Mansfield Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Storrs Mansfield, Connecticut.
- Location
- 100 Warren Circle, Storrs Mansfield, Connecticut 06268
- CMS Provider Number
- 075402
- Inspections on file
- 23
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Mansfield Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with hypothyroidism, anxiety, and dermatitis had multiple ordered medications, including Levothyroxine, Xanax, and Dupixent, that were not administered as prescribed, with MAR entries showing missed doses and not‑available status despite prior delivery from the pharmacy. Nursing notes and APRN documentation did not show that the physician or APRN were notified of missed Levothyroxine and Xanax doses, and a later APRN note linked missed morning Xanax doses to intermittent seizure‑like activity. Interviews with the DNS and LPNs confirmed that doses were omitted, medications were sometimes incorrectly documented as not available, and providers were not notified of these omissions, in contrast to facility policy requiring timely administration and appropriate notification.
A resident with anxiety, dermatitis, and hypothyroidism did not consistently receive ordered medications, including Levothyroxine, Xanax, and Dupixent, as documented on the MAR. Levothyroxine doses were missed on consecutive days, with one omission unexplained and another marked as not available despite prior delivery from the pharmacy, and no provider notification was documented. A scheduled Dupixent dose was delayed due to unavailability, and a Xanax dose was missed and marked as not available even though the medication had been received, again without documented provider notification. An APRN later noted the resident experienced intermittent seizure-like activity when the morning Xanax dose was missed and stated she should have been notified of omissions. Interviews with the DNS and LPNs revealed issues with agency staff marking medications as not available, failure to verify and obtain medications from stock or pharmacy, and lack of provider notification, contrary to facility medication administration and documentation policy.
A resident with severe cognitive and physical impairments, requiring two-person assistance for mechanical lift transfers, was transferred by a single nurse aide who failed to secure all sling loops and did not follow safety protocols. The resident, who was restless and on anticoagulant therapy, tipped forward during the transfer and sustained a head injury. The incident was not immediately reported, and other staff confirmed they did not assist or witness the transfer.
A resident with severe dementia and mobility impairments was injured during a mechanical lift transfer when a nurse aide, working alone, failed to follow the care plan's behavioral interventions and did not request assistance despite the resident's agitation. The resident struck their head on the lift after a sling loop detached, and the incident was not reported to nursing staff until injuries were later discovered.
Multiple residents were transferred using mechanical lifts by only one staff member, despite care plans and facility policy requiring two staff for such transfers. In one case, a resident sustained a leg fracture due to improper use of the lift and lack of required safety measures. Staff interviews and documentation confirmed awareness of the two-person requirement, but it was not consistently followed.
Surveyors found that food items in the kitchen were not labeled with expiration or open dates, and staff with facial hair, including the Dietary Manager and a Dietary Aide, plated food without wearing required beard restraints. Facility policy requires proper labeling of food and the use of hair and beard restraints during food handling.
Staff did not consistently use required PPE when providing care to a resident on Enhanced Barrier Precautions for a chronic wound, and infection control surveillance reports were found to be incomplete, lacking key data and analysis. Despite clear care plans and facility policies, observations and staff interviews confirmed lapses in both PPE use and infection documentation.
The facility did not complete or review required antibiotic surveillance reports at medical staff meetings, and a resident received antibiotics for a UTI despite lab results indicating colonization or contamination and not meeting McGeer's criteria. Staff interviews confirmed that antibiotic stewardship protocols were not consistently followed, and antibiotics were administered without proper indication.
The facility did not maintain a complete and accurate system for recording the receipt and disposition of controlled medications. Audits were performed, but reconciliation between yellow and white Controlled Substance Disposition Records was incomplete and delayed, and audit sheets were missing. The ADNS did not audit records until receiving documentation from nursing units, resulting in inadequate reconciliation and failure to meet the facility's policy for controlled drug record keeping.
A resident with significant mobility deficits and multiple diagnoses required two-person assistance for mechanical lift transfers. During a transfer performed by a single aide, the resident's foot slipped, resulting in an incident that was not followed by a registered nurse assessment or proper documentation, despite facility policy requiring such action. The resident was later found to have a leg fracture after reporting pain and swelling.
