Skyview Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Wallingford, Connecticut.
- Location
- 35 Marc Drive, Wallingford, Connecticut 06492
- CMS Provider Number
- 075057
- Inspections on file
- 32
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Skyview Rehab And Nursing during CMS and state inspections, most recent first.
A resident with bipolar disorder, dementia without behavioral disturbance, and anxiety, who was documented as alert, oriented, and independent in ADLs with intact cognition and no wandering behaviors, was initially assessed as not at risk for elopement and had a physician order permitting LOA with someone. Later, an LPN applied a Wanderguard to the resident’s ankle for reported exit-seeking, completed an elopement evaluation marking the resident at risk, but did not obtain consent from the resident’s conservator or document such contact, and the DON acknowledged that consent and less restrictive interventions should have preceded Wanderguard use. Despite the care plan subsequently labeling the resident an elopement risk and including Wanderguard use, the MAR and TAR did not show monitoring for wandering or exit-seeking behaviors, and the conservator later stated they had not been informed of prior exit-seeking, had not consented to the Wanderguard, and that the resident later described the facility as feeling like a jail.
A resident with bipolar disorder, dementia, and anxiety, who was independent with ADLs and identified as an elopement risk with a Wanderguard in place, left on an LOA with a friend after the conservator consented. The resident did not return as expected, staff were unable to reach involved parties, police were notified, and most of the resident’s belongings were found missing. The resident was then discharged without documentation that the departure was AMA or that AMA procedures were followed per facility policy. When the resident was later hospitalized and referrals were sent back, the facility had open beds but refused readmission, citing that the resident had left AMA and was placed on a corporate denial list, despite the administrator acknowledging that the resident’s return would not endanger others and lacking policies for handling non-return from LOA and readmissions.
A resident with bipolar disorder, dementia, and anxiety, who was independent in ADLs but care planned as an elopement risk, was allowed to go on LOA with a friend after the conservator consented. Nursing late entries documented the LOA, the resident’s failure to return, multiple unsuccessful attempts to contact involved parties, notification of police and clinical leadership, and discovery that most belongings were gone, while the census showed the resident as discharged. However, the Director of Social Services did not document the LOA outcome or the discharge in the clinical record and did not submit the required discharge notification to the State LTC Ombudsman portal, stating unawareness that non-return from LOA constituted a discharge, despite a facility policy requiring detailed discharge documentation.
A resident with bipolar disorder, dementia, and anxiety, who was care planned as an elopement risk and had a court-appointed conservator, was allowed to go on LOA with a friend after an RN obtained the conservator’s consent and an expected return time. The RN did not document the conservator communication or the anticipated return time in the clinical record before the end of the shift, and the LOA log did not capture an expected return time. The oncoming RN, unaware of when the resident was due back and noting that residents often return as late as 10:00 PM, did not begin attempts to locate the resident until that time, at which point calls to the friend, the resident, and family were unsuccessful and the conservator was first notified. This reflected a failure to maintain complete and accurate medical records and to facilitate communication about the resident’s LOA and expected return.
A resident with multiple chronic conditions and moderately impaired cognition had a missing electronic tablet after a hospital transfer, which the resident’s conservator reported to the Administrator as stolen and in need of investigation. A social worker acknowledged being told the device was missing and that a replacement was needed but did not document this communication in the medical record and stated she was not told it was stolen. Facility records showed no grievance, no investigation, and no State reportable event related to the missing device, despite facility policy requiring alleged violations to be reported to the Administrator and appropriate authorities.
A resident with moderately impaired cognition and multiple chronic conditions had a personal electronic tablet reported missing after a hospital stay. The resident’s representative reported the missing or stolen tablet to the Administrator, and the SW was informed that the device was missing and needed replacement, but this communication was not documented in the medical record. Review of records and interviews with the DNS, Administrator, and SW showed that no investigation into the alleged misappropriation was initiated or completed, despite facility policy requiring reporting and a written social service report for alleged violations.
A resident received two sets of medications in one evening, including another resident's medications, after an LPN placed a refused dose back in the med cart and later gave it to a NA to administer, who then gave it to the wrong resident. On another occasion, an LPN and an RN each administered medications without checking resident identification bands, relying instead on familiarity, despite facility policy requiring verification by wristband or photo and limiting medication preparation and administration to licensed staff.
