and plans to apply for conservatorship. The facility's own policy indicated that priority admission should be granted to individuals discharged from the facility within fifteen days, but this was not followed in the resident's case.
Failure to Develop Pain Management Care Plan
Penalty
Summary
A resident with significant cognitive impairment and a history of a cervical vertebra fracture, as well as pain in the left ankle and foot, was admitted to the facility. The resident required extensive assistance with activities of daily living and had physician orders for Tramadol to manage severe pain. Documentation showed that the resident reported pain daily, and pain assessments indicated both non-verbal and verbal expressions of pain, with pain levels frequently rated as 6 out of 10. Despite these findings and the facility's policy requiring the development and implementation of pain management interventions, there was no evidence that a pain management care plan was created for this resident. The Director of Nursing confirmed during an interview and record review that a pain management care plan had not been developed to address the resident's ongoing pain.
Failure to Reconcile Medications at Discharge
Penalty
Summary
A deficiency occurred when a resident with diagnoses including perforated gastric ulcer, peripheral vascular disease, and essential hypertension was discharged home without proper reconciliation of their medications. The resident, who was cognitively intact and required assistance with self-care and medication administration, was supposed to have their discharge medications reviewed and reconciled prior to leaving the facility. However, documentation revealed that the resident was discharged with medications belonging to two other residents, and the medication reconciliation process was not completed as required. Interviews with facility staff, including a social worker, the Director of Nurses, and an LPN, confirmed that the standard procedure is to review and reconcile medications with the resident or responsible party before discharge. The LPN responsible for the discharge admitted to not reconciling the medications, resulting in the resident receiving incorrect medications upon discharge.
Failure to Follow Hospital Discharge Orders for Biliary Tube Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including chronic obstructive pulmonary disease, malignant neoplasm of the pancreas, biliary tract disease, fatty liver, and chronic kidney disease, did not receive specialized treatment as ordered. The resident had a biliary drain following a hospital stay, with the hospital discharge summary specifying that the biliary tube should be flushed with 10cc normal saline twice daily to maintain patency. However, review of the facility's documentation and physician orders revealed that while there was an order to cleanse the drain site and apply a dressing, there was no order to flush the biliary tube as directed by the hospital discharge summary. Interviews with facility staff confirmed that the hospital's instructions regarding flushing the biliary tube were not followed.
Failure to Evaluate and Develop Pain Management Plan
Penalty
Summary
A resident was admitted with multiple diagnoses, including acute pulmonary edema, cellulitis, and pressure ulcers. Physician orders were in place for Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. Initial assessments indicated the resident had no cognitive impairment and was not experiencing pain at admission. However, subsequent progress notes documented that the resident reported daily headaches with pain levels ranging from 1 to 7 on a 1-10 scale over several days, and Acetaminophen was administered daily with varying effectiveness, including a report of no effect on one occasion. Despite these ongoing reports of pain, the facility failed to conduct pain evaluations or develop a care plan to address pain management during the period when the resident was experiencing and reporting pain. The facility's pain management policy required a pain evaluation, physical evaluation, and physician notification when a new onset of pain was reported, as well as the development and implementation of both pharmacological and nonpharmacological interventions. An interview with the Director of Nurses confirmed that these steps were not taken during the relevant period.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A resident with dementia and muscle weakness, who had severely impaired cognition and required assistance for ambulation and transfers, was subjected to the inappropriate use of a physical restraint. The resident's care plan specified one-person assistance for ambulation with a rolling walker and did not include any order or assessment for the use of a restraint or seat belt in the wheelchair. Despite this, a staff member used a gait belt to secure the resident to a wheelchair, restricting the resident's ability to stand or move freely. The incident occurred when two nursing assistants found the resident in a closet and placed the resident in a wheelchair in the common area. One nursing assistant, following the direction of an LPN according to her account, applied a gait belt around both the resident and the wheelchair, clipping it within the resident's reach. There was uncertainty among staff as to whether the resident could unclip the belt independently. Interviews revealed conflicting accounts regarding who directed the use of the gait belt, but it was confirmed that the gait belt was used to prevent the resident from standing, which was not in accordance with facility policy or the resident's care plan. Facility policies reviewed indicated that gait belts are to be used only for transfer and ambulation assistance, and that physical restraints require a specific physician order and assessment. The resident had not been assessed for restraint use, and there was no physician order for such an intervention. The use of the gait belt in this manner constituted a failure to ensure the resident was free from physical restraints, as required by both facility policy and resident rights.
Failure to Timely Report and Notify Authorities of Resident Restraint Incident
Penalty
Summary
Staff failed to report an alleged incident of mistreatment in a timely manner and did not notify the State Agency within the required timeframe after becoming aware of the allegation. A resident with dementia and severely impaired cognition, who required assistance for ambulation and transfers, was found to have been restrained in a wheelchair using a gait belt by a nursing assistant, following the direction of an LPN. The gait belt was used to restrict the resident's movement, which was not in accordance with facility policy on restraint use. Another nursing assistant witnessed the event but did not immediately report it, and the incident was not brought to the attention of facility leadership until several days later, after a non-nursing staff member reported a rumor about the event. The facility became aware of the incident on the morning of 12/9/2024 but did not notify the State Agency until over three hours later, exceeding the policy requirement to report violations of mistreatment immediately, but not later than two hours after the violation. Interviews with staff and review of facility documentation confirmed that the use of the gait belt as a restraint was inappropriate and that there was a delay in both internal and external reporting of the incident.
