Lord Chamberlain Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Stratford, Connecticut.
- Location
- 7003 Main Street, Stratford, Connecticut 06614
- CMS Provider Number
- 075412
- Inspections on file
- 29
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Lord Chamberlain Manor during CMS and state inspections, most recent first.
A resident with acute respiratory failure, septic shock, intact cognition, and high ADL assistance needs was discharged home with documentation stating that skilled home care services (nursing, PT, OT, and HHA) had been arranged. Post-discharge, the listed home care agency reported having no record of the resident and not serving the resident’s geographic area, and another RN from the agency confirmed no referral was received. The DNS acknowledged the resident should have had home care but was unsure about service start timing or agency coverage, and the SW confirmed that no home care services were provided and could not explain why a referral was not made or confirmed, contrary to the facility’s own transfer and discharge policy.
A resident with a history of stroke, atrial fibrillation, and antiphospholipid syndrome did not receive Coumadin therapy as ordered, with missed doses and delayed or missing INR monitoring. Documentation was inconsistent, and staff did not act on subtherapeutic INR results in a timely manner, resulting in significant medication errors and failure to maintain the therapeutic INR range.
Two residents with significant medical histories, including atrial fibrillation and recent hospitalizations, were prescribed Coumadin and received the medication for several weeks. Despite physician orders for anticoagulation therapy and required INR monitoring, the facility did not develop or document care plans addressing anticoagulation therapy or bleeding risk for either resident, as required by facility policy. Interviews with the DON, Administrator, and an RN confirmed the omission and the lack of explanation for why the care plans were not completed.
A resident with atrial fibrillation and a history of TIA did not consistently receive Coumadin as ordered, due to multiple transcription errors by LPNs and incorrect dosing entries by an APRN. Missed doses and delays in obtaining new orders led to the resident's INR frequently falling outside the therapeutic range, contrary to physician instructions and facility protocol.
A resident with confusion and a recent femur fracture, identified as an elopement risk and wearing a wander guard, was able to leave the facility unsupervised after a Dietary Aide opened a non-alarmed cafe door without consulting nursing staff. The resident was later found at a nearby gas station without the wander guard and refused to return, requiring EMS intervention.
A resident with dementia and a high fall risk exhibited increased agitation and combative behavior, including medication refusal and the need for constant redirection. Although a physician was notified of agitation on admission and a PRN medication was ordered, there was no evidence that the physician was informed of the resident's further behavioral escalation during the night shift, contrary to facility policy. This lapse occurred prior to the resident experiencing an unwitnessed fall and subsequent hospital transfer.
A resident with multiple chronic conditions experienced vaginal bleeding and repeatedly refused to use an ordered AVAP device at bedtime. Nursing staff documented these events and communicated among themselves and to respiratory therapy, but failed to notify the medical provider in a timely manner as required. This resulted in a delay in provider awareness and intervention for significant changes in the resident's condition.
A resident with a surgical abdominal wound was transferred to the hospital for infection and was not allowed to return to the facility after the hospital cleared them for discharge. Nursing staff reported being instructed not to readmit the resident, though the supervisor did not recall giving this direction. The facility's administrator confirmed that residents should be permitted to return within 48 hours, and the facility's policy supports resident return after hospitalization.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube and a PICC line, despite the resident's diagnoses of severe sepsis and infection due to an orthopedic prosthetic device. The resident required substantial assistance and was receiving intravenous therapy. There was no EBP signage or PPE outside the resident's room, and the nursing assistant was unaware of the need for additional precautions. The oversight was acknowledged by the LPN and DNS, who confirmed that the resident should have been on EBP due to the presence of indwelling medical devices.
A resident with a history of leg amputation and other medical conditions was not treated with dignity when requesting wheelchair leg rests before a dialysis appointment. Despite the resident's request, an LPN attempted to transport the resident without the leg rests, contrary to facility protocol. The facility's policy required leg rests unless the resident requested otherwise, and the Administrator acknowledged the importance of listening to residents' requests.
A resident with a fracture and muscle weakness was unable to use the standard call bell due to stiff buttons, despite being alert and oriented. The facility had alternative call bell options, but they were not provided, and the policy did not address procedures for residents unable to use a standard call bell. This led to the resident attempting to get out of bed without assistance.
