Saint John Paul Ii Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Danbury, Connecticut.
- Location
- 33 Lincoln Avenue, Danbury, Connecticut 06810
- CMS Provider Number
- 075354
- Inspections on file
- 28
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Saint John Paul Ii Center during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with severe cognitive impairment and high fall risk was found on the floor by a nurse aide, who moved the resident back to bed without notifying the charge nurse or RN supervisor and without an RN assessment. The resident later reported pain and was diagnosed with a displaced humerus fracture. Facility policy required immediate reporting and RN assessment after a fall, which was not followed.
A resident with severe cognitive impairment and dependent transfer status was found on the floor and was manually lifted back into bed by a nurse aide, contrary to the care plan requiring two staff and a mechanical lift. The aide did not check the transfer status or report the fall, and the resident was later diagnosed with a displaced humerus fracture.
A resident who required two-person assistance for mechanical lift transfers was moved by a single nurse aide, contrary to facility policy. During the transfer, the sling shifted and struck the resident's nose, causing a minor nosebleed. The aide did not request help from another aide present in the room, despite being trained on the two-person transfer requirement. The resident's care plan and facility policy both specified the need for two staff during such transfers.
A resident with multiple medical conditions was subjected to inappropriate physical contact when a nurse aide, following a verbal altercation with an LPN, grabbed the resident's wrist in the hallway after the resident intervened. The incident was witnessed by staff and reported, and the facility's zero-tolerance abuse policy was not followed.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
The facility did not ensure that a licensed pharmacist consistently performed required monthly drug regimen reviews for several residents with complex medical conditions, resulting in missing documentation for multiple months. Interviews indicated that changes in pharmacy providers and facility ownership contributed to the lack of pharmacy consultant services and incomplete medication reviews, contrary to facility policy.
Surveyors identified that medication refrigerators were found unlocked, expired medications were not discarded, and refrigerator temperature logs were incomplete in two medication rooms. Staff interviews confirmed lapses in daily checks and documentation, as well as a broken lock on a refrigerator used for medication storage, contrary to facility policy.
Staff failed to serve meals at appropriate temperatures, with food items significantly cooling between leaving the kitchen and being served to a resident. Despite food leaving the kitchen at high temperatures, by the time the last resident was served, items were well below the acceptable minimum for hot foods, contrary to facility policy and staff expectations.
A resident with a history of mental health disorders received a new diagnosis of schizoaffective disorder, but the facility did not refer this new diagnosis to the state mental health authority for a required Level II evaluation. The social worker was unaware that a new referral was needed for a long-term care resident with a previous Level II, resulting in the omission.
A resident with neuromuscular disease and limited mobility, requiring assistance with ADLs, did not consistently receive scheduled showers as documented in their care plan. Staff interviews and medical record review confirmed missed showers, with staff citing insufficient availability and lack of follow-up on the resident's complaints. Facility policy required real-time documentation of ADL care, but records did not reflect that showers were provided as scheduled.
Two residents experienced deficiencies: one did not have a written physician order entered for a diagnostic x-ray after a fall, leading to confusion about the intended imaging, and another had a cervical collar that was repeatedly positioned incorrectly by staff who were not fully trained on proper application, despite a physician's order and facility policy requiring correct placement.
A resident with severe cognitive impairment and a stage 3 pressure ulcer was found using a specialty air mattress without a physician's order or documented instructions for mattress settings, contrary to facility policy. Licensed staff could not locate the required order or evidence of regular monitoring, resulting in a deficiency related to pressure ulcer care.
A resident with obesity, dysphagia, and aphasia experienced significant unplanned weight loss, but staff failed to obtain timely reweights and did not document or notify the physician as required by facility policy. The resident's weight was not checked within the required timeframe after hospital readmission, and the responsible RN was unaware of the missed weights and did not update the care plan or notify the physician.
Licensed staff, including an LPN hired in 2023, did not have required clinical competency validations completed for 2024. Review of employee files and facility documentation showed these validations were missing for all licensed staff, and the DON confirmed that none had been completed due to the departure of the responsible staff member. The facility could not provide a policy for clinical competency validations.
Two residents with severe cognitive impairment and court-appointed conservators did not have proper consent or refusal obtained from their responsible parties for influenza vaccination for the current season. Although the facility attempted to contact conservators and power of attorneys, the process was incomplete, and immunization records did not indicate whether the vaccine was offered or administered.
