New London Sub-acute And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterford, Connecticut.
- Location
- 90 Clark Lane, Waterford, Connecticut 06385
- CMS Provider Number
- 075158
- Inspections on file
- 23
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 22 (3 serious)
Citation history
Health deficiencies cited at New London Sub-acute And Nursing during CMS and state inspections, most recent first.
A cognitively and physically impaired resident with severe dementia and dependence for transfers was left unsupervised in a shared room with a roommate who had dementia, delusional disorder, and a history of escalating agitation, paranoia, yelling, wandering, and refusals of care. Despite repeated behavioral episodes and a PRN trazodone order that had previously been effective, staff did not develop a behavior care plan, did not create a plan for refusals, did not administer the PRN medication in response to agitation, did not reattempt administration after refusal, and did not use alternative non-pharmacologic interventions. During a night shift, the aggressive resident became belligerent, refused food and trazodone, threw food at staff, remained agitated and talking to him/herself, and was then left in the room with the vulnerable roommate without close supervision. About thirty minutes later, staff found the aggressive resident standing over the roommate with a hairbrush, and the roommate had facial and hand bruising and was covered in lotion; EMS and ED records described an assault with a heavy hairbrush and imaging confirmed an acute subarachnoid hemorrhage, leading surveyors to cite Immediate Jeopardy for failure to prevent abuse.
Two residents with dementia, dysphagia, and other comorbidities were placed at risk when staff failed to follow ordered IDDSI-modified diets and required meal supervision. One resident, ordered an IDDSI Level 6 soft and bite-sized diet with supervision and adaptive utensils, was routinely given crustless peanut butter and jelly sandwiches that were not ordered and not allowed for that texture level, and was left without a clearly assigned NA supervising the dining room. The resident choked while eating a peanut butter and jelly sandwich, became red in the face and appeared unable to breathe, and required an LPN to perform the Heimlich maneuver to expel the obstructing food. Another resident, ordered an IDDSI Level 5 minced and moist diet with honey-thick liquids per SLP recommendations, was repeatedly served crustless peanut butter and jelly sandwiches despite the SLP not approving an exception and IDDSI guidance prohibiting nut butters and regular bread for that texture. Staff interviews and record reviews showed that meal tickets and Kardex entries did not consistently match physician and SLP orders, staff were unaware of IDDSI restrictions, and no clear assignment for dining room supervision was made, contributing to the deficiency.
The facility failed to ensure timely provider notification after significant changes in condition for two residents. One resident with dementia and dysphagia experienced a choking episode during a meal that required the Heimlich maneuver; the supervising RN texted the primary APRN but, after receiving no response, did not contact the on-call provider or Medical Director, instead entering orders independently and delaying direct provider notification. Another resident with multiple neuropsychiatric diagnoses had escalating agitation, refused PRN trazodone and several scheduled evening medications, and was found in another resident’s bed despite repeated redirection attempts; the RN documented the behaviors and missed medications but did not notify any on-call provider or psychiatric APRN. These actions did not follow facility policies requiring prompt physician notification and accurate documentation after accidents, significant changes in condition, and repeated medication refusals.
A resident with severe cognitive impairment and limited mobility, sharing a room with another cognitively impaired, ambulatory resident on a secured memory unit, sustained facial and hand injuries and was later found to have an acute subarachnoid hemorrhage after the roommate was discovered at the bedside holding a brush and yelling. Nursing notes documented escalating paranoia and behavioral symptoms in the ambulatory resident prior to the incident, with PRN psychotropic medication administered. The DON was informed of the alleged resident‑to‑resident physical abuse in the early morning hours but did not notify the state agency until more than three hours after the event, exceeding the facility’s abuse reporting policy requirement to report abuse allegations within two hours.
Surveyors found that the facility failed to update and implement care plans for two residents. One resident with dementia and dysphagia experienced a choking episode and subsequently had provider and therapy orders for a downgraded diet and 1:1 feeding, but the RCP, Kardex, and meal ticket were not revised to reflect the 1:1 feeding requirement, and the resident was later observed self-feeding without indicated 1:1 assistance. Another resident with cognitive and psychiatric diagnoses exhibited ongoing agitation, yelling, paranoia, wandering, and repeated refusals of medications, vital signs, lab work, and care, culminating in an incident involving a roommate, yet no behavior or refusal-of-care RCP had been developed despite this documented pattern.
A resident with dementia, chronic pain, osteoporosis, and limited mobility was assaulted by a roommate, sustaining visible contusions and facial bruising. Despite an active PRN acetaminophen order and a care plan directing staff to anticipate and respond to pain, nursing staff did not complete a pain assessment, did not document any pain evaluation, and did not offer or administer PRN pain medication before the resident was transferred to the hospital. EMS documented severe bruising, swelling, and pain, and the ED later confirmed multiple contusions and an acute subarachnoid hemorrhage, with acetaminophen not given until several hours after the injuries.
A resident with dementia, delusional disorder, anxiety, and depression, living on a secured memory unit, exhibited ongoing agitation, yelling, paranoia, wandering, and refusals of care. Despite a PRN trazodone order for anxiety, restlessness, or agitation and a care plan calling for supervision, cueing, and medication administration with monitoring, staff did not consistently offer or document use of the PRN medication, did not document ineffective interventions or reapproaches, and did not have a specific behavior or refusal-of-care care plan. Multiple nurses and NAs described repeated episodes of yelling, talking to self, demanding food, refusing offered items, and being in and out of bed, culminating in an altercation in which a roommate was found with visible injuries, while the MAR showed no PRN trazodone administration during these escalating behaviors and the facility could not provide a behavioral management policy.
Two residents with ESRD, heart failure, acute kidney failure, and type II DM had multiple critical lab values (elevated creatinine and BUN) that were reported by the lab to nursing staff but were not documented as promptly communicated to a provider, and there was no documentation that an RN supervisor assessment was completed as required by policy. Nursing notes lacked entries showing provider notification, times of contact, or new orders at the time critical results were received or later reviewed, and provider documentation of these critical values occurred one or more days after the lab reports. An RN reported signing off lab results as reviewed in the EHR to clear alerts, not realizing only providers should do so, and could not recall specific notifications made, while leadership interviews confirmed expectations for immediate provider notification, RN supervisor follow-up assessment, and complete documentation that were not met in these cases.
Two residents with dementia, dysphagia, and prior stroke were ordered IDDSI 5 and 6 modified diets with specific texture and supervision requirements, but staff routinely provided crustless peanut butter and jelly sandwiches that were not permitted or properly prepared under those IDDSI levels. One resident, ordered a level 6 soft and bite-sized diet with supervision, was habitually given halved peanut butter and jelly sandwiches without an SLP-approved exception and experienced a choking episode in the dining room that required an LPN to perform the Heimlich maneuver. The other resident, ordered a level 5 minced and moist diet with honey-thick liquids per SLP recommendations, continued to receive crustless peanut butter and jelly sandwiches with every meal based on nursing-entered orders that were not supported by SLP evaluation or the diet slip. Dietary staff prepared sandwiches only crustless and cut in halves or quarters, not into IDDSI-compliant bite-sized or minced pieces, and multiple NAs and nursing staff reported they were unaware that peanut butter and jelly sandwiches and nut butters were not allowed on these modified diets or where to find IDDSI guidance, despite facility policies requiring adherence to physician/SLP diet orders and the diet manual.
The facility failed to complete required MDS admission, quarterly, and annual assessments within 14 days of the ARD for six residents. One admission MDS was completed several days late, and multiple quarterly and annual MDS assessments remained incomplete past their required due dates. An LPN acknowledged knowing the 14‑day requirement and reported that she did not complete or delegate the assessments before going on vacation. The DON confirmed the 14‑day completion requirement and stated unawareness that the MDSs were overdue, while facility policy assigns responsibility for timely MDS completion to the MDS Coordinator.
A resident with a history of falls, heart failure, anxiety, and moderately impaired cognition, but assessed as independent with transfers and wheelchair use, was allowed to use the bathroom and self-transfer. While transferring from a wheelchair to the toilet using a bathroom grab bar, the bar detached from the wall, causing the resident to fall to the floor. Initial assessment showed no visible injury, but the resident later developed chest pain, and imaging ordered by an APRN revealed multiple rib fractures. A NA reported finding the resident on the floor with the grab bar dislodged, and the Administrator stated that while monthly environmental rounds were conducted, they did not previously include checking the stability of grab bars.
Two residents were affected when the facility failed to maintain a safe and sanitary environment. A resident with a history of falls and limited mobility, who was allowed to self-transfer, used a bathroom grab bar that detached from the wall during a wheelchair-to-toilet transfer, resulting in a fall and later-confirmed rib fractures; facility environmental rounds did not include checking grab bar stability. Another dependent, severely cognitively impaired resident with CHF, prior UTIs, and pressure-ulcer risk was found to have a mattress emitting a strong urine odor beneath clean linens, despite reports from a visitor about urine smells and the absence of any mattress-cleaning schedule in facility checklists.
A resident’s representative reported multiple care complaints and concerns over an extended period to SW staff, the DSS, and the Administrator, initially without awareness of the formal grievance process and later via multiple emails due to uncertainty about using the grievance form. The Administrator, SW, and DSS each acknowledged receiving these complaints and either addressing them directly or forwarding them but did not treat them as formal grievances, did not enter them into the grievance log, did not document outcomes, and did not provide written resolutions to the representative. These actions did not follow the facility’s Resident Rights and Grievance policies, which require documentation of complaints, actions taken, and resolution, and a response to grievances.
A resident with COPD, CHF, severely impaired cognition, and oxygen dependence had physician orders for continuous oxygen at 0–4 L to maintain O2 saturation above 92%, with monitoring each shift and care plan directives to monitor oxygen and portable tank levels. Although the MAR showed continuous oxygen use and documented saturations, a visitor reported multiple occasions where the resident used empty portable tanks, and unused tanks were often empty. On one observation, the resident was found in bed with the nasal cannula off, the concentrator powered down, and tubing placed out of reach; staff, including a NA, an LPN, and the DON, all stated the oxygen should have been on and could not explain why it was off. The LPN documented that the resident’s O2 saturation was 90% before oxygen was reapplied, contrary to the physician’s order and facility policy requiring oxygen to be administered as ordered.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with advanced cancer and cognitive impairment missed multiple scheduled doses of morphine and lorazepam because the facility did not follow up with the pharmacy to clarify new orders or request refills before the supply was exhausted. The facility also failed to document that missed doses were reported to supervisors or the provider, resulting in lapses in pain and agitation management.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required.
Annual performance evaluations were not completed for two nurse aides as required by facility policy. One aide's evaluations for two consecutive years were missing, while another aide's annual review was overlooked and not documented. Errors in recordkeeping and staff transitions contributed to the failure to complete these evaluations, as confirmed by interviews with administration and HR.
The facility did not ensure that medications were administered as scheduled and failed to notify providers when medications were missed or administered late. Multiple residents experienced late or omitted medication administrations, and ongoing audits failed to identify these issues. The DON and Administrator were unaware of the continued deficiencies, despite being responsible for QAPI oversight.
A deficiency was cited when a resident's care plan did not include all necessary interventions, lacked measurable timetables, and failed to specify actions to address the resident's needs, as evidenced by incomplete documentation in the resident's records.
