Meriden Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 360 Broad Street, Ste 1, Meriden, Connecticut 06450
- CMS Provider Number
- 075295
- Inspections on file
- 33
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Meriden Health And Rehab during CMS and state inspections, most recent first.
A resident with MS, paraplegia, dementia, and depression experienced an acute change in mental status, including word-finding difficulty and dysarthric speech. An LPN notified the supervisor RN, who initially felt the resident was at baseline, but later another LPN confirmed the change in condition. The APRN, contacted via AV technology, identified the situation as an acute, critical problem, agreed with hospital transfer, and documented that EMS had been activated. However, EMS records showed that dispatch was not contacted until 41 minutes after the APRN’s note. When EMS arrived, the resident was obtunded with very low systolic BP, requiring IV fluids and Narcan before transport, demonstrating a delay in timely EMS activation following a significant change in condition.
A resident with severe cognitive impairment and a history of wandering and aggressive behavior was able to enter another resident's room and push them off the bed, and later pushed a roommate off the bed, resulting in both residents being found on the floor and one sustaining a subdural hematoma. Facility staff did not provide adequate supervision or protection, despite documented behavioral risks and care plan interventions.
A resident with a history of falls and multiple comorbidities was admitted and identified as a moderate fall risk, requiring extensive assistance and supervision. Despite this, no baseline care plan addressing fall risk was developed within 48 hours of admission, and the care plan was only created after the resident sustained an unwitnessed fall that led to pain and an emergency department evaluation.
A resident with dementia, hemiplegia, and high fall risk did not have floor mats placed on both sides of the bed as required by the care plan. Documentation and staff interviews confirmed the mats were not in place during a fall, despite care plan directives and facility policy requiring such interventions.
A resident with a history of falls and mobility issues was found on the floor after an unwitnessed fall and was left alone in their room while waiting for EMS to arrive. The facility lacked a policy specifying that staff should remain with the resident during this time, despite expectations from the DON that supervision should be provided.
A resident with a history of constipation and multiple sclerosis underwent a STAT abdominal x-ray that revealed critical findings, but nursing staff failed to promptly notify the physician or APRN of the results. Although the x-ray report was available in the EMR and faxed to the facility, staff did not access or act on the results for several hours, and the physician was not informed until the following morning, contrary to facility policy.
A resident with a history of multiple sclerosis and constipation underwent a follow-up KUB x-ray that revealed a critical finding suspicious for partial sigmoid volvulus. Despite the results being available in the EMR and faxed to the facility, staff did not access or review the results for over 12 hours, repeatedly documenting that results were pending. The lack of timely review and notification to the provider resulted in a delayed hospital transfer for the resident.
A resident was readmitted after a hospital stay and received Levemir insulin and oral anti-diabetic medications that were not ordered by the provider, due to inaccurate transcription and lack of verification of medication orders in the EMR. Nursing staff administered insulin without required blood glucose checks, and the resident's blood sugars were not monitored, resulting in severe hypoglycemia and a change in condition that was not promptly recognized or treated.
Annual performance appraisals were not completed for several nurse aides, with some not receiving an appraisal in over a year and one lacking any appraisal record. The HR Director had not initiated or completed appraisals and was unfamiliar with the process, and the facility could not provide a relevant policy.
A resident with multiple pressure ulcers, bowel incontinence, and high risk for further skin breakdown was admitted and assessed as dependent for ADLs and not oriented. The care plan created for this resident addressed only wounds and enhanced barrier precautions, omitting interventions for incontinence, pressure ulcer risk, and the active sacral wound, contrary to facility policy and assessment findings.
The facility failed to follow provider orders for two residents: one received Levemir insulin without required blood glucose checks, resulting in severe hypoglycemia and emergency transfer, while another did not receive a documented weekly skin assessment as ordered for pressure ulcer prevention. Nursing staff confirmed the lapses, and required documentation and protocols were not followed.
Following a resident-to-resident altercation involving two residents with dementia and anxiety disorders, the facility did not provide or document timely social services support or follow-up as required by policy. Despite care plans calling for investigation, psychiatric follow-up, and observation for mental distress, there was no evidence in the clinical record that social services met with or followed up with the residents involved in the days after the incident.
A resident with Alzheimer's, heart failure, and respiratory failure became unresponsive, and staff failed to perform a complete assessment or initiate emergency interventions such as CPR, use of the AED, or immediate oxygen administration, despite the resident's full code status. EMS found the resident with low oxygen saturation and initiated resuscitation upon arrival.
A resident with dementia and a history of wandering exited the memory care unit by observing and memorizing the door code, then unlocking the doors and leaving the building. Staff observed the resident at the lock pad but did not immediately redirect, allowing the resident to exit before intervention. The resident had refused a wander guard bracelet, and the facility's elopement prevention measures were not effectively implemented in this case.