A resident with diabetes was discharged without receiving necessary education on insulin administration, diabetes management, or use of a glucometer, and was also sent home without prescribed medications and supplies due to a lack of medication reconciliation and communication among staff.
A resident with multiple diagnoses, including seizure disorder and anxiety, repeatedly refused prescribed morning doses of Primidone and Hydroxyzine over a month. Despite facility policy requiring physician notification for medication refusals, nursing staff did not inform the physician or document the refusals beyond the MAR. The unit manager, APRN, and DON were unaware of the refusals, resulting in a deficiency due to lack of required communication.
A resident with multiple diagnoses, including seizures and anxiety, repeatedly refused prescribed medications, but the facility did not develop or implement a comprehensive care plan to address these refusals. Despite documentation of frequent medication refusals and facility policy requiring individualized care planning for such situations, staff interviews confirmed that no specific interventions or care plan were in place.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Notify RN and Assess Resident After Fall
Penalty
Summary
A resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility, who required maximum assistance for bed mobility and was dependent for transfers, experienced an unwitnessed fall during the night. The resident, who had severely impaired cognition, was found on the floor by a nurse aide who, without notifying the charge nurse or RN supervisor, picked the resident up and placed them back in bed. The resident later complained of pain and was found to have a displaced fracture of the left humerus. The nurse aide admitted to not reporting the fall to nursing staff and to moving the resident without an RN assessment, despite knowing facility policy required notification and assessment before moving a resident after a fall. The RN supervisor on duty was unaware of the fall until informed later by management, and confirmed that the nurse aide should have reported the incident so an RN assessment could be completed. Facility documentation and interviews confirmed that the resident required two staff and a mechanical lift for transfers, and that the nurse aide acted alone and failed to follow protocol. The facility's falls management policy defined a fall as any instance of a patient found on the floor and required immediate reporting and assessment, which was not followed in this case.
Failure to Follow Care Plan for Dependent Transfer After Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility was not transferred in accordance with their care plan. The resident, who had severely impaired cognition and was dependent for transfers, was found on the floor by a nurse aide during the night. The care plan required two staff and a mechanical lift for all transfers due to the resident's high fall risk and physical limitations. However, the nurse aide, without checking the resident's transfer status, lifted the resident alone and placed them back in bed without using the required mechanical lift or seeking assistance. The nurse aide did not report the fall to the charge nurse as required. The resident subsequently complained of pain and was found to have a displaced fracture of the left humerus, confirmed by hospital evaluation. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed that the resident's care plan specified the use of a mechanical lift with two staff for all transfers, and that the nurse aide's actions were not in accordance with facility policy or the resident's care plan.
Failure to Follow Two-Person Mechanical Lift Transfer Policy Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to morbid obesity, osteoarthritis, gait abnormalities, and generalized muscle weakness, was transferred using a mechanical lift by only one nurse aide, contrary to the facility's policy requiring two staff members for such transfers. The resident's care plan and care card both specified the need for two-person assistance during mechanical lift transfers. On the day of the incident, the assigned nurse aide performed the transfer alone because other aides were occupied, and did not request assistance from another aide who was present in the room but separated by a curtain. During the solo transfer, the sling of the mechanical lift shifted and the resident's nose was struck by the end of the sling straps, resulting in a minor nosebleed. The resident was alert and oriented, reported the incident, and denied hitting any metal part of the lift, attributing the injury to the sling straps. A subsequent assessment found no other injuries, and x-rays were normal. The resident later expressed reluctance to get out of bed, which was noted as potentially related to the incident. Interviews with staff confirmed that the nurse aide was aware of the policy requiring two staff for mechanical lift transfers and had received training on this procedure. The facility's policy explicitly stated that two trained staff are required for all mechanical lift transfers, regardless of manufacturer instructions. The nurse aide admitted to not following this policy and did not seek help from the other aide present in the room.