A controlled medication prescribed for a resident with anxiety and depressive disorder was found missing after a shift change. The medication was last verified during a count by two nurses, but one nurse left the medication cart keys unsecured and the incoming nurse did not immediately take possession of them. This lapse in medication security and accountability resulted in the loss of nearly all tablets from the resident's supply.
A resident's controlled medication, Ativan, was discovered missing, and the facility failed to report the incident to state authorities within the required two-hour window. The delay occurred despite internal awareness of the missing medication and an ongoing investigation, with external agencies not notified until several days after the initial discovery.
A resident with a history of stroke and dysphagia developed worsening respiratory symptoms, including a productive cough and abnormal lung sounds, over several days. Nursing staff documented these changes but did not notify the provider until the resident experienced further decline, including altered mental status and hypoxemia, resulting in hospitalization for probable aspiration pneumonia. Facility policy required prompt provider notification for changes in condition, which was not followed in this case.
A resident with hemiplegia and intact cognition submitted a grievance requesting more frequent care checks, timely linen changes, and specific hygiene assistance. Although the facility discussed these concerns in a care plan meeting, the resident's care plan and care card were not updated to reflect the preferences, and there was no documentation of staff education on the new care needs.
A resident with left-sided weakness and a history of falls was provided with a new mattress and bed frame, but necessary fall prevention measures, such as bolsters, were not included with the new equipment. The omission led to the resident falling from bed and sustaining shoulder pain.
A resident with essential tremor did not receive medications as per physician orders due to transcription errors and supply issues. Propranolol was given in a non-extended-release form, and Bupropion was omitted because it was not available. The DNS confirmed these errors during an interview.
Failure to Notify Provider of Missed Medications and Omissions
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when ordered medications were not administered as prescribed for one resident reviewed for medication administration. The resident had intact cognition and diagnoses including anxiety, dermatitis, and hypothyroidism, with care plans directing thyroid replacement therapy as ordered and psychotropic medications as ordered, with monitoring and reporting of issues. Physician orders included daily Levothyroxine for hypothyroidism, daily Xanax for anxiety, and biweekly Dupixent injections for dermatitis. Review of the MAR showed Levothyroxine was not documented as administered on two consecutive days, with one entry indicating the drug was not available and on order, despite pharmacy records showing a 30‑tablet supply had been delivered earlier. Nursing notes did not show that the physician was notified of these missed Levothyroxine doses. The MAR also showed a scheduled Dupixent dose was not given on the due date because it was not available and was administered two days later, with documentation that the physician was notified only to renew the Dupixent order date, not regarding the delay in administration. Additionally, a daily Xanax dose was missed on one day due to being marked as not available, and although the medication was ordered and received that same day, there was no documentation that the physician was notified of the missed dose. APRN progress notes around these timeframes did not reflect any notification of the medication omissions, and a later APRN note documented that the resident experienced intermittent seizure‑like activity when the morning Xanax dose was missed. Interviews with the DNS and LPNs confirmed that Levothyroxine and Xanax doses had not been administered as ordered, that staff documented medications as not available, and that the providers were not notified of these omissions, contrary to facility expectations and policy for medication administration and documentation.
Failure to Administer and Document Ordered Medications and Notify Provider of Omissions
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered for one resident with anxiety, dermatitis, and hypothyroidism. The resident had intact cognition and was care planned to receive thyroid replacement therapy daily and antianxiety medication as ordered, with monitoring and documentation of effects. Physician orders for March directed daily Levothyroxine for hypothyroidism, daily Xanax for anxiety, and Dupixent every 14 days for dermatitis. Review of the March MAR showed Levothyroxine was not documented as administered on two consecutive days, with one day lacking any explanation and the next day marked as not available and on order, despite pharmacy records showing a 30-tablet supply had been delivered earlier. Nursing notes did not show that the physician was notified of these missed Levothyroxine doses. The MAR also showed Dupixent was not administered on a scheduled date due to unavailability and was given two days later, after the order was renewed with a new start date. Xanax was not documented as administered on one day due to being marked as not available, even though pharmacy records indicated it had been ordered and received that same day, and there was no documentation that the provider was notified of this omission. An APRN progress note later documented that the resident continued to experience intermittent seizure-like activity when the morning dose of Xanax was missed, and the APRN stated she should have been notified of medication omissions. Interviews with the DNS and LPNs confirmed that Levothyroxine should have been available, that there were issues with agency staff documenting medications as not available, that required checks of emergency stock and pharmacy contact were not carried out as per facility expectations, and that providers were not notified when medications were not administered, contrary to facility policy on medication administration and documentation.