The facility failed to complete Advance Directive forms for three residents upon admission, leading to discrepancies in their documented code statuses. One resident was initially documented as a full code but later expressed a wish to be DNR. Another resident was documented as a full code without a signed form, and a third resident also lacked a signed form despite being documented as a full code. Staff interviews revealed a failure to ensure the completion and proper documentation of Advance Directives.
A resident with cognitive and mood disorders was not provided with activities of interest, specifically music, as indicated in their MDS assessment. The Resident Care Plan and Care Card did not reflect the resident's interest in music, and the behavior monitoring form lacked documentation of music being offered. Observations showed minimal engagement in activities, and the Recreation Director, aware of the resident's interest, did not provide music during a brief visit.
The facility failed to securely store resident-identifiable information and medical records, with boxes containing sensitive data found in unlocked rooms and under fire suppression devices. The Administrator was aware of the storage issue, which arose after records were moved from sold outbuildings, but the method did not comply with the facility's policy to protect records from hazards.
The facility failed to maintain sanitary conditions in the laundry area, with clean hangers stored improperly with dirty laundry and laundered rags stored near damaged walls exposing insulation and debris. The Administrator acknowledged the need for improvement, and facility policy requires clean laundry to be covered for transport.
The facility failed to develop and implement comprehensive care plans for two residents. One resident, with cognitive impairments, had a care plan that did not include their interest in music, despite it being identified as important. Another resident with CHF was not monitored for symptoms as required by their care plan, and staff interviews revealed a lack of documentation and adherence to facility policy. These deficiencies highlight a lack of individualized care planning and monitoring for residents' specific needs.
The facility failed to conduct comprehensive assessments for two residents. A resident with Parkinson's disease did not receive a full neurological assessment after an unwitnessed fall with a head injury, as required by facility policy. In another case, a resident under hospice care was pronounced deceased by an RN who only noted the absence of a pulse, omitting other vital signs and assessments. Both incidents reflect a failure to adhere to the facility's policies for thorough assessments.
A resident was observed wearing a stained hospital gown and jeans due to the facility's failure to return personal laundry in a timely manner. The resident, who was cognitively intact and required partial assistance for dressing, expressed a preference for wearing their own street clothes. Interviews revealed that laundry was not collected as scheduled due to staff absence, resulting in the resident's laundry not being washed for an extended period.
The facility failed to provide the Notice of Medicare Non-coverage (NOMNC) form to two residents before their planned discharges, as required by policy. One resident with rhabdomyolysis, HIV, and hypertension, and another with spinal stenosis, hypertension, and hypothyroidism, were discharged without receiving the necessary NOMNC forms. The Administrator confirmed the oversight and noted the MDS Coordinator's responsibility in this process, but could not explain the failure to comply with the policy.
During an evening shift, three dependent residents with dementia and other serious conditions were not fed dinner or provided incontinent care by the assigned nurse aide, who was observed spending time at the nurses' station and leaving the facility without authorization. The residents' care needs, including feeding and hygiene, were not met until other staff were reassigned later in the shift, resulting in a delay of essential care.
Allegations that a nurse aide failed to provide care and meals to three dependent residents were not reported immediately to the Administrator or State Agency as required. The delay occurred despite facility policy mandating prompt reporting of suspected neglect, and involved multiple staff who did not escalate the issue in a timely manner.
An agency nurse aide began working without receiving the required orientation or education on facility policies, including the abuse and neglect policy, as mandated by facility procedures. Documentation and interviews confirmed that the orientation process was not completed prior to the aide's first shift, despite established policies assigning this responsibility to the Nursing Supervisor.