Failure to Protect Resident from Inappropriate Physical Contact by Staff
Penalty
Summary
A deficiency occurred when a resident, who had multiple medical diagnoses including surgical aftercare, dysthymic disorder, and hypertensive heart disease, was subjected to inappropriate physical contact by a nurse aide. The resident, who was alert and oriented, reported that the nurse aide grabbed their wrist too hard during an altercation that began with a verbal argument between the nurse aide and an LPN in the hallway. The resident intervened by asking the nurse aide to calm down, at which point the nurse aide approached and grabbed the resident's wrist. The resident immediately objected to being touched and pulled away, stating, 'don't touch me.' Multiple staff statements corroborated that the nurse aide engaged in a loud verbal altercation and then physically grabbed the resident's wrist in the hallway. The incident was witnessed by other staff and reported to the nursing supervisor. The facility's policy mandates zero tolerance for abuse and requires staff to prevent any form of abuse or neglect. The nurse aide's actions were in direct violation of this policy, as the physical contact was not warranted and occurred in the context of a heated exchange.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, were not provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Consistently Complete Monthly Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist consistently performed monthly drug regimen reviews, including review of the medical chart, for several residents as required by policy. For four of five residents reviewed for unnecessary medication use, documentation showed that monthly pharmacy reviews were missing for specific months. In some cases, such as with residents diagnosed with end stage renal failure, anxiety, major depression, dementia, schizophrenia, diabetes, and other serious conditions, the required monthly reviews were not completed or could not be located in the clinical records. Care plans for these residents indicated they were at risk for complications related to psychotropic and other high-risk medications, and interventions included monitoring for side effects and consulting with a pharmacist as needed. Interviews with the Director of Nursing Services (DNS) revealed that a change in pharmacy providers and a change in facility ownership led to lapses in pharmacy consultant services, resulting in missed monthly medication regimen reviews. The DNS was unable to provide documentation for the missing months and could not explain the absence of pharmacy consultations for other periods. Facility policy required monthly review and documentation of medication administration records, but these were not consistently completed or available for review for the affected residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication storage and labeling in two medication rooms. In one instance, a medication refrigerator containing medications was found unlocked, and a registered nurse acknowledged forgetting to secure it. In another medication room, an expired ear wax removal medication, which should have been discarded after the resident's departure, was found stored. Nursing staff are responsible for weekly checks for expired medications, but the expired item had been missed. Additionally, temperature logs for medication refrigerators were incomplete, with numerous days across several months lacking documentation of temperature checks and signatures. Staff interviewed confirmed that temperature logs are required to be completed daily during the overnight shift but could not explain the lapses. Furthermore, a refrigerator storing medications was found unlocked due to a broken lock, and staff were unsure how long the lock had been inoperable. Facility policy requires daily temperature checks and removal of expired medications from storage areas.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, as required by policy. Observations showed that food trucks left the kitchen with hot food items at high temperatures (pureed eggs at 200°F, pureed hash browns at 198°F, and pureed bread at 182°F). However, by the time the last resident on Unit 2 North was served, the temperatures of these items had dropped significantly (pureed hash browns at 110.1°F, pureed bread at 106°F, and pureed eggs at 106.3°F). The time between the food leaving the kitchen and being served to the last resident was approximately 46 minutes. Staff from various departments were observed passing out dietary trays, and the last resident served was dining in their room. Interviews with the Food Service Director and the DNS confirmed that the expectation is for meals to be served warm, with 135°F identified as the acceptable minimum temperature for hot foods. Both acknowledged that the temperatures measured at the time of service were not warm enough for consumption. The DNS also noted that food trays should be distributed immediately upon arrival to the unit and suggested that better organization of trays and delivery could improve efficiency. The facility's policy requires that each resident receive food and drink that is palatable and at a safe and appetizing temperature, which was not met in this instance.
