Silver Springs Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 33 Roy St, Meriden, Connecticut 06450
- CMS Provider Number
- 075337
- Inspections on file
- 26
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Silver Springs Care Center during CMS and state inspections, most recent first.
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.
The facility failed to protect two cognitively impaired residents with dementia, schizophrenia, and anxiety disorders from non-consensual sexual contact. One resident, wheelchair-bound and fully dependent for ADLs with severely impaired cognition, had a care plan noting a history of being the target of non-consensual sexual advances and calling for close observation as indicated. Another resident, also severely cognitively impaired but ambulatory, had a care plan addressing dementia-related memory and thinking problems. A staff member observed these two residents in an elevator, kissing, with one resident’s hand inside the other’s pants. Both residents were conserved and unable to consent to intimate touching, and the incident was determined by leadership to be inappropriate and sexual in nature, contrary to the facility’s abuse policy prohibiting non-consensual sexual contact.
The facility failed to thoroughly investigate a resident-to-resident sexual incident involving two cognitively impaired residents with dementia and psychiatric diagnoses. A recreation assistant observed the residents kissing in an elevator, with one resident’s hands inside the other’s pants, and reported the event to the DNS. Although the facility interviewed the witness and the involved residents, it did not obtain timely interviews or statements from other staff to determine how long the residents were unsupervised or where they had been prior to the incident, despite a policy requiring identification and interviewing of staff who might be witnesses and review of work schedules.
A resident with multiple chronic conditions experienced an unwitnessed fall from a wheelchair, resulting in facial injuries and a nasal fracture. Facility records showed that required neurological checks were not completed or documented as per policy before the resident was transferred to the hospital. Leadership confirmed the assessments should have been done, but documentation was missing for several required intervals.
A resident with severe dementia and agitation, known to wander, was physically pushed by a nurse aide after striking the aide while attempting to exit a secured unit. The push caused the resident to fall and hit their head, as confirmed by multiple staff interviews and video footage. The incident was initially reported as a fall, but later determined to be physical abuse in violation of facility policy.
A resident with severe dementia became physically aggressive while attempting to exit a secured unit and was pushed by a staff member, resulting in a fall and head injury. The incident was not accurately reported to the DON, and the true nature of the event was only discovered five days later through camera footage, leading to a delayed notification to the State Agency, in violation of facility policy requiring immediate reporting of suspected abuse.
A resident with severe dementia and agitation experienced a witnessed fall, after which no staff obtained or recorded vital signs as required by facility policy. The RN Supervisor later entered fabricated vital signs into the electronic transfer form to facilitate hospital transfer documentation. The DON confirmed awareness of the falsified documentation, and the facility's policy requiring assessment and documentation after a change in condition was not followed.
A resident with severe cognitive impairment and multiple health conditions did not receive timely incontinence care, and the resulting allegation of neglect was not promptly reported to the State Agency as required by facility policy. The incident was only reported after surveyor inquiry, and no investigation report was available.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely incontinence care, as reported by a nursing assistant. The concern was reported to a supervising RN, who attempted to notify nursing leadership, but there was no evidence that the required investigation was initiated or documented according to facility policy.
The facility did not ensure timely replacement of expired sink faucet filters in multiple resident rooms, as required by manufacturer guidelines, and failed to maintain records of filter changes. Staff interviews confirmed that filters were overdue for replacement despite a known infectious agent in the water and ongoing monitoring.
A resident receiving Methadone for opioid dependence did not receive a scheduled dose after six bottles of the medication went missing. The ADON placed the Methadone on a supervisor's desk instead of in the double-locked cabinet, and required counts and documentation were not performed by nursing supervisors during shift changes. The medication was not found, and the resident required alternative pain management and monitoring for withdrawal symptoms.
A resident receiving Methadone for opioid dependence missed a scheduled dose after the medication was improperly stored and not counted according to facility policy. The Methadone was left on a supervisor's desk instead of being placed in a double-locked cabinet, and no inventory count was performed by two nurses. As a result, the medication was missing at the time of administration, leading to withdrawal symptoms for the resident.
