Matulaitis Rehabilitation & Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Putnam, Connecticut.
- Location
- 10 Thurber Rd, Putnam, Connecticut 06260
- CMS Provider Number
- 075411
- Inspections on file
- 19
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Matulaitis Rehabilitation & Skilled Care during CMS and state inspections, most recent first.
A resident with dementia and a known elopement risk was found outside exterior fire doors after a fire alarm event in which a bathroom fan caught fire and activated the facility’s alarm system. Later observation showed that one of the exterior fire doors, controlled by a keypad and magnetic lock, did not latch shut on its own and had to be pulled closed, with interior weather stripping noted on the bottom of the door. The Maintenance Director reported that fire alarms disable door alarms and cause the doors to open automatically, acknowledged that the doors were old and known to require pulling to close, and stated that maintenance did not check the doors after the alarm to ensure they were secured. The DNS also confirmed that the exterior fire doors were not checked for secure closure following the fire event.
A resident with dementia, insomnia, repeated falls, and documented wandering was assessed as an elopement risk and placed in a room far from the nurses’ station and near an exterior exit. The care plan included only general interventions (e.g., orientation, frequent checks, familiar objects) and did not address specific behaviors such as nighttime wandering, confusion, searching for family, and packing belongings to leave. Psychiatric notes and staff interviews confirmed ongoing late-night wakefulness, agitation, and exit-seeking behaviors, and the resident was later found outside an alarmed exterior fire door. Despite facility policy requiring targeted elopement measures, the resident’s elopement care plan lacked individualized interventions tied to these known risk factors.
A resident with dementia, insomnia, a history of wandering, and moderately impaired cognition was assessed as at risk for elopement and had an elopement care plan, but no wander guard was applied despite facility policy. The resident was independently ambulatory, exhibited nighttime confusion and wandering, and was housed in a room far from the nurses’ station and closest to exterior fire doors. After a prior fire alarm event, maintenance did not verify that the exterior fire doors re-latched, even though the doors were known to require being pulled shut and had weather stripping that could impede closure. During the night, staff heard an alarm they did not recognize, later determined to be from the exterior fire doors, and found one door slightly ajar before discovering the resident missing and then located outside on the ground just beyond the doors. Staff, including nursing and CNAs, reported they had not participated in elopement drills, and leadership confirmed that no elopement drills had been conducted despite policy requiring periodic drills for residents at risk of wandering or elopement.
The facility failed to consistently document sanitizer concentration levels in the kitchen, as required by policy. Staff interviews and document reviews revealed missing entries in the sanitizer verification logs for several months, indicating that the sanitizing solution was not always checked before use. The Dietary Manager acknowledged the responsibility of dietary staff to verify and document the sanitizer concentration.
A resident admitted with a mid-back surgical incision did not have the surgical wound or related skin impairment included in their care plan, despite physician orders and facility policy requiring monitoring and care planning for such conditions. Interviews with the DNS and MDS Coordinator confirmed the omission, which was not addressed at the time of admission.
Two residents with altered skin integrity did not receive required wound measurements, and one used an external catheter device without a physician's order or staff training. Additionally, a Braden Scale pressure ulcer risk assessment was not completed on admission or at a change in condition for a resident with a worsening pressure ulcer, contrary to facility policy.
A resident admitted with a stage 4 pressure ulcer did not receive timely interventions, including delayed provision of an air mattress and turning schedule, and lacked prompt staging and assessment of the wound. The ulcer worsened significantly, and documentation of wound measurements was inconsistent, contrary to facility policy.
A resident with urinary incontinence and multiple comorbidities used an external catheter system without a physician's order, and staff interacted with the device without receiving any training. The family and a private aide managed the device without facility oversight, and there was no policy or staff education in place regarding its use.
A resident with dementia and other medical conditions was allegedly slapped by a nursing assistant during a night shift. The incident led to an investigation, conflicting statements from staff, and the termination of the nursing assistant for not adhering to the facility's dignity policy.