A significant medication error occurred when an LPN pre-poured and stored a cup of evening medications for a resident who had initially refused them, then later handed that cup to a nursing assistant to administer, despite policy that only licensed staff prepare and give medications and that refused doses be discarded. The nursing assistant, aware that only licensed nurses should administer medications, took the cup into a shared room and gave the drugs to the wrong roommate, who had multiple chronic conditions including dementia, Parkinson’s disease, and diabetes and had already received a full set of scheduled evening medications. As a result, the resident received additional psychotropic, cardiac, antibiotic, and diabetic medications intended for the roommate, subsequently developed encephalopathy, and was found by the physician to have been exposed to excessive doses and combinations of metformin, tramadol, and beta-blockers with associated clinical effects.
A resident with chronic pain, depression, and anxiety, who was cognitively intact and dependent on staff for daily care, reported feeling fearful after a staff member shook their dinner tray. The resident informed an LPN, who said the concern would be reported to the DNS, but the DNS did not interview the resident or address the allegation promptly, resulting in a delayed investigation of the abuse claim.
Staff failed to use a gait belt and rolling walker during the transfer of a resident with significant mobility limitations and a history of fractures, despite care plan and facility policy requirements. Instead, staff used improper manual techniques, which was confirmed through interviews and documentation review. The resident was later found to have pain and bruising, and was diagnosed with a right humerus fracture, necessitating further medical intervention.
Unauthorized Use of Wanderguard Restraint and Inadequate Elopement Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraint and to obtain required consent from the resident’s conservator before applying a Wanderguard device. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbance, and anxiety disorder, but on admission was documented as alert and oriented to person, place, time, and situation, verbally appropriate, and independent with all ADLs, bed mobility, transfers, and ambulation. An initial elopement risk scale completed at admission identified the resident as not at risk for elopement, and nursing notes and the MAR from admission through several days afterward did not document disorientation, verbalizations of wanting to leave, or exit-seeking behaviors. A physician’s order allowed the resident to go on leave of absence (LOA) with someone, and the admission MDS showed intact cognition (BIMS 15) and no wandering or behavioral symptoms. On a later date, LPN #1 documented that a Wanderguard was placed on the resident’s left ankle due to exit seeking and completed an elopement evaluation identifying the resident as at risk for elopement. However, the note did not indicate that the resident’s conservator of person had been contacted for approval prior to placement of the Wanderguard, and LPN #1 later stated she was unaware the resident was conserved and placed the device without contacting the conservator. The DON, who was the nursing supervisor that day, reported being aware that the resident wanted to leave and that the Wanderguard was applied, and acknowledged that the conservator should have been contacted for approval and that other interventions should have been attempted and documented before using a Wanderguard. Facility documentation, including the MAR and TAR, did not show monitoring for wandering or exit-seeking behaviors after the Wanderguard was applied, despite the care plan later identifying the resident as an elopement risk and including Wanderguard use as an intervention. Subsequently, the resident requested to go on LOA with a friend. At one point, an RN documented that the resident could not go on LOA because neither the resident nor the RN could reach the conservator. Later, a late entry note by another RN documented that the conservator consented to the LOA and that the resident left with a friend, with the LOA book signed. A further late entry note documented that the resident did not return from LOA as expected, attempts to contact the friend, the resident, the resident’s son, and the conservator were unsuccessful, and the police and facility leadership were notified; it was also noted that most of the resident’s belongings were gone. The conservator later reported that the facility had not obtained consent prior to placing the Wanderguard, had not reported prior exit-seeking or wandering behaviors, and that the resident later stated not wanting to return to the facility because it felt like a jail. The facility’s Wanderguard policy allowed placement when the care team decided a resident was at risk for wandering, but the facility did not provide requested policies on conservator notification and behavior monitoring.