Delay in EMS Activation After Acute Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely activation of emergency medical services (EMS) after a significant change in condition was identified and after the APRN directed transfer to the hospital. Resident #1 had multiple sclerosis, paraplegia, dementia, depression, anemia, and was dependent for personal hygiene, bed mobility, and transfers. The resident’s care plan included monitoring for changes in condition and behavior, and for new onset confusion related to pain medications. On the evening in question, the APRN documented at 9:32 PM that, via audio/visual technology at 9:00 PM, she had been notified that Resident #1 had an acute altered mental status with word-finding difficulty and dysarthric speech. She noted vital signs were stable, the resident was not in acute distress, identified the problem as acute and critical, questioned a possible MS flare or stroke, and agreed with transfer to the hospital. Earlier in the shift, LPN #1 reported to RN #1 that Resident #1 had mental status changes with stable vital signs and requested hospital transfer; RN #1 assessed the resident and felt the resident was back to baseline. Around 7:00 PM, LPN #1 asked LPN #2, who was working on another unit, to assess the resident; LPN #2 confirmed that the resident’s mental status had worsened compared to the day shift, with increased confusion and difficulty finding words. LPN #1 stated she then notified the responsible party, called EMS, and contacted the on-call APRN, who agreed EMS should be called, but she could not recall the specific times of these calls. LPN #2 reported returning around 8:30 PM to assist with the AV device to contact the APRN and leaving about 8:45 PM. Despite the APRN’s documentation at 9:32 PM that EMS had been activated and that she agreed with hospital transfer, the EMS run sheet showed that EMS dispatch was not notified until 10:13 PM, creating a 41-minute gap between the APRN note and the EMS call. When EMS arrived at 10:28 PM, they found Resident #1 obtunded and responsive only to painful stimuli, with an initial systolic blood pressure of 50. EMS administered IV fluids and Narcan, with improvement in mental status and blood pressure, and transported the resident to the hospital at 10:53 PM. Interviews with LPN #1, LPN #2, RN #1, and the DON did not clarify why EMS was not called until 10:13 PM despite the APRN’s earlier documentation and the facility’s Change in Condition Reporting Policy, which directed timely recognition and communication of significant changes in condition.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and protection for residents with severe cognitive impairment and known behavioral issues, resulting in multiple incidents of resident-to-resident physical altercations. One resident with diagnoses including dementia, schizoaffective disorder, and a brain lesion, and who was on hospice services, exhibited wandering and aggressive behaviors. Despite these known risks, this resident was able to enter another resident's room and push that resident off the bed, as well as later push a roommate off the bed, causing both residents to fall to the floor. Clinical records and facility documentation revealed that the resident responsible for the altercations had a history of severe cognitive impairment, required supervision for transfers and ambulation, and had documented wandering and behavioral issues. The care plan directed staff to be present on the unit during the evening shift to redirect wandering behaviors, but the resident was still able to access other residents' rooms and physically interact with them. In one incident, the resident pushed a roommate off the bed, resulting in both residents being found on the floor and requiring hospital evaluation. The resident who initiated the altercation was found to have a subacute right subdural hematoma with subfalcine herniation following the incident. Interviews with facility leadership confirmed that the resident with behavioral issues had no roommate until after the first incident, and that the roommate was assigned despite available beds on other units. The facility was unable to explain how the roommate was protected from harm, given the known history of aggressive behavior. Facility policy prohibits abuse by anyone, including other residents, but the actions taken were insufficient to prevent further incidents of mistreatment.
Failure to Develop Timely Baseline Care Plan for Fall Risk
Penalty
Summary
A deficiency occurred when the facility failed to develop a baseline admission care plan addressing a new resident's risk for falls within the first 48 hours of admission. The resident, who had a history of falls and multiple diagnoses including metabolic encephalopathy, osteoarthritis, osteomyelitis, low back pain, muscle weakness, and difficulty walking, was assessed as a moderate fall risk upon admission. The clinical record and facility documentation did not show that a baseline care plan was created to address this risk, despite the resident's need for extensive assistance with bed mobility and toileting, supervision for transfers, and use of assistive devices. The lack of a timely care plan persisted until after the resident experienced an unwitnessed fall, which resulted in complaints of pain and required evaluation in the emergency department. Interviews and record reviews confirmed that the expectation was for a baseline care plan to be in place for residents identified as at risk for falls, but this was not completed until after the incident occurred.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of falls, specifically neglecting to ensure that floor mats were placed on both sides of the bed as directed in the care plan. The resident, who had diagnoses including dementia, hemiplegia and hemiparesis following a stroke, muscle weakness, and difficulty walking, was identified as high risk for falls. The care plan included several interventions such as keeping the bed in a low position, using body pillows, and placing floor mats on each side of the bed. Despite these directives, documentation and staff interviews revealed that the floor mats were not in place at the time of a fall incident. On one occasion, the resident was found on the floor mat after a fall, but on a subsequent occasion, the resident was found on the floor without documentation that the mats were in place. The nurse's notes and incident reports failed to confirm the presence of the mats during the second fall, and staff interviews confirmed that the mats were not in place at that time. The DON acknowledged that it was staff responsibility to implement all care plan interventions and was not aware that the mats were missing during the incident investigation. Facility policies required comprehensive, person-centered care plans with measurable objectives and timely implementation, but these were not followed in this case.