Inappropriate Use of Resident Council Funds
Penalty
Summary
The facility failed to ensure that Resident Council funds were utilized appropriately, as evidenced by the improper use of these funds for activities and services that should have been covered by the facility's budget. Interviews with residents revealed that they felt obligated to vote in favor of using Resident Council funds for music, entertainment, and art classes, as these activities were not provided by the facility. The Administrator confirmed that the facility allocates a monthly budget for the recreation department, which includes art supplies and entertainment, but the Director of Recreation indicated that the budget was insufficient, leading to the use of Resident Council funds. The review of bank statements showed that these funds were used to pay for music entertainment and art classes, despite the facility's responsibility to cover these costs. Additionally, the Resident Council funds were used to pay for the annual licensure fee for the beauty salon chair, a cost that should have been borne by the facility. The Administrator was unaware of these expenditures and acknowledged that the facility should have covered the beauty salon license fee. The lack of oversight and a facility policy for managing Resident Council funds contributed to the inappropriate use of these funds, as the Administrator had not reviewed how the funds were being dispersed.
Failure to Complete Background Checks and References
Penalty
Summary
The facility failed to ensure that required references and background checks were completed prior to hiring six staff members, including nursing assistants, LPNs, and RNs. The Director of Human Resources (HR) was responsible for completing these checks and obtaining two professional references for each employee before they started working. However, upon review, it was found that the personnel files for all six employees lacked the necessary background check/eligibility forms and, in some cases, the required professional references. This oversight allowed these employees to begin working at the facility without the proper screening. The facility's Abuse Prohibition Policy mandates the screening of personnel for a history of abuse, which includes conducting criminal background checks and obtaining at least two reference checks. These requirements were not met, as evidenced by the incomplete employee files. The HR New Hire Checklist also specifies that pre-offer paperwork should include completed and signed references and fingerprinting information. Despite these policies, the HR department did not adhere to the procedures, resulting in the deficiency noted during the survey.
Failure to Change and Label Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing and labeling of oxygen tubing for residents requiring respiratory care. Resident #7, who was dependent on supplemental oxygen due to chronic respiratory failure and COPD, had oxygen tubing that was not changed weekly as per the physician's order and facility policy. The tubing was observed to be dated several weeks prior, and the responsible LPN was unaware of the policy requirements. Resident #16, with diagnoses including acute and chronic respiratory failure and COPD, also had issues with the timely changing of oxygen tubing. The tubing was labeled with a date that did not align with the facility's policy of weekly changes, and the resident could not recall when it was last changed. Documentation inconsistencies were noted in the treatment administration record, which did not match the observed dates on the tubing. Resident #20 and Resident #81 also experienced similar deficiencies. Resident #20's oxygen tubing was found on the floor, unlabeled, and not discarded as required by the facility's policy. Resident #81's tubing was not changed according to the weekly schedule, and the responsible LPN was unaware of why the task was overlooked. These observations indicate a systemic issue with adherence to the facility's policy on oxygen tubing maintenance.
Failure to Conduct Required Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to conduct performance evaluations for nursing assistants as required by their employee handbook and internal policies. The Director of Human Resources (HR) acknowledged that it was her responsibility to ensure all employee files were complete, including performance evaluations at 6 months and annually for employees hired before June 2023, and at 3 months and annually for those hired after. However, upon review, it was found that several nursing assistants had missing evaluations. For instance, one nursing assistant hired in 2022 lacked both the 6-month and annual evaluations due in 2023, while another hired in 2005 had not had an evaluation since 2019. Similar lapses were noted for other nursing assistants, with some not having evaluations for multiple years. The HR Director admitted awareness of the backlog in evaluations and mentioned a new Director of Nursing Services (DNS) at the facility. The Administrator, upon being informed of the issue, acknowledged the deficiency and discussed it with HR. The employee handbook, updated in June 2023, specifies that the first 90 days of employment is an introductory period during which performance should be reviewed, followed by annual evaluations. Despite these guidelines, the facility did not adhere to its own policies, resulting in incomplete employee records and unrecognized staff performance.
Failure to Notify Medical Personnel of Critical Changes
Penalty
Summary
The facility failed to notify the appropriate medical personnel and responsible parties regarding significant changes in the condition of two residents. For one resident with type 2 diabetes and end-stage renal disease, the facility did not inform the physician or APRN of blood glucose readings that exceeded the ordered parameters on multiple occasions. Despite having a care plan that required such notifications, the nursing staff did not document any communication with the physician/APRN about these elevated blood sugar levels, which were recorded on four separate dates. In another case, a resident with diabetes and mild cognitive impairment refused a prescribed medication due to its taste, but the facility did not notify the physician or document the refusal in the progress notes. The resident explicitly requested that the physician be informed of the refusal, yet there was no record of such communication. The facility also failed to provide a policy regarding the refusal of medications when requested.