Failure to Ensure Exterior Fire Doors Securely Closed After Fire Alarm
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by ensuring that exterior fire doors in a resident-accessible area were functional and able to securely close. A resident admitted with dementia, repeated falls, and insomnia had been identified as at risk for elopement, and an elopement care plan was in place. A reportable fire event occurred when a bathroom fan on one wing caught fire, triggering the fire alarm system and emergency response. Following this fire alarm, the exterior fire doors on another wing alarmed during the night, and a safety check revealed that the at-risk resident was found outside those exterior fire doors on their hands and knees, with no injuries identified at that time. Subsequent observation of the same exterior fire doors showed that, although they were locked and equipped with a keypad and magnetic locks, one of the two doors did not latch shut on its own and had to be pulled closed to secure it. The Maintenance Director stated that when the fire alarm is activated, the alarms on the exterior fire doors are disabled and the doors open automatically, and acknowledged that the prior fire alarm could have caused the doors to open and then not properly close and latch afterward. He also acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, despite knowing that the doors were old and required pulling to close, and that interior weather stripping might contribute to the failure to close securely. The DNS confirmed that after the fire event, the exterior fire doors were not checked to ensure they were secured and latched.
Failure to Individualize Elopement Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop a person-centered, individualized care plan to address an assessed elopement risk for one resident. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, leading to initiation of an elopement care plan. The Resident Care Plan documented that the resident was at risk for elopement related to dementia, with a history of wandering in the community and at the facility, and a past occupation as an elevator repair person who believed he had service calls and wanted to leave at night. Interventions listed were general in nature, such as introducing staff in a calm manner, explaining routines, orienting to room and environment, performing frequent checks, placing a picture in the business office, and encouraging family to bring familiar objects. The resident’s MDS showed moderately impaired cognition, independent ambulation of at least 150 feet, and wandering behaviors several days per week. Clinical documentation and interviews showed specific behaviors and circumstances that increased the resident’s elopement risk but were not reflected in individualized care plan interventions. Psychiatric notes over several months described late evening and early morning wakefulness, agitation, confusion, wandering, insomnia, and the resident looking for a family member at night, with PRN Trazodone ordered for agitation/insomnia. Staff interviews reported that the resident stayed up at night, wandered the hall, and packed belongings at night to go home. The resident’s room was located far from the nursing station and closest to an exterior fire door. An incident report documented that an exterior fire door alarm sounded during the night and the resident was found outside that door on hands and knees. Despite the facility’s written policy that residents identified as elopement risks would have a wander guard bracelet, photo ID placement, and periodic elopement drills, the care plan did not include individualized interventions addressing the resident’s nighttime wandering, confusion, searching for family, packing to leave, or room location near an exit, and the facility had not conducted or documented elopement drills.
Failure to Secure Exterior Fire Doors and Implement Elopement Interventions for At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that exterior fire doors in a resident-accessible area were secured and to provide adequate supervision and interventions for an ambulatory resident assessed as at risk for elopement, resulting in the resident exiting the building unsupervised. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, with an elopement care plan initiated. The resident care plan documented dementia-related elopement risk, a history of wandering in the community and at the facility, and a past occupation as an elevator repair person with a pattern of thinking he had service calls and wanting to leave at night. Interventions listed included calm introductions, explanation of routines, orientation to room and environment, frequent checks as necessary, a picture in the business office, and encouraging family to bring familiar objects; no wander guard was initiated at that time. Clinical documentation showed the resident had late evening and early morning wakefulness, agitation, confusion, and wandering, including middle-of-the-night confusion and looking for a family member, with PRN Trazodone ordered for agitation/insomnia. The quarterly MDS identified moderately impaired cognition (BIMS 11), independent ambulation of at least 150 feet, and wandering behaviors occurring one to three days per week. A fall assessment tool identified the resident as high risk for falls. Despite these findings and the facility’s own policy stating that residents identified as elopement risks should have a wander guard bracelet initiated and checked each shift, the DNS stated the resident did not have a wander guard because the resident was not considered exit seeking or making statements of wanting to leave. The DNS also acknowledged that the resident’s room, which was the closest to the exterior fire