Resident Left Unattended After Unwitnessed Fall
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, osteoarthritis, osteomyelitis, low back pain, muscle weakness, a history of falls, and difficulty walking, experienced an unwitnessed fall. The resident was found on the floor after sliding forward out of a wheelchair while attempting to reach the bathroom. The clinical record indicated the resident was at moderate risk for falls, required extensive assistance with bed mobility and toileting, and was unable to independently stand. Following the fall, the resident complained of bilateral hip and right shoulder pain, and the on-call Advanced Practice Registered Nurse directed that the resident be sent to the Emergency Department for evaluation. Facility documentation and the EMS report revealed that the resident was left alone on the floor in their room while awaiting EMS arrival. The facility did not have a policy in place at the time addressing whether staff should remain with a resident after a fall while waiting for EMS, although the Director of Nursing stated it was the expectation that staff would stay with the resident. The facility's unwitnessed falls policy directed that residents not be moved if a fracture or serious condition was suspected, but did not specify supervision requirements during the wait for EMS.
Failure to Timely Notify Physician of Critical X-ray Results
Penalty
Summary
The facility failed to ensure timely notification of a physician or APRN regarding critical x-ray results for a resident with multiple sclerosis, obstructive and reflux uropathy, and a history of constipation. The resident was identified as cognitively intact and at risk for constipation, with interventions in place to monitor and manage bowel function. On the day in question, the resident underwent a STAT abdominal x-ray due to loose stools, which revealed a severe colonic ileus and a suspicious finding for partial sigmoid volvulus. The radiology report, marked as critical, was available in the facility's EMR and faxed to the facility in the evening. Despite the critical nature of the findings, nursing documentation indicated that staff were unaware of the x-ray results for several hours after they became available. Nursing notes from the evening and overnight shifts repeatedly stated that results were pending, even though the report had been faxed and uploaded to the EMR. The radiology team attempted to notify the facility by phone and fax, eventually reaching a nurse supervisor in the early morning hours, but the physician was not notified until after the night shift ended. Interviews with nursing staff revealed that the process for checking and reviewing faxed results was inconsistent, with one RN supervisor stating she may have missed the report due to the high volume of paperwork. Another RN supervisor indicated she did not notify the physician because she had not received the printed report, despite being verbally informed of the results. The facility's policy required prompt notification of the physician for significant changes in a resident's condition, but this was not followed in this instance.
Delayed Access to Critical X-ray Results for Resident with Bowel Complications
Penalty
Summary
Facility staff failed to access and act upon critical x-ray results in a timely manner for a resident with a history of multiple sclerosis, obstructive and reflux uropathy, and constipation. The resident was identified as cognitively intact and at risk for constipation, with care plan interventions to monitor for signs of constipation and administer medications as ordered. On one occasion, the resident received a bowel regimen and was ordered a KUB x-ray to rule out constipation and small bowel obstruction. The initial x-ray showed severe colonic ileus with moderate stool, but no obstruction. A follow-up KUB was ordered and performed, with results indicating a coffee bean shaped gas shadow suspicious for partial sigmoid volvulus, a critical finding. The results were available in the facility's EMR and faxed to the facility, but staff did not access or review the results for over 12 hours. Nursing notes repeatedly indicated that the results were still pending, despite the results being available in both the EMR and via fax. The resident was ultimately transferred to the hospital after the results were finally reviewed. Interviews with staff revealed that there was no consistent process for checking the fax machine or EMR for new results, and that the facility's systems did not provide alerts or confirmations for new critical findings. Staff reported high volumes of paperwork and lack of clear protocols for timely review of incoming results. The delay in accessing and acting upon the critical x-ray findings led to a significant delay in notifying the provider and transferring the resident for further care.
Failure to Prevent Significant Medication Error During Readmission
Penalty
Summary
A significant medication error occurred when a resident was readmitted to the facility following a hospital stay. During the readmission process, the responsible RN discontinued all previous medication orders in the electronic medical record (EMR) and then renewed all discontinued orders, including some that were not present on the hospital discharge documents and had been discontinued nearly a year prior. This included Levemir insulin, which was not ordered by the readmitting provider and was not listed as an active order on the hospital discharge summary. Additionally, oral anti-diabetic medications that were supposed to be stopped per the hospital discharge documents were also renewed and administered. Multiple nursing staff administered Levemir insulin to the resident over several days without obtaining required blood glucose checks prior to administration, as specified in the provider's order. The provider's order also directed that insulin should be held if blood sugar was less than 80, but this was not followed. The resident's blood sugars were not monitored from the time of readmission until the resident experienced a significant change in condition. When the resident became unresponsive and exhibited abnormal movements, staff failed to immediately check blood glucose, delaying identification of severe hypoglycemia. Interviews and documentation revealed that the medication transcription and verification process was not followed according to facility policy. The nurse practitioner did not review the active medication list in the EMR during post-readmission visits, and the third shift nurse did not verify the orders for accuracy. The facility's orientation materials for agency staff did not include clear procedures for medication reconciliation or order transcription during admission or readmission. As a result, the resident received medications that were not ordered, and critical monitoring steps were missed, leading to a hypoglycemic event requiring emergency intervention.
