Manchester Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, Connecticut.
- Location
- 385 W Center St, Manchester, Connecticut 06040
- CMS Provider Number
- 075333
- Inspections on file
- 24
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Manchester Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and existing stage 4 pressure ulcers had a care plan calling for turning, a low air-loss mattress, and heel offloading, but there was no physician order for offloading boots or for skin checks under the boots. Over several months, documentation did not show any directive to assess skin beneath the boots each shift, and a weekly skin check noted no new issues. Subsequently, an APRN and the ADON identified a new open area on the dorsal left foot, attributed by the ADON to rubbing from the boot strap, and a wound physician documented a full-thickness wound with 100% slough requiring ongoing treatment. Interviews with the APRN, the wound physician, and the ADON indicated the wound was not identified timely and that, had the boots been removed and the skin assessed every shift, the area could have been detected earlier and the wound’s progression potentially limited.
A resident with severe cognitive impairment, multiple chronic conditions, poor oral hygiene, and documented oral/dental problems was seen by a dental provider who found devastated dentition with cavities on every tooth, likely infection, and recommended full-mouth x‑rays, extractions, and frequent cleanings. The findings were not documented in the clinical record as progress notes, and the provider was not notified. Over the next several months, the resident repeatedly missed scheduled dental hygienist visits due to scheduling issues and hospitalizations, without evidence of nursing or provider notification or alternative follow-up. The social services director acknowledged seeing the dental note but did not inform nursing, the DON was unaware of the visit and missed appointments despite schedules addressed to her, and the APRN was not informed of the dental findings, contrary to the facility’s own notification-of-changes policy.
A resident with multiple diagnoses experienced an unwitnessed fall and was hospitalized. Upon return, required neurological monitoring was not completed or documented for several hours, and staff failed to follow the expected monitoring schedule. The facility did not have a clear policy guiding post-fall neurological checks, leading to missed assessments and inaccurate documentation.
A facility failed to honor a resident's advanced directive choices due to severe cognitive impairment. Despite a hospital directive for DNR status, the resident incorrectly signed as full code without a witness or physician's signature. The facility did not contact the resident's representative within 24 hours to confirm wishes, and no progress notes indicated attempts to reach them. The DNS acknowledged the need for representative involvement, and the case manager confirmed no legal forms were signed by the representative, despite daily visits.
A resident with a history of falls and hip replacement was not consistently ambulated as per physician orders, despite the care plan requiring ambulation twice daily with a walker. Nursing staff failed to document or provide rationale for missed ambulation opportunities, and the resident expressed concerns about not being walked regularly. Interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's mobility.
The facility failed to conduct annual performance reviews for two nurse aides, as required by their policy. The Director of HR admitted that a process change led to missed evaluations, and the DNS, who was not in her role at the time, has since been completing evaluations as expected.
A facility failed to conduct behavior monitoring for a resident on Seroquel, an antipsychotic medication prescribed for dementia with insomnia. Despite recommendations to update the medication order with specific behaviors for monitoring, the resident's representative did not want changes. The APRN and DNS acknowledged that behavior monitoring was not implemented as required by the facility's policy, which mandates targeted behavior monitoring and non-pharmacological interventions for residents on psychotropic medications.
A malfunctioning call bell system in two units caused continuous ringing, disturbing residents and staff. The issue began several days prior, and attempts to fix it with an adapter failed. The Maintenance Director tried to contact the vendor, but the problem persisted over the weekend. The Administrator acknowledged the malfunction, which violated the facility's noise control policy.