Failure to Ensure Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe dementia, hemiplegia, hemiparesis, muscle weakness, and a history of subarachnoid hemorrhage, who was dependent on staff for all activities of daily living and required two-person assistance for mechanical lift transfers, was transferred by only one nurse aide using a mechanical lift. The resident was noted to be fidgety, anxious, restless, and flailing arms at the time of the transfer. Despite these behaviors, the nurse aide proceeded with the transfer alone, contrary to the resident's care plan and facility policy, which required two staff members for such transfers. During the transfer, one of the loops on the lift sling became detached from the hook, causing the resident to tip forward in the sling and strike their head on the mast of the lift. The nurse aide admitted to being in a rush and failing to ensure all loops were securely attached before lifting the resident. After the incident, the nurse aide lowered the resident back into the wheelchair, secured the loop, and completed the transfer to bed without notifying a nurse or reporting the incident at that time. The resident was later found by an LPN to have a raised, discolored area above the right eye and minor bleeding near the right ear, which had not been present earlier. Due to the resident's cognitive impairment, they were unable to communicate what had happened. The incident was initially treated as an injury of unknown origin until the nurse aide later reported the accident. Interviews with other staff confirmed that no one assisted the nurse aide during the transfer, and the required safety checks and reporting procedures were not followed.
Failure to Follow Care Plan During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a mechanical lift transfer, resulting in the resident sustaining an injury. The resident had severe dementia with agitation, hemiplegia, hemiparesis, muscle weakness, and required substantial assistance with mobility and transfers. The care plan specified interventions for behavioral symptoms, including offering diversion, redirection, calm communication, step-by-step explanations, stopping care if the resident became combative or resistive, and notifying the provider if behaviors increased or persisted. On the evening of the incident, a nurse aide attempted to transfer the resident from a wheelchair to bed using a mechanical lift while the resident was visibly anxious, restless, and flailing their arms. Despite these behaviors, the aide proceeded with the transfer alone, without reporting the behaviors to nursing staff or requesting assistance, as required by the care plan and facility policy. During the transfer, a loop on the lift became detached, causing the resident to tip forward and strike their head on the lift's mast. The aide then completed the transfer without notifying nursing staff of the incident or the resident's behaviors. Later, nursing staff discovered injuries to the resident's head and ear, which were not present earlier in the day. The resident was sent to the emergency department for evaluation, where a forehead hematoma was diagnosed. The incident was initially treated as an injury of unknown origin until the aide reported the details of the transfer. Interviews confirmed that the aide did not follow the prescribed interventions for managing the resident's behaviors and did not adhere to the requirement for two staff during mechanical lift transfers.
Failure to Ensure Required Staff Assistance During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that required staff assistance was utilized during mechanical lift transfers for multiple residents, as observed and documented in the clinical records and through staff interviews. For one resident with metabolic encephalopathy, dementia, and renal failure, staff were observed transferring the resident from the bathroom to a wheelchair using a mechanical lift with only one staff member present, despite care plans, physician orders, and facility policy requiring two staff for such transfers. The nurse aide involved acknowledged awareness of the two-person requirement but proceeded alone, and this was confirmed by interviews with other staff and review of facility policy. Another resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease suffered a left tibia and fibula fracture following a mechanical lift transfer performed by a single nurse aide. The aide did not use the required leg support straps and failed to ensure the resident's feet remained on the lift platform, resulting in the resident's leg slipping and subsequent injury. Documentation and interviews confirmed that the resident required two staff for transfers and that the lift's safety features were not properly used. The incident was not initially acknowledged in the facility's reportable event documentation, and the aide admitted to performing the transfer alone due to lack of available assistance. A third resident with dementia, diabetes, anemia, and hemiplegia was also transferred using a mechanical lift by a single staff member, contrary to care plan instructions and facility policy. The staff member stated she was trained by other staff that only one person was needed, despite documentation and interviews with the DNS, staff development nurse, and physical therapist confirming the two-person requirement. These failures to follow established protocols and care plans for mechanical lift transfers resulted in unsafe conditions and, in one case, resident injury.