A resident prescribed Methadone for opioid dependence did not receive a scheduled dose because the medication was missing after being improperly stored and not counted upon arrival or during shift change. The ADON placed the Methadone on a supervisor's desk instead of in a double-locked cabinet, and staff failed to perform required counts and documentation, resulting in the loss of the controlled substance.
The facility did not ensure that the MAR accurately reflected the administration of Methadone for multiple residents with opioid dependence or abuse. For several days, there was no documentation in the EMR that Methadone was given as ordered, despite facility policy requiring immediate and accurate recordkeeping for controlled substances. Nursing leadership confirmed the documentation lapses and the responsibility of Nursing Supervisors to maintain accurate MARs.
The facility's Dietary Department had several deficiencies, including unclean conditions in the cold room due to sheetrock dust and debris, and improper food storage practices. Bags of cereal and orzo lacked expiration dates, and several food items in the refrigerator exceeded the 72-hour discard policy. Additionally, the kitchen wall had broken tiles with dust and debris present. The Director of Food Services acknowledged these issues, which were not in compliance with the facility's Food Storage policy.
A resident with GERD and other conditions received crushed Pantoprazole without an order, despite pharmacy recommendations to switch to Omeprazole capsules. The facility delayed implementing this change for 86 days, initially prescribing Omeprazole in tablet form instead of capsules. Staff interviews revealed no explanation for the delay, and the facility's policy for timely response to pharmacy reviews was not followed.
A facility failed to monitor a resident on long-term antibiotics per its stewardship policy. The resident, with multiple diagnoses including an infection due to a knee prosthesis, was prescribed Ciprofloxacin without an end date. Despite the care plan noting the need for monitoring, the LPN did not track the resident's ongoing antibiotic use, mistakenly documenting it as a one-time dose. This oversight was contrary to the facility's policy aimed at preventing resistant bacteria spread.
The facility failed to implement care plan interventions for two residents identified as fall risks. One resident's siderail pads were not in place as required, and another resident was left unattended on the bed edge despite a history of falls. Staff acknowledged the lapses, indicating a failure to follow the care plans designed to prevent injury.
A resident with muscle weakness and COPD required assistance with personal hygiene but was not shaved since admission, contrary to their grooming preference. The resident was told to wait for the hairdresser, leading to a delay in care. The facility's policy required nursing personnel to offer AM and PM care, including shaving, but this was not followed until after surveyor inquiry.
A facility failed to follow care plans and medication orders for residents with skin conditions, respiratory issues, and opioid dependence. A resident did not consistently receive ordered foot boots, another had incorrect bed positioning due to transcription errors, and three residents missed Methadone doses due to oversight in medication pick-up. Staff interviews revealed a lack of awareness and system issues contributing to these deficiencies.
A facility failed to conduct a baseline AIMS assessment for a resident on Risperdal, an antipsychotic medication. The resident, with dementia and PTSD, was severely cognitively impaired and dependent on staff. Facility policy required AIMS assessments every six months but did not include a baseline assessment upon admission. Despite a pharmacist's recommendation for a baseline assessment, it was not performed, as psychiatric services were expected to conduct it.
A resident with Parkinson's Disease and cognitive impairment experienced multiple falls without the responsible party being notified, contrary to the facility's policy. Despite having a care plan addressing fall risks, the facility failed to inform the responsible party of three specific falls, as confirmed by the ADN and DNS.