Failure to Monitor Offloading Boots and Prevent New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and monitoring for a dependent resident at high risk for skin breakdown. The resident had multiple diagnoses including dementia, Parkinson’s disease, CKD stage 3, hypothyroidism, protein-calorie malnutrition, and type 2 diabetes, and was dependent on staff for personal hygiene, bed mobility, and transfers. A quarterly MDS documented severely impaired cognition and three unhealed stage 4 pressure ulcers present on admission, and the care plan identified impaired skin integrity with interventions such as turning and repositioning every two hours, use of a low air-loss mattress, and offloading heels as tolerated. A Braden Scale assessment identified the resident as high risk for pressure injuries, and a wound care note documented that a prior left medial foot wound had resolved. Despite these identified risks and care plan interventions, the clinical record from mid-May through late September did not contain any physician order to utilize offloading boots or to check the skin under the boots every shift. A weekly skin check on 9/21/25 documented no new skin issues. On 9/23/25, an APRN was asked to evaluate a wound on the resident’s left foot and documented a left dorsal foot wound requiring daily cleansing and silver alginate dressing. Later that day, the ADON documented discovering an open area on the left dorsal foot, approximately 3 cm by 0.5 cm, and attributed it to the resident’s skin rubbing against the strap of the offloading booties. The ADON noted that the offloading boots were removed and replaced, and that new dressing orders were obtained, but there was no prior order directing use of the boots or skin checks under them. On 9/25/25, the wound care physician documented a new full-thickness wound on the left dorsal foot measuring 1.1 cm by 0.9 cm by 0 cm with 100% slough and moderate serosanguinous drainage, and recommended offloading heels per facility protocol. A later note on 3/19/26 showed the left dorsal foot wound persisted as a stage 4 pressure ulcer. Interviews with the APRN, the wound care physician, and the ADON indicated that the wound was not identified timely, that the resident should have had an order to offload both heels while in bed, and that offloading boots, once used, should have been removed every shift to assess the underlying skin. They stated that if the skin under the boots had been assessed every shift, the area could have been identified earlier and the progression to a full-thickness wound might have been prevented or less severe. The facility’s pressure injury policy referenced systematic prevention and management based on risk factors such as impaired mobility, comorbidities, cognitive impairment, and malnutrition, but there was no available policy specific to offloading boots.
Failure to Notify Provider and Follow Up on Significant Dental Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s provider and nursing staff of significant dental findings and to follow up on recommended dental care. A resident with dementia, Parkinson’s disease, stage 3 chronic kidney disease, hypothyroidism, protein-calorie malnutrition, type 2 diabetes mellitus, and three unhealed stage 4 pressure ulcers was care planned for oral/dental health problems, including poor oral hygiene and the need to monitor and report signs and symptoms of oral/dental issues. A dental visit on 9/25/25 documented that the resident had cavities on every tooth, devastated dentition likely infected or a great source of bacteria, and that the resident would be healthier without the remaining teeth. The dentist recommended an FMX to determine the best referral for further intervention and dental cleanings every three months due to poor oral health. However, from 9/25/25 through 3/25/26, the clinical record contained no progress notes about this dental visit, the need for x‑rays, the condition of the dentition, or any notification to the provider about these issues. Subsequent dental hygienist schedules showed that the resident was not treated on multiple dates over approximately six months, with reasons including not being on the hygienist’s list and the resident being at the hospital, and there was no evidence that these missed visits were communicated to nursing or the provider. The Director of Social Services, who managed outside providers, acknowledged seeing the 9/25/25 dental note but did not ensure nursing was aware of the findings or arrange additional follow-up, and confirmed the resident was repeatedly on the list but not seen. The DON stated she was unaware of the 9/25/25 dental visit and the missed hygienist visits, despite schedules being addressed to her, and indicated that the Director of Social Services should have notified nursing and a provider of the missed visits. The APRN reported she was unaware of the dental findings and would have evaluated and treated the resident if notified, and that alternative arrangements should have been made after missed appointments due to hospitalization. The facility’s Notification of Changes policy required informing and consulting with the provider and notifying the resident or representative when there is a significant change requiring alteration of treatment, but there was no policy available for outside consults and follow-up.
Failure to Complete and Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely and complete neurological monitoring following an unwitnessed fall involving a resident with diagnoses including Parkinson's disease, cervicalgia, and bipolar disorder. The resident, who was cognitively intact and independently ambulatory, was found outside the facility after an apparent elopement attempt. Initial assessments documented that the resident denied head injury and pain, and neurological checks were performed prior to the resident's transfer to the hospital. Upon return from the hospital, documentation of required neurological monitoring was missing for several hours, and the monitoring schedule was not followed as per facility standards. Further review revealed that neurological assessments were not resumed or documented upon the resident's return, despite the expectation for hourly checks to continue. The nurse responsible stated that vital signs were taken and the resident refused neurological monitoring at one point, but this refusal was not documented. Additionally, the nurse did not recall completing or attempting the required neurological assessments at the scheduled times, and documentation inaccurately indicated the resident was still hospitalized during periods when the resident was present in the facility. The facility lacked a clear policy or procedure directing staff on when to conduct post-fall neurological monitoring, relying instead on electronic medical record prompts. The Director of Nursing confirmed that neurological monitoring should have resumed upon the resident's return and continued for 72 hours, but acknowledged that the facility did not have a written policy to guide staff. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed the failure to complete and document neurological assessments as required.