A facility failed to include dialysis needs and medication monitoring in a baseline care plan for a resident with end-stage renal disease and bipolar disorder. Despite physician orders for dialysis and mood stabilization medication, the care plan omitted these critical elements due to staff oversight. The Director of Nursing acknowledged the oversight, which contravened the facility's policy requiring comprehensive care plans within 48 hours of admission.
A resident with congestive heart failure and muscle weakness required two-person assistance for bed mobility, as per physician's orders. However, a nurse aide assisted the resident alone, leading to discomfort and dissatisfaction. The aide believed the resident could assist themselves, despite the care plan specifying total dependence. The facility's policy mandates adherence to care plans, which was not followed in this case.
A facility failed to ensure correct medication administration for a resident with NPO status and a gastrostomy tube. Despite the resident's condition requiring all medications to be administered via the tube, several orders were incorrectly transcribed as 'by mouth' in the EHR. Staff interviews revealed a lack of clarification and correction of these orders, contrary to facility policy.
The facility failed to implement physician-ordered safety measures for two residents. One resident with a history of seizures was observed without required bumper guards and floor mats, despite orders and a care plan specifying these precautions. Another resident, with multiple health issues, was not wearing heel booties as ordered to offload heels, despite staff signing off on compliance. Facility policies on seizure precautions and physician orders were not effectively followed, leading to these deficiencies.
A facility failed to provide appropriate assistance during a resident's transfer, leading to a fall, and did not conduct a smoking assessment for another resident, who continued to smoke on the premises. The facility also failed to enforce its no-smoking policy, resulting in cigarette waste accumulation.
A resident with acute respiratory failure and heart failure did not receive oxygen as per physician orders, leading to a deficiency in care. Despite orders for continuous oxygen at 2 liters via nasal cannula, the resident was observed without oxygen on multiple occasions. Staff, including an LPN and the DNS, were unable to explain the presence of multiple conflicting oxygen orders or why continuous oxygen was signed off when not administered. The facility's policy for reviewing physician orders was not followed, resulting in the deficiency.
A facility failed to identify and monitor a resident's AV fistula, essential for dialysis care. The resident, dependent on dialysis, was not assessed for the fistula upon admission, and the baseline care plan lacked documentation of its presence. Facility policies require monitoring of AV fistulas every shift, but this was not done due to oversight in entering batch orders and MAR instructions.
A facility failed to ensure a resident receiving Zyprexa had an appropriate diagnosis and monitoring. The resident, admitted with anxiety/depression disorder, was prescribed Zyprexa for anxiety, which is not an appropriate diagnosis. Orthostatic BP monitoring was delayed, and AIMS testing was not conducted. The resident was unaware of the medication's purpose, and the DNS confirmed anxiety disorder was not a valid diagnosis for antipsychotic use.
A facility failed to provide a resident with the requested alternative menu option, despite the resident's care plan identifying nutritional status and diet as a concern. The resident, who had dysphagia, depression, and gastro-esophageal reflux disease, reported not receiving requested menu substitutions. An observation confirmed the resident received pudding instead of yogurt. Interviews revealed that dietary and nurse aides did not consistently check dietary slips and meal tray contents, with one aide stating she was often too busy to verify trays.
A resident admitted with sepsis, chronic kidney disease, and type 2 diabetes was not offered an influenza vaccine, nor was there documentation of refusal or prior immunization. The facility's policy required offering the vaccine to all eligible residents, but this was not adhered to, as revealed in an interview with an RN.
Failure to Arrange and Confirm Home Care Services Prior to Discharge
Penalty
Summary
The facility failed to ensure that a resident was discharged with arranged home care services as identified in the discharge planning process. The resident had diagnoses including acute respiratory failure and septic shock, an admission MDS showing a BIMS score of 14 (intact cognition), and required maximal assistance with toileting and transfers, with a care plan indicating assistance with ADLs. The facility’s discharge summary documented that the resident was being discharged home and would receive skilled services, including nursing, PT, OT, and home health aide, and a nursing note stated the resident was discharged home with home care services. However, interviews and record review revealed that the home care agency listed on the discharge summary had no record of the resident and did not service the resident’s home area. A second RN from the home care agency reported they never received a referral for the resident. The DNS acknowledged the resident should have been discharged home with home care services but was unsure when services were to start and did not know if the agency served the resident’s area. The social worker confirmed that the listed home care agency reported the resident never received services after discharge and could not identify why a referral was not made and confirmed to a home care agency, despite the facility’s transfer and discharge policy directing that discharge be planned with resident participation and assistance in adjusting to the new living environment.