The facility did not maintain effective administrative oversight, resulting in repeated failures to ensure scheduled anxiety and narcotic pain medications were administered as ordered, timely medication refills and deliveries, and proper notification to providers of medication omissions. Significant medication errors persisted, and leadership interviews confirmed ongoing noncompliance and lack of oversight processes.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident experienced a significant medication error due to a failure in the medication administration process.
Physician orders for multiple residents were not reviewed or signed monthly as required, due to lack of awareness by facility leadership and the medical director, as well as unresolved access issues in the electronic medical record system. The facility did not have a policy specifying the frequency for physician order reviews, and the orders remained unsigned for at least two months.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes that affected the resident.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with dementia and a physician's order requiring supervision for ambulation and leave of absence was able to exit the facility unattended due to the front entrance door being left unlocked and unmonitored. Staff interviews revealed inconsistent practices regarding door security and front desk monitoring, which allowed the resident to leave the premises without staff knowledge, in violation of facility policy and the resident's care plan.
An LPN administered medications to 22 residents by memory after being unable to access the electronic MAR, without notifying supervisors or using alternative documentation for non-narcotic medications. This action bypassed established protocols for ensuring the 5 Rights of medication administration and resulted in Immediate Jeopardy.
An LPN administered morning medications to 22 residents by memory without access to the EMAR or any MAR documentation, failing to follow facility policy and without notifying supervisors. Additionally, a resident with heart failure and dementia experienced significant weight fluctuations without required reweighs or documentation, contrary to facility policy.
A resident with dementia and other health conditions alleged that an LPN pushed them onto a bed and took away their phone, causing distress and fear. The facility did not conduct a thorough investigation, failed to report the incident as required, and allowed the LPN to continue providing care to the resident even after the abuse was substantiated by surveyors. These failures led to an Immediate Jeopardy finding.
A resident with dementia alleged physical abuse by an LPN, including being pushed onto a bed and having their phone removed when calling for help, with the LPN continuing to provide care after the incident. The facility's investigation was incomplete, lacking documentation and interviews. In a separate event, two residents were involved in a physical altercation, with one striking the other in the face and the other pushing back. The facility failed to fully document and investigate these incidents, resulting in a deficiency for not protecting residents from abuse.
A resident with no cognitive impairment and multiple medical conditions was not invited to participate in care planning meetings, despite expressing a desire to attend. The social worker stated this was due to a conservator's request, but could not provide documentation to support this claim, and facility records did not show the resident was invited or declined to attend.
Several residents with complex medical needs experienced frequent shortages of clean towels and washcloths, resulting in missed or delayed showers and the use of makeshift materials for personal care. Staff and management were aware of the ongoing linen shortages but did not implement effective solutions, and the facility's policy lacked guidance for such situations. Additionally, a malfunctioning lock on a memory care unit's shower room door allowed unsupervised resident access, with lapses in staff monitoring and no policy provided for maintaining a secure environment.
Multiple residents with cognitive and medical impairments were placed on a secured memory care unit without documented clinical criteria, initial or ongoing assessments, physician orders, or evidence of resident or representative involvement in the placement decision. Staff confirmed there was no written policy or assessment process for admission to the secured unit, and residents could not independently exit the unit.
The facility failed to report multiple incidents of suspected resident-to-resident and staff-to-resident physical mistreatment to state protective services and the state agency as required. Despite documentation of physical altercations and allegations of abuse involving residents with cognitive impairments and behavioral issues, mandated notifications were not made in a timely manner, and staff interviews revealed a lack of understanding of reporting requirements.
Surveyors identified that the facility's medication error rate exceeded 5% due to repeated late administration of scheduled medications. Multiple residents, including those with complex medical conditions and varying cognitive statuses, received their morning medications well past the prescribed timeframe. Nursing staff reported ongoing difficulties in completing timely medication passes and had previously informed administration of these issues, but late administration persisted across several units.
Surveyors found that kitchen equipment had significant debris and residue buildup, opened and repackaged food items in storage were not properly labeled or dated, and a resident's reheated food was not checked with a thermometer as required. The Food Service Director confirmed that cleaning and labeling procedures were not consistently followed, and that staff reheated food without verifying temperatures per policy.
A review found that 31 employees had not received mandatory abuse and neglect training, despite facility policy requiring annual education for all staff. Additionally, the training provided was incomplete, lacking several federally required components such as screening, identification of abuse indicators, mandated reporting, and information on exploitation and restraints. Interviews confirmed that the Staff Development nurse and DON did not ensure the training matched facility policy or federal requirements.
The facility did not have a compliance and ethics program or policy, and staff were not provided with compliance and ethics training. Interviews confirmed that the existing Code of Conduct was not communicated to all staff and lacked key elements such as reporting procedures, identification of a compliance officer, and internal monitoring processes.
The facility failed to follow abuse prevention and reporting policies after two residents were involved in a physical altercation and another resident alleged mistreatment by an LPN. Key details were omitted from incident reports, investigations were incomplete or undocumented, and the accused LPN continued to provide care to the resident. Additionally, abuse prevention was not addressed in the facility's QAPI program.
A resident with dementia, CHF, and severe hearing loss did not have their care plan reviewed and revised quarterly as required. Due to an oversight, the resident was not scheduled for a care conference, and the MDS Coordinator failed to include the resident on the list for care plan updates, resulting in the care plan not being updated within the required timeframe.
A resident with severe cognitive impairment, incontinence, and limited mobility was not turned or repositioned every two hours as ordered by a physician, despite being at risk for pressure ulcers. Staff, including an RN, social worker, and nurse aides, entered the resident's room but did not reposition the resident over a nearly three-hour period. The responsible nurse aide was unaware of the repositioning requirement due to a lack of electronic charting prompts, and the LPN did not document any refusal of care. This failure to follow the care plan and physician's order resulted in a deficiency related to pressure ulcer prevention.
A resident with severe cognitive impairment and high fall risk was repeatedly observed seated in a wheelchair without the required pelvic positioning belt, despite physician orders and documented staff education. Nursing staff admitted to forgetting to apply the belt, and therapy staff confirmed its necessity for proper positioning and safety. Facility policies required adherence to such orders, but the belt was not consistently used as directed.
Two residents with dementia and high fall risk did not receive required supervision or assistive devices during ambulation and meals, as ordered by physicians and outlined in care plans. Staff were unaware of or did not follow orders for supervision and use of a walker, resulting in unsupervised ambulation and an unwitnessed fall during an unsupervised meal for one resident with dysphagia.
A resident with a history of pressure ulcer, CHF, and diuretic use did not receive adequate hydration, as daily fluid intake consistently fell below the established goal. Despite care plan interventions and facility policy requiring monitoring and assessment for dehydration, no dehydration assessment was completed during the period of low intake. Clinical staff did not effectively monitor or respond to the resident's hydration status, and lab results indicated potential dehydration.
A resident with severe cognitive impairment and respiratory conditions received continuous oxygen therapy for several days without a valid physician's order after the previous order expired. Nursing staff and supervisors were aware of the ongoing oxygen administration but did not ensure a current order was in place, contrary to facility policy.
A resident with end stage renal disease requiring dialysis did not have consistent communication and documentation between the dialysis center and facility, resulting in missing treatment records and unrecorded post-treatment weights. Additionally, staff failed to monitor and total the resident's daily fluid intake as ordered, leading to repeated exceedances of the prescribed fluid restriction. Facility staff were unaware of these lapses, and responsibilities for monitoring were unclear.
Nurse aides were unable to access essential resident care information in the EMR, requiring assistance from licensed staff despite prior training. This deficiency affected two residents with dementia and physical impairments, whose individualized care plans required specific interventions for mobility and feeding.
A resident receiving hemolytic treatments was sent with medication that was not properly packaged by the pharmacy and without an assessment for self-administration, contrary to facility policy. An LPN improperly secured narcotic keys by locking them in the medication cart, and required bimonthly narcotic audits were not conducted due to lack of staff training and oversight. The DON also failed to maintain proper records and storage for unused narcotics awaiting destruction, resulting in multiple breaches of medication management protocols.
A resident with severe dementia and Parkinson's disease, who required adaptive eating equipment and substantial assistance, was not consistently provided with the necessary utensils and cups during meals. Despite clear documentation on the meal ticket and care plan, staff were unaware of the resident's needs, and adaptive equipment was observed unused or missing during multiple meal observations.
Failure to Manage Aggressive Behaviors and Protect Cognitively Impaired Roommate From Assault
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively and physically impaired resident from abuse by a roommate with known, escalating aggressive and delusional behaviors. One resident had dementia with severely impaired cognition (BIMS score of 3), required substantial assistance with bed mobility, was dependent on staff for transfers, and used a wheelchair for mobility. This resident’s care plan identified impaired cognitive function, communication problems, hearing impairment, and limited physical mobility related to a CVA, with interventions including anticipating and meeting needs, cueing, reorienting, supervising as needed, and ensuring a safe environment. Despite these identified vulnerabilities and the need for supervision and safety, the resident was left in a shared room with a roommate who had documented behavioral issues. The roommate carried diagnoses including metabolic encephalopathy, dementia, mild cognitive impairment, delusional disorder, anxiety disorder, and major depressive disorder. From admission, this resident was noted to have a change in mental status, chronic decline, and wandering, and was residing on a secured memory unit, ambulating independently without a device. A PRN order for trazodone 25 mg every six hours as needed for anxiety, restlessness, or agitation was in place. Clinical documentation from early in the month showed multiple episodes of increased agitation, yelling, confusion, paranoia, combativeness with care, and repeated refusals of medications, weights, skin checks, vital signs, blood work, and treatments. On one occasion, the resident was found in another resident’s bed and could not be redirected despite multiple attempts. However, the care plan did not include a behavior care plan or a care plan addressing refusals, despite these ongoing behavioral and refusal patterns. In the days immediately preceding the incident, staff documented that the aggressive resident was paranoid, yelling, talking to him/herself, and not easily redirected, with medications only taken after multiple attempts. Trazodone had previously been administered and documented as effective for behavioral symptoms, but on the evening and night before the assault, staff did not administer the PRN trazodone in response to documented agitation and behavioral symptoms, did not reattempt administration after refusal, and did not implement alternative non-pharmacological interventions. During the night, the resident became belligerent when breakfast could not be provided, refused offered food and fluids, threw food at staff, refused trazodone, and remained agitated and talking to him/herself. Staff left this resident unsupervised in the shared room with the cognitively and physically impaired roommate, with only brief observation outside the door and no frequent checks, despite ongoing agitation. Approximately thirty minutes later, staff heard a loud noise and entered the room to find the aggressive resident standing over the impaired roommate, holding a round hairbrush and yelling. The impaired resident was found with bruising to the left eye and face, bruising to the right hand, and hair and face saturated with lotion. EMS documentation recorded that staff reported finding the aggressive resident on top of the roommate, beating the roommate in the face and head with a heavy hairbrush, with severe bruising, swelling, discoloration, pain, and tenderness to the face and forehead, and lotion dripping from the ears. Hospital imaging confirmed a new acute subarachnoid hemorrhage compared to prior imaging, and the resident’s blood thinner was held for two weeks. Subsequent observations noted persistent facial and extremity bruising and that the resident appeared scared and fearful after the incident. The facility’s DON stated that if the aggressive resident had been supervised, the incident could have been prevented, and the surveyors determined these failures constituted Immediate Jeopardy to resident health and safety. Staff interviews further described that the aggressive resident had been intermittently talking to him/herself, screaming, slamming doors, wandering the halls, and yelling during the night, and that staff recognized in hindsight that the resident should have been brought to a common area for supervision rather than left in the room. Nursing staff acknowledged not immediately administering PRN trazodone when behaviors began, not reapproaching after refusal, and leaving the resident alone in the room with the vulnerable roommate while the resident was still talking to him/herself. The psychiatric APRN reported not receiving clear behavior reports, stated that trazodone should have been offered and its effectiveness documented when behaviors occurred, and indicated that the resident should have been supervised and ensured to be completely calm and back to baseline before returning to the shared room. The facility’s abuse prevention policy required assessing, care planning, and monitoring residents with behaviors that may lead to conflict, and the Q15 minute and 1:1 policy described procedures for observation of residents at risk of aggression, but a behavioral management policy was not provided when requested. These documented actions and inactions led to the abusive incident and the resulting Immediate Jeopardy finding.