Failure to Monitor Vital Signs and Neurological Status
Penalty
Summary
The facility failed to adhere to physician's orders for Resident #63, who was admitted with chronic obstructive pulmonary disease, end-stage renal disease, and congestive heart failure. The care plan required monitoring of vital signs every shift, but records from March 1 to April 22 showed that vital signs were not taken for 91 out of 135 shifts. Interviews with the LPN and DNS confirmed the inconsistency in monitoring, and the facility's policy mandates that vital signs be monitored and reported if abnormal. For Resident #94, who has Alzheimer's disease and dementia, the facility did not conduct neurological monitoring as per policy after an incident where the resident was struck on the head by another resident. The policy required frequent neurological checks following a head injury, but only 1 out of 20 required checks were documented. The DNS was unaware of the lapse in monitoring, and the facility's policy outlines specific intervals for neurological assessments following head injuries. Both deficiencies highlight a failure to follow established protocols for monitoring residents' health conditions, as evidenced by the lack of documentation and adherence to physician's orders and facility policies. These lapses were identified through clinical record reviews and staff interviews, indicating a need for improved compliance with care standards.
Failure to Properly Utilize Air Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper utilization of an air mattress for a resident with multiple pressure injuries. The resident, who was admitted with severe malnutrition and several pressure injuries, had a physician's order for a specialty air mattress with specific settings to be checked every shift. However, observations revealed that the air mattress pump was set incorrectly at 10/65 lbs instead of the prescribed 10/105 lbs, which was supposed to correspond to the resident's weight. This discrepancy was confirmed by a regional nurse, who noted that the settings and physician's order were incorrect and should have been adjusted according to the resident's weight changes. The facility's policy on alternating pressure air mattresses required verification of physician orders and settings according to manufacturer guidelines. Despite this, the Director of Nursing Services (DNS) indicated that the air mattress was set based on physician orders, and it was the responsibility of the nursing staff to monitor the functioning and pressure settings every shift. The wound nurse was specifically responsible for ensuring the air mattress was set according to the resident's weight. This failure to adhere to the correct settings and policy guidelines contributed to the deficiency in providing appropriate pressure ulcer care for the resident.
Failure in Weight Monitoring and Meal Quality
Penalty
Summary
The facility failed to ensure proper weight monitoring and nutritional care for a resident with a history of weight loss and malnutrition. The resident was admitted with diagnoses including mild protein calorie malnutrition, weakness, and dementia, and was supposed to have their weight monitored weekly as per physician's orders. However, the clinical records showed a lack of consistent weight documentation, with a significant weight loss of 10 lbs. occurring between 2/26 and 3/4, which was not promptly addressed. The dietician's notes confirmed the weight loss and recommended increased nutritional supplements, but the facility did not consistently follow through with the required weekly weight checks. The resident reported receiving burnt meals, which affected their appetite and contributed to the weight loss. Observations by the survey team confirmed that meals served to the resident were often overcooked, with test trays showing blackened and hardened food. Despite the resident's complaints and the dietician's recommendations, the facility did not adequately address the issue of meal quality, which was a contributing factor to the resident's nutritional decline. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight monitoring and meal quality. The LPN responsible for recording the resident's weight failed to ensure a re-weight was conducted after noting a discrepancy, and the DNS was unaware of the burnt meals issue. The facility's policy required weights to be documented weekly, but this was not consistently done, leading to a failure in monitoring the resident's nutritional status effectively.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately for a resident who was admitted with chronic respiratory failure and chronic obstructive pulmonary disease. A physician's order directed the administration of Acetaminophen for pain, and the resident was last given the medication for a pain rating of 8/10. However, a medication cup containing two white tablets was observed on the resident's bedside table, which the resident indicated had been there for about a week. This indicates that the medication was not administered according to the facility's policy, which requires the nurse to remain at the bedside until the medication is taken. Interviews with nursing staff confirmed that medications should not be left at the bedside and that the nurse is expected to ensure the resident takes the medication before leaving. The facility's policies on oral medication administration and self-administration of medications were not followed, as the resident had not been evaluated for the ability to self-administer medications safely. The failure to adhere to these policies led to the deficiency observed during the survey.
Failure to Provide Palatable and Presentable Meals
Penalty
Summary
The facility failed to ensure that residents were provided with palatable and presentable meals, as observed during a survey. On one of the nursing units, test trays of cheese ravioli with tomato sauce were found to be blackened and hardened, indicating that the meals were not prepared to a satisfactory standard. During the meal service on the Skyview unit, the ravioli on the steam table was observed to be charred and blackened, with the tomato sauce appearing dry, cracked, and discolored. Out of 22 meals served, 11 were returned and exchanged for alternatives, highlighting the unacceptability of the meal quality. The Dietary Director admitted that the ravioli had been overcooked due to being left in the oven too long and acknowledged that the meals should not have been served to residents. The director also failed to inspect the test trays before providing them to the survey team and did not observe the meals prepared for residents before they were served. Additionally, the facility did not provide documentation related to test tray monitoring, which was supposed to be conducted three times weekly to ensure proper food quality and appearance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