doors and farthest from the nursing station, was the only room available at admission. On the night of the event, a bathroom fan fire on another wing had triggered the fire alarm the previous day, which the Maintenance Director stated could cause exterior fire doors to open and then not close and latch properly once the alarm was completed. He acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, and that the D-wing exterior fire doors were known to require being pulled shut to secure, with weather stripping possibly contributing to incomplete closure. In the early morning hours, staff heard an alarm they did not recognize and initially did not know it was from the exterior fire doors; they required direction from the supervisor to check those doors. The NA found the D-wing exterior fire door slightly ajar, closed it, and then began a resident head count, discovering the resident missing from the room nearest the doors. When the exterior doors were opened, the resident—who had been last seen in bed around midnight and was known to pack belongings at night to go home—was found outside on hands and knees. Both the NA and RN reported they had not participated in any elopement drills, and the DNS confirmed the facility had not conducted elopement drills and had no documentation of such drills, despite policy requiring periodic elopement drills for residents at risk for wandering/elopement.
Inconsistent Sanitizer Verification in Kitchen
Penalty
Summary
The facility failed to consistently complete sanitation logs for the sanitizing sink according to its policy. During a kitchen tour, a dietary aide was observed washing a pitcher in a 3-bay sink, with two large gray baking pans soaking in the sanitizing sink. The dietary aide admitted to not checking the sanitizer concentration level, relying on the cook who checked it in the morning. A review of facility documentation revealed that the sanitizer level was not checked before washing and sanitizing breakfast dishes. Furthermore, the pot sink and bucket sanitizer verification logs from June to December 2024 showed missing documentation for breakfast and lunch times across several months. Interviews with staff revealed that the sanitizing sink was filled with solution in the morning, but the concentration test results were not always documented. The Dietary Manager confirmed that it was the dietary staff's responsibility to check the sanitizing solution before use and acknowledged that staff might forget to document the concentration. The facility's policy requires that testing of the sanitizing solution be documented each time the sink is refilled, and the person filling the sink is responsible for this documentation.
Failure to Timely Update Care Plan for Surgical Incision on Admission
Penalty
Summary
The facility failed to timely review and revise the care plan to address a surgical incision present on admission for one resident. The resident, who had a history of spinal fusion, chronic congestive heart failure, urinary incontinence, muscle weakness, and required assistance with personal care, was admitted with a mid-back surgical incision. The admission observation and physician's order both documented the presence of the incision and directed staff to monitor it for signs of infection every shift. However, the care plan did not identify the actual skin impairment related to the surgical wound. Interviews with the Director of Nursing Services and the MDS Coordinator confirmed that a care plan for the surgical incision should have been initiated upon admission, but this was missed. Facility policy required that the comprehensive, person-centered care plan include all identified problem areas and risk factors, but the surgical wound was not incorporated into the resident's care plan as required.
Failure to Assess Wounds, Obtain Orders for Medical Devices, and Complete Pressure Ulcer Risk Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with altered skin integrity. For one resident with a history of spinal fusion, chronic congestive heart failure, urinary incontinence, and muscle weakness, the facility did not measure two surgical incisions from admission through discharge, despite policy requiring weekly wound assessments including measurements. Documentation showed that staff were unable to assess the incision on admission due to family refusal, but there was no evidence of subsequent measurements or documentation throughout the resident's stay. Interviews with clinical staff confirmed that wound protocols were not followed, and the Director of Nursing was unable to explain the lack of measurements. Additionally, the same resident utilized an external catheter device throughout their stay without a physician's order, as documented in nursing notes. The device was applied and removed by the family and a private aide, with facility staff only turning it on/off or emptying it as needed, despite not being trained on its use. There was no facility policy or staff training regarding the external catheter, and the Director of Nursing acknowledged that a physician's order should have been obtained and that staff should not have managed the device without proper oversight. For a second resident with a right femur fracture, Parkinson's disease, dementia, and a stage 4 pressure ulcer, the facility failed to complete a Braden Scale pressure ulcer risk assessment on admission and at a change in condition, as required by policy. The resident was admitted with a pressure ulcer, which worsened during the stay, but the Braden Scale was not completed until 25 days after admission. Interviews with nursing leadership confirmed that the assessment should have been done on admission and with the change in condition, but they were unable to explain the omission.