Failure to Readmit Resident After LOA Without AMA Documentation or Safety Justification
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return following a Leave of Absence (LOA), despite having available beds and no documentation that the resident left Against Medical Advice (AMA) or that readmission would endanger others. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbances, and anxiety disorder, and had a court-appointed conservator of person responsible for personal care and medical decisions. Upon admission, the resident was alert and oriented, verbally appropriate, and independent with ADLs, bed mobility, transfers, and ambulation. The care plan identified the resident as an elopement risk due to impaired safety awareness and exit-seeking behaviors, with interventions including monitoring for verbalizations about leaving and use of a Wanderguard on the left ankle. A physician’s order allowed the resident to go on LOA with someone. On the day of the LOA, a nurse documented (as a late entry) that the conservator consented to the LOA and that the resident left with a friend who stated they would return around 6:00 PM and signed the LOA book. Later that night, another late entry note documented that by 10:15 PM the resident had not returned from the LOA. Staff attempted to contact the friend, the resident, the resident’s son, and the conservator, left multiple voicemails and an email, notified the police, APRN, and DON, and discovered that most of the resident’s belongings were gone. The facility census showed the resident was discharged the following day, but the clinical record did not contain documentation that the resident left AMA or that an AMA discharge process was followed, as required by the facility’s discharge policy. Subsequently, when the resident was hospitalized and referrals were sent back to the facility, the Admissions Director reported that the facility had open female beds but declined readmission, citing that the resident had left AMA and refused to return, and that the resident was placed on a corporate denial list. The Administrator acknowledged that the resident’s return would not endanger other residents but cited the resident’s ambulatory status and ability to remove a Wanderguard as concerns, and also stated unawareness of requirements for readmissions after extended LOAs or AMA situations. Requested policies regarding residents not returning from LOA and readmission time frames were unavailable.
Failure to Document Discharge and Notify Ombudsman After Resident Does Not Return From LOA
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s discharge in the clinical record and to notify the State Long-Term Care Ombudsman of the discharge after the resident did not return from a leave of absence (LOA). The resident had diagnoses of bipolar disorder, dementia without behavioral disturbances, and anxiety disorder, and had a court-appointed conservator of person. On admission, the resident was documented as alert and oriented, verbally appropriate, and independent with all ADLs, bed mobility, transfers, and ambulation. The care plan later identified the resident as an elopement risk related to impaired safety awareness and exit-seeking behaviors, with interventions including use of a Wanderguard and monitoring. A physician’s order allowed the resident to go on LOA with someone. Late entry nursing notes documented that the RN obtained consent from the conservator for the resident to go on LOA with a friend, that the friend picked the resident up and signed the LOA book, and that by late evening the resident had not returned. Subsequent nursing documentation showed multiple unsuccessful attempts to contact the friend, the resident, and the resident’s son, as well as attempts to contact the conservator, and notification of the police, APRN, and DON. It was later identified that most of the resident’s belongings were gone from the room, and the police reported they were unable to contact the friend but would continue their search. The facility census reflected that the resident was discharged on that date. However, review of the clinical record did not show any documentation by the Director of Social Services regarding the outcome of the LOA or the resident’s discharge. The State Long-Term Care Ombudsman confirmed there was no discharge notice submitted through the required portal, including for a resident leaving against medical advice. Review of the Ombudsman portal with the Director of Social Services confirmed that the discharge was not reported, and the Director stated she was unaware that failure to return from LOA constituted a discharge and therefore did not document the LOA outcome or discharge, nor submit the required Ombudsman notification. The facility’s discharge policy required recording all pertinent documentation in the medical record and describing the sequence of events with timed notations, but there was no available policy on reporting discharges to the Ombudsman.