Failure to Maintain Therapeutic INR Levels and Timely Coumadin Management
Penalty
Summary
The facility failed to ensure that a resident receiving Coumadin (Warfarin) therapy had their INR levels maintained within the physician-ordered therapeutic range of 2.5 to 3.5. The hospital discharge summary specified Coumadin dosing and required INR monitoring every other day, with dose adjustments as needed. However, clinical record review revealed that INR tests were not consistently performed as ordered, and Coumadin doses were not always administered according to the prescribed schedule. There were multiple days when the resident did not receive any Coumadin, and INR results were frequently below the therapeutic range without timely intervention or dose adjustment. Documentation on the Coumadin Tracking Form was inconsistent and sometimes contained conflicting information regarding current doses, new orders, and next INR test dates. There were also instances where new orders were not obtained or acknowledged by a physician or APRN, and INR results were not acted upon in a timely manner. Interviews with clinical staff confirmed that the resident's INR levels were not maintained within the therapeutic range, and that the management of Coumadin therapy was not efficient or consistent with the facility's own Coumadin protocol policy. The resident had significant medical conditions, including cerebral infarct with hemiplegia, atrial fibrillation, and antiphospholipid syndrome, all of which increased the importance of maintaining therapeutic anticoagulation. Despite these risks, the facility did not provide adequate monitoring or management of the resident's Coumadin therapy, resulting in significant medication errors as identified by both facility staff and external reviewers. The deficiency was cited as Immediate Jeopardy due to the failure to maintain the ordered therapeutic INR range and to ensure timely and appropriate medication administration and monitoring.
Failure to Timely Develop Care Plans for Residents on Anticoagulation Therapy
Penalty
Summary
The facility failed to develop and implement timely care plans for anticoagulation therapy for two residents who were prescribed Coumadin (Warfarin) following their admission. Both residents had medical histories that included conditions such as atrial fibrillation, cerebral infarct with hemiplegia/hemiparesis, antiphospholipid syndrome, and transient ischemic attack, and were ordered to receive daily Coumadin with specific instructions for INR monitoring and dose adjustments. Despite these orders and the administration of Coumadin over several weeks, review of the clinical records and resident care plans revealed that neither resident had a care plan addressing anticoagulation therapy or the associated risk for bleeding, as required by facility policy and the Coumadin protocol. Interviews with the DON, Administrator, and an RN confirmed that it was the responsibility of the nursing or MDS team to ensure care plans reflected resident needs and treatment plans, and that comprehensive care plans should be completed within the required timeframe after admission. The facility was unable to provide documentation of care plans for anticoagulant use for either resident and acknowledged that such care plans should have been in place. The reason for the omission could not be identified during the interviews.
Failure to Accurately Administer and Manage Coumadin Therapy
Penalty
Summary
The facility failed to ensure that Coumadin was administered and managed according to physician orders and the resident's therapeutic INR goal. A resident with a history of atrial fibrillation and transient ischemic attack was admitted with orders for Coumadin and a target INR range of 2.0 to 3.0. Multiple errors were identified in the transcription and administration of Coumadin orders, resulting in missed doses on several occasions. Specifically, LPNs transcribed Coumadin orders to start on incorrect dates, causing the resident to miss scheduled doses on three separate days. Additionally, there were inconsistencies and delays in obtaining new Coumadin orders when INR results were outside the therapeutic range. On several occasions, the resident's INR was either above or below the target range, but no new orders were documented or implemented in a timely manner. There was also a documented instance where an APRN intended to increase the Coumadin dose but incorrectly entered a lower dose, which was then administered to the resident. Facility documentation and interviews confirmed that the resident's Coumadin therapy was not consistently managed to maintain the INR within the prescribed range. The facility's Coumadin protocol required accurate logging of INR results, current and new orders, and timely physician notification, but these procedures were not consistently followed. Both the APRN and physician acknowledged that Coumadin doses should not have been missed and that orders should have been transcribed accurately.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility without staff knowledge or supervision. The resident, who had a history of confusion and was assessed as a fall and elopement risk, was admitted with a left femur fracture and had a wander guard bracelet placed on their wrist. Despite these precautions, the resident expressed a desire to leave the facility, was noted to be exit-seeking, and required standby assistance for mobility. On the day of the incident, the resident entered the facility's cafe and requested to go outside. A Dietary Aide, unaware of the resident's elopement risk and without confirming with nursing staff, assisted by opening the cafe side door, which was not equipped with a wander guard alarm system. The resident exited through this door and was later found at a gas station across a four-lane road, approximately 0.3 miles from the facility. At the time of discovery, the resident no longer had the wander guard bracelet and refused to return to the facility, requiring EMS intervention for transport. Facility documentation and staff interviews confirmed that the Dietary Aide did not check for the presence of the wander guard or consult with nursing staff before allowing the resident outside. The lack of adequate supervision and the absence of an alarm system on the cafe door directly contributed to the resident's unsupervised exit from the facility.