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 Protect Cognitively Impaired Residents From Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect two residents from sexual abuse by not ensuring they were free from non-consensual sexual contact. Resident #1, admitted in December 2014, had vascular dementia, schizophrenia, anxiety disorder, severely impaired cognition with a BIMS score of 4, was dependent for personal hygiene, toileting, and bathing, and used a wheelchair. Resident #1’s care plan dated 12/22/25 documented a history of engaging in non-consensual sexual advances by others and directed that close observation levels be applied as indicated per policy. Resident #2, admitted in July 2008, had vascular dementia, schizophrenia, anxiety disorder, and severely impaired cognition with a BIMS score of 6, required set-up/clean-up assistance with personal, oral hygiene, and toileting, and ambulated independently. Resident #2’s care plan dated 1/27/26 identified dementia with memory, thinking, problem-solving, and language impairment, and directed staff not to attempt to correct statements the resident believed and to provide simple responses. On 2/9/26, a Recreation Assistant entered an elevator and observed Resident #1 sitting in a wheelchair kissing Resident #2, while Resident #2’s hand was inside Resident #1’s pants. When questioned by the Recreation Assistant, Resident #2 removed the hand from Resident #1’s pants and told the staff member to mind her business. The incident was reported to the Director of Nursing Services. The Director of Behavioral Health and Social Services later questioned Resident #2, who stated it was just a kiss. The DNS identified that both residents were conserved, unable to consent to intimate touching, and deemed the incident to be inappropriate and sexual in nature. The facility’s Abuse Policy in effect at the time stated that residents would not be subjected to abuse by anyone and defined sexual abuse to include non-consensual sexual contact of any type with a resident. Despite these policies and the known cognitive impairments and care plan directives, the residents were not adequately protected from non-consensual sexual contact, resulting in the abuse incident.
Failure to Thoroughly Investigate Resident-to-Resident Sexual Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation following a resident-to-resident sexual incident. Resident #1, admitted in December 2014 with vascular dementia, schizophrenia, and anxiety disorder, had severely impaired cognition (BIMS score of 4), was dependent for personal hygiene, toileting, and bathing, and used a wheelchair. Resident #1’s care plan identified a history of engaging in non-consensual sexual advances by others, with interventions including close observation as indicated per policy. Resident #2, admitted in July 2008 with vascular dementia, schizophrenia, and anxiety disorder, also had severely impaired cognition (BIMS score of 6), required set-up/clean-up assistance for personal and oral hygiene and toileting, and ambulated independently. Resident #2’s care plan noted dementia-related memory and thinking problems, with interventions to avoid correcting the resident’s believed statements and to provide simple responses. On the date of the incident, a Recreation Assistant observed Resident #1 and Resident #2 kissing in an elevator, with Resident #2’s hands in Resident #1’s pants, and this was documented on a Reportable Event Form by the DNS. The facility’s investigation included interviews with the witness (Recreation Assistant) and both residents, but did not include interviews or statements from other staff to determine how long the residents had been unsupervised or their locations prior to the incident. Subsequent interviews with a NA assigned to Resident #2 and an LPN assigned to Resident #1 revealed each had last seen their assigned resident around early afternoon, but these interviews were not part of the original investigation. The DNS acknowledged that the investigation should have included staff interviews to establish a timeline and resident whereabouts, as required by the facility’s “Reportable Events-Reporting Allegations and Incidents; Investigation (CT)” policy, which directs identifying and interviewing staff who were potential witnesses and reviewing work schedules, with efforts to interview staff before the end of their shifts.
Failure to Complete Timely Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to complete timely neurological monitoring after an unwitnessed fall involving a resident with chronic obstructive pulmonary disease, morbid obesity, and heart failure. The resident, who was non-ambulatory and used a wheelchair, experienced a fall in the elevator after being pushed by another resident. The fall resulted in a nasal bone fracture and facial laceration, requiring hospital evaluation and treatment. Facility documentation, including the Neurological Check Sheet and nursing notes, lacked evidence that neurological assessments were performed as required by facility policy in the period following the fall and prior to the resident's transfer to the hospital. The facility's policies directed neurological checks at specific intervals after unwitnessed falls or suspected head injuries. However, the neurological assessment form was incomplete, with missing entries for vital signs, hand grasps, level of consciousness, pupil response, and nurse initials for the required time points. Interviews with facility leadership confirmed that neurological assessments should have been completed and documented, but no such documentation was available for the period before EMS arrival or for two of the required four-hour assessments. The failure to perform and document neurological checks was not in accordance with the facility's established protocols.
Resident Pushed by Staff Member Resulting in Fall and Injury
Penalty
Summary
A resident with severe dementia, agitation, mild cognitive impairment, and muscle weakness was involved in a physical altercation with a staff member, resulting in a fall. The resident had a BIMS score indicating severely impaired cognition and was known to wander, with care plan interventions directing staff to offer assistance and redirect the resident as needed. On the day of the incident, the resident was attempting to exit the memory care unit and became agitated, striking a nurse aide who was trying to enter the unit. In response, the nurse aide pushed the resident, causing the resident to fall and hit their head against the wall. Multiple staff members witnessed the event, and their accounts confirmed that the nurse aide used physical force after being struck by the resident. The incident was initially reported as a fall, with documentation indicating the resident lost balance after striking the staff member. However, subsequent interviews and review of camera footage revealed that the staff member had pushed the resident, which directly led to the fall and injury. The facility's abuse policy prohibits physical abuse and the use of corporal punishment, stating that residents must not be subjected to abuse by anyone, including staff. Despite this policy, the staff member's actions constituted physical abuse, as confirmed by witness statements and video evidence. The incident was not immediately reported as abuse, and the true nature of the event only came to light several days later upon review of surveillance footage.
Failure to Timely Report Suspected Abuse Following Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify the Administrator and/or designee of a physical altercation between a staff member and a resident, resulting in a delayed report to the State Agency. The incident involved a resident with severe dementia, agitation, and mild cognitive impairment, who attempted to exit the memory care unit and became physically aggressive with a staff member. During the altercation, the staff member pushed the resident, causing the resident to fall and hit their head against the wall. The resident was subsequently transported to the emergency department for evaluation, but no acute behavioral issues were found upon return. Despite the seriousness of the incident, the initial reports from staff to the Director of Nursing (DON) did not accurately convey that the resident had been pushed by the staff member. The DON was informed that the resident had hit the staff member and then lost balance, leading to the fall. It was only five days later, after a review of camera footage prompted by another staff member, that it became clear the resident had been pushed. This delay in recognizing and reporting the incident as potential abuse resulted in the State Agency not being notified within the required two-hour timeframe. Facility policy mandates that all allegations or suspicions of abuse must be reported immediately to supervisors and the appropriate authorities, including the State Agency, within two hours if abuse is involved. In this case, the failure to communicate the true nature of the incident and to identify all witnesses led to a significant delay in reporting, contrary to facility policy and regulatory requirements.
Failure to Obtain and Accurately Document Vital Signs After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe dementia, agitation, and muscle weakness experienced a witnessed fall in the hallway. The resident was noted to be sitting on the floor with their head against the wall and was resistive to a skin check and range of motion assessment. Despite facility policy requiring assessment and documentation of vital signs following a fall, no staff—including nurse aides and the charge nurse—attempted to obtain or record the resident's vital signs after the incident. The resident was subsequently transferred to the emergency department for evaluation. When completing the required eInteract Transfer Form in the electronic health record, the RN Supervisor entered fabricated vital signs into the form several hours after the incident, as the system would not allow the form to be locked and printed without this information. The Director of Nursing confirmed awareness of the falsified documentation and stated that staff are prohibited from such actions. The facility's Change of Condition policy directs that assessment findings be documented and reported to the physician, but this was not followed in this case. A policy on Nursing Documentation was not available for review.
Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
An allegation of neglect involving a resident with multiple sclerosis, epilepsy, depression, anxiety, and severe cognitive impairment was not reported to the State Agency (SA) as required. The resident, who was dependent on staff for activities of daily living and had a care plan addressing communication difficulties and skin integrity risks, did not receive incontinence care until late in the 7 AM to 3 PM shift. A nursing assistant reported this delay in care to the RN supervisor at the end of the shift, and the supervisor submitted a written statement by sliding it under the office door of the Director of Nursing Services (DNS) or Assistant DNS (ADNS), but did not confirm receipt. The DNS later acknowledged awareness of the allegation but was unable to locate or provide an investigation report and confirmed that the concern should have been reported to the SA. The facility's abuse policy required immediate reporting and investigation of abuse or neglect allegations, including notification of the administrator and DNS or designee, and prompt reporting to appropriate authorities. The failure to report the allegation to the SA was only rectified after surveyor inquiry.
Failure to Investigate Alleged Neglect of Dependent Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse/neglect for a resident with multiple complex medical conditions, including multiple sclerosis, epilepsy, depression, anxiety, and overactive bladder. The resident was severely cognitively impaired, dependent on staff for activities of daily living, and required frequent incontinence care. According to a nursing assistant's written statement, the resident did not receive incontinence care until late in the shift, and this concern was reported to the supervising RN at the end of the shift. The RN supervisor submitted the statement by sliding it under the office door of the Director of Nursing Services (DNS) or Assistant Director of Nursing Services (ADNS) but did not confirm receipt. The DNS later acknowledged awareness of the allegation but was unable to provide an investigation report and indicated that the ADNS, who was covering at the time, was unavailable. Facility policy required immediate reporting and prompt investigation of abuse allegations, including removal of the alleged abuser from resident care and initiation of an investigation within 24 hours. However, there was no evidence that an investigation was conducted or that the required procedures were followed after the allegation was reported.
Failure to Replace Expired Sink Faucet Filters for Infection Control
Penalty
Summary
The facility failed to follow infection prevention and control guidelines by not ensuring that resident room sink faucet filters were changed once expired. During a facility tour, it was observed that several resident room sink faucet filters were past their expiration dates, with some being 6 to 7 days overdue. Manufacturer instructions indicated that the filters should be used for a maximum of 31 days following initial connection. The Maintenance Director confirmed that he and the maintenance assistant were responsible for changing the filters, but was unaware that several filters were overdue for replacement. Additionally, the facility did not maintain records or logs of water filter changes, and the Maintenance Director stated that the Maintenance Assistant should have changed the filters during his absence. Interviews with the DNS and Corporate Clinical Director revealed that the building had a known infectious agent in the water, and the water was being monitored. They confirmed that the 31-day sink faucet filters in the affected rooms should have been changed when due. The lack of timely filter changes and absence of documentation contributed to the facility's failure to adhere to infection prevention and control protocols.
Failure to Secure and Account for Controlled Substance Results in Loss of Methadone
Penalty
Summary
The facility failed to ensure the proper storage and handling of a controlled medication, Methadone, prescribed to a resident with a history of opioid dependence and substance abuse. The resident was receiving medication-assisted therapy, and a physician's order directed a daily dose of Methadone. On one occasion, the Assistant Director of Nursing (ADON) picked up seven bottles of Methadone from a clinic, administered one dose to the resident, and placed the remaining six bottles on the supervisor's desk in a locked office, rather than in the designated double-locked cabinet. No medication count was performed with another supervisor at the time of receipt, and the chain of custody was not documented as required by facility policy. The following day, nursing staff discovered that the six bottles of Methadone were missing when attempting to administer the scheduled dose. There was no count of the Methadone during shift changes, and the medication was not found despite a search and investigation. Interviews with nursing supervisors and the ADON confirmed that the required procedures for controlled substance storage, counting, and documentation were not followed. The facility's policies specified that Methadone should be counted by two supervisors, documented on a chain of custody form, and stored in a double-locked cabinet, but these steps were not taken. As a result of these lapses, the resident missed a scheduled dose of Methadone and required alternative medication and monitoring for withdrawal symptoms. The facility's investigation confirmed that the Methadone was not properly secured or accounted for, and the medication was ultimately lost. The failure to follow established protocols for controlled substances led to the misappropriation of the resident's medication.
Failure to Secure and Account for Methadone Results in Missed Dose
Penalty
Summary
A deficiency occurred when a resident with a history of opioid dependence and currently receiving medication-assisted therapy with Methadone did not receive a scheduled dose due to improper storage and handling of the medication. The Assistant Director of Nursing (ADON) picked up seven bottles of Methadone from a clinic and, upon returning to the facility, administered one dose to the resident but placed the remaining bottles on the supervisor's desk in a locked office rather than in the designated double-locked cabinet. No medication count was conducted with a second nursing supervisor at the time of placement, and no count was performed during shift changes. As a result, when the next scheduled dose was to be administered, the Methadone could not be located, leading to a missed dose. The resident, who was alert and oriented, initially denied withdrawal symptoms but later reported moderate body aches, restlessness, anxiety, and irritableness, which were managed per physician orders. Facility policy required all controlled substances, including Methadone, to be stored in a locked cabinet with accurate inventory maintained and counted by two nursing supervisors. The failure to follow these procedures resulted in the omission of a critical medication dose and subsequent withdrawal symptoms for the resident.
Failure to Secure and Account for Methadone Upon Receipt and During Shift Change
Penalty
Summary
The facility failed to ensure that Methadone, a controlled substance prescribed to a resident for opioid dependence, was properly counted and securely stored according to facility policy and professional standards. Upon arrival from the Methadone clinic, the Assistant Director of Nursing (ADON) transported seven bottles of Methadone in a locked suitcase, administered one dose to the resident, and then placed the remaining six bottles on the supervisor's desk in the supervisor's office, rather than in the designated double-locked cabinet. No medication count was performed with a second nursing supervisor at the time the Methadone was brought into the facility, and the chain of custody was not documented as required by policy. During the subsequent shift change, the outgoing and incoming nursing supervisors did not conduct a count of the Methadone bottles, as mandated by facility policy. The next day, a nursing supervisor discovered that the Methadone was missing when attempting to administer the scheduled dose, and the omission was reported. Interviews with staff confirmed that the required counts and secure storage procedures were not followed, and the Methadone was not found after an internal investigation. The resident involved had a history of opioid dependence and was alert and oriented at the time of the incident. The omission of the Methadone dose was documented, and the resident was monitored for withdrawal symptoms, but denied experiencing any. Facility policies clearly required controlled substances to be counted upon receipt, documented, and stored in a double-locked cabinet, but these procedures were not followed in this instance.
Failure to Document Methadone Administration in MARs
Penalty
Summary
The facility failed to ensure that the Medication Administration Record (MAR) accurately reflected the administration of Methadone for seven of eight sampled residents with opioid dependence or abuse. Clinical record reviews and examination of the electronic medical record (EMR) for these residents revealed multiple instances where there was no documentation that Methadone was administered on various days throughout February 2025, despite active physician orders for daily dosing. The absence of documentation was noted for each resident on several specific dates, with some residents missing documentation for up to thirteen days in the month. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that facility policy requires each administered medication, especially controlled substances like Methadone, to be immediately documented in the EMR and on accountability records. Both the ADON and DON acknowledged that the MARs for the affected residents did not consistently show that Methadone was administered as ordered, and identified that Nursing Supervisors are responsible for ensuring the accuracy of these records. Facility policies reviewed also emphasized the necessity of accurate and immediate documentation following administration of controlled substances.
Deficiencies in Food Storage and Sanitation in Dietary Department
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the Dietary Department, as observed during a tour. In the cold room, the floor was covered with a white, dusty, powdery material, identified as sheetrock dust and debris, with visible shoe prints throughout. An old green garden hose was also stored on the floor. The Director of Food Services acknowledged the issue, stating that the dust resulted from recent sheetrock replacement and that housekeeping services had been requested but not yet provided to clean the area. Additionally, in the dry storage room, bags of crisped rice cereal and orzo were found without expiration dates, and the original boxes with the manufacturer's expiration dates were missing. In the cold room walk-in refrigerator, several containers of food were found to be past the facility's policy of discarding prepared foods within 72 hours. Items such as chopped Salisbury steak, cranberry sauce, sliced turkey breast, cucumber salad, rice/orzo, chopped pineapple, and pancakes were all beyond the 72-hour limit. The Director of Food Services confirmed that the cook on duty was responsible for discarding food according to policy. Furthermore, the kitchen wall between the ice machine and the housekeeping closet had broken, cracked, and missing tiles, with the wall behind them dusty and crumbling, and debris on the floor. The facility's Food Storage policy mandates that all storage areas be clean and sanitary, and that ready-to-eat foods have expiration or use-by dates, which was not adhered to in this instance.
Failure to Implement Pharmacy Recommendations for Medication Administration
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident diagnosed with gastroesophageal reflux disease (GERD), Wernicke's encephalopathy, and anxiety. The resident was receiving crushed medications without an order, including Pantoprazole, which is enteric-coated and should not be crushed. The pharmacy recommended switching from Pantoprazole to Omeprazole capsules, which can be opened and administered with applesauce, but this change was not implemented until 86 days later. During this period, the resident continued to receive Pantoprazole inappropriately, and when Omeprazole was finally ordered, it was initially prescribed in tablet form instead of the recommended capsule form. Interviews with facility staff revealed that the Director of Nursing Services was responsible for addressing pharmacy recommendations, but there was no explanation for the delay in implementing the recommended changes. The facility's policy required a response to the Drug Regimen Review within 7 to 14 days, yet the recommendations were not acted upon within this timeframe. The Regional Director Pharmacist confirmed that the delayed release form of Omeprazole is more effective when administered as a capsule, and crushing the tablet could lead to less effective acid suppression and increased gastrointestinal symptoms.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to monitor a resident on long-term antibiotics according to its antibiotic stewardship policy. Resident #112, who had diagnoses including hemiparesis, hemiplegia, infection due to a knee prosthesis, and epileptic seizures, was prescribed Ciprofloxacin 500 mg twice daily without an end date. The resident's care plan noted the infection and antibiotic treatment, with instructions to follow the facility's policy for tracking infections. However, the Infection Preventionist, an LPN, did not have Resident #112 on the antibiotic monitoring list, mistakenly documenting the resident as having received only a one-time dose in October 2024. Upon further inquiry, it was revealed that Resident #112 had been on suppressive antibiotic therapy since April 2024, but the LPN was unaware of the ongoing antibiotic use. This oversight was contrary to the facility's antibiotic stewardship policy, which aims to promote improved antibiotic use and prevent the spread of resistant bacteria. The deficiency was identified during an interview and record review, highlighting the lack of proper monitoring and documentation for Resident #112's antibiotic regimen.
Failure to Implement Care Plan Interventions for Fall Risk Residents
Penalty
Summary
The facility failed to implement the care plan interventions for Resident #12, who was identified as a fall risk due to a history of falls. Despite the care plan specifying the use of padded siderails, observations over several days revealed that the siderail pads were not in place while the resident was in bed. The pads were found on the floor and on dressers in the room, rather than covering the siderails as intended. Nurse aide #7 confirmed that it was the responsibility of the night shift to place the siderail pads, but if they were missing, it was her responsibility to ensure they were in place. The absence of siderail pads during the surveyor's observations indicated a failure to follow the care plan, potentially exposing Resident #12 to injury. For Resident #121, the facility also failed to adhere to the care plan interventions related to fall prevention. The resident, who had a history of falls and required substantial assistance with transfers, was observed sitting unattended on the edge of the bed, contrary to the care plan's directive. Nurse aide #1 acknowledged leaving the resident unattended to provide care to another resident, and the Director of OT/PT, along with the Regional Director of PT, also left the resident unattended despite being aware of the fall risk interventions. This repeated oversight demonstrated a lack of adherence to the care plan, which was designed to prevent falls and ensure the resident's safety.