Failure to Label Food and Use Beard Restraints in Kitchen
Penalty
Summary
Surveyors observed multiple instances where food items stored in the facility's refrigerators and freezers were not labeled with expiration or open dates. Specifically, an open package of waffles, a partially consumed Starbucks mocha drink, shredded cabbage, Parmesan cheese wrapped in saran wrap, a box of pizza slices, a package of beef patties, an opened package of hot dogs, and oatmeal raisin cookie dough were all found without proper labeling. The Dietary Manager confirmed during interviews that these items should have been labeled with both the date they were opened and their expiration dates, in accordance with facility policy. Additionally, staff members, including the Dietary Manager and a Dietary Aide, were observed plating food without wearing required beard restraints, despite having facial hair. The facility's policies mandate that hair restraints, including beard guards, must be worn at all times in the kitchen and that facial hair should be fully covered. The Dietary Manager acknowledged during interviews that beard restraints should have been worn during food preparation.
Failure to Ensure PPE Use and Complete Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure that staff consistently used appropriate personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and did not maintain complete infection control surveillance data. During the review of the infection control program for April 2023 to January 2024, it was found that monthly surveillance infection reports and analysis of infection trends were incomplete. The facility relied on monthly Antibiotic Reports for surveillance, but these reports lacked critical information such as whether infections were healthcare-associated or community-acquired, if McGeer's criteria were met, and details on new prophylactic treatments. Interviews with facility staff confirmed that the infection control surveillance reports were incomplete during this period, and it was the responsibility of the Infection Preventionist at the time to complete and analyze these reports. A resident with a history of neurocognitive disorder, Lewy bodies dementia, trigeminal neuralgia, and a sacral pressure ulcer was identified as requiring EBP due to a chronic wound. The care plan specified the use of gown and gloves during high-contact care activities. However, observations revealed that staff did not consistently follow these precautions. On multiple occasions, staff members provided wound care and incontinence care to the resident without donning the required PPE, such as gowns and masks, despite clear indicators (blue dots on name plaques) that the resident was on EBP. Staff interviews confirmed awareness of the EBP requirements, but they could not explain the failure to use PPE during care. Facility policy required maintaining separate infection records for each resident with an infection, analyzing clusters, and monitoring the infection control program quarterly or as indicated at quality improvement meetings. Despite these policies, the facility did not ensure complete documentation or consistent PPE use, as evidenced by direct observation and staff interviews. The lack of adherence to EBP protocols and incomplete infection surveillance documentation constituted the identified deficiencies.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its antibiotic stewardship program was properly implemented and monitored, as required by policy. During a review of the program, it was found that the antibiotic surveillance tracking report, which should include data on antibiotic use, patterns, and resistance trends, was not completed or reviewed at quarterly medical staff meetings for the period of April 2023 to January 2024. Monthly antibiotic reports were also found to be incomplete, missing key information such as infection source, whether McGeer's criteria were met, and details on new prophylactic use. Quarterly reports lacked any information regarding the antibiotic stewardship program, and staff interviews confirmed that the responsibility for completing these reports was not fulfilled during the period in question. For one resident reviewed for unnecessary medications, the facility did not follow its antibiotic stewardship protocols. The resident, who had diagnoses including metabolic encephalopathy, chronic kidney disease stage 4, and altered mental status, was administered antibiotics for a urinary tract infection (UTI) despite laboratory results suggesting colonization or contamination rather than infection. The resident's care plan included both treatment and prophylactic antibiotics, and medication administration records confirmed that these were given as ordered. However, progress notes and lab results indicated that urine cultures showed multiple organisms with no predominant species, and the resident did not exhibit classic symptoms of UTI. Staff interviews revealed that antibiotics were continued even when McGeer's criteria were not met, and the process for reviewing these criteria was not consistently followed. Further interviews with clinical staff and the medical director highlighted inconsistencies in the application of antibiotic stewardship practices. The infection preventionist noted an increase in antibiotic prescribing for UTIs that did not meet established criteria, and the APRN acknowledged not always using McGeer's criteria, citing altered mental status as a justification. The medical director stated that antibiotics should not be continued without culture sensitivity and suggested alternative treatments. The facility's own policy requires oversight and monitoring of antibiotic use to minimize resistance, but these procedures were not adhered to, resulting in the administration of antibiotics without proper indication.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a complete and accurate system for recording the receipt and disposition of all controlled medications. During a review of the bi-monthly narcotic drug audit, it was found that while audits were being conducted to check for locked medication carts, proof of use sheets, correct narcotic counts, signed shift change count sheets, correct labeling, and removal of expired medications, there was a lack of comprehensive reconciliation between the yellow and white Controlled Substance Disposition Records (CSDR). The oldest yellow CSDR sheet had not been reconciled with the corresponding white CSDR, nor had the medications been documented as destroyed, and audit sheets were missing from the record book. An interview with the ADNS revealed that she was responsible for the controlled drug audits, which were performed twice a month. However, she stated that she did not audit the yellow CSDR sheets until she received the white CSDR sheets from the nursing units, resulting in incomplete and delayed reconciliation. The facility's own policy required special record keeping for all controlled drugs, but the current practice did not ensure adequate medication reconciliation, leaving the system vulnerable to medication diversion.