Failure to Refer New Mental Health Diagnosis for Level II Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to refer a newly identified mental health diagnosis to the appropriate state-designated mental health authority for a Level II evaluation, as required by policy. The clinical record review for one resident revealed that although a previous Level II evaluation had been completed for a diagnosis of delusional disorder, a new diagnosis of schizoaffective disorder was identified several months later without evidence of a subsequent referral for reassessment. The facility's policy mandates prompt notification to the state mental health authority after a significant change in mental or physical condition for residents with mental disorders. The resident involved had a history of schizoaffective disorder, mild cognitive impairment, and delusional disorder, and was assessed as severely cognitively impaired but independent in certain activities of daily living. The care plan noted ongoing psychosocial distress and the use of antipsychotic medication, with interventions including evaluation for psychiatric or behavioral health consults. During interviews, the social worker indicated she was unaware that a new referral was required for a new mental health diagnosis in a long-term care resident with a prior Level II evaluation, leading to the failure to initiate the necessary referral process.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
A deficiency occurred when a resident with Guillain-Barre Syndrome and muscle weakness, who required assistance with activities of daily living (ADLs) such as bathing and grooming, did not consistently receive scheduled showers. The resident's care plan specified the need for assistance with bathing, and the Minimum Data Set (MDS) assessment confirmed the resident required partial to moderate assistance for bathing and transfers. Despite being cognitively intact, the resident reported missing two scheduled showers and stated that staff told them the day staff were too busy to provide the shower. Documentation in the medical record confirmed the absence of showers on the scheduled dates, and only one shower was documented during the review period, with bed baths provided on other dates. Multiple staff interviews corroborated the resident's complaint, with nurse aides and the unit manager acknowledging the missed showers and the resident's requests. Staff indicated that the resident sometimes requested showers at times when adequate staff were not available to assist, and there was confusion or lack of follow-up regarding the resident's complaints. Review of nursing progress notes and behavior monitoring did not identify any care refusal or behaviors that would have prevented the resident from receiving showers. Facility policy required real-time documentation of ADL care, but the medical record did not reflect that showers were provided as scheduled.
Failure to Obtain Written Physician Order and Improper Cervical Collar Positioning
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of repeated falls experienced a fall after dinner and complained of right thigh pain. The Advanced Practice Registered Nurse (APRN) was notified and verbally ordered an x-ray, and the responsible party was informed that an x-ray would be completed. However, there was inconsistency in the documentation regarding whether a hip or femur x-ray was ordered, and no written physician order was entered into the electronic order management system as required by facility policy. The radiology report later indicated a femur x-ray was performed, but the lack of a written order created confusion about the intended diagnostic procedure. Another deficiency was identified involving a resident admitted with a cervical spine fracture and a physician's order to maintain a cervical collar at all times, except for care. Observations revealed that the resident's cervical collar was not appropriately positioned, with the chin piece on the resident's chin and the front piece floating above the chest. Nursing staff believed this was the correct placement, and one LPN stated she had not received the in-service training provided by physical therapy. The Director of Physical Therapy later confirmed the collar was not properly positioned and adjusted it accordingly. Documentation showed that staff education on collar alignment had been provided only to those present at the initial in-service. Review of the resident's care plan and nursing notes did not indicate prior issues with the resident moving the collar or behaviors affecting its alignment. Only after surveyor inquiry was the care plan updated to address resistance to care related to the cervical collar. Facility policy specified correct collar placement, but this was not consistently followed, resulting in improper positioning of the cervical collar for the resident.
Failure to Obtain Physician Order and Monitor Specialty Mattress Settings for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a stage 3 pressure ulcer, not present on admission, was found to be using a specialty air mattress without a physician's order specifying the mattress settings. The resident's care plan included interventions such as the use of a pressure redistribution surface and regular repositioning, but there was no documentation of a physician's order for the mattress or instructions regarding its settings and monitoring. During observations and staff interviews, it was revealed that licensed staff were unable to locate any physician order or guidance for the air mattress settings, despite facility policy requiring such an order and regular monitoring by nursing staff. The facility's policy also stipulated that the mattress settings should be adjusted according to manufacturer recommendations and checked by a licensed nurse, which was not documented as being done for this resident.
Failure to Obtain and Document Weights per Policy for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document resident weights according to its own policy for a resident with a history of weight loss and multiple risk factors, including obesity, dysphagia, and aphasia. The resident experienced significant weight loss over a period of weeks, with electronic records showing a drop from 155.0 pounds to 147.6 pounds, and later to 140.0 pounds. Despite these changes, no reweight was obtained within 24 hours to verify the weight loss, as required by facility policy. Additionally, a readmission weight was not obtained within 48 hours after the resident returned from the hospital, and the first weight post-readmission was documented six days later, two days after the dietician requested it. The facility's policy required prompt reweighing and documentation in cases of unplanned weight loss or gain of 5 pounds or more, as well as timely notification to the physician and updates to the care plan. However, interviews and record reviews revealed that the responsible RN was unaware of the missed weights and did not monitor weights after hospital readmissions. There was also no documentation that the physician was notified of the significant weight loss, nor evidence that the care plan was adjusted in response to these changes.