Failure to Provide Timely Pressure Ulcer Interventions and Assessment
Penalty
Summary
A deficiency occurred when a resident admitted with a stage 4 pressure ulcer did not receive timely and appropriate interventions as required by facility policy. Upon admission, the resident was noted to have a pressure ulcer to the coccyx, but the ulcer was not staged, and a Braden Scale assessment to identify risk for further skin breakdown was not completed in a timely manner. The initial care plan included interventions such as a pressure-relieving mattress and repositioning, but an air mattress was not provided until three days after admission, despite the presence of a pressure ulcer. Orders for regular turning and repositioning were also delayed until three days post-admission. The clinical record showed that the pressure ulcer increased in size significantly within a few days, and there was a lack of consistent and timely wound measurements and assessments, with a ten-day gap in documentation. The wound was not staged or assessed according to facility policy, which requires weekly assessments. The resident's condition deteriorated, with the ulcer worsening and signs of infection developing, leading to a transfer to the emergency department for further evaluation. Upon return, a wound care consult was ordered, and the wound was found to have slough and necrotic tissue, requiring debridement and specialized wound care products. Interviews with facility staff confirmed that the expected interventions, such as providing an air mattress and implementing a turning schedule, were not initiated on admission as required. The Director of Nursing Services and a registered nurse acknowledged the delay in implementing these interventions and the lack of timely wound assessment and staging. The facility's policies require immediate risk assessment, staging, and implementation of pressure ulcer prevention and treatment measures, which were not followed in this case.
Lack of Staff Training and Oversight for External Catheter Use
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for a resident using an external catheter system. The resident, who had a history of spinal fusion, chronic congestive heart failure, urinary incontinence, and previous UTIs, was documented as using an external catheter during their stay. However, there was no physician's order for the device, and the care plan only addressed general incontinence care without mention of the external catheter. Facility staff did not apply or remove the catheter, but did turn it on/off and emptied it as needed, despite not having received any training on the device. The family and a private aide were allowed to manage the catheter without facility oversight. Interviews with staff and administration confirmed that there was no policy or staff education regarding the use of the external catheter system. The DNS acknowledged that the facility permitted the family and private aide to manage the device and that staff interacted with the device without proper training. No policy on the external catheter system was provided when requested, and the APRN stated that the device should not have been used without a physician's order and appropriate staff training due to infection risks.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity. Resident #1, who had diagnoses including dementia with psychotic disturbances, infection to cystostomy catheter, heart failure, and depression, was involved in an incident where a nursing assistant (NA #1) allegedly slapped the resident. The incident occurred during the night shift when Resident #1 was restless and attempting to get out of bed. Another nursing assistant (NA #2) reported witnessing NA #1 slap Resident #1 in the face, which led to an immediate investigation and the removal of NA #1 from care duties. NA #1 denied slapping the resident but admitted to placing her hand over the resident's mouth to quiet him down, which was deemed inappropriate by the facility's Director of Nursing (DON). The facility's policy on dignity and respect was not followed, leading to the termination of NA #1's employment. The incident report and investigation revealed conflicting statements from the involved staff members, making it difficult to substantiate the abuse claim. However, the DON acknowledged that NA #1's actions were not in line with the facility's policy on treating residents with dignity and respect. The facility's Quality of Life - Dignity Policy emphasizes that each resident should be cared for in a manner that promotes their well-being and self-esteem. The failure to adhere to this policy resulted in the deficiency noted in the report.
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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