Failure to Complete RN Assessment After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease, who required maximal assistance for mobility and transfers, was not assessed by a registered nurse following an incident during a mechanical lift transfer. The resident's care plan and aide care card specified the need for two staff members to assist with transfers using the Sara or Hoyer lift. However, on the day of the incident, a nurse aide performed the transfer alone due to lack of available assistance. During the transfer, the resident's left foot slipped off the lift platform, and the resident reported leg weakness. The aide stopped the transfer and sought help from a nurse. The charge nurse, an LPN, responded and assisted in transferring the resident back to bed, then to a wheelchair using the Hoyer lift. The LPN checked the resident for pain, bruising, or deformity, and found none at that time. No immediate documentation or assessment by a registered nurse was completed following the incident, and no accident/incident report was initiated. The following day, the resident complained of pain, and swelling and redness were observed, leading to further evaluation and discovery of a left tibia fracture. Interviews with facility staff confirmed that the incident was not documented as required by facility policy, which mandates that a licensed nurse or supervisor complete and document an evaluation of the resident's condition after an incident. The nursing supervisor and LPN both acknowledged that a nursing assessment and note should have been completed, and the administrator and DNS agreed that the event constituted an incident requiring such documentation.
Failure to Protect Resident's Controlled Medication from Misappropriation
Penalty
Summary
A controlled medication, Ativan, prescribed for a resident with diagnoses including cerebral infarction, anxiety, and depressive disorder, was found missing from the facility. The medication, delivered in a bubble pack containing thirty tablets, was last verified as present during a shift change count by two nurses. Subsequently, it was discovered that twenty-nine tablets were missing. Documentation and interviews revealed that the nurse responsible for the 3-11PM shift left the medication cart keys on top of the cart and proceeded to another unit, while the incoming 11PM-7AM nurse did not immediately take possession of the keys or access the cart, despite both nurses having signed off on the controlled medication count. The incident was reported to the Director of Nursing and the Drug Enforcement Agency, and an internal investigation was conducted, including audits and staff interviews. The facility's abuse policy defines misappropriation of resident property as the wrongful use of a resident's belongings without consent. The investigation was unable to determine how the Ativan went missing, but the failure to maintain proper control and accountability of the medication, as well as lapses in the handoff process and medication cart security, led to the loss of the resident's controlled medication. The resident was alert and oriented at the time, with a care plan in place for medication administration and monitoring.
Failure to Timely Report Missing Controlled Medication
Penalty
Summary
The facility failed to report the misappropriation of a resident's controlled medication, Ativan, to the state agency within the required two-hour timeframe. A resident with diagnoses including cerebral infarction, anxiety, and depressive disorder was prescribed Ativan 1 mg as needed for anxiety. On a specified date, it was discovered that 29 tablets of Ativan were missing from the resident's medication supply. The missing medication was identified during a shift change count, and subsequent investigation revealed discrepancies in the medication count process and handling of the medication cart keys by nursing staff. The incident was reported to the Director of Nursing, but there was a delay in notifying the Administrator and external authorities. The Administrator was informed of the missing medication two days after it was reported to the Director of Nursing, and the incident was not reported to the Department of Consumer Protection, Drug Enforcement Division, Department of Public Health, or local law enforcement until four days after the initial discovery. The facility's abuse policy requires immediate reporting of alleged violations, including misappropriation of resident property, to the Administrator and Director of Nurses. However, the delay in reporting the missing medication constituted a failure to comply with this policy and regulatory requirements.