Failure to Notify Physician of Resident's Increased Agitation
Penalty
Summary
The facility failed to ensure timely physician notification regarding a resident's increased agitation. The resident, who had dementia with behavioral disturbance and a history of falls, was admitted following a recent hospitalization for a fall and was identified as a high fall risk. Nursing documentation showed that the resident exhibited increased agitation, restlessness, and combative behavior during the night shift, including refusing medications and requiring constant redirection. Although the physician was notified of agitation on the day of admission and a PRN Trazodone order was obtained, there was no evidence that the physician was notified of the further increase in agitation and combative behavior observed during the early morning hours of the following day. Facility policy required that the physician, resident, and family/legal representative be informed of changes in condition. Interviews with staff and the physician confirmed that the physician was not notified of the resident's increased agitation on the morning in question, despite expectations and policy. The lack of timely notification occurred prior to an unwitnessed fall, after which the resident was found on the floor with a head injury and transferred to the hospital.
Failure to Notify Medical Provider of Change in Condition and Treatment Refusals
Penalty
Summary
The facility failed to ensure timely notification of a medical provider regarding a resident's change in condition. The resident, who had multiple diagnoses including COPD, sleep apnea, chronic cellulitis, morbid obesity, and congestive heart failure, was admitted with orders for continuous oxygen and use of an AVAP (a type of CPAP) device. The resident also had an unstageable pressure injury and required mechanical lift transfers. On one occasion, the resident experienced vaginal bleeding, which was noted by nursing staff and assessed by an RN, but there was no documentation that the MD or APRN was notified of this change until over eight hours later, when a PA was finally contacted and orders were obtained. Additionally, the resident repeatedly refused to use the AVAP device at bedtime and overnight, as documented by multiple LPNs. Although these refusals were communicated among nursing staff and to the respiratory therapist, there was no evidence that the APRN or MD was notified of the refusals, despite facility expectations and physician orders requiring such notification. Interviews with staff confirmed that refusals of the AVAP device were not consistently reported to the medical provider, and the acting DON stated that such refusals should have been communicated to the APRN. The lack of timely notification to the medical provider regarding both the vaginal bleeding and the repeated refusals to use the AVAP device constituted a failure to inform the provider of significant changes in the resident's condition and non-compliance with physician orders. This deficiency was confirmed through clinical record review, facility documentation, and staff interviews.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
A resident with a diagnosis of abdominal wound due to intestinal perforation and small bowel obstruction was transferred to the hospital for a wound infection. The resident had a physician's order for specific wound care and was noted to be alert and oriented with a surgical wound requiring ongoing treatment. Documentation showed that the wound was stable at the time of the last evaluation, and the care plan included instructions to provide wound care per treatment orders. Following the hospital transfer, the resident was not readmitted to the facility despite the hospital indicating the resident was ready for discharge back to the facility. An RN reported receiving instructions during shift change not to accept the resident's return, although the supervisor did not recall giving such a directive. The facility's administrator stated that residents are permitted to return within 48 hours per federal guidelines and was unaware of the reason for the denial. The facility's bed hold policy allows residents to return after hospitalization, but the resident was not permitted to do so in this instance.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube and a peripherally inserted central catheter (PICC). The resident, who was cognitively intact, required substantial assistance with mobility and was dependent on toileting. Diagnosed with severe sepsis, septic shock, and an infection due to an internal orthopedic prosthetic device, the resident was receiving intravenous therapy and had a feeding tube. Despite these conditions, there was no posted signage for EBP outside the resident's room, and the nursing assistant providing care was unaware of the need for additional precautions, as the care card did not indicate EBP, and no personal protective equipment (PPE) was available outside the room. The oversight was further confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing Services (DNS), who acknowledged that the resident should have been on EBP due to the presence of indwelling medical devices. The facility's policy required an order for EBP and the implementation of signage and PPE for residents with such devices. However, the necessary steps were not taken upon the resident's admission, and the charge nurse responsible for the admission did not obtain a physician's order or ensure the placement of EBP signage and PPE. This lapse in protocol was identified as an oversight by the DNS and the Infection Preventionist.