Removal Plan
- Ensure Resident #3 receives all medications according to provider order
- Educate all nursing staff on medication reconciliation and diabetes management
- Audit all residents prescribed insulin
- Audit all readmission orders
Failure to Complete Annual Performance Appraisals for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance appraisals for all nurse aides as required. Review of personnel files for five nurse aides revealed that four had not received a performance appraisal in over 16 months, and one had no record of any performance appraisal since their date of hire. The personnel files showed that the last documented appraisals for several nurse aides were dated more than a year ago, and one nurse aide's file lacked any appraisal documentation entirely. Interviews with the Director of Human Resources (HR), the Administrator, and the Director of Nursing Services (DNS) confirmed that annual performance appraisals were not conducted as expected. The HR Director, who had been in the role for five months, had not initiated or completed any appraisals during that time and was unfamiliar with the process. Additionally, the facility was unable to provide a policy regarding performance appraisals when requested.
Failure to Develop Comprehensive Care Plan for Resident with Pressure Ulcers and Incontinence
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with significant medical needs, including bowel incontinence and pressure ulcers. The resident was admitted with diagnoses such as pyelitis cystica and a sacral pressure ulcer, and was assessed as not oriented to person, place, time, or situation, and dependent on two or more staff for activities of daily living. Clinical assessments identified the resident as being at high risk for developing pressure ulcers, with existing unstageable pressure ulcers on both buttocks and an active gluteal cleft wound with 100% slough. The Minimum Data Set (MDS) also documented the resident's risk and presence of a stage three pressure ulcer. Despite these findings, the resident's care plan only addressed wounds and enhanced barrier precautions, such as signage and use of gloves and gowns, but did not include interventions for incontinence, pressure ulcer risk, or the active sacral wound. Facility policy requires that care plans incorporate all identified problem areas and risk factors, assign responsibility for care elements, and reflect current standards of practice. An interview with the Director of Nursing Services confirmed that the care plan should have addressed the resident's pressure injury risk, current wound, and incontinence, but these were omitted.
Failure to Follow Provider Orders for Insulin Administration and Weekly Skin Assessments
Penalty
Summary
The facility failed to follow provider orders and established protocols for two residents, resulting in deficiencies related to medication administration and skin assessments. For one resident with type 2 diabetes mellitus, Parkinson's disease, anxiety disorder, and depression, a physician's order specified that Levemir insulin should be held if blood sugar was less than 80. However, the medication was administered on multiple occasions without obtaining or documenting blood sugar levels as required. This resident subsequently experienced a significant change in condition, including unresponsiveness and involuntary movements, and was found by EMS to have a critically low blood sugar of 29. The resident was treated with dextrose and transported to the emergency department, where their condition improved. Interviews with nursing staff confirmed that insulin was administered without checking blood sugar, and documentation of blood glucose results was missing for the relevant period. Facility policy required verification of insulin orders and documentation of blood glucose results prior to administration, but these steps were not followed. The Director of Nursing Services acknowledged that blood sugar checks should have been performed and documented before administering insulin. For another resident admitted with osteomyelitis of the vertebra and a sacral wound, a physician's order directed weekly body audits (skin checks) on a specific day and shift. The resident was identified as high risk for pressure ulcers and had multiple pressure injuries. However, the medical record did not show that a weekly skin check was completed and documented for one week as ordered. The Director of Nursing Services confirmed that weekly skin assessments should be performed as ordered, but the facility did not have a preventative skin assessment policy, and no documentation was provided for the missed assessment.
Failure to Provide Timely Social Services Support After Resident Altercation
Penalty
Summary
The facility failed to provide timely social services support to residents involved in a resident-to-resident altercation. One resident with Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, and depression, who had severely impaired cognition, was involved in an incident where they struck another resident. The care plan for this resident included interventions such as investigation, reporting, psychiatric follow-up, and observation for mental distress, but review of social services notes revealed no documentation of social services involvement from the date of the incident through several days after. Another resident involved in the same altercation, who also had Alzheimer's disease, dementia, and anxiety disorder with moderately impaired cognition, was assessed after the incident and found to have no injuries. The care plan for this resident similarly called for investigation, reporting, psychiatric follow-up, and observation for mental distress. However, there was no documentation in the social services notes indicating that social services support was provided or that follow-up occurred in the days following the incident. Interviews with facility leadership and the social worker confirmed that the facility's policy requires the social worker to meet with all residents involved in abuse incidents as soon as possible and to follow up daily for 72 hours, documenting all encounters. The social worker acknowledged that documentation was lacking and could not confirm whether support was provided to one of the residents. The facility's policy also directs that social services provide written reports of findings to the Administrator and DON, but there was no evidence this was done.