Failure to Follow IDDSI Diet Orders and Provide Required Meal Supervision, Resulting in Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents on altered texture diets received food and supervision consistent with physician orders and IDDSI guidelines, resulting in an Immediate Jeopardy situation. One resident with dementia, oropharyngeal dysphagia, cerebrovascular disease, and type II diabetes mellitus had a physician’s order for a regular diet with IDDSI Level 6 soft and bite-sized texture, IDDSI 0 thin liquids, use of adaptive utensils, and supervision with meals. The resident’s care plan identified impaired cognition, a potential swallowing problem, and the need for supervision with meals, adherence to the prescribed diet, upright positioning, slow eating, thorough chewing, and monitoring for signs of dysphagia. Despite these orders and care plan interventions, the resident was routinely provided peanut butter and jelly sandwiches that were not ordered and not permitted on an IDDSI Level 6 diet, and staff were unaware that nut butters and regular bread were contraindicated for this texture level. On a specific date and time, the resident was in the dining room eating lunch when a peanut butter and jelly sandwich was served and consumed. The resident experienced a choking episode, was observed to be red in the face and appearing unable to breathe, and required an LPN to perform the Heimlich maneuver, which dislodged food and dentures from the resident’s mouth. The SLP present in the dining room reported that the resident’s diet orders had not been followed and that the resident had not been evaluated or cleared for peanut butter and jelly sandwiches. Staff interviews revealed that multiple NAs and an LPN believed the resident “always” received crustless, halved peanut butter and jelly sandwiches with meals and snacks, and they were unaware that such sandwiches were not allowed on the ordered diet or that IDDSI guidance prohibited nut butters and regular dry bread. The Food Service Director confirmed that the resident’s meal tickets included a peanut butter and jelly sandwich with each meal without a corresponding diet order slip, and that sandwiches for residents on modified diets were only crustless and halved, not cut into IDDSI-compliant bite-sized pieces. The deficiency also includes a failure to provide required supervision and assistance during meals. The resident’s orders and care plan required supervision with meals and, after the choking incident, one-to-one feeding assistance; however, on later observation, the resident was seen feeding themself in the dining room, with no indication of one-to-one feeding assistance on the meal ticket and without the ordered built-up utensils. Staff interviews and review of the staffing assignment sheet showed that no NA had been assigned to supervise the dining room for the lunch meal when the choking incident occurred, despite staff acknowledging that at least one NA should be present in the dining room once meals are served. The resident’s Kardex only indicated a mechanically altered diet and supervision for eating, which was not consistent with the physician’s orders for one-to-one feeding assistance following the choking event. A second resident with oropharyngeal dysphagia, cerebral infarction, severely impaired cognition, and a mechanically altered diet was also affected by similar failures. This resident had SLP recommendations and physician orders for an IDDSI Level 5 minced and moist texture and IDDSI 3 moderately thick/honey liquids. The SLP’s discharge summary did not approve peanut butter and jelly sandwiches, and the SLP later clarified that the resident was not safe to consume such sandwiches except under one-to-one SLP observation and that no exception for peanut butter and jelly sandwiches was included on the diet slip. Despite this, nursing entered and the APRN signed physician orders allowing crustless peanut butter and jelly sandwiches with every meal, and the resident was repeatedly observed being served crustless peanut butter and jelly sandwiches, first halved and later quartered. Staff reported that this resident “always” received a crustless peanut butter and jelly sandwich with meals. IDDSI guidance for Level 5 minced and moist diets prohibits regular dry bread and sticky foods such as nut butters, meaning the sandwiches provided were inconsistent with the ordered diet texture and SLP recommendations. Across both residents, the facility lacked clear implementation of its Modified Textures and Feeding Residents policies. The Modified Textures policy required that residents receive foods in the consistency ordered by the physician and/or speech therapy, that textures follow the Diet Manual, and that texture needs be regularly screened by the speech therapist. The Feeding Residents policy required ensuring that the food listed on the dietary card matched the food on the tray. However, meal tickets and diet cards did not accurately reflect physician and SLP orders, staff were unaware of IDDSI restrictions, and there was no available policy for dining room supervision or for diet consistency/texture exceptions. These actions and inactions led to residents receiving non-ordered, unsafe food textures and inadequate supervision during meals, creating a choking hazard and resulting in an Immediate Jeopardy finding.
Failure to Notify Providers After Choking Event and Behavioral Escalation
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and appropriate provider notification following significant changes in condition and behavioral incidents for two residents. For one resident with dementia, oropharyngeal dysphagia, cerebrovascular disease, and type II diabetes, care plans and orders required a mechanically altered diet, supervision with meals, and monitoring for signs of swallowing difficulty. During a lunch meal, this resident experienced a choking episode in the dining room that required the Heimlich maneuver. After the incident, the resident was assessed by the RN supervisor, who documented clear but diminished lung sounds, stable vital signs, and no further coughing, and the resident was kept at the nurse’s station for further evaluation. The RN supervisor reported that she texted the primary APRN to report the choking incident but did not receive a response. Despite the lack of response, she did not contact the on-call provider or the Medical Director. Instead, she independently entered orders for vital signs every four hours for three days, downgraded the resident’s diet, and initiated a speech screen, and only notified the APRN the following morning. The APRN later stated that she had been off duty at the time of the incident and that the RN should have contacted the on-call provider or Medical Director after not receiving a timely response, so that a chest x-ray could have been ordered the same day to evaluate for aspiration. Facility policy on change of condition required the nurse to notify the attending or on-call physician when there had been an accident or incident involving the resident or a significant change in physical, emotional, or mental condition. For another resident with metabolic encephalopathy, dementia, mild cognitive impairment, delusional disorder, anxiety disorder, and major depressive disorder, orders included PRN trazodone for anxiety, restlessness, or agitation. Nursing documentation showed that this resident had increased agitation and yelling, could not be redirected, and refused evening and PRN medications. The resident was found lying in another resident’s bed, and multiple attempts by staff to remove and reorient the resident were initially unsuccessful, with the resident remaining irate and difficult. The nurse documented the behaviors, the inability to administer medications, and the incident of the resident being in another resident’s bed, but there was no documentation that any provider was notified of the missed medications, refusal of PRN trazodone, or the escalating behaviors. Medication administration records confirmed that several scheduled evening medications and topical treatments were not administered that shift. Interviews with the RN, the psychiatric APRN, and the DON confirmed that no on-call provider or psychiatric APRN had been notified of the behavioral escalation, medication refusals, or the incident of the resident being in another resident’s bed. The DON stated that an on-call provider should have been notified for missed or refused medications, escalation in behaviors, and behavioral incidents. Facility policies on change of condition, charting and documentation, and medication refusal required provider notification for significant changes in condition and for repeated medication refusals, as well as accurate documentation of such notifications, which did not occur in these cases.
Failure to Timely Report Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to notify the state agency within two hours of an allegation of resident‑to‑resident physical abuse, as required by facility policy. The facility’s Abuse Reporting policy dated 6/2023 defines abuse, including physical abuse such as hitting and slapping, and directs that allegations involving abuse be reported no later than two hours after the allegation is made. In this case, an incident occurred in the early morning involving two residents on a secured memory unit, and the Director of Nursing (DON) did not submit the report to the state agency until more than three hours after the incident, exceeding the required two‑hour timeframe. One resident involved (Resident #8) had diagnoses including dementia without behavioral disturbances, chronic pain, major depressive disorder, and anxiety disorder, with severely impaired cognition (BIMS score of 3), impaired communication, hard of hearing, and limited physical mobility related to a CVA. Orders and the resident care plan indicated the resident required extensive assistance with mobility and transfers and needed supervision, cueing, and a safe environment. The other resident (Resident #7) had diagnoses including metabolic encephalopathy, dementia, mild cognitive impairment, delusional disorder, anxiety disorder, and major depressive disorder, resided on a secured memory unit, and ambulated independently without an assistive device. Resident #7’s care plan included use of psychotropic medications and interventions such as anticipating needs, consistent routines, cueing, reorienting, and supervision as needed. On the night of the incident, nursing documentation showed Resident #7 was experiencing paranoia, yelling, and difficulty being redirected, and had received PRN trazodone for anxiety, restlessness, or agitation. At approximately 3:30 AM, staff heard a loud noise and found Resident #7 in the roommate’s room, standing next to Resident #8’s bed holding a round brush and yelling. Resident #8 had lotion in the hair and visible injuries including a red mark to the left side of the nose, bruising to the left eye, and bruising to the right hand. Emergency department records later documented contusions to the head, face, and right hand and imaging consistent with an acute subarachnoid hemorrhage. Interview and website review confirmed the incident occurred at 3:30 AM, the DON first became aware by around 5:00 AM, but the incident was not reported to the state agency until 6:41 AM, and the DON acknowledged the report should have been made within the two‑hour reporting window.