Failure to Timely Accommodate Resident's Grooming Request
Penalty
Summary
The facility failed to accommodate a resident's grooming request in a timely manner, leading to a deficiency in providing care and assistance for activities of daily living. Resident #125, who was diagnosed with general muscle weakness and chronic obstructive pulmonary disease, required substantial assistance for personal hygiene. The resident expressed a preference for choosing grooming options and was independent in decision-making. However, upon observation and interview, it was found that the resident had not been shaved since admission and was told to wait for the hairdresser, who was only available on Wednesdays. This delay in grooming was not documented as a refusal of care in the nursing progress notes. The facility's policy directed that nursing personnel should offer AM and PM care, including shaving according to personal preference. Despite this, the resident was left with a beard approximately 3 inches long, which was against their usual grooming preference. The LPN confirmed that nurse aides were responsible for shaving, and the resident was eventually shaved after surveyor inquiry. The resident was under the impression that they had to pay for shaving, which contributed to the delay in receiving the necessary personal care.
Deficiencies in Care Plan Adherence and Medication Management
Penalty
Summary
The facility failed to adhere to a physician's order for Resident #12, who was diagnosed with dementia, muscle weakness, and reduced mobility, among other conditions. The resident was at risk for skin integrity issues and was ordered to wear bilateral soft multi-podus boots at all times, except during care. However, observations revealed that the boots were often not applied, as they were found on the floor or dresser instead of on the resident's feet. Staff interviews indicated that the resident frequently removed the boots, and there was a lack of consistent application as per the care plan. For Resident #18, who had severe cognitive impairment and chronic respiratory conditions, the facility failed to transcribe a physician's order for bed positioning to prevent shortness of breath. Observations showed that the resident's bed was often in a flat position, contrary to the order to keep the head elevated. Interviews with staff revealed a lack of awareness of the positioning needs, and the order was not reflected on the NA Care Card, which was supposed to guide care. The issue was attributed to a transition to a new electronic health record system, which led to transcription errors. Additionally, the facility failed to ensure the availability of Methadone for three residents with opioid dependence. Residents #35, #118, and #129 missed their Methadone doses due to an oversight in picking up the medication from the clinic. The Assistant Director of Nursing was responsible for obtaining the Methadone but lacked a formal tracking system for pick-up dates, leading to missed doses. The Medication Error Reports confirmed the oversight, and interviews with staff highlighted the absence of a structured process for managing Methadone pick-ups.
Failure to Conduct Baseline AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct a baseline Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication, Risperdal. The resident, who had diagnoses including dementia, anxiety, and PTSD, was identified as severely cognitively impaired and dependent on staff for personal hygiene. The facility's policy required AIMS assessments every six months but did not include conducting a baseline assessment upon admission. Despite a recommendation from the pharmacist for a baseline AIMS assessment to monitor for involuntary movements, the facility did not perform this assessment upon the resident's admission. Interviews with facility staff, including a social worker and a registered nurse, revealed that the responsibility for conducting AIMS assessments was assigned to psychiatric services, which had not yet performed the assessment. The facility's policy and procedures did not mandate a baseline AIMS assessment on admission, and the psychiatric provider had not yet seen the resident. The pharmacist's recommendation for a baseline AIMS assessment was not immediately acted upon, as the psychiatric provider was expected to conduct the assessment. This oversight led to a deficiency in monitoring the resident for potential side effects of the antipsychotic medication.
Failure to Notify Responsible Party After Resident Falls
Penalty
Summary
The facility failed to notify the responsible party of a resident after multiple falls, which is a violation of their own Fall Management Policy. The resident in question, who has diagnoses including Parkinson's Disease, cognitive impairment, and a fluency disorder, experienced twelve falls over the course of the year. Despite the facility's policy requiring notification of the resident's physician and family or responsible party in the event of a fall, the responsible party was not informed of three specific falls that occurred on 4/2/24, 6/2/24, and 10/11/24, all of which resulted in no injury. The resident's care plan, dated 8/28/23, acknowledged a history of falls with injury and included interventions such as education on call bell usage and ensuring the resident was not left unattended while sitting on the side of the bed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the oversight in notifying the responsible party and could not provide a reason for the failure. The resident was noted to be cognitively intact, with unclear speech, requiring substantial assistance with transfers, and reliant on a motorized wheelchair.
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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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