Failure to Complete Clinical Competency Validations for Licensed Staff
Penalty
Summary
Licensed staff, including an LPN hired in May 2023, did not have documented clinical competency validations completed for the year 2024. Review of employee files and facility documentation revealed that these required validations were missing for all licensed staff. The facility assessment emphasized the importance of employee competency assessment and education as essential for proper resident care, and staff are expected to understand their scope of practice and daily responsibilities. During an interview, the Director of Nursing Services confirmed that no licensed staff had received clinical competency validations for 2024, attributing this lapse to the departure of the staff member responsible for conducting the validations. Additionally, the facility was unable to provide a policy for clinical competency validations for licensed staff.
Failure to Obtain Proper Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain proper consent or refusal for influenza vaccination from the responsible parties of two residents with severe cognitive impairment and court-appointed conservators. In the first case, a resident with severe cognitive impairment and a conservator had previously received consent for the influenza vaccine from the conservator, but the conservator changed, and no new consent or refusal was obtained from the new conservator for the current vaccination season. The immunization record did not indicate whether the resident had received or been offered the influenza vaccine for the current season. In the second case, another resident with severe cognitive impairment was initially self-responsible and gave consent for the influenza vaccine, but later had a conservator appointed. For the current vaccination season, neither consent nor refusal was obtained from the new conservator. Although the facility attempted to contact conservators and power of attorneys via email to obtain consent, the process was incomplete, and the immunization record did not reflect whether the vaccine was offered or administered for the current season.
Failure to Provide Discharge Education and Medication Reconciliation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, among other diagnoses, was discharged from the facility without receiving necessary education on diabetes management, specifically regarding the use of newly prescribed Insulin Lispro, insulin sliding scale, and self-injection techniques. The clinical record and facility documentation showed that the resident did not receive teaching or training on diabetes care, use of a glucometer, or insulin administration during their stay, despite care plans and physician orders indicating these needs. Nursing notes failed to document any education provided on these critical aspects of diabetes self-management prior to discharge. Additionally, the facility failed to perform proper medication reconciliation before the resident's discharge. The discharge summary and medication list indicated that the resident was to continue with Insulin Lispro and gabapentin, but these medications and necessary supplies were not provided to the resident upon discharge. Communication breakdowns between nursing staff and the prescribing provider led to the assumption that the resident had all required medications, resulting in the omission of new prescriptions and supplies needed for safe transition home. Interviews with facility staff confirmed that the resident was discharged without the prescribed medications and without the required education on their use. The facility's own discharge planning policy required reconciliation of all pre- and post-discharge medications and provision of education, but these steps were not completed. The deficiency was identified after the home care nurse reported the missing medications and lack of discharge teaching, prompting an internal investigation that confirmed the failures in discharge planning and education.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician when a resident repeatedly refused prescribed medications, as required by facility policy. The resident, who had diagnoses including seizures, anxiety, depression, ADHD, and gender identity disorder, was care planned for medication administration and monitoring for side effects and effectiveness. Despite physician orders for Primidone and Hydroxyzine, the resident refused the morning doses of Primidone on 18 out of 30 days and Hydroxyzine on 10 out of 30 days during a one-month period. Documentation review confirmed these refusals were recorded in the Medication Administration Record (MAR). Interviews with nursing staff revealed that the charge nurse was aware of the refusals but could not recall notifying the physician or documenting the refusals in a nurse's note. The unit manager and APRN were not aware of the medication refusals and stated that their expectation was to be notified in such cases. The Director of Nursing confirmed there was no documentation of physician notification regarding the refusals, and facility policy required such notification. This lack of communication and documentation led to the deficiency.
Failure to Develop and Implement Care Plan for Medication Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's repeated refusals of prescribed medications. The resident, who had diagnoses including seizures, anxiety, depression, ADHD, and gender identity disorder, was prescribed Primidone for seizures and Hydroxyzine for anxiety. Despite a care plan that addressed behavioral concerns and medication monitoring, there was no specific care plan or interventions in place to address the resident's frequent medication refusals. The Medication Administration Record showed that the resident refused Primidone on 18 out of 30 days and Hydroxyzine on 10 out of 30 days during the review period, with only one nurse's note documenting a refusal. Interviews with facility staff, including the unit manager and Director of Nursing Services (DNS), confirmed that a care plan should have been implemented for medication refusals, but none was found in the clinical record. The facility's own policy required a person-centered care plan that addresses services not provided due to a resident's exercise of rights, such as refusing treatment. The DNS was unable to provide documentation or an explanation for the lack of a comprehensive care plan addressing the resident's medication refusals.
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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