Failure to Honor Resident's Advanced Directive Choices
Penalty
Summary
The facility failed to ensure that the advanced directive choices for a resident with severe cognitive impairment were reviewed and honored. The resident was admitted with a hospital discharge directive indicating a do not resuscitate (DNR) status, and a physician's order confirmed this status along with do not intubate (DNI) and a registered nurse may pronounce (RNP) orders. However, the advanced directive form in the clinical record was incorrectly signed by the resident as a full code, without a witness or physician's signature, despite the resident's severe cognitive impairment. The facility did not contact or educate the resident's representative to confirm the resident's wishes regarding the advanced directive. Interviews revealed that the resident's representative was not contacted within the expected 24-hour period after admission to discuss the resident's code status, and no progress notes indicated attempts to reach the representative. The Director of Nursing Services (DNS) acknowledged that the resident's cognitive impairment required the representative's involvement, and the current code status form was invalid. The case manager, responsible for coordinating care conferences, confirmed that the resident's representative was not asked to sign any legal forms, despite being present at the facility daily. The facility's policy required that decisions regarding advanced directives be documented and honored, but this was not adhered to in this case.
Failure to Provide Prescribed Ambulation for Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the mobility of a resident, identified as Resident #80, who was admitted with diagnoses including falls, hip replacement, and chronic pain. The care plan required ambulation of 150 feet with a rolling walker and minimal assistance. However, the nursing assistant flow sheets revealed numerous missed opportunities for ambulation, with many instances lacking documentation or rationale for the failure to ambulate. Despite physician orders and the resident's expressed desire to ambulate twice daily to regain strength and independence, the nursing staff did not consistently follow through with the prescribed ambulation. Interviews with the resident, Director of Rehabilitation, nursing assistant, Director of Nursing Services (DNS), and APRN highlighted a breakdown in communication and adherence to the care plan. The resident reported that ambulation did not occur as ordered, and the nursing assistant admitted to not offering ambulation due to the resident's therapy and recreation schedule. The DNS and Administrator expected compliance with physician orders, and the APRN indicated a need for notification if ambulation did not occur. However, no notifications were made, and the resident's ambulation was not documented or communicated effectively, leading to a deficiency in care.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for two certified nurse aides, NA #3 and NA #4, as required by their Performance Evaluation policy. NA #4, who was hired in 1995, did not have a documented performance review for 2023, with the last review dated in 2022. Similarly, NA #3, hired in 2022, also lacked a documented performance review for 2023. This deficiency was identified through a review of personnel files and interviews with facility staff. The Director of Human Resources acknowledged that the facility was undergoing a process change for completing annual evaluations, which resulted in some evaluations being missed. The Director of Nursing, who was not in her current role during the time the evaluations were missed, stated that she has since been completing evaluations around the anniversary of hire dates. The facility's policy mandates annual reviews to assess position goals and provide feedback, but this was not adhered to for the two nurse aides in question.
Failure to Monitor Behavior for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure behavior monitoring was conducted for a resident on antipsychotic medications, specifically Seroquel, which was prescribed for dementia with insomnia. The resident, who had severely impaired cognition and required total assistance with daily activities, was admitted with a physician's order for Seroquel. Despite the pharmacy's recommendation to update the antipsychotic order with a specific behavior that could be quantitatively and objectively documented, the APRN noted that the resident representative did not want the medications changed. The APRN indicated that behavior monitoring should have been initiated upon admission, but it was not implemented. Interviews with the psychiatric APRN and the DNS revealed that behavior monitoring flow sheets were not in place as required by the facility's policy. The DNS acknowledged that the nurse supervisor was responsible for ensuring behavior monitoring was initiated on admission, but it was not done for this resident. The facility's policy mandates that residents on psychotropic medications must have targeted behavior monitoring and receive non-pharmacological interventions to facilitate reduction or discontinuation of the medications. However, this was not adhered to in the case of the resident on Seroquel.
Call Bell System Malfunction Causes Disturbance
Penalty
Summary
The facility failed to maintain a homelike environment due to a malfunctioning call bell system that affected two of the three units. Observations identified continuous call bell ringing on the North unit, and an LPN confirmed the malfunction began several days prior. An email from the Maintenance Director indicated that the issue was known and an adapter was installed, but it did not resolve the problem. The Maintenance Director attempted to contact the vendor, but the issue persisted over the weekend, causing disturbances to residents and staff. The Administrator acknowledged the malfunction and agreed to contact the vendor for an immediate resolution. The facility's policy on noise control emphasizes providing care in a calm and comfortable environment, which was not upheld in this instance.
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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