Failure to Update Care Plans for One-to-One Feeding and Behavioral/Refusal Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise resident care plans to reflect physician orders and identified care needs for two residents. For one resident with dementia, oropharyngeal dysphagia, cerebrovascular disease, and type II diabetes, the quarterly MDS showed severely impaired cognition and a need for supervision with eating and dependence for oral care, bed mobility, and transfers, with a mechanically altered diet. The existing Resident Care Plan (RCP) identified impaired cognition and a potential swallowing problem, with interventions such as supervision with meals, following the prescribed diet, upright positioning, slow eating, thorough chewing, and monitoring for signs of dysphagia and respiratory issues. Despite these identified needs, after a choking incident in the dining room that required the Heimlich maneuver, the RCP and Kardex were not updated to reflect new physician and therapy orders for one-to-one feeding assistance. Following the choking episode, documentation showed that the resident’s diet was downgraded and that a provider ordered one-to-one feeding for meals, with an additional order specifying occupational therapy ADL recommendations for 1:1 feeding. A speech evaluation identified that the resident was unable to self-feed due to cognition, required rate modification, had decreased safety awareness, and required one-to-one feeding assistance, with a recommendation for a minced and moist diet excluding certain foods. However, subsequent observation of the lunch meal showed the resident feeding independently, with a meal ticket that did not indicate the need for one-to-one feeding assistance. The Kardex still showed a mechanically altered diet with supervision for eating, not one-to-one feeding, and the RCP had not been revised to include the one-to-one feeding order. Interviews with the DON and MDS nurse confirmed that the care plan and Kardex should have been updated immediately when the change in supervision needs was identified and that this had not occurred. For a second resident with metabolic encephalopathy, dementia, mild cognitive impairment, delusional disorder, anxiety disorder, and major depressive disorder, the record documented a pattern of agitation, yelling, paranoia, wandering, and repeated refusals of medications, vital signs, lab work, weights, body evaluations, and topical treatments. Nursing notes and order administration entries over multiple days described increased agitation, yelling, difficulty with redirection, refusal of evening and as-needed medications, refusal to go to the resident’s room, and refusal of vital signs and lab work. Additional notes described the resident as alert but confused, paranoid, talking loudly to self, tearful, anxious, and sometimes taking medications only with significant encouragement. The pattern culminated in an incident where the resident, after becoming belligerent about not receiving breakfast, was found in a roommate’s area holding a brush, with the roommate observed to have lotion in the hair and visible bruising and a red mark to the face and hand. Review of the clinical record showed there was no RCP addressing behaviors or refusals of care prior to this incident, and the DON stated that nursing or the IDT should have identified the pattern of behaviors and refusals from admission and initiated care plans and interventions as soon as the behaviors were identified. Facility policies on Care Plans and Resident Profiles directed that RCPs can be revised at any time on an interim basis, must include physical, cognitive, and psychosocial problems, and must address residents’ needs on an individualized basis, and that nursing staff must be aware of all current care needs by checking the resident profile at the start of and throughout each shift. Despite these policies, the RCP and Kardex for the first resident were not revised to reflect the physician-ordered one-to-one feeding assistance after the choking event, and no behavior or refusal-of-care RCP was developed for the second resident despite ongoing documented agitation, paranoia, yelling, wandering, and repeated refusals of care. Requested facility policies for staff supervision for meals in the dining room and for therapy recommendations were not available.
Failure to Assess and Manage Pain After Resident-to-Resident Assault
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate pain management to a resident following a resident‑to‑resident assault. The resident had diagnoses including dementia without behavioral disturbances, chronic pain, major depressive disorder, anxiety disorder, osteoporosis, a history of CVA, and severely impaired cognition (BIMS score of 3). The resident’s care plan identified potential for pain due to osteoporosis and chronic pain, impaired cognition and communication, and limited mobility, with interventions to anticipate pain needs, respond immediately to any complaint of pain, administer analgesics per orders, and monitor for pain in a non‑verbal resident. A physician’s order for PRN acetaminophen 325 mg, two tablets every four hours as needed for pain, was in place. During the night, the resident was assaulted by a roommate, resulting in visible injuries including a red mark to the nose, bruising to the left eye, and a bruise to the right hand, as documented by an RN. The nurse’s note did not document any pain assessment or offer of pain medication following the incident. Further documentation showed no pain assessment or pain evaluation completed after the assault, despite facility policy requiring pain assessments on admission, quarterly, and as needed, including monitoring non‑verbal or dementia residents for behavioral signs of pain. The MAR showed that the ordered PRN acetaminophen was not administered on the date of the incident. EMS records indicated staff reported the resident had been beaten in the face and head with a heavy hairbrush and that the resident knew they were injured; EMS documented severe bruising, swelling, discoloration, pain, and tenderness to the face, around the eyes, and forehead. Hospital ED records confirmed contusions to the head, face, and right hand and later imaging identified an acute subarachnoid hemorrhage. The ED record showed acetaminophen 650 mg was not administered until several hours after the injuries occurred. The RN involved acknowledged she did not think to administer pain medication or complete a full pain assessment following the change in condition and was preoccupied with the roommate involved in the assault.
Failure to Manage Escalating Behaviors and Use PRN Psychotropic Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and manage escalating behavioral symptoms for a resident with multiple mental health diagnoses, including dementia, delusional disorder, anxiety disorder, major depressive disorder, and metabolic encephalopathy. The resident had been admitted for change in mental status, chronic decline, and wandering, and resided on a secured memory unit. The resident’s care plan addressed impaired cognitive function, use of psychotropic medications, and general interventions such as anticipating needs, maintaining consistent routines and caregivers, cueing, reorienting, supervising as needed, and administering medications as ordered with monitoring and documentation of side effects and effectiveness. However, the clinical record from admission through mid-month documented repeated episodes of agitation, yelling, confusion, paranoia, combativeness with care, and refusals of medications and treatments without a specific behavior or refusal-of-care care plan in place. A physician order directed that trazodone 25 mg be administered every six hours as needed for anxiety, restlessness, or agitation. Despite this order, the Medication Administration Record showed no administration of PRN trazodone for the resident’s documented anxiety, restlessness, or agitation on the days leading up to and including the date of the altercation. On one afternoon, a nurse documented that the resident was paranoid, yelling, and not easily redirected, and that medications were eventually taken after multiple attempts, but there was no documentation of what non-pharmacological interventions were used to de-escalate the behavior or that PRN trazodone was offered. On the overnight shift, another nurse documented that the resident became belligerent when unable to have breakfast, refused offered food and fluids, and later was found in the roommate’s bed area after a loud noise, with the roommate exhibiting visible injuries. The record did not show that PRN trazodone was administered prior to or following these behaviors, nor that ineffective interventions and reapproaches were consistently documented. Interviews with clinical staff further demonstrated gaps in behavioral management and documentation. The psychiatric APRN reported seeing the resident multiple times and making several medication adjustments but did not receive clear staff reports about the resident’s behaviors or incidents, and stated that staff should have offered the ordered trazodone when anxiety, restlessness, or agitation occurred and documented both the behaviors and medication effectiveness. The DON stated that when a psychiatric provider orders medication for anxiety, agitation, or restlessness, staff should attempt to administer it when behaviors occur and, if refused, implement other safety interventions and reapproach the resident several times. One RN, working her first shift on the unit, described the resident as demanding and yelling about food and acknowledged she did not think to check for available medication to calm the resident and did not know trazodone was ordered. Another RN, who did not normally work on the locked memory unit, described multiple episodes of yelling, talking to self, demanding breakfast, refusing food and drinks, and throwing food, and stated she attempted to give trazodone once but did not reapproach after refusal, despite having previously seen trazodone be effective. Nursing assistants described the resident’s ongoing pattern of yelling, shrieking, talking to self, slamming doors, wandering, and being in and out of bed prior to the incident, with difficulty redirecting the resident. The facility also lacked a provided behavioral management policy, and the existing medication refusal policy, which required re-offering medications to confused residents within an hour and documenting refusals, was not followed as evidenced by the lack of consistent reapproach and documentation related to the PRN trazodone and behavioral episodes.
Failure to Promptly Report and Document Critical Lab Results and RN Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that abnormal and critical laboratory results were promptly reported to providers and followed by an RN supervisor assessment, as required by facility policy. For one resident with end stage renal disease, dependence on hemodialysis, and type II diabetes mellitus, lab work showed a critically high creatinine level of 4.24, reported to the facility in the evening and later reviewed by an RN the following morning. Nursing notes from the date of the lab and the following day did not document that the critical creatinine value was reported to a provider or that an RN supervisor assessed the resident. A provider note from that day did not reference the critical value or any notification, and the provider did not document review of the critical result until two days later. For another resident with heart failure, acute kidney failure, and type II diabetes mellitus, multiple critically high BUN levels were reported over several dates, but there was no documentation that these critical values were promptly communicated to a provider or that an RN supervisor assessment occurred at the time of each result. A critically high BUN of 73 was reported to an RN, but there were no nursing notes for that day and no documentation of provider notification when the result was received or when later reviewed by another RN; the provider did not document review of this lab until two days later. Subsequent critical BUN values of 70, 80, and 75 were each reported to nursing staff and later reviewed by the same RN, yet nursing notes over the corresponding periods did not show timely provider notification or RN supervisor assessment, and provider documentation of these critical values occurred one day later in each instance. Interviews further clarified the actions and inactions contributing to the deficiency. The RN who reviewed many of the critical results stated she was aware of the critical values and believed she had reported them but could not recall to whom, at what time, or whether new orders were obtained, and she was unaware that policy required an RN supervisor assessment to accompany abnormal lab reporting. She also reported that she had been signing off lab results as reviewed in the electronic record to clear them from her homepage, not realizing that only providers should sign off results under the results tab. The Medical Director stated that RNs receiving critical values should immediately notify a provider and document the provider’s name, time of notification, and any new orders, and that only providers should sign off lab work as reviewed. The DON stated that the RNs involved should have ensured immediate provider notification and complete documentation of the notification details for the critical lab results, and acknowledged uncertainty about who should sign off lab work as reviewed and about the specifics of the abnormal lab and physician notification policies.
Failure to Follow IDDSI-Consistent Modified Diet Orders and Staff Incompetence With Texture Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to provide prescribed modified-texture diets in accordance with physician orders, the diet manual, and IDDSI guidelines, and failure to ensure staff competency with IDDSI diets for two residents with dysphagia. Resident #1 had dementia, oropharyngeal dysphagia, cerebrovascular disease, and type II diabetes, with a physician’s order for a regular diet with IDDSI 6 soft and bite-sized texture and thin liquids, use of adaptive equipment, and supervision with meals. Despite these orders and a care plan identifying potential swallowing problems and the need for supervision and adherence to the prescribed diet, Resident #1 was routinely provided peanut butter and jelly sandwiches that were crustless and halved, not cut into 1.5 cm by 1.5 cm pieces as required for IDDSI 6, and peanut butter was not permitted on that texture level per IDDSI guidance. Staff, including nursing and dietary, reported that Resident #1 “always” received peanut butter and jelly sandwiches with meals and as snacks, and there was no SLP evaluation or physician order authorizing an exception for peanut butter and jelly sandwiches. On the day of the choking incident, Resident #1 was in the dining room eating lunch when a choking episode occurred, requiring an LPN to perform the Heimlich maneuver, which dislodged a piece of food and the resident’s dentures. The SLP present in the dining room for another resident heard banging, turned to see Resident #1 red in the face and apparently not breathing, and alerted the LPN, who then intervened. The SLP later stated that the choking incident could have been prevented if the resident’s diet orders had been followed and confirmed that peanut butter and jelly sandwiches are not included in a level 6 diet unless specifically evaluated and ordered as an exception, with the sandwich cut into 1.5 cm by 1.5 cm pieces. Multiple NAs and an LPN reported they were unaware that peanut butter and jelly sandwiches were not permitted on a level 6 diet, did not know where IDDSI guidance was posted, and believed the resident could have peanut butter and jelly sandwiches. The Food Service Director confirmed that Resident #1’s meal tickets included a peanut butter and jelly sandwich at each meal without any supporting diet order slip and that sandwiches for residents on modified diets were only made crustless and cut in half, not into IDDSI-compliant bite-sized pieces. Resident #2 had oropharyngeal dysphagia and a history of cerebral infarction, with an initial physician’s order for a regular diet with IDDSI 6 soft and bite-sized texture and honey-thick liquids, and permission for soft crustless sandwiches including peanut butter and jelly, with supervision at meals. A subsequent SLP screen identified overt signs of aspiration and led to a change in diet to IDDSI 5 minced and moist texture with honey-thick liquids. The SLP’s discharge summary recommended continuing IDDSI 5 minced and moist and honey-thick liquids and did not document that the resident was safe to consume peanut butter and jelly sandwiches or that any exception was approved. Nonetheless, nursing entered physician orders on two later dates allowing crustless peanut butter and jelly sandwiches with every meal, and these orders remained in effect. The clinical record from the SLP discharge forward did not show any SLP evaluation approving peanut butter and jelly sandwiches for this resident. Observations in the dining room showed Resident #2 being served crustless peanut butter and jelly sandwiches with meals, first halved and later quartered, while on an IDDSI 5 minced and moist diet, despite IDDSI guidance that this level excludes regular dry bread and sticky foods such as nut butters and requires food to be soft, moist, and minced into 4 mm pieces. NAs confirmed that the resident always received a crustless peanut butter and jelly sandwich with meals. The SLP later clarified that although she had trialed crustless peanut butter and jelly sandwiches during therapy, the resident was not safe to consume them without one-to-one SLP observation and that her written diet slip at discharge did not authorize peanut butter and jelly sandwiches. The APRN acknowledged signing the peanut butter and jelly sandwich orders in bulk, assuming SLP approval, and the DON stated she did not know why nursing entered those orders when they were not recommended by the SLP. Facility policies required that residents receive foods in the consistency ordered by the physician and/or speech therapy, that diet textures follow the diet manual and be transcribed correctly to diet cards, that texture needs be guided by the speech therapist or dietician, and that food on the tray match the dietary card, but these requirements were not followed for the two residents. Overall, the deficiency centers on the facility’s failure to follow physician and SLP diet orders and IDDSI standards for modified textures, specifically by providing peanut butter and jelly sandwiches that were not permitted or properly prepared for residents on IDDSI 5 and 6 diets, and on staff’s lack of knowledge and competency regarding IDDSI diet restrictions and preparation. This resulted in residents with dysphagia receiving food items and textures inconsistent with their ordered diets and the facility’s own policies.
Untimely Completion of Required MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive MDS assessments within 14 days of the Assessment Reference Date (ARD) for six sampled residents. For one resident, the admission MDS had an ARD of 3/18/26 and was required to be completed by 4/1/26, but was not completed until 4/6/26, making it five days late. For another resident, a quarterly MDS with an ARD of 4/1/26 and a due date of 4/15/26 had still not been completed as of 4/20/26, making it five days late. A third resident’s quarterly MDS, with an ARD of 4/2/26 and a due date of 4/16/26, also remained incomplete as of 4/20/26, four days past the required completion date. Additionally, three other residents had overdue assessments: one resident’s annual MDS with an ARD of 4/4/26 and due date of 4/18/26 was still incomplete on 4/20/26, two days late, and two residents’ quarterly MDS assessments with the same ARD and due date were also not completed by 4/20/26, each two days late. The MDS nurse (LPN) acknowledged that admission, quarterly, and annual MDS assessments are due within 14 days of the ARD and stated she did not complete these assessments before going on vacation and did not delegate them to the MDS Coordinator. The DON confirmed that each MDS should be completed within 14 days of the ARD, reported being unaware that MDSs were not being completed on time, and stated that the LPN should have delegated the assessments. Facility policy dated 7/2023 specifies that MDS assessments must be completed within 14 days for new admissions and reviewed quarterly and annually, with the MDS Coordinator responsible for timely completion.
Grab Bar Detachment Leads to Resident Fall and Rib Fractures
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards when a bathroom grab bar used for transfers dislodged from the wall while being used by a resident, resulting in a fall and subsequent rib fractures. The resident had diagnoses including a history of falls, heart failure, and anxiety, and a quarterly MDS showed moderately impaired cognition (BIMS score of 12) but independence with care, transfers, and wheelchair use. The resident’s care plan identified limited physical mobility and risk for falls, with interventions such as staff assistance with daily care as needed, provision of a urinal at night, call bell within reach, and use of non-skid socks. On the evening of the incident, the resident attempted to transfer from a wheelchair to the toilet using the bathroom grab bar, which dislodged from the wall, causing the resident to come down with knees on the floor between the wheelchair and toilet. Initial nursing documentation indicated no immediate injuries, marks, or bruises, and the resident reported no significant pain until several days later, when chest pain developed. A chest x-ray ordered by the APRN identified fractures of the left 5th to 7th ribs, and subsequent nursing notes documented pain management and use of an incentive spirometer. In interviews, the resident reported being permitted to use the bathroom and self-transfer independently, and described grasping the grab bar, its detachment from the wall, and falling with the head against the door before using the call bell for assistance. A nurse aide corroborated finding the resident on the knees on the floor with the grab bar on the floor. The Administrator reported that maintenance conducted monthly environmental rounds and assessed assigned resident rooms, but checking the stability of grab bars had not been part of those rounds prior to this incident.
Failure to Maintain Safe Grab Bars and Sanitary Mattress Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment for one resident and a sanitary sleeping environment for another. One resident with a history of falls, heart failure, anxiety, limited physical mobility, and moderately impaired cognition was care planned as being at risk for falls and was allowed to use the bathroom and self-transfer independently. While attempting to transfer from a wheelchair to the toilet using a bathroom grab bar, the grab bar detached from the wall, causing the resident to come down with knees on the floor and head against the door. The resident later reported chest pain, and a chest x-ray identified fractures of the left 5th to 7th ribs. Staff documentation and interviews confirmed that the grab bar was found dislodged on the floor and that prior to this incident, the facility’s monthly environmental rounds did not include checking grab bars for stability. The deficiency also includes the facility’s failure to ensure a sanitary sleeping environment for another resident with diagnoses including congestive heart failure, history of UTIs, and history of pressure ulcers, who was severely cognitively impaired, dependent for all care, and required a mechanical lift with two-person assistance. The resident’s care plan identified a self-care deficit and risk for skin breakdown, with interventions including regular repositioning, incontinence care, and use of barrier cream. A visitor reported that the resident’s mattress sometimes smelled of urine. During an observation with nursing staff, the resident was found incontinent of urine; while the brief did not have an odor, lifting the mattress sheet revealed a strong urine odor from the mattress. Interviews showed confusion among staff about responsibility for mattress cleaning, and facility documentation, including the Cleaning Checklist and Monthly Environmental Round Logs, did not identify a mattress cleaning schedule or checks of grab bar stability.
Failure to Log, Investigate, and Provide Written Resolution of Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to honor a resident representative’s right to voice grievances and receive a response. A resident representative (Person #1) reported multiple care complaints and concerns about Resident #2 over a prolonged period to Social Workers (SWs), the Director of Social Services (DSS), and the Administrator. Person #1 was not initially aware of the facility’s grievance process and, once informed that such a process existed, sent multiple emails regarding complaints and concerns because he/she did not know how to use the grievance form. Person #1 reported not receiving any written resolutions or being made aware of how the complaints and concerns were resolved and expressed dissatisfaction with the lack of follow-through. The Administrator acknowledged that Person #1 had reported care complaints and concerns and stated she addressed them immediately but did not treat them as grievances, did not ensure they were entered into the grievance log, and did not investigate them as required by the facility’s grievance policy. She also did not provide written follow-up to Person #1 regarding findings or resolutions. The SW similarly reported that although she addressed the complaints and concerns identified in email correspondence, she did not log them as grievances, did not document the outcomes, and did not follow the grievance policy. The DSS reported that Person #1 had sent multiple emails with complaints and concerns, which she either addressed or forwarded to the former Administrator, but she also did not log them as grievances, document outcomes, or follow the grievance policy. This was inconsistent with the facility’s Resident Rights Policy, which states residents have the right to have the facility respond to their grievances, and the Grievance Policy, which requires the SW to document the complaint, actions taken, and resolution in the grievance log.
Failure to Ensure Ordered Oxygen Therapy Was Provided
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with physician-ordered oxygen therapy actually received oxygen as ordered. The resident had COPD, CHF, a history of pressure ulcers, severely impaired cognition, was oxygen dependent, and dependent for all care. A physician’s order directed oxygen at 0–4 liters to maintain oxygen saturation above 92% and required oxygen saturation checks every shift. The resident’s care plan included interventions to administer medications as ordered, change oxygen and nebulizer tubing as ordered, monitor oxygen saturation as ordered, and check portable oxygen tank levels every three hours when in use. The MAR for January and February documented continuous oxygen administration and shift oxygen saturation readings. Despite these orders and documentation, interviews and observations showed that oxygen was not consistently provided as ordered. A visitor reported seeing the resident on multiple occasions using a portable oxygen tank that contained no oxygen and noted that unused portable tanks were often empty. During an observation, the resident was found in bed with the nasal cannula not in place, the oxygen concentrator powered off, and the oxygen tubing placed on top of a dresser out of the resident’s reach. Staff interviews revealed that a NA had fed the resident earlier and stated the oxygen was on at that time, and an LPN reported administering a nebulizer treatment earlier with oxygen in use and documented saturations of 95% and 98%. Both the NA and LPN stated they did not know why the oxygen was off and confirmed the oxygen should have been on, and the DON reported seeing the resident earlier with oxygen on and stated no one should have turned it off. When the LPN checked the resident’s oxygen saturation before reapplying oxygen, it was 90%, below the ordered threshold of above 92%. The facility’s policy stated oxygen is to be administered per physician’s orders.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Communication
Penalty
Summary
The facility failed to ensure timely follow-up with pharmacy services to fill new medication orders and refill standing orders before the supply was exhausted for a resident with multiple complex diagnoses, including ovarian cancer, schizoaffective disorder, and severe cognitive impairment. The resident, who was receiving hospice care, had physician orders for morphine sulfate ER and morphine sulfate oral solution for pain management. However, the morphine sulfate ER was not administered for several days after being ordered due to lack of availability, and the as-needed morphine solution was not given in its place. Documentation showed that the pharmacy had requested clarification on the order, but the facility did not respond promptly, resulting in missed doses. Additionally, the facility did not communicate with the pharmacy in a timely manner to ensure medication delivery before the supply was depleted. The resident also had a physician order for lorazepam intensol for agitation and pain, but missed multiple doses over several days due to the facility not requesting a refill in time and not requesting a STAT delivery when the supply ran out. Nurse documentation did not reflect that missed doses were reported to nursing supervisors or the provider as required by facility policy. Interviews with pharmacy representatives and the DON confirmed that the facility's lack of timely communication and follow-up led to the resident missing scheduled doses of both morphine and lorazepam.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes the failure to provide prompt notification to all required parties when significant events impacting the resident occurred.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two of five nurse aides reviewed. One nurse aide, hired in July 2023, was due for annual performance reviews in 2024 and 2025, but no documentation of these evaluations was available or could be located. Another nurse aide, hired in April 2024, had a probationary evaluation completed in June 2024, but the required annual performance review for 2025 was not found in the personnel file and had not been completed. Interviews with the Administrator and Human Resources confirmed that annual evaluations are required on the month of hire for each nurse aide, but these evaluations were either overlooked, not completed, or incorrectly scheduled due to errors in recordkeeping and staff transitions. Review of facility policy confirmed the requirement for annual evaluations to assess performance, skills, and adherence to standards.
Failure to Ensure Timely Medication Administration and Provider Notification
Penalty
Summary
The facility failed to maintain compliance with previously cited deficiencies related to significant medication errors and failures in provider notification. During a complaint survey, it was found that three residents were not administered scheduled medications, and the provider was not notified of these missed administrations. Additionally, three residents received scheduled medications late, and again, the provider was not notified. Despite ongoing audits and QAPI meetings that reviewed survey results and claimed compliance improvement, documentation revealed continued late and omitted medication administrations during and after the Plan of Correction period. The Director of Nursing was unaware that late medication administrations were still occurring, as this information was not captured in the audits being conducted. The audits performed were random and did not identify ongoing issues with late and omitted medication administrations. The Administrator was unable to explain why the previous Plan of Correction was ineffective and acknowledged that the audits did not detect the continued deficiencies. The facility's QAPI policy assigned responsibility for monitoring the program to the Administrator and Director of Nursing, but the ongoing issues were not identified or addressed through their processes.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records, which did not contain comprehensive or measurable interventions to address the resident's assessed needs.
Failure to Ensure Timely Medication Administration and Administrative Oversight
Penalty
Summary
The facility failed to administer its resources effectively and did not provide adequate administrative oversight to ensure staff compliance with medication administration and resident care. Specifically, the facility did not maintain compliance with a previously established plan of correction related to medication administration errors. There were repeated failures to ensure that scheduled anxiety and narcotic pain medications were administered as ordered, that medications were refilled before supplies were exhausted, and that medications were delivered to the facility in a timely manner. Additionally, the facility did not ensure that the Advanced Practice Registered Nurse (APRN) was notified of medication omissions, annual performance evaluations were completed as required, or that clinical records were complete and accurate. Survey findings revealed that significant medication errors persisted, including late administration of medications and lack of notification to nursing supervisors or providers when medications were missed or delayed. Interviews with facility leadership confirmed that, despite previous citations and corrective plans, the facility had not returned to compliance and lacked a process for effective administrative oversight to address these ongoing issues. The deficiencies were identified as immediate jeopardy and substandard care in the area of pharmacy services, specifically regarding residents being free of significant medication errors.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Physician Review and Signature of Orders
Penalty
Summary
The facility failed to ensure that physician orders for all eleven residents reviewed were signed and reviewed monthly in accordance with facility practices. Clinical record reviews showed that for each resident, medical orders were not reviewed or signed for at least one or more months, specifically in May and June. Interviews with the Administrator and a regional RN confirmed that the medical director was responsible for this task, but they were unaware that the orders had not been signed for the specified months. The facility was also unable to provide a policy detailing the required frequency for physician order reviews. Further investigation revealed that the medical director was new to the facility and to long-term care, and had not been informed of the regulatory requirements for signing physician orders. The medical director reported being unable to sign orders electronically due to lack of access in the electronic medical record system, and as of the date of the interview, the issue had not been resolved and the orders remained unsigned. No alternative method for signing the orders had been implemented.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Secure Front Entrance Resulting in Unsupervised Resident Exit
Penalty
Summary
A deficiency occurred when a resident with diagnoses of dementia, depression, and convulsions, who had a physician's order to leave the facility only with a responsible party and required supervision for transfers and ambulation, was able to exit the facility unattended. The resident was last seen in the dining room and was later found off facility grounds in a nearby parking lot. The resident was able to ambulate independently but required assistance due to fall risk and impaired cognition, as documented in the care plan and confirmed by therapy staff. The investigation revealed that the front entrance door, which was supposed to be locked when the receptionist was not present, was found unlocked on the morning of the incident. Staff interviews indicated that the door was sometimes left unlocked for convenience, allowing staff and housekeepers to enter, and that there was not always someone monitoring the front desk. The receptionist, who arrived after the resident had already left, confirmed the door was unlocked upon arrival and had seen someone matching the resident's description walking outside. Facility policy required that residents not be unsupervised outside the facility, and staff were expected to monitor the front entrance. However, inconsistent practices regarding the locking and monitoring of the front door allowed the resident to leave the building without staff knowledge or supervision, contrary to the resident's care plan and physician's orders.
Medications Administered by Memory Without MAR Access
Penalty
Summary
A Licensed Practical Nurse (LPN) administered medications to 22 residents on a secured memory unit without access to the electronic Medication Administration Record (MAR) due to technical difficulties with the Point Click Care (PCC) system. The LPN was unable to log into the system from the start of her shift and attempted to use multiple computers without success. Despite being unable to access the MAR, the LPN proceeded to administer all scheduled medications by memory, without any written or electronic reference to the current medication orders, dosages, or administration times for each resident. The LPN did not notify a supervisor or the Assistant Director of Nursing (ADNS) about her inability to access the system, nor did she use any alternative documentation methods for non-narcotic medications during the medication pass. The residents affected had complex medical histories, including diagnoses such as dementia, diabetes, heart failure, Parkinson's disease, and other chronic conditions requiring multiple medications with specific administration instructions. The LPN relied solely on memory for medication administration, which did not ensure adherence to the 5 Rights of medication administration: right patient, right drug, right dose, right route, and right time. The only documentation maintained was for narcotic medications, as required by the facility's narcotic book, but all other medications were not documented at the time of administration. The LPN acknowledged that this practice was not appropriate and was against facility policy, which requires the use of the MAR and immediate notification of a supervisor if access issues occur. Facility leadership, including the ADNS and corporate regional nurse, confirmed that the LPN did not follow established protocols for medication administration and failed to communicate the access issue in a timely manner. The ADNS stated that the LPN should have contacted a supervisor or herself to resolve the access issue before proceeding with medication administration. The facility's policies and job descriptions require that all medication administration be documented and that the 5 Rights be followed to ensure resident safety. The failure to use the MAR and to document medication administration as required resulted in a deficiency that was identified as Immediate Jeopardy.
Immediate Jeopardy: Medications Administered Without MAR and Failure to Reweigh After Significant Weight Changes
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered morning medications to 22 residents in a secured memory unit without access to the electronic Medication Administration Record (EMAR) system. The LPN was unable to log into the EMAR system from the start of her shift and attempted to use multiple computers without success. Despite this, she proceeded to administer medications to all assigned residents by memory, without referencing the MAR or any alternative documentation to ensure the correct medications, dosages, times, or routes were followed. The LPN did not notify a supervisor or the Assistant Director of Nursing (ADNS) about her inability to access the EMAR, as required by facility policy, and failed to document the administration of non-narcotic medications by any means. Only narcotic medications were recorded, as they required a signature in a separate narcotic log. The LPN acknowledged that this practice was inappropriate and not in accordance with facility policy, which mandates the use of the MAR to ensure the five rights of medication administration. The deficiency was further compounded by the lack of communication and oversight. The ADNS and other supervisory staff were not informed of the EMAR access issue until after the medication pass was completed. Interviews with facility leadership confirmed that the LPN should have contacted a supervisor for assistance with EMAR access and that administering medications without the MAR was against policy. The facility's EMAR policy requires nurses to read physician orders, complete the five checks, administer medications as ordered, and document administration in the EMAR. However, the facility was unable to provide a policy specifically for MAR utilization when requested. Additionally, a separate deficiency was identified regarding the monitoring of resident weights for a resident with diagnoses including dementia, anxiety, heart failure, and chronic atrial fibrillation. The resident was to be weighed weekly, with significant weight changes requiring reweighs according to facility policy. However, there were multiple instances of significant weight fluctuations without evidence of reweighs or documentation of refusals. Nursing staff confirmed that reweighs should have occurred on several occasions when the resident experienced notable weight changes, but there was no documentation to support that these actions were taken.
Failure to Investigate and Remove Staff After Substantiated Abuse Allegation
Penalty
Summary
A resident with diagnoses including dementia, personality disorder, and hypertensive heart disease with heart failure, who was assessed as having no cognitive impairment, made an allegation of abuse against an LPN. The resident reported being pushed onto the bed by the LPN while alone in the room, having their phone taken away, and experiencing humiliation and fear as a result. The resident also stated that the LPN continued to provide care after the alleged incident, despite the resident's distress and ongoing fear. The facility failed to conduct a thorough investigation into the abuse allegation. The Director of Nursing (DNS) did not provide documentation of a comprehensive investigation, such as staff or resident interviews, staff statements, or a detailed timeline. The only documentation available was an undated, unsigned summary created after the fact, which lacked essential details and was based on the DNS's memory rather than contemporaneous records. The DNS relied on the resident's history of making accusations to dismiss the allegation and allowed the LPN to resume providing care to the resident. Additionally, the DNS did not report the incident to the State Agency as required by facility policy and state regulations. Despite being informed by surveyors that the abuse allegation had been substantiated, the facility allowed the LPN to continue working on the resident's unit and to have access to the resident. The LPN was not removed from the schedule until after further surveyor inquiry. The facility's own policies required immediate reporting and investigation of abuse allegations, as well as removal of implicated staff from resident care, but these procedures were not followed. The failures in investigation, reporting, and staff removal resulted in a finding of Immediate Jeopardy.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from abuse by both staff and other residents, as evidenced by multiple incidents involving three residents. One resident with dementia and a personality disorder, but no cognitive impairment, alleged that an LPN physically pushed them onto a bed and removed their phone when they called for help. The resident reported feeling humiliated and afraid, and the LPN continued to provide care to the resident after the incident. The facility's investigation into the allegation was inadequate, lacking documentation, staff and resident interviews, and failed to substantiate the claim despite the resident's consistent statements and the LPN's admission of providing care against the resident's will. In another incident, a resident with severe cognitive impairment was struck in the face by another resident with a history of unprovoked aggression. The altercation occurred in the hallway when the first resident attempted to prevent the second from pushing an item. The aggressive resident was immediately placed on 1:1 monitoring, and both residents were assessed for injuries. The care plans for both residents were updated to address the behaviors, but the incident documentation was incomplete, as it did not initially include that the first resident also pushed the second resident into a wall in response. The facility's abuse policy defines abuse as the willful infliction of injury or intimidation, and requires thorough investigation and documentation of all allegations. However, in both cases, the facility failed to conduct comprehensive investigations, did not collect or maintain necessary documentation, and did not ensure that staff or residents were protected from further abuse. The lack of timely and thorough investigation, as well as the failure to remove implicated staff from resident care, contributed to the deficiency.
Failure to Involve Resident in Care Planning Meetings
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, hypertensive heart disease with heart failure, and osteoarthritis was not allowed to participate in the development and implementation of their person-centered plan of care. The resident was assessed as having no cognitive impairment and expressed a desire to attend Resident Care Conferences (RCCs), but was not invited to these meetings. Review of care plan documentation and RCC sign-in sheets over several months showed no evidence that the resident was invited, attended, or declined to attend the meetings. Interviews revealed that the social worker did not invite the resident to RCCs, citing a request from the resident's conservator, who allegedly did not want the resident to attend due to the resident's tendency to voice concerns during meetings. However, the social worker was unable to provide any documentation of this request from the conservator. Attempts to contact the conservator were unsuccessful, and facility policy required individualized care planning with resident participation.
Failure to Provide Adequate Linens and Maintain Secure Environment
Penalty
Summary
The facility failed to provide clean bed and bath linens in good condition and in sufficient quantity for resident care, as well as to ensure a safe and secure environment on a locked memory care unit. Multiple residents with significant medical conditions, including chronic obstructive pulmonary disease, heart failure, diabetes, dementia, and mobility impairments, reported frequent shortages of towels and washcloths. These shortages led to delays or missed showers, use of baby wipes purchased by residents, and staff resorting to cutting up blankets or using bed sheets and Chux pads for bathing and drying. Residents expressed feelings of indignity and dissatisfaction, with some too intimidated to complain to management. Staff interviews confirmed the recurring lack of linens, and the Director of Environmental Services and Administrator were aware of the issue but did not take timely action to resolve it, relying on scheduled laundry deliveries from a sister facility and lacking a contingency plan for shortages. Observations and interviews revealed that the facility's linen supply was insufficient for the census of 104 residents, with only 14 washcloths and 17 hand towels available for use across two shifts. The facility's linen stocking policy did not address procedures for handling shortages, and staff reported having to improvise with available materials. The Assistant Director of Nursing was also aware of the complaints and the use of makeshift washcloths, having notified the Administrator and Director of Environmental Services previously. Despite daily or near-daily laundry counts, the facility did not maintain an adequate supply to meet residents' needs. Additionally, on the secured memory care unit, the locking mechanism on the shower room door was found to be broken, allowing residents unsupervised access to the room. The Director of Maintenance and Administrator were unaware of the malfunction until it was brought to their attention during the survey. Although the Administrator initially assigned staff to monitor the area, there was a lapse in supervision, leaving the area unmonitored while the door remained unsecured. The facility was unable to provide a policy for ensuring a safe and secure environment on the memory care unit.
Failure to Document Criteria and Consent for Secured Memory Care Unit Placement
Penalty
Summary
Surveyors identified that for 11 residents placed on a secured memory care unit, the facility failed to establish and document clinical criteria for placement, did not perform or record initial assessments or periodic reassessments for continued placement, and did not obtain or document physician orders for such placement. The residents involved had diagnoses including dementia, Parkinson's disease, diabetes, congestive heart failure, schizophrenia, and other chronic conditions, with varying levels of cognitive impairment and functional dependence. Despite these complex needs, there was no evidence in the clinical records that justified their placement on the secured unit based on individualized assessments. Additionally, the facility did not document that residents or their representatives were involved in the decision-making process regarding placement on the secured memory care unit. There was no record of consent or notification provided to residents or their representatives about the placement or about their rights to independent egress. Observations during the survey confirmed that residents could not independently exit the secured unit, as the doors required a staff-entered code for entry and exit, and only staff were observed operating the keypad. Interviews with the Director of Nursing and a registered nurse revealed that there was no written policy or established criteria for admission to the secured memory care unit. The staff acknowledged the absence of initial or ongoing assessments for placement, lack of physician orders, and lack of documentation regarding resident or representative consent. The facility was unable to provide a policy for the secured memory care unit when requested by surveyors.
Failure to Timely Report Suspected Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure timely and appropriate reporting of suspected abuse, neglect, or theft, specifically regarding resident-to-resident and staff-to-resident physical mistreatment. Multiple incidents involving residents with cognitive impairments and behavioral issues were not reported to state protective services as required. In several cases, altercations between residents, including physical strikes, were documented in facility records, but there was no evidence that these incidents were reported to the appropriate state authorities. For example, one resident with dementia and a history of aggression struck other residents, and although the police and responsible parties were notified, protective services were not informed as mandated. Additionally, the facility did not report certain allegations of abuse to the state agency within the required timeframe. In one instance, a cognitively intact resident alleged that a staff member physically mistreated them during a transfer, and the incident was not reported to the state agency or protective services in a timely manner. Interviews with facility staff, including the social worker and the Director of Nursing Services (DNS), revealed a lack of understanding and compliance with mandatory reporting requirements. The DNS admitted to not submitting required reports due to oversight and misunderstanding of the reporting obligations. Facility policy required immediate reporting of suspected mistreatment, neglect, or abuse to the administrator or designee and notification of the state licensing and certification agency within two hours. However, the facility did not provide a policy for reporting to state protective services when requested. Connecticut state law mandates reporting suspected elder abuse to the Department of Social Services within 72 hours, but the facility failed to meet this requirement in multiple documented cases.
Medication Error Rate Exceeds Allowable Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, as required, with an observed error rate of 15.6%. Surveyors found that multiple residents did not receive their medications within the prescribed timeframe, with morning medications scheduled for 8:00 AM and 9:00 AM being administered significantly late, in some cases after 11:00 AM. These late administrations were directly observed by surveyors and confirmed through interviews with nursing staff, who reported ongoing difficulties in completing timely medication passes and had previously notified nursing administration of these issues. Specific residents affected included individuals with diagnoses such as paranoid schizophrenia, anxiety, glaucoma, hypertension, atrial fibrillation, heart failure, COPD, chronic kidney disease, and dementia. Many of these residents were cognitively intact, while others had varying degrees of cognitive impairment. Medications delayed included critical treatments such as antihypertensives, anticoagulants, antipsychotics, and insulin, with some doses being administered up to several hours past the allowed window. Facility documentation and direct observation confirmed the late administration of these medications across multiple units. Interviews with staff, including LPNs and advanced practice registered nurses, acknowledged the late medication passes and the challenges faced in adhering to scheduled administration times. The facility's own policy required medications to be given at the time ordered or within 60 minutes before or after the designated time, and to report medication errors immediately. Despite this, the survey identified a pattern of late medication administration affecting numerous residents, with staff indicating that administration delays were a known and ongoing issue.
Deficiencies in Kitchen Sanitation, Food Labeling, and Food Reheating Procedures
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's dietary department related to food safety and sanitation. During a tour of the kitchen, there was a heavy accumulation of debris and residue on the juice machine vent, stove, and oven doors. The Food Service Director (FSD) acknowledged that comprehensive cleaning of the juice machine was overdue and that documentation of the last cleaning could not be provided. The FSD also noted that the stove had not been cleaned after a spill over the weekend and that residue inside the oven doors could not be accessed by staff for cleaning. Facility policy required daily and monthly cleaning of kitchen equipment, but these procedures were not consistently followed. In the dry storage area, opened food items such as cake mix and pasta were found without required labeling or dating, and several unopened bags were removed from their original packaging without expiration dates. The FSD confirmed that all food items should be labeled with open and expiration dates per facility policy. Additionally, a nursing assistant reheated a resident's food in the nourishment room using a microwave but did not use a thermometer to verify the food reached the required temperature of 165°F, as no thermometer was present. The FSD confirmed that nursing staff were expected to use a thermometer to check food temperatures, in accordance with the facility's reheating policy.
Failure to Provide Comprehensive Abuse and Neglect Training to All Staff
Penalty
Summary
The facility failed to provide all staff with required abuse and neglect training, as evidenced by documentation showing that 31 employees, representing 19% of the workforce, had not received any abuse and neglect training since prior to 2024. Despite facility policy mandating annual in-service training for all staff, interviews with the Administrator, Staff Development nurse, and HR Director confirmed that these employees were still actively employed and had not been included in the mandatory training sessions. The Staff Development nurse, responsible for ensuring compliance with training requirements, was unable to explain the lapse and acknowledged the failure to implement the policy as directed. Additionally, the content of the abuse and neglect training provided to staff was found to be insufficient and not aligned with federal requirements or the facility's own policy. The training omitted key components such as screening for abuse, identification of abuse indicators, mandated reporting, misappropriation of resident property, exploitation, use of restraints, and recognition of staff burnout or stress. The Staff Development nurse admitted to not reviewing or updating the training materials and had only recently begun distributing the facility's abuse policy to staff, several months after being directed to do so. The DON confirmed that the training should be based on facility policy, which was not the case.
Failure to Develop and Implement Compliance and Ethics Program
Penalty
Summary
The facility failed to develop and implement a compliance and ethics program, as well as to provide staff with compliance and ethics training. Interviews with the Administrator and two Regional RNs revealed that there was no compliance and ethics program or policy in place, and that such training was not included in new hire orientation or annual training. Although a Code of Conduct policy existed, it was not communicated to all facility staff and did not include essential components such as identification of a compliance officer or committee, procedures for reporting ethical concerns, secure and confidential reporting mechanisms, internal monitoring and auditing, or processes for response and corrective action. The Director of Nursing Services was unavailable for interview, and the requested compliance and ethics policy was not provided.
Failure to Report, Investigate, and Prevent Abuse and Neglect
Penalty
Summary
The facility failed to properly implement and follow its abuse prevention, reporting, and investigation policies for multiple residents. In one incident, a resident with severe cognitive impairment and dementia was slapped by another resident with a history of unprovoked aggression. The altercation was observed by an LPN, but the written statement omitted key details, such as the retaliatory action by the first resident. The Director of Nursing Services (DNS) was unaware of the full extent of the incident due to incomplete reporting, and the required documentation and reporting procedures were not followed as outlined in facility policy. In another case, a cognitively intact resident with a history of making accusatory statements alleged that an LPN physically mistreated them during a transfer and removed their phone when they called for help. The DNS was aware of the allegation but failed to conduct or document a thorough investigation, as required by policy. The investigation lacked staff and resident interviews, written statements, and did not include an interview with the accused LPN. Despite the policy requiring removal of staff accused of abuse from resident care pending investigation, the LPN continued to have access to the resident for numerous shifts after the allegation, and the incident was not properly reported to the State Agency. Additionally, the facility did not integrate abuse prevention and response into its Quality Assurance and Performance Improvement (QAPI) program. The administrator and DNS confirmed that abuse was not included in QAPI meetings or staff training, and the QAPI plan did not address communication or coordination regarding abuse, neglect, or exploitation. This lack of integration further contributed to the facility's failure to ensure resident protection and compliance with regulatory requirements.
Failure to Review and Revise Resident Care Plan Quarterly
Penalty
Summary
A deficiency occurred when the facility failed to review and revise the Resident Care Plan (RCP) for a resident with diagnoses including dementia, congestive heart failure, and bilateral sensorineural hearing loss. The resident was identified as having severe cognitive impairment and required varying levels of assistance with daily activities. The RCP in effect addressed the resident's communication difficulties due to hearing loss, with interventions focused on discussing concerns with the resident and family and encouraging the resident to express thoughts. However, documentation showed that after a care conference was held, no subsequent resident care conferences were conducted as required. Interviews with facility staff revealed that quarterly resident care conferences are used to update care plans, but the resident in question was not scheduled for a conference in the required quarter due to an oversight. The MDS Coordinator, responsible for generating the list of residents needing care conferences, failed to include the resident on the list for the relevant period, and could not locate the list provided for scheduling. Facility policy requires quarterly care plan reviews and updates within seven days of the comprehensive MDS assessment, which was not met in this case.
Failure to Reposition Resident as Ordered, Leading to Pressure Ulcer Deficiency
Penalty
Summary
A deficiency occurred when staff failed to turn and reposition a resident with a physician's order for repositioning every two hours. The resident, who had diagnoses including dementia, generalized muscle weakness, and incontinence, was identified as being at risk for pressure ulcers and required maximum assistance for bed mobility. Despite a care plan and physician's order specifying the need for turning and repositioning every two hours, observations showed that the resident remained on their back for an extended period from 9:00 AM to 11:50 AM without being repositioned. Multiple staff members, including a registered nurse, social worker, and nurse aides, entered the room but did not reposition the resident during this time. Interviews revealed that the nurse aide responsible for the resident was unaware of the repositioning requirement, as the electronic charting system did not trigger a directive for this task. The nurse aide confirmed that the resident had not been turned or repositioned since the start of her shift at 7:00 AM. Additionally, the LPN on duty acknowledged the physician's order but had not attempted to reposition the resident and could not provide documentation of any refusal by the resident. The facility's policy required position changes every 2 to 3 hours for dependent residents, but this was not followed, resulting in a failure to provide appropriate pressure ulcer care.
Failure to Apply Pelvic Positioning Belt as Ordered
Penalty
Summary
A deficiency occurred when staff failed to consistently apply a pelvic positioning belt for a resident with Parkinson's disease, vascular dementia, and muscle weakness, as ordered by the physician. The resident was identified as severely cognitively impaired, non-ambulatory, and at high risk for falls, requiring assistance with transfers and proper positioning in a wheelchair. The care plan and therapy notes specified the need for a pelvic positioning belt to maintain body alignment, promote safety, and decrease the risk of skin breakdown. Despite clear orders and documented staff education on the use of the pelvic positioning belt, multiple observations revealed the resident seated in a wheelchair without the belt applied on several occasions. Nursing assistants and LPNs acknowledged responsibility for applying the belt but admitted to forgetting to do so after transferring the resident. Therapy staff and the Director of Nursing confirmed the necessity of the belt for the resident's safety and positioning, and that nursing staff were responsible for its application. Facility policies required adherence to physician orders and the provision of physical therapy services as prescribed. However, the pelvic positioning belt was not consistently applied as ordered, and a specific policy on wheelchair equipment or pelvic positioning belts was not provided upon request. This failure to follow physician orders and ensure proper use of assistive devices led to the identified deficiency.
Failure to Provide Required Supervision and Assistive Devices for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at high risk for falls and with specific supervision and assistive device requirements received care in accordance with physician orders and care plans. One resident with dementia, muscle weakness, unsteadiness, and a history of falls was identified as a high fall risk and had orders for ambulation with supervision and a 2-wheeled walker. Despite these orders, the resident was repeatedly observed ambulating without staff supervision or the required assistive device. Nursing assistants and licensed staff were unaware of the resident's need for a walker and supervision, and the walker was found unused and stored in the resident's room. The facility's policy required staff to assist residents with walkers as indicated by physician orders, but this was not followed. Another resident with dementia, dysphagia, and muscle weakness, also identified as a fall risk, had orders for hand-held assistance with ambulation and 1:1 supervision during meals. This resident was observed ambulating independently in the hallway without staff assistance, and staff acknowledged being too busy to provide the required supervision. The care plan and physician orders specified the need for assistance, but staff failed to adhere to these requirements, resulting in the resident being left unsupervised. Additionally, the same resident with dysphagia was left alone in their room with a meal tray, despite orders and care plan interventions requiring 1:1 supervision during meals due to swallowing difficulties and risk of aspiration. The resident experienced an unwitnessed fall while unsupervised during breakfast. Staff involved were unaware of the resident's supervision needs and were unable to access care-specific information at the time. The facility's policies and updated mealtime guidelines were not followed, and staff failed to ensure the resident received the required supervision and assistance.
Failure to Ensure Adequate Hydration for Resident at Risk of Fluid Deficit
Penalty
Summary
The facility failed to provide adequate hydration to a resident with a history of pressure ulcer, neuromuscular bladder dysfunction, and congestive heart failure, who was also on diuretic therapy. The resident's fluid intake goal was established at 1400-1700 ml per 24 hours, as documented in both the dietary assessment and a physician's order. Despite this, a review of intake records over a 19-day period showed that the resident did not meet the fluid goal on any day, with daily intake ranging from 240cc to 1200cc. The care plan included interventions such as education on fluid intake, monitoring and documenting intake and output, and reporting signs of dehydration, but these interventions were not effectively implemented. Nursing documentation and interviews revealed that intake and output were recorded by nursing assistants and entered into the electronic health record by nurses, with the 3:00 PM to 11:00 PM nurse responsible for totaling the 24-hour intake and output. However, there was no evidence that a dehydration assessment was completed during the period of low intake, despite facility policy requiring evaluation for dehydration if fluid goals were not met for three consecutive days. Laboratory results during this period indicated elevated BUN/Creatinine levels, suggestive of potential dehydration, and the resident experienced increased confusion, urinary retention, and required a urinary catheter and antibiotics for a urinary tract infection. Interviews with clinical staff, including the APRN and dietician, confirmed that the resident's fluid needs were not met and that assessments for dehydration were not performed as required. The APRN relied on verbal reports rather than reviewing intake and output records, and the dietician stated that she would expect dehydration assessment and lab work if fluid goals were not consistently met. The facility's dehydration policy outlined the need for monitoring and assessment, but these steps were not followed, resulting in a failure to ensure the resident's hydration needs were addressed.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that a physician's order was in place for the administration of continuous oxygen to a resident with multiple respiratory and cardiac diagnoses, including pneumonitis, CHF, pleural effusion, and hypoxia. The resident, who was severely cognitively impaired and dependent for mobility and care, had a previous physician's order for oxygen therapy that expired on 3/10/25. Despite this, clinical documentation and direct observations confirmed that the resident continued to receive continuous oxygen from 3/11/25 to 3/18/25 without a valid physician's order. Multiple nursing notes and staff interviews acknowledged the ongoing administration of oxygen during this period, and staff were unable to provide a current order when asked. Facility policy required a physician's order for continuous oxygen administration, and both nursing staff and the DNS confirmed that such an order was necessary and should have been obtained. The lack of follow-through after the expiration of the previous order resulted in the resident receiving oxygen therapy without proper authorization. This deficiency was identified through review of the clinical record, staff interviews, and direct observation of the resident receiving oxygen without a current order.
Failure to Ensure Communication and Monitoring for Dialysis and Fluid Restriction
Penalty
Summary
The facility failed to ensure appropriate communication and documentation between the dialysis treatment center and the facility for a resident with end stage renal disease who was dependent on dialysis. Physician orders required the resident to attend dialysis three times per week, with staff responsible for recording post-treatment weights from the dialysis center's communication book. However, documentation from the dialysis center was missing for several treatment dates, and there was no evidence that staff contacted the center to obtain the required information. Interviews revealed that the communication book was not always sent or returned with the resident, and staff could not explain the missing documentation or why follow-up was not conducted as per facility practice and agreements. Additionally, the facility failed to comply with physician orders regarding fluid restriction and intake monitoring for the same resident. Orders specified a daily fluid restriction and required nursing staff to document intake and output every shift, with the 3:00 PM to 11:00 PM shift responsible for totaling the 24-hour intake. Review of records showed that the resident's fluid intake exceeded the prescribed limit on multiple occasions, and the required 24-hour totals were not consistently calculated or communicated. Interviews with nursing staff and supervisors indicated a lack of awareness of the resident's fluid overages and confusion regarding responsibility for monitoring and totaling intake. The facility's own policies and care plans outlined the need for accurate documentation and communication regarding both dialysis treatment and fluid management. Despite these directives, there were repeated failures to obtain and record necessary information from the dialysis center and to monitor and report fluid intake as ordered. These lapses resulted in the facility's inability to follow physician orders and ensure safe, appropriate care for the resident requiring dialysis and fluid restriction.
Failure of Nursing Staff to Demonstrate EMR Competency for Resident Care
Penalty
Summary
Nursing staff, specifically nurse aides, failed to demonstrate competency in accessing and utilizing the electronic medical record (EMR) system to obtain resident-specific care information. In two separate instances, nurse aides were unable to retrieve essential care details for residents with significant cognitive and physical impairments, including information on ambulation status, supervision levels, and mealtime guidelines. In both cases, the nurse aides had to rely on licensed nursing staff to access the EMR and provide the necessary information, despite having previously received training on the system. The residents involved had complex care needs, including dementia, muscle weakness, unsteadiness, a history of falls, and dysphagia. Their care plans required staff to follow specific interventions for mobility, supervision, and feeding. The inability of nurse aides to independently access the EMR resulted in a failure to ensure that care was provided according to each resident's individualized plan. Interviews with supervisory staff confirmed that nurse aides were expected to have the competency to access this information, and the lack of a provided policy on EMR training was noted.
Deficiencies in Pharmaceutical Services and Controlled Substance Management
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident receiving hemolytic treatments. Specifically, a resident with end stage renal disease and anemia, who required hemolytic treatment three times a week, was sent to treatment with hydralazine medication that was not properly packaged by the pharmacy. Instead, an LPN removed the medication from the resident’s blister card, placed it in a clear plastic pouch, labeled it by hand, and sent it in the communication binder. The medication was not in pharmacy-provided Leave of Absence (LOA) packaging, and there was no way for the treatment center staff to verify the medication. Additionally, the facility did not assess the resident for self-administration of medication, despite the treatment center’s policy that only self-administered medications could be taken during treatment. The APRN and DON were unaware of these practices, and the facility’s own policies required pharmacy-labeled medications and self-administration assessments, which were not followed. Further deficiencies were observed in the handling and security of narcotic medications. During an observation, an LPN was found to have locked narcotic keys inside the medication cart, rather than keeping them on her person as required by facility policy. The DON confirmed that narcotic keys should always be kept separately and in the possession of the nurse on duty, not locked in the cart. This practice was not being followed, indicating a lapse in controlled substance security protocols. The facility also failed to conduct required bimonthly narcotic audits. The ADNS was not performing these audits and was unaware it was her responsibility, as she had not been instructed or educated by the DON. The DON also had not completed any bimonthly audits since starting in the position. Additionally, the DON stored unused narcotics for destruction in a double-locked cabinet but did not maintain a log of these medications after receiving them from the units. The Controlled Substance Disposition Record was kept wrapped around the medication blister pack, contrary to policy requirements. These actions demonstrate multiple failures in the facility’s medication management and controlled substance accountability processes.
Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's disease, severe dementia, and adult failure to thrive was not provided with adaptive eating equipment as specified in their care plan and meal ticket. The resident was identified as severely cognitively impaired and required substantial to maximum assistance with eating, as well as adaptive equipment such as a built-up spork, lip plate, and handled cup with a straw. Despite these documented needs, observations revealed that the adaptive equipment was not consistently provided during meals. On one occasion, the required sippy cup was missing and the built-up spork was left unused on the delivery cart. Staff assisting the resident were unaware of the need for adaptive equipment, even though it was clearly indicated on the meal ticket. Family members reported that the resident did not always have access to drinks and silverware, and staff appeared unaware of the resident's needs when concerns were raised. The Food Service Director confirmed that adaptive equipment was labeled and placed on the silverware carts, with the expectation that nursing assistants would distribute it as needed. However, repeated observations showed the resident without the necessary adaptive equipment during meals, and staff interviews indicated a lack of awareness regarding the resident's requirements.
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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