Failure to Perform Complete Assessment and Emergency Response for Unresponsive Resident
Penalty
Summary
A deficiency occurred when facility staff failed to conduct a complete and accurate assessment of a resident who became unresponsive. The resident, who had diagnoses including Alzheimer's, heart failure, and respiratory failure, was care planned for alterations in respiratory status and congestive heart failure, with interventions to document changes in condition. On the night of the incident, the resident was found pale and not responding normally. The nursing supervisor assessed the resident, who became unresponsive for a few seconds. Despite the resident's full code status, the supervisor did not access the crash cart, use the AED, or initiate CPR. Oxygen was not immediately administered, and vital signs were not obtained before emergency services arrived. Emergency medical services found the resident with an oxygen saturation of 62% and provided oxygen via a non-rebreather mask. Upon further assessment, the resident was unresponsive with no palpable pulses or heart sounds, and CPR was initiated by EMS before transfer to the hospital. Facility policy required staff to assess and document vital signs, neurological status, and level of consciousness during acute changes in condition, but these steps were not fully carried out during the event. Interviews confirmed that the required emergency interventions and assessments were not performed prior to EMS arrival.
Resident Elopement Due to Failure in Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with dementia, phobic anxiety, and mood disorder, who was identified as a wanderer and elopement risk, was able to exit the memory care unit through a locked door. The resident's care plan included interventions such as identifying wandering patterns, redirection, and providing structured activities. Despite these interventions, the resident was observed by staff at the lock pad, where the resident entered the door code, unlocked the doors, and exited the building. Staff interviews revealed that although the resident was seen at the lock pad, immediate redirection did not occur, and the resident was able to leave the facility before staff could intervene. Facility documentation indicated that the resident had memorized the door code, which is changed monthly or more often as needed, and the new code is verbally communicated to staff. The resident refused the placement of a wander guard bracelet and became agitated, leading to a hospital transfer for evaluation. The facility's elopement prevention policy required assessment and interventions for residents at risk of wandering or elopement, but in this instance, the resident was able to circumvent the locked door system and exit unsupervised.
Failure to Complete Advance Directive Forms for Residents
Penalty
Summary
The facility failed to complete Advance Directive forms for three residents upon admission, leading to discrepancies in their documented code statuses. Resident #1, diagnosed with chronic obstructive pulmonary disease, Erb's Paralysis, and hypertension, was initially documented as a full code in the Resident Care Plan and nurse practitioner notes. However, upon further communication, it was revealed that the resident's actual wish was to be a Do Not Resuscitate (DNR). The absence of a signed Advance Directive form led to a misrepresentation of the resident's wishes in the Electronic Medical Record (EMR). Similarly, Resident #41, with diagnoses including heart failure and neurogenic bladder, was documented as a full code without a signed Advance Directive form. The Medical Records Coordinator noted the resident was conserved, and the social worker needed to contact the conservator to obtain the form. Resident #46, suffering from a neurocognitive disorder and other conditions, also lacked a signed Advance Directive form, despite being documented as a full code. Interviews with staff revealed a failure to ensure the completion and proper documentation of Advance Directives, resulting in potential misalignment with the residents' actual wishes.
Failure to Provide Activities of Interest for Resident
Penalty
Summary
The facility failed to provide activities of interest for a resident diagnosed with mild cognitive impairment, anxiety disorder, and adjustment disorder with depressed mood. The resident's annual Minimum Data Set (MDS) assessment indicated an interest in listening to music, but this was not reflected in the Resident Care Plan (RCP) or the Resident Care Card. The RCP only noted a mood problem and included interventions such as reviewing the activity calendar and encouraging the resident to identify activities of choice. However, it did not specify the resident's interest in music or any other activities. Additionally, a physician's order required documentation of music or activity interventions on the behavior monitoring form, but the form did not indicate that music was offered. Observations and interviews revealed that the resident received minimal engagement in activities. The Recreation Participation Record showed limited participation in activities such as TV/movie/music and social events. During an observation, the resident was found lying in bed without any active stimulation, and a brief 1 to 1 visit by the Recreation Director did not include offering music, despite the director's awareness of the resident's interest. The Recreation Director, who had recently started working at the facility, acknowledged the oversight and noted that a radio should have been provided.
Insecure Storage of Resident Records
Penalty
Summary
The facility failed to ensure the secure storage of resident-identifiable information and medical records, as observed during a survey. In an unoccupied wing of the facility, several rooms were found to contain bankers boxes with resident medical records, including personally identifiable information such as names, dates of birth, medical record numbers, and diagnoses. These boxes were stored in unlocked rooms, with some located directly below fire suppression devices, which is against the facility's Records Retention Policy. Additionally, a dead mouse was found near the boxes in one of the rooms, indicating a potential pest hazard. The facility's Administrator acknowledged awareness of the storage situation, explaining that the records were moved from outbuildings, known as The Cottages, to the unoccupied rooms after the sale of The Cottages. Despite this awareness, the storage method did not comply with the facility's policy, which mandates that records be kept in a locked area free from hazards such as fire, flooding, and pests. The presence of controlled substance disposition records and other sensitive information in unsecured locations further highlights the deficiency in maintaining the security and integrity of resident records.
Inadequate Sanitary Conditions in Laundry Area
Penalty
Summary
The facility failed to maintain sanitary conditions in the laundry area, as observed during a tour with various staff members. In the soiled laundry area, a dirty laundry bin was found containing a bag of dirty, personal resident laundry. Clean hangers were improperly stored, hanging from the edge of the dirty bin and placed under and next to the bag of dirty laundry. Additional clean hangers were stored on top of a dirty item receptacle. A laundry aide confirmed that these hangers were considered clean and ready for use, while an RN acknowledged that clean items should not be stored with dirty items. In the clean laundry area, a bin filled with laundered rags designated for kitchen use was stored inappropriately. The bin was placed touching a wall with several broken and open areas of sheetrock, including a large crack and a fist-sized hole. There were also larger areas of missing sheetrock exposing insulation, dust, debris, and dirt. A window along this wall was covered with plastic secured by duct tape, which also served as a dryer vent. The Administrator noted that the area could use improvement. According to the facility's policy, all clean laundry must be covered for transport back to the facility, and resident clothing should be folded or pressed and hung in the clean laundry area for transfer to residents' rooms.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive individualized care plan for Resident #7, who was admitted with mild cognitive impairment, anxiety disorder, and adjustment disorder with depressed mood. The resident's Minimum Data Set (MDS) assessment identified listening to music as an activity of importance, yet the Resident Care Plan (RCP) did not include a person-centered, comprehensive problem with interventions related to the resident's preferred activities. Interviews with the Recreation Director and the MDS Coordinator revealed that no activity assessments had been completed to identify the resident's leisure interests, and the care plan was not comprehensive or individualized as it did not include music as an interest. For Resident #24, who had diagnoses including congestive heart failure (CHF), the facility failed to implement the Resident Care Plan to monitor the resident for CHF. The care plan included interventions to check breath sounds and monitor for signs or symptoms of CHF, but the physician's orders did not include monitoring for these symptoms. Observations identified edema in the resident's right hand, and interviews with facility staff revealed a lack of monitoring or assessments for CHF. The facility policy required monitoring of residents with CHF, but there was no documentation of such monitoring for Resident #24.
Failure to Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to complete a neurological assessment for a resident who experienced an unwitnessed fall with a head injury. Resident #20, diagnosed with Parkinson's disease, diabetes mellitus, and hypertension, was identified as being at risk for falls. Despite the facility's policy requiring neurological checks following such incidents, the records showed that only vital signs were taken, and the necessary neurological assessments, including pupillary reaction, hand grasps, and level of consciousness, were not documented. Interviews with the Director of Nurses and an LPN confirmed the oversight, but no explanation was provided for the incomplete assessments. In a separate incident, the facility did not perform a comprehensive assessment at the time of pronouncement of death for Resident #54, who had chronic obstructive pulmonary disease, hyperlipidemia, and dementia. The resident was under hospice care with a DNR/RNP order. When RN #3 pronounced the resident deceased, the assessment was limited to noting the absence of a pulse, without including other vital signs or assessments such as lung sounds and pupillary reaction, as required by the facility's policy. The RN admitted to being unaware of the complete assessment requirements, and the Administrator could not explain the omission. Both incidents highlight a failure to adhere to the facility's policies for conducting thorough assessments in critical situations. The lack of complete neurological checks for Resident #20 and the incomplete death pronouncement assessment for Resident #54 indicate a gap in following professional standards of practice, as outlined in the facility's policies.
Failure to Return Personal Laundry Timely
Penalty
Summary
The facility failed to ensure the timely return of personal laundry for a resident, leading to a deficiency in maintaining the resident's dignity. The resident, who was cognitively intact and required partial assistance for dressing, was observed wearing a hospital gown with stains and jeans, as their personal clothing had not been returned from the laundry. The resident expressed a preference for wearing their own street clothes and reported that staff had not prioritized retrieving their clothing. Interviews revealed that the laundry for the resident's floor was scheduled weekly, and due to staff absence, the resident's laundry was not collected on the designated day. Consequently, the resident's laundry had not been washed since December 30, 2024, and was not scheduled to be done until January 13, 2025. This delay in laundry service resulted in the resident being unable to maintain a dignified appearance, as outlined in the facility's policy to provide an adequate supply of clean personal clothing for each resident at all times.
Failure to Provide NOMNC Forms Before Discharge
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-coverage (NOMNC) form to two residents prior to their planned discharges, as required by facility policy. Resident #306, who was diagnosed with rhabdomyolysis, human immunodeficiency virus disease, and hypertension, was discharged home on 8/16/24. Although a nurse's note indicated that the resident's family member was informed of all discharge instructions, the clinical record did not show that a NOMNC notice was provided. Similarly, Resident #307, with diagnoses of spinal stenosis, hypertension, and hypothyroidism, was discharged home on 11/29/24, but their clinical record also lacked evidence of a NOMNC notice. An interview with the facility's Administrator revealed that the MDS Coordinator was responsible for ensuring that all residents receive a NOMNC form before a planned discharge. However, the Administrator acknowledged that both residents should have received the form and did not, and was unable to explain why the forms were not provided according to facility policy. The facility's NOMNC policy specifies that the Resident Care Coordinator must issue the NOMNC to every resident in person at least two calendar days prior to discharge, or document the means of delivery if not done in person. The MDS Coordinator was unavailable for interview to provide further insight into the oversight.
Failure to Provide Timely Feeding and Incontinent Care to Dependent Residents
Penalty
Summary
Three residents with significant cognitive and physical impairments, including dementia, epilepsy, adult failure to thrive, and chronic obstructive pulmonary disease, were dependent on staff for activities of daily living such as eating and incontinent care. Care plans for these residents required staff assistance with eating, toileting hygiene, and repositioning, as well as prompt pericare after episodes of incontinence. On the evening shift in question, the assigned nurse aide failed to provide these essential care services, resulting in the residents not being fed dinner and not receiving necessary incontinent care during the shift. The deficiency was identified when staff reported to the Nursing Supervisor that the assigned nurse aide was not attending to residents, instead spending time at the nurse's station and leaving the facility for an extended period without authorization. Upon investigation, it was found that the aide had not provided care or meals to the assigned residents. When another aide was later assigned to one of the residents, the resident was found in bed in a fetal position with dried feces, indicating a prolonged period without care. Documentation and interviews confirmed that the residents did not experience immediate ill effects, but there was a clear delay in the provision of required care. The facility's own policy prohibits abuse and neglect, yet the actions and inactions of the assigned nurse aide on the evening shift resulted in neglect of the residents' basic needs. The incident was reported to facility management, and the residents were eventually reassigned to other staff who provided the necessary care, but only after a significant delay during which the residents' care needs were not met as required by their care plans.
Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to ensure that allegations of neglect involving three residents were reported immediately to the Administrator and/or designee and to the State Agency within the required two-hour timeframe after the allegations were identified. The residents involved had significant cognitive and physical impairments, including dementia, epilepsy, incontinence, and dependence on staff for activities of daily living such as eating and toileting. The care plans for these residents required staff assistance with eating, turning, repositioning, and incontinent care after each episode. On a specific evening shift, staff alleged that a nurse aide did not provide care or feed dinner to three residents assigned to her. The 3-11PM Nursing Supervisor first received a complaint from another nurse aide at 5:00 PM and subsequently observed that the nurse aide in question was absent from the unit for a period of time. The supervisor confirmed with the charge nurse that the aide had not been performing her duties and had left the facility without authorization. The supervisor contacted the aide, who returned to the facility, but the supervisor did not immediately report the allegations to the covering DON or Administrator. The Staff Development Coordinator, who was acting as the DON, was informed of the allegations just before 9:00 PM and immediately notified the Administrator. However, the State Agency was not notified until the following day at 11:45 AM. Facility policy required immediate reporting of suspected abuse or neglect to the DON or Administrator, but this protocol was not followed, resulting in a delay in both internal and external notifications regarding the allegations of neglect.
Failure to Provide Required Orientation to Agency Nurse Aide
Penalty
Summary
A nurse aide employed by an outside agency began working at the facility without receiving the required orientation and education as outlined in the facility's policy. Review of facility documentation confirmed that the agency nurse aide was not provided with orientation or training prior to starting her first shift. During an interview, the nurse aide stated that she did not receive any information or education on facility policies, including the abuse and neglect policy, before beginning her shift. Further review and interview with the DON revealed that the facility had established policies and procedures mandating orientation and education for all agency staff before their initial shift, including review of the abuse and neglect policy. However, documentation showed that this process was not followed for the agency nurse aide, and the DON was unable to explain why the orientation and education were not provided. The responsibility for conducting the orientation was assigned to the Nursing Supervisor, but the required steps were not completed.
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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