Failure to Document LOA Details and Communicate Expected Return Time for Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident with an identified elopement risk and a court-appointed conservator of person. The resident had diagnoses of bipolar disorder, dementia without behavioral disturbances, and anxiety disorder, and had been admitted alert, oriented, and independent with ADLs, mobility, and ambulation. A court of probate document showed that a conservator was appointed to ensure the resident’s personal care, safety, and medical or other professional care. The resident’s care plan identified the resident as an elopement risk due to impaired safety awareness and exit-seeking behaviors, with interventions including use of a Wanderguard and monitoring. A physician’s order allowed the resident to go on a Leave of Absence (LOA) with someone. On the day of the LOA, a nurse (RN #1) obtained consent from the conservator for the resident to go out with a friend and was informed by the friend that they would return around 6:00 PM. However, these communications and the anticipated return time were not documented in the clinical record prior to the end of RN #1’s shift. The LOA log recorded the time the resident was signed out but did not include a column for anticipated return time, and no nurse’s note was written at that time regarding the LOA. As a result, the oncoming nurse (RN #2), who worked the 3:00 PM to 11:00 PM shift, was not informed of the expected 6:00 PM return time and was unaware of when the resident was scheduled to return. RN #2 later noted that many residents return from LOAs as late as 10:00 PM and, lacking any documented anticipated return time, did not begin attempts to locate the resident until 10:00 PM when the resident had not returned. At that point, multiple unsuccessful attempts were made to contact the friend, the resident, and the resident’s son, and the conservator was notified by voicemail and email. The conservator reported being first notified at 10:00 PM and stated a preference to have been notified immediately. Facility policies required that staff inquire about anticipated LOA duration and that services and changes in the resident’s condition be documented in the medical record to facilitate communication among the interdisciplinary team. The failure to document the conservator communication and anticipated LOA return time, and to communicate this information during shift change, resulted in an incomplete and inaccurate clinical record and delayed recognition and response when the resident did not return as expected.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of a resident’s personal property to the State Agency as required by its abuse policy. One resident with Type 2 diabetes, non-pressure chronic skin ulcers, a history of malignant neoplasm of the bladder, and a BIMS score of 12 indicating moderately impaired cognition had a care plan identifying risk for falls and the need to keep personal items within reach. The resident’s conservator reported that the resident’s electronic tablet was missing after a hospital transfer and stated that the device had been stolen while the resident was in the hospital. The conservator reported notifying the Administrator, who allegedly stated the facility would investigate the missing device. Despite this notification, facility records from early 2025 through early 2026 showed no grievance filed regarding missing items or the missing tablet, and no State Reportable event was completed for the missing device. A social worker acknowledged being informed by the conservator that the tablet was missing and that a replacement was needed, but stated she was never told it was stolen and did not document this communication in the resident’s medical record. In interviews, the DNS, Administrator, and social worker confirmed that no investigation was completed and no report was made to the State Agency regarding the missing tablet, contrary to the facility’s abuse policy requiring alleged violations to be reported to the Administrator with notification to the State Agency and other parties.
Failure to Investigate Alleged Misappropriation of Resident’s Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete and thorough investigation into an allegation of misappropriation of a resident’s personal property. The resident had Type 2 diabetes, non-pressure chronic skin ulcers, and a history of malignant neoplasm of the bladder, with a BIMS score of 12 indicating moderately impaired cognition. The resident’s care plan identified a risk for falls and directed staff to anticipate needs and keep personal items within reach. A representative (Person #1) reported the resident’s missing electronic tablet to the Administrator approximately one month before the survey. However, review of the clinical record, facility documentation, and social service progress notes over a more than two-month period showed no documentation that an investigation into the missing tablet was initiated or completed. The social worker reported that the resident’s conservator (Person #2) informed her that the resident’s tablet was missing after a hospital stay and that a replacement was needed, but she stated she was never told the device was stolen and did not document this communication in the medical record. Person #2 stated that the tablet was stolen while the resident was in the hospital and that he/she notified the Administrator, who said the facility would investigate the missing device. Interviews with the DNS, Administrator, and social worker confirmed that no investigation had been completed regarding the missing tablet. This lack of investigation and documentation occurred despite the facility’s abuse policy requiring that alleged violations be reported to the Administrator, with notification to the state agency and others, and that the social service representative provide a written report of findings through social service progress notes in the medical record.
Failure to Follow Safe Medication Administration and Resident Identification Practices
Penalty
Summary
The deficiency involves failures in safe medication administration practices, including resident identification, proper disposal of refused medications, and limiting medication administration to licensed personnel. One resident received his or her scheduled medications at approximately 8:30 PM and then was given another resident's medications at about 10:15 PM, resulting in a reported medication error. At the time, the resident was described as alert, slightly lethargic, and able to respond verbally and appropriately. The error occurred after one resident initially refused medications, which were then labeled with that resident's name and placed back into the medication cart instead of being disposed of. Later, those medications were handed by an LPN to a nursing assistant to administer, and the nursing assistant gave them to the wrong resident. Additional observations on a later date showed that two nurses failed to verify resident identity before administering medications. One LPN administered medications to a resident without checking the wristband, stating that he or she was familiar with the resident, despite acknowledging that facility policy required checking the wristband. Similarly, an RN administered medications to another resident without confirming identity, also citing familiarity and acknowledging that policy required verification by wristband or photo. Interviews with the DNS and review of facility policy confirmed that only licensed personnel were to prepare and administer medications, refused medications were to be disposed of immediately with new doses prepared if needed later, and resident identification was to be verified by wristband or photo before each medication administration.
Significant Medication Error When One Resident Received Another Resident’s Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when one resident received medications prescribed for another resident. Resident #1, who had vascular dementia, Parkinson’s disease, and anxiety disorder, had moderately impaired cognition and required maximum assistance with personal care. Resident #1’s care plan included use of antipsychotic medications for Parkinson’s-related hallucinations, with directions to administer medications per physician orders and monitor for side effects and effectiveness. On the evening in question, Resident #1 received his or her scheduled medications, including multiple agents for cholesterol, diabetes, Parkinson’s disease, hypertension, constipation, pain, and neuropathy. Resident #2, who had bipolar disorder, Type 2 diabetes mellitus, and atherosclerotic heart disease, also had moderately impaired cognition and required moderate assistance with personal care. Resident #2’s care plan addressed mood problems related to major depressive disorder, bipolar disorder, and anxiety disorder, with directions to administer medications per physician orders and monitor for side effects and effectiveness. On the same evening, Resident #2 refused several medications, including atorvastatin, Belsomra, lurasidone, trazodone, buspirone, carvedilol, doxycycline, and metformin, and requested they be given later. The LPN labeled a medication cup with Resident #2’s name and placed it back into the medication cart instead of disposing of the refused medications. Later that night, the LPN gave the pre-poured, labeled cup of Resident #2’s medications to a nursing assistant and asked the assistant to administer them to Resident #2, despite facility policy and the DNS’s stated standard of practice that only licensed personnel prepare and administer medications and that refused medications be disposed of immediately. The nursing assistant, who acknowledged knowing that only licensed nurses were to administer medications, took the cup into the shared room and administered the medications to Resident #1 instead. This error was discovered after Resident #2 requested pain medication, and it was recognized that the medications given by the nursing assistant to Resident #1 were intended for Resident #2. Resident #1 was subsequently found to have received additional medications including trazodone, lurasidone, buspirone, carvedilol, doxycycline, and metformin, and developed encephalopathy, which the physician identified as more likely related to trazodone toxicity or possibly metabolic encephalopathy in the setting of RSV infection and hypoxia. The physician also identified that the total doses of metformin, tramadol, and the combination of carvedilol with previously administered metoprolol placed the resident at risk for low blood sugar, hypotension, drowsiness, lethargy, nausea/vomiting, and decreased blood pressure and heart rate.
Failure to Timely Investigate Alleged Abuse
Penalty
Summary
The facility failed to timely investigate an allegation of abuse involving a resident with chronic pain, depression, and anxiety, who was cognitively intact and required assistance with activities of daily living. The resident reported to the social worker that a staff member had shaken their dinner tray in a manner that made the resident feel fearful it might be thrown at them. The incident was said to have occurred on a Sunday, and the resident initially reported their concerns to an LPN, who stated she would inform the RN supervisor (DNS). However, the DNS did not visit the resident that day, and the resident indicated that no one else came to discuss the incident until days later. Interviews and documentation revealed that both the LPN and the aide involved informed the DNS about the resident's concerns on the day of the incident. The DNS acknowledged being aware of the situation but did not interview the resident at that time, only learning later during the investigation that the resident had felt afraid. Facility policy required prompt reporting and investigation of abuse allegations, including obtaining statements and completing a reportable event form, but these steps were not carried out in a timely manner, resulting in a delay in addressing the resident's report of potential abuse.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to utilize a gait belt and rolling walker during the transfer of a resident who required assistance from two staff members. The resident, who had diagnoses including osteoarthritis, a history of a healed traumatic fracture of the right arm, vascular dementia, and was identified as a fall risk with limited mobility, was care planned to receive assistance of two staff for transfers and to use safety equipment such as a gait belt. Despite these interventions being documented in the care plan and facility policy, staff transferred the resident by placing their arms under the resident's arm and grabbing the resident's pants, without using a gait belt, as confirmed by staff interviews. Following this improper transfer technique, the resident was noted to have pain and bruising on the right upper arm, which led to further medical evaluation. Imaging revealed an old, impacted fracture of the right humeral head and neck with evidence of osteopenia and osteoporosis. