Mystic Healthcare & Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mystic, Connecticut.
- Location
- 475 High St, Mystic, Connecticut 06355
- CMS Provider Number
- 075271
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Mystic Healthcare & Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A facility failed to maintain a safe environment when a dirty meal tray cart with uncovered leftover food and an open garbage was routinely left overnight in a hallway outside a locked kitchen, accessible to cognitively impaired, wandering residents on modified diets, including pureed and mechanical soft textures with thin liquids. One resident with dementia, dysphagia, severe memory deficits, and dependence on staff for eating accessed a peanut butter sandwich from the unattended cart and choked, requiring an LPN to perform the Heimlich maneuver. Staff interviews revealed that this resident habitually wandered at night seeking food and had previously attempted to take food from the cart, but these behaviors were not reported to licensed staff. The Director of Food Service and DON were aware that the cart was not consistently locked in the kitchen, and a new RN supervisor on duty had not been oriented to the meal tray collection and cart storage process. The facility lacked a specific policy on food cart storage or food disposal, despite having general policies on safe environment and management of wandering and elopement risk, resulting in an Immediate Jeopardy finding.
A resident with dementia, COPD, dysphagia, severe memory deficits, and dependence on staff for eating had a care plan and Resident Care Card directing a regular pureed diet with thin liquids, aspiration monitoring during meals, and removal of accessible food due to food-seeking behavior. Staff failed to follow these directives when the resident, who habitually wandered at night looking for food, accessed a peanut butter sandwich from a food cart and choked, requiring an LPN to perform the Heimlich maneuver. A NA had previously seen the resident attempt to take and eat food from the cart, did not report these incidents to nursing staff, was unaware of the prescribed pureed diet, and provided snacks at night without knowledge of dietary restrictions, while the DON was unaware of the prior food cart incidents.
A resident with dementia, dysphagia, severe memory deficits, and dependence on staff for eating was care planned and ordered for a regular, pureed diet with thin liquids and had a Wanderguard for wandering risk. During a night shift, the resident, who habitually wandered the halls seeking food, accessed a food cart outside the locked kitchen, took a peanut butter sandwich inconsistent with the prescribed diet, and began choking. A NA observed the choking and alerted an LPN, who performed the Heimlich maneuver. The NA reported having previously seen the resident attempt to take and eat food from the food cart but did not report these behaviors to licensed staff and was unaware of the resident’s pureed diet, while the DON was unaware of the prior unsafe eating incidents.
A resident with significant physical and mental health needs was subjected to loud and derogatory remarks by a nursing assistant during toileting care. Two other NAs witnessed the incident and reported that the staff member questioned the resident's need for care and expressed frustration about being assigned to the resident, in violation of facility policies on resident rights and abuse prevention.
A resident with significant care needs was subjected to disparaging and vulgar remarks by a nursing assistant regarding incontinence and food intake. Although two staff members reported the incident to supervisory staff, the nursing supervisor did not escalate the allegation, initiate an incident report, or remove the accused staff member from duty. The DON was not informed until the next day, resulting in a delay in addressing the abuse allegation as required by facility policy.
A resident with cognitive impairment and muscle weakness sustained significant burns to the thigh and genital area after spilling hot chocolate, due to the facility's failure to implement an ordered sippy cup intervention and lack of communication among staff. The resident continued to receive hot beverages in open cups, and required assessments and investigations into the injuries were not completed as per facility policy.
A resident with dementia, muscle weakness, and polyneuropathy developed new wounds that were not promptly addressed in the care plan, with a delay of 10 days before updates were made. Additionally, the care plan did not include interventions for the resident's frequent refusals of care, despite staff being aware of this behavior. Facility policy required timely updates to care plans for changes in resident status, but this was not followed.
A resident with dementia and polyneuropathy experienced injuries of unknown origin, but staff failed to perform a timely full body skin assessment after the initial wound was discovered, and did not document nursing notes every shift as ordered by the physician. Facility policy requiring immediate assessment and documentation of unexplained injuries was not followed, as confirmed by staff interviews and record review.
Several residents with cognitive and physical impairments reported mistreatment and fear related to a staff member, but the facility failed to document grievances, provide required follow-up, or offer timely support as outlined in its own policy. Staff interviews and record reviews confirmed that complaints were not properly recorded or resolved, and administrative staff were unaware of key incidents.
Multiple residents with cognitive and physical impairments reported verbal and physical mistreatment by a staff member, but staff failed to document, investigate, and report these abuse allegations to the State Agency as required by facility policy. Despite some immediate actions, such as staff suspension, there was no evidence of timely notification or proper follow-up.
Multiple residents reported abuse or neglect by a staff member, including physical and verbal mistreatment, but the facility failed to conduct complete investigations or document the allegations as required. Staff did not consistently obtain statements from all involved, and complaints were not always recorded in nurse's notes or the grievance log, resulting in unresolved and uninvestigated incidents.
A resident with dementia and severe cognitive impairment, requiring two staff for care due to behavioral issues, was forcefully pushed into a wheelchair by a staff member who was providing care alone. The resident sustained a bruise and skin tear, and the incident was not promptly reported or investigated according to facility policy, resulting in a failure to protect the resident from abuse.
A resident with dementia and behavioral disturbances, who was care planned for two staff to provide care during a specific shift due to aggression and sundowning, was instead cared for by a single nursing assistant. The staff member was unaware of the updated care plan and the requirement was not communicated, resulting in care being provided alone and an incident involving physical altercation and injury.
Immediate Jeopardy from Unsecured Food Cart Access by Wandering Residents with Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to the storage and handling of food carts and leftover food. A food cart used for collecting dirty meal trays was routinely left overnight in the hallway outside a locked kitchen door, without a cover on the cart or on the attached garbage container. This cart, sometimes containing leftover food on plates or in an open garbage, was accessible to cognitively impaired residents with wandering behaviors and prescribed modified diets. The facility did not have a policy addressing food cart storage or proper disposal of food, and the process for securing the cart inside the kitchen was not consistently followed, despite the expectation that the supervising nurse would lock the cart in the kitchen. Four residents with cognitive impairment, dysphagia, and/or wandering and elopement risk were identified as being affected by this unsafe practice. One resident had dementia, COPD, dysphagia, severe memory deficits, was dependent on staff for eating, and was on a regular pureed diet with thin liquids. This resident’s care plan and physician orders included a Wanderguard for wandering and elopement risk and interventions for wandering and nutrition, including a pureed diet and cues to eat slowly. Another resident had cerebral infarction, COPD, diabetes, severe memory deficits, and was on a low concentrated sweet, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering and elopement. A third resident had dementia, diabetes, dysphagia, severe memory deficits, required set-up assistance for meals, and was on a low concentrated sweet, no added salt, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering. A fourth resident had schizophrenia, anxiety, dysphagia, moderate memory deficits, was independent with eating and mobility, and was on a regular mechanical soft diet with thin liquids, with a Wanderguard and identified risk for choking due to poor dental hygiene. The unsafe environment directly resulted in a choking episode for one resident. During an overnight shift, a nurse aide observed this resident, known to wander the halls at night looking for food and able to open unit double doors, at the food cart outside the locked kitchen door, choking after taking a piece of a peanut butter sandwich from the unattended cart. The LPN on duty performed the Heimlich maneuver, and the resident expelled the sandwich contents and returned to baseline. The nurse aide reported that the resident had previously attempted to take food from the dirty food cart on multiple occasions and had once taken a bite of a sandwich from the cart, but these incidents were not reported to licensed staff. The DON was aware the resident wandered and wore a Wanderguard but was not aware the resident was seeking food from the cart. The Director of Food Service and DON both acknowledged that the cart was not consistently locked in the kitchen, and the new RN supervisor on duty the night of the choking episode had not been trained on the meal tray collection process or the requirement to secure the cart, contributing to the failure to prevent access to the food cart and resulting in Immediate Jeopardy. Additional information from interviews further supports the pattern of unsafe practice. The Director of Food Service described the standard process of using the cart to collect trays, scrape food into the attached garbage, and return the cart to the kitchen, and stated that when dietary staff left at night, an empty cart was left outside the locked kitchen for staff to return remaining dishes, with the expectation that food would be scraped into the open garbage. He reported having previously informed Administration that the cart was not being stored inside the locked kitchen. A dietary aide on the morning shift confirmed that his first task was to empty plates from the cart left in the hallway overnight and that sometimes food remained on plates and sometimes it had been scraped into the open garbage. The Building Specific Orientation Tour for the RN supervisor did not include training on meal tray collection or food cart storage. The facility’s existing policies on providing a safe and homelike environment and on elopements and wandering residents required a safe physical layout and systematic monitoring and management of residents at risk for wandering and elopement, but there was no specific policy addressing food cart storage or food disposal, and the failure to secure the cart and to communicate and act on known wandering and food-seeking behaviors led to the identified deficiency and Immediate Jeopardy.
Failure to Follow Care Plan for Pureed Diet and Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed a resident’s person-centered care plan and Resident Care Card (RCC) regarding a prescribed pureed diet and required monitoring for aspiration. The resident had dementia, COPD, dysphagia, severe short- and long-term memory deficits (BIMS score of 2), was dependent on staff for eating, and was identified as at risk for weight loss, wandering, and elopement. The care plan and RCC directed a regular, pureed texture diet with thin liquids, cues to eat slowly, maintaining an upright position after meals, offering snacks between meals and at bedtime as appropriate, monitoring during meals for aspiration, and removing food from the whole room due to the resident’s tendency to seek food from the roommate. Physician’s orders also specified a regular, pureed texture diet with thin liquids. Despite these directives, staff actions and inactions led to the resident accessing and consuming food inconsistent with the prescribed diet. During the night shift, the resident habitually wandered the hallway looking for food and had previously attempted to take food from the dirty food cart and had taken a bite of a sandwich from the cart, but the NA who observed these behaviors did not report them to a nurse, believing staff were already aware. The NA was not aware the resident was on a pureed diet and reported giving the resident snacks such as chocolate pudding during the night. On one occasion, the resident took a piece of a peanut butter sandwich from the food cart located outside the locked kitchen door and choked on it, requiring the LPN to perform the Heimlich maneuver to expel the sandwich. The DON later stated she was unaware of the prior incidents with the food cart and that the NA should have reported them, while facility policy directed that staff follow the plan of care and Care Card.
Failure to Ensure Staff Awareness of Prescribed Diet and Reporting of Unsafe Eating Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff were aware of a cognitively impaired resident’s prescribed pureed diet and to report and address unsafe eating behaviors. The resident had dementia, COPD, dysphagia, severe memory deficits (BIMS score of 2), was dependent on staff for eating, and had care plan interventions for a regular, pureed diet with thin liquids, cues to eat slowly, remaining upright after meals, and snacks between meals and at bedtime. The resident was also care planned and ordered for a Wanderguard due to wandering and elopement risk. Despite these orders and care plan interventions, the resident was able to access a food cart located outside the locked kitchen door and obtain a peanut butter sandwich that was inconsistent with the prescribed pureed diet. On the night of the incident, the resident wandered in the hallway and took a piece of a peanut butter sandwich from the food cart, then began choking. NA #1 observed the resident at the food cart choking and alerted LPN #1, who performed the Heimlich maneuver and the resident expelled the sandwich contents. NA #1 reported that the resident habitually wandered the hallway during the night looking for food, had previously attempted to take food from the dirty food cart, and had been seen taking a bite of a sandwich from the cart, but these prior incidents were not reported to licensed staff because NA #1 believed staff were already aware. NA #1 was not aware the resident was on a pureed diet and had been giving the resident snacks such as chocolate pudding at night. The DON stated she was unaware of the prior sandwich incident and confirmed that NA #1 had not reported the resident’s attempts to take or eat food from the food cart and that such incidents should have been reported to a licensed nurse.
Failure to Protect Resident from Verbal Mistreatment by Staff
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, anxiety, and major depression, who was dependent on staff for toileting and other activities of daily living, was subjected to verbal mistreatment by a nursing assistant (NA). The resident was frequently incontinent and required emotional support as part of their care plan. On the evening in question, two other nursing assistants witnessed and reported that the NA assigned to the resident spoke to them in a loud and derogatory manner, questioning why the resident needed to defecate and expressing frustration about having the resident on her assignment. The incident was reported to supervisory staff, and it was noted that the resident appeared stunned by the interaction. Facility documentation and interviews confirmed that the NA's communication style was inconsistent with facility expectations and policies regarding resident rights and abuse prevention. Although the facility's internal investigation did not substantiate abuse due to the resident's inability to recall the incident, multiple staff members corroborated the inappropriate language and tone used by the NA. The supervisor and DON were aware of previous concerns regarding the NA's communication style, but the incident was not immediately investigated in detail at the time it was reported.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
Staff failed to promptly report an allegation of verbal abuse involving a resident who was dependent for toileting, transfers, and bed mobility, and had a history of stroke, anxiety, and major depression. The incident occurred when a nursing assistant (NA) made disparaging and vulgar remarks to the resident regarding their incontinence and dietary intake. Two other staff members witnessed or overheard the incident and reported it to the charge nurse and supervisor. Despite being informed of the incident, the nursing supervisor did not initiate an incident report, notify the Director of Nursing (DON), or remove the accused staff member from duty to protect residents. The supervisor also did not gather specific details about the interaction or recognize the need for immediate escalation, even though she acknowledged that such behavior would be considered abusive. The DON was not notified of the allegation until the following day, resulting in a delay in the investigation and appropriate response. Facility policy required immediate reporting of suspected abuse to management, but this protocol was not followed, leading to a failure in timely reporting and response to the abuse allegation.
Failure to Prevent and Respond to Resident Burns from Hot Beverage Spill
Penalty
Summary
A resident with dementia, generalized muscle weakness, and polyneuropathy experienced multiple incidents resulting in injuries, including burns from a hot beverage spill. The resident was assessed as having moderately impaired cognition and was independent with eating and mobility. Despite this, the resident sustained a significant burn wound to the right inner thigh and genital area after spilling hot chocolate, as identified by occupational therapy and wound care staff. The clinical record did not initially identify the cause of the inner thigh wound, nor did it document wound treatment, monitoring, or preventative interventions after the wound was discovered. Following the burn incident, a physician's order was entered for the resident to use a sippy cup for all beverages to prevent further accidents. However, this intervention was not implemented effectively. Multiple staff members, including nursing assistants, therapy, and dietary staff, were unaware of the sippy cup order, and the intervention was not reflected on the resident's care card or adaptive equipment lists. Observations confirmed that the resident continued to receive hot beverages in open cups, and staff interviews revealed a lack of communication and process for ensuring adaptive equipment orders were followed. Additionally, the facility failed to conduct a full investigation into the injuries of unknown origin, as required by policy. There was no documentation of a completed accident and investigation report for the initial wound, and a full body skin assessment was not performed after the incident. The facility's policy required immediate assessment and investigation of unexplained injuries, but these steps were not documented or completed. The serving temperatures of hot beverages were also found to be high, with no policy provided regarding safe serving temperatures.
Failure to Timely Update Care Plan After New Wounds and Address Refusals of Care
Penalty
Summary
The facility failed to timely review and revise the care plan for a resident following the discovery of new wounds and did not address the resident's frequent refusals of care. Specifically, after a 16 cm by 7 cm skin tear was identified on the resident's right inner thigh, there was no documentation of an intervention being implemented immediately after the wound was discovered. Additionally, the resident's care plan was not updated to reflect the new wound until 10 days after the initial identification. The facility's own policy and the Director of Nursing Services (DNS) confirmed that interventions and care plan updates should have occurred within 24 hours of the incident, but this did not happen. Furthermore, documentation related to the investigation of the injury of unknown origin could not be located by the DNS. The resident, who had diagnoses including dementia, generalized muscle weakness, and polyneuropathy, also had a documented history of refusing care such as bathroom assistance, use of the call bell, personal care, and showering. Despite this, the care plan and care card did not include interventions or strategies to address these refusals, such as reapproaching the resident. Multiple nursing assistants and the DNS confirmed the resident's pattern of refusals, but the social worker responsible for updating behavior-related care plans was not aware of these refusals. The facility's policy required ongoing changes in resident status to be updated in the care plan, but this was not followed in this case.
Failure to Perform Timely Full Body Skin Assessment and Required Documentation After Injury
Penalty
Summary
The facility failed to ensure that a full body skin assessment was performed after the discovery of an injury of unknown origin for a resident with dementia, generalized muscle weakness, and polyneuropathy. After a significant skin tear was identified on the resident's right inner thigh, neither the charge nurse nor the wound nurse completed a full body skin assessment at the time of discovery. The first documented full body skin assessment occurred three days later, which did not reveal any new wounds. Interviews with nursing staff confirmed that the assessment was not performed immediately, as each nurse believed the other would complete it. Additionally, the facility did not comply with physician orders to document nursing notes every shift for 72 hours following the discovery of a wound to the resident's genitals. Review of the clinical record showed multiple shifts where required documentation was missing. The Director of Nursing Services (DNS) confirmed that notes should have been documented every shift per the physician's order, but this was not done. Facility policy required immediate assessment and documentation of unexplained injuries, as well as weekly and as-needed full body skin audits by licensed nurses. Despite these policies, the required assessments and documentation were not completed as directed after the discovery of the resident's injuries. The failure to follow these protocols was confirmed through staff interviews and review of facility documentation.
Failure to Address and Document Resident Grievances and Allegations of Abuse
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy regarding prompt resolution and support after allegations of abuse or mistreatment. Multiple residents with varying degrees of cognitive and physical impairment reported incidents involving a nursing assistant who was described as rude, rough, and frightening. These residents expressed fear, anxiety, and reluctance to seek assistance due to the staff member's behavior. Despite these reports, there was no evidence in the grievance book or social service documentation that grievances were filed or that the required follow-up and support were provided to the residents. Interviews with staff revealed that although some staff members were made aware of the residents' complaints and concerns, they either did not document the incidents or failed to ensure that grievance forms were completed and submitted according to facility policy. Social service notes did not reflect any follow-up or support for the residents after the allegations, and the required daily meetings with residents for 72 hours following an abuse allegation were not documented. Additionally, administrative staff and the Director of Nursing were unaware of some of the reported incidents and could not locate any related grievance forms or investigations, despite being listed as participants in disciplinary records. The facility's own policy required that concerns and complaints be actively addressed, documented, and communicated to the resident or their representative. However, the review of records and interviews confirmed that these procedures were not followed for several residents who reported mistreatment. The lack of documentation and follow-up resulted in unresolved grievances and a failure to provide the necessary support to residents after allegations of abuse or mistreatment.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and mistreatment to the State Agency for four out of six residents reviewed. Multiple residents with varying degrees of cognitive impairment and physical dependency reported incidents involving a nursing assistant who was described as rude, rough, and verbally abusive. These allegations were communicated to various staff members, including occupational therapy, social work, and nursing supervisors. In several cases, residents expressed fear and distress related to the staff member's behavior, and some reported being afraid to request assistance due to concerns about being yelled at or mistreated. Despite these reports, there was a lack of documentation and follow-up regarding the allegations. Staff interviews revealed that while some immediate actions, such as suspending the accused staff member, were taken, there was confusion and inconsistency about whether the incidents met the criteria for abuse and should be reported to the State Agency. Statements and grievances were not consistently documented, and there was no evidence that the required notifications to the State Agency were made. The facility's own policy required immediate reporting of any abuse allegations, but this protocol was not followed. The review of the State Agency Reportable Events website confirmed that none of the incidents involving the four residents were reported as required. Interviews with current and former staff, including the DON and Administrator, indicated an inability to identify or locate documentation related to the incidents. The lack of timely reporting and investigation of these abuse allegations constitutes a deficiency in the facility's compliance with mandated abuse reporting requirements.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to appropriately investigate and document allegations of abuse or neglect for multiple residents. In one case, a resident with dementia and behavioral disturbances reported being physically assaulted by a staff member, resulting in visible bruising. Although an initial investigation was started, the facility did not obtain statements from all staff present during the incident, as acknowledged by the Director of Nursing Services (DNS) and Administrator. The investigation was therefore incomplete, and not all relevant staff were interviewed. Several other residents with varying cognitive and physical impairments reported concerns about a specific nursing assistant's (NA) behavior, including verbal abuse, rough care, and fear of retaliation. These complaints were reported to various staff members, including nursing supervisors and social workers, but were not consistently documented in nurse's notes or the grievance book. In some cases, staff members who received the complaints did not recall being notified, and there was a lack of follow-up or resolution communicated to the residents. Additionally, statements and documentation related to these allegations were either not completed or not retained, and the facility was unable to identify or locate records of certain complaints and investigations. The facility's abuse prevention policy requires prompt and thorough investigation of all abuse allegations, including interviewing all relevant staff and reporting to the appropriate authorities. However, the report shows that the facility did not follow these procedures for multiple allegations, resulting in incomplete investigations and a lack of documentation. The DNS and Administrator were unaware of some complaints and could not account for missing records or unresolved grievances, indicating systemic failures in responding to and investigating abuse allegations as required by policy.
Failure to Protect Resident from Abuse and Follow Care Plan
Penalty
Summary
A resident with dementia and severe cognitive impairment, who required supervision and two staff for care during certain shifts due to aggression and sundowning behaviors, was involved in an incident where a staff member was observed pushing the resident forcefully into a wheelchair. The resident had a history of combative behaviors and was care planned for specific interventions, including staff explanations and the presence of two staff during care. Despite these interventions, the staff member provided care alone and did not follow the care plan requirements. On the evening of the incident, another staff member witnessed the resident being pushed down into the wheelchair by the shoulders in a manner described as not gentle but a hard push. The resident repeatedly asked the staff member to leave, but the staff member remained, leading to the resident striking the staff member. The resident was later found with a bruise and skin tear on the right hand, which the resident attributed to being punched by the staff member. The incident was not immediately reported to supervisory staff, and initial reports to the nurse on duty were not acted upon or escalated as required by facility policy. The facility's documentation and interviews revealed that the required reporting and investigation procedures were not followed promptly. The nurse on duty did not report the incident to the appropriate supervisor, and the staff member involved continued to work with the resident despite the care plan indicating two staff were needed. The facility's abuse prevention policy required immediate reporting and protection of residents during investigations, but these procedures were not adhered to, resulting in a failure to ensure the resident was free from abuse.
Failure to Provide Two Staff for Care as Required by Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that two staff members were present to provide care to a resident with dementia and behavioral disturbances during the 3:00 PM to 11:00 PM shift, as required by the resident's care plan. The resident, who had severely impaired cognition and a history of aggression and sundowning behaviors, was care planned to have two staff for all care during this shift. On the evening in question, only one nursing assistant provided care, contrary to the care plan and the resident's care card instructions. The nursing assistant was not aware of the recent update to the care plan and reported that the change had not been communicated to him, although he acknowledged that he should have followed the care card. The incident was reported after the resident alleged that a male staff member entered the room, was rough, and hit the resident multiple times, resulting in a bruise and a small scab on the resident's hand. Facility investigation found that the resident, who was known to be combative, had struck the nursing assistant, but there was no evidence to substantiate abuse by the staff member. Interviews with staff and facility leadership confirmed that the care plan requiring two staff was not followed, and the nursing assistant should have requested assistance when the resident became agitated. The facility was unable to provide a policy on Resident Care Cards when requested.
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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