Failure to Timely Notify Provider of Resident's Change in Condition Leading to Hospitalization
Penalty
Summary
The facility failed to notify the healthcare provider in a timely manner regarding a resident's change in condition, which ultimately led to a hospitalization. The resident, who had a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction, was documented as having diminished lung sounds upon admission. Over several days, nursing notes recorded the development and progression of respiratory symptoms, including a non-productive cough, crackles on auscultation, and later a productive cough with moderate white secretions. Despite these documented changes in respiratory status from 8/30/24 through 9/2/24, there was no evidence that the provider was notified during this period. On 9/3/24, the resident exhibited further decline, including altered mental status, increased confusion, a low-grade fever, and a decreased oxygen saturation level. At this point, the provider was notified, and the resident was transferred to the emergency department. Hospital records indicated that the resident arrived with hypoxemia, fever, and tachycardia, and was subsequently diagnosed with probable aspiration pneumonia and treated with antibiotics. Interviews with facility staff and the APRN confirmed that the expectation was for immediate provider notification upon the initial observation of a productive cough and abnormal lung sounds, which did not occur. Facility policy required that any change in condition be promptly communicated to the provider, the resident, and the family or responsible party. The review of documentation and staff interviews revealed that this policy was not followed, as the provider was not informed of the resident's respiratory changes until several days after the initial symptoms were observed. This delay in notification was confirmed by both the APRN and the previous DNS, who stated that provider notification should have occurred immediately upon the identification of the change in lung sounds and cough.
Failure to Update Care Plan and Communicate Resident Preferences After Grievance
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, anxiety, and gait abnormalities, who was cognitively intact, required moderate assistance with activities of daily living such as toileting, bathing, and dressing. The resident submitted a grievance requesting more frequent care checks, prompt changing of soiled linens, and specific attention to scalp and jawline hygiene during bathing due to dry skin. Although the facility received these care requests and held a care plan meeting with the interdisciplinary team, the resident, and the resident's spouse to discuss the concerns, the care plan and care card were not updated to reflect the resident's preferences and requests. Additionally, there was no documentation provided to show that staff had been educated on the resident's specific care concerns and preferences. The facility's Resident Rights policy requires prompt efforts to resolve grievances and reasonable accommodation of individual needs and preferences, but the failure to update the care plan and care card, as well as the lack of staff education, demonstrated noncompliance with these requirements.
Failure to Provide Fall Prevention Measures with New Bed Equipment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a new piece of equipment, specifically a mattress and bed frame, had the necessary fall prevention measures in place for a resident with a history of hemiplegia, hemiparesis, and mobility impairments. The resident required moderate assistance for bed mobility and transfers and was identified as being at risk for falls due to left side weakness and use of psychotropic medications. The care plan included interventions such as keeping the bed in a low position and using non-skid footwear, as well as the use of bolsters to prevent falls from bed. After an initial fall, a mattress with bolsters was ordered, but when a larger replacement mattress and bed frame were subsequently ordered, bolsters were not included or specifically ordered for the new equipment. The facility administrator did not verify whether the new mattress came with bolsters and assumed that pillows placed under the sheet would suffice as a preventive measure. As a result, the resident experienced another fall from bed, sustaining left shoulder pain, though without serious injury.
Medication Administration Errors Due to Transcription and Supply Issues
Penalty
Summary
The facility failed to administer medications in accordance with physician orders for a resident diagnosed with essential tremor. The hospital discharge orders specified the administration of Propranolol 60 mg 24-hour capsule daily, but the facility administered a non-extended-release Propranolol HCL oral tablet 60 mg instead. This discrepancy was identified when the resident was being discharged and reported the error. The Director of Nursing Services (DNS) confirmed that the error was due to a transcription mistake, and the incorrect medication was sourced from the facility's emergency supply. Additionally, the facility did not administer Bupropion HCL ER (XL) 150 mg oral tablet extended release as ordered by the physician. The medication was omitted because it had not been received from the pharmacy, and there was none available in the facility's emergency supply. These incidents highlight a failure in the medication administration process, specifically in transcribing and ensuring the availability of prescribed medications.
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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