Failure to Provide Dignified Care for Resident Requesting Wheelchair Leg Rests
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity when requesting wheelchair footrests. Resident #374, who had a medical history including acquired absence of the left leg below the knee, generalized muscle weakness, end-stage renal disease, and hypertension, was observed sitting in a wheelchair without leg rests. The resident, who was alert and oriented but forgetful, requested the surveyor to inform the nurse about the need for leg rests before being transported to a dialysis appointment. Despite the request, LPN #5 attempted to push the wheelchair forward without informing the resident, intending to transport the resident to the physical therapy room to obtain the leg rests. LPN #5 acknowledged that the resident should have had the leg rests applied before being transported. The facility's protocol, as confirmed by the Administrator and Occupational Therapist, required that residents in wheelchairs have leg rests applied unless the resident requested otherwise. The facility policy also stated that extremities should be supported once a resident is transferred to a wheelchair. The Administrator recognized that residents have a right to be listened to and treated with dignity, and LPN #5 should have adhered to the resident's request for leg rests.
Failure to Provide Appropriate Call Bell for Resident
Penalty
Summary
The facility failed to accommodate the physical limitations of Resident #525 by not providing an appropriate call bell system. Resident #525, who had a fracture of the right femur, a history of falling, and muscle weakness, was unable to use the standard call bell due to the stiffness of the buttons. Despite being alert and oriented, the resident could not press the call bell to call for assistance, as observed during multiple interviews and observations with staff. The facility had alternative call bell options, such as manual handheld bells and soft touch pads, but these were not provided to the resident. The deficiency was further highlighted by the fact that the facility's policy did not address procedures for residents unable to use a standard call bell. Interviews with staff revealed that while the call bell's functionality was checked upon admission, there was no assessment of the resident's ability to use it. Despite the availability of alternative call bells, they were not stocked on the unit and required a request to Maintenance for delivery. The failure to provide an appropriate call bell led to Resident #525 attempting to get out of bed without assistance, as noted in a nursing progress note.
Failure to Address Dialysis Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that addressed the immediate needs of a resident with end-stage renal disease who was dependent on renal dialysis. Upon admission, the resident had diagnoses including type 2 diabetes with diabetic chronic kidney disease and bipolar disorder. Physician orders indicated that the resident required dialysis at an outpatient facility three times a week and was prescribed Lamotrigine for mood stabilization. However, the Baseline Resident Care Plan (RCP) did not include the resident's dialysis needs or medication monitoring, despite addressing other categories such as activities of daily living, elimination, pain, falls, and behavior. Interviews and record reviews revealed that the omission of dialysis and psychotropic medication evaluation in the Baseline RCP was due to staff oversight. The Director of Nursing Services acknowledged that the Baseline RCP should have included goals, weights, diet, and other elements specific to dialysis. The facility's policy mandates that a baseline care plan be completed within 48 hours of admission, including resident goals, services, treatments, and a summary of medications and dietary instructions. The failure to include these critical elements in the care plan represents a deficiency in meeting the resident's immediate needs.
Failure to Provide Required Assistance for Bed Mobility
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with diagnoses including congestive heart failure, respiratory failure, muscle weakness, and obesity, received the required assistance with bed mobility according to physician's orders. The resident, who was non-ambulatory and bed/chair-bound, was identified as needing the assistance of two staff members for bed mobility. However, during an observation, a nurse aide assisted the resident alone, contrary to the physician's order and the care plan, which specified the need for two-person assistance. The resident expressed discomfort and dissatisfaction with the assistance provided, noting that the inconsistency in the number of aides assisting made them feel annoyed. Interviews with the nurse aide and the physical therapist revealed that the aide was aware of the resident's need for assistance but chose to assist alone, believing the resident could help themselves by holding onto the bed rails. The physical therapist emphasized the importance of following care plans and orders to prevent potential injury to the resident. The facility's policy for positioning and repositioning residents requires staff to check the care plan and follow the specified number of staff required for assistance, which was not adhered to in this instance.
Failure to Ensure Correct Medication Administration Route for NPO Resident
Penalty
Summary
The facility failed to ensure that medication orders for a resident with a gastrostomy tube and NPO (nothing by mouth) status were correctly documented with the appropriate route of administration. The resident, who was admitted with conditions including dysphagia and GERD, had multiple physician orders indicating medications to be given by mouth, despite the NPO status. These discrepancies were found in the electronic health record (EHR) and were not corrected by the nursing staff responsible for transcribing the orders. Interviews with the resident and staff, including an APRN and an LPN, confirmed that the resident was aware of their NPO status and that all medications and nutrition should be administered via the gastrostomy tube. The APRN acknowledged that the orders were transcribed incorrectly into the EHR and that the original handwritten orders did not specify a route of administration. The LPN admitted to not realizing the error due to being accustomed to oral administration of medications and did not seek clarification from the prescriber. The Director of Nursing Services (DNS) also confirmed the oversight and emphasized that all medication orders should specify a route of administration. The facility's policy requires that any discrepancies in medication orders be clarified and corrected by the nursing supervisor. However, this protocol was not followed, leading to the incorrect transcription of medication orders for the resident.
Failure to Implement Physician-Ordered Safety Measures
Penalty
Summary
The facility failed to implement physician-ordered safety measures for a resident with seizure precautions. The resident, who had a history of seizures, encephalopathy, and hemiplegia following a stroke, was observed multiple times without the required bumper guards on bed rails and floor mats at the bedside. Despite a care plan and physician's orders specifying these precautions, staff did not ensure their implementation. Observations revealed that the necessary equipment was either misplaced or not used, and the nurse aide care card lacked the updated information about these safety measures. Additionally, a Licensed Practical Nurse (LPN) admitted to signing off on the Treatment Administration Record (TAR) without verifying the presence of the safety equipment. Another deficiency involved a resident with acute respiratory failure, congestive heart failure, and chronic kidney failure, who was supposed to have heel booties applied to offload heels while in bed or a recliner chair. Observations showed that the resident was not wearing heel booties as ordered, despite staff signing off on the Medication Administration Record (MAR) indicating compliance. An LPN acknowledged the oversight and admitted to not checking the application of heel booties before signing the MAR. The Director of Nursing Services (DNS) confirmed the requirement for heel booties but could not explain the staff's failure to apply them. The facility's policies on seizure precautions and physician orders were not effectively followed, leading to these deficiencies. The seizure precautions policy directed the use of padded side rails for residents at risk, while the policy on physician orders lacked specificity regarding the application of heel booties. These lapses in following physician orders and facility policies resulted in the failure to provide appropriate care and safety measures for the residents involved.
Deficiencies in Resident Transfer Assistance and Smoking Policy Enforcement
Penalty
Summary
The facility failed to provide appropriate assistance during the transfer of a resident, identified as Resident #374, who had significant mobility and cognitive impairments. The resident, who required maximum assistance of two staff members for pivot transfers due to conditions such as acquired absence of the left leg below the knee and generalized muscle weakness, was transferred by a single nurse aide. This resulted in the resident's right leg giving out and the resident falling to the floor. The nurse aide did not adhere to the care plan and occupational therapy recommendations, which specified the need for two staff members during transfers. Another deficiency was identified concerning Resident #624, who was admitted with conditions including sepsis and type 2 diabetes mellitus. The facility failed to conduct a smoking assessment as part of the initial admission assessment, despite the resident's regular smoking activity. The resident informed staff of their smoking habits, yet the facility, which was a non-smoking environment, was unaware of the resident's smoking until it was brought to their attention during the survey. The smoking assessment form was left blank, and the resident continued to smoke on facility grounds without proper supervision or intervention. Additionally, the facility did not ensure the proper disposal of cigarette materials, as evidenced by the observation of over 100 cigarette butts in the mulch surrounding the seating area by the water fountain. The facility's policy stated it was a non-smoking environment, yet the grounds were littered with cigarette waste, indicating a lack of enforcement of the no-smoking policy and inadequate maintenance of the designated smoking area.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to administer oxygen to a resident as per physician orders, leading to a deficiency in respiratory care. The resident, who had diagnoses including acute respiratory failure with hypoxia, heart failure, and muscle weakness, had multiple physician orders for oxygen administration. These orders included applying oxygen as needed to maintain oxygen saturations over 92%, applying oxygen at 15 liters via nasal cannula or non-rebreather mask if oxygen saturation fell below 90%, and administering oxygen at 2 liters via nasal cannula at baseline every shift. However, observations on multiple occasions identified the resident sitting without oxygen, despite the order for continuous oxygen at 2 liters via nasal cannula. Staff, including an LPN and the DNS, were unable to explain why the resident had three different oxygen orders or why staff was signing off that the resident was on continuous oxygen when they were not. The LPN indicated a misunderstanding of the orders, believing the resident was on an as-needed basis and did not require continuous oxygen. The DNS confirmed the presence of three different current oxygen orders and noted that staff should have consulted with the Nursing Supervisor or Respiratory Therapist to clarify and discontinue unnecessary orders. The facility's policy required physician orders to be reviewed every 24 hours for accuracy, but discrepancies were not addressed, leading to the deficiency.
Failure to Monitor Dialysis Fistula
Penalty
Summary
The facility failed to properly identify and monitor a resident's arteriovenous (AV) fistula, which is crucial for dialysis care. The resident, who has end-stage renal disease and relies on dialysis, was not properly assessed for the presence and condition of the AV fistula upon admission. The baseline care plan and admission nursing assessment did not document the existence of the AV fistula, nor did they include any monitoring or assessment protocols for it. This oversight was confirmed through interviews with the resident, nursing staff, and the Director of Nursing Services (DNS), who acknowledged that the necessary batch orders for dialysis residents were not entered due to staff oversight. The facility's policies require that AV fistulas be monitored every shift for bruit and thrill, with documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, these assessments were not conducted or documented for the resident. The Nursing Supervisor and DNS both confirmed that the lack of documentation and assessment was due to the MAR not indicating the need to check the fistula, and the batch orders not being entered. This failure to adhere to the facility's Hemodialysis and A-V Fistula Policies resulted in the deficiency noted in the report.
Inappropriate Use and Monitoring of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving an antipsychotic medication, Zyprexa, had an appropriate diagnosis and monitoring. Resident #674 was admitted with diagnoses including anxiety/depression disorder, chronic obstructive pulmonary disease, and breast cancer. Despite being alert, oriented, and having a pleasant mood with no unwanted behaviors, a physician's order was made to administer Zyprexa for anxiety disorder, which is not an appropriate diagnosis for its use. The facility did not conduct orthostatic blood pressure monitoring as ordered until seven days after the initial order. Additionally, progress notes from APRNs failed to identify an appropriate diagnosis for Zyprexa, and the attending physician's review did not address the reason for its use. The facility also neglected to perform an Abnormal Involuntary Movement Scale (AIMS) test as recommended by a pharmacy consultant and did not document behavior monitoring. Interviews with the Director of Nursing Services (DNS) and Resident #674 revealed that the resident was unaware of the reason for taking the antipsychotic medication, and the DNS acknowledged that anxiety disorder was not a supporting diagnosis for its use. The facility's policy on antipsychotic medication use specifies that such medications should only be used when necessary to treat specific conditions and should not be used for symptoms like mild anxiety or restlessness.
Failure to Provide Requested Menu Substitutions
Penalty
Summary
The facility failed to provide the requested alternative menu option for Resident #625, who had diagnoses including dysphagia, depression, and gastro-esophageal reflux disease. The resident's care plan identified nutritional status and diet as a concern, with interventions to provide diet and fluids as ordered. However, during an interview, the resident reported not receiving the menu substitutions they had requested. An observation confirmed that the resident received pudding instead of the requested yogurt. Interviews with dietary and nurse aides revealed a lack of consistent checking of dietary slips and meal tray contents, with one nurse aide stating she was often too busy to verify the trays, leading to the resident not receiving the correct meal items.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to offer an influenza vaccine to Resident #624, who was admitted in October 2024 with diagnoses including sepsis, chronic kidney disease, and type 2 diabetes. The Baseline Resident Care Plan identified the resident as being at risk for falls, with interventions such as the use of a call bell. The admission nursing assessment noted the resident was alert and oriented, with a right hip incision. Physician orders included administering the Pneumovax 23 vaccine for pneumonia prophylaxis, but there was no order for an influenza vaccine. An interview with RN #1 revealed that the admitting nurse, charge nurse, and infection preventionist were responsible for offering the influenza vaccine and documenting the resident's acceptance or refusal. However, there was no documentation of the resident being offered the vaccine, declining it, or having previous immunization evidence for the 2024-2025 flu season. The facility's policy required offering the influenza vaccine to all residents without medical contraindications or previous immunization evidence between October 1st and March 31st, which was not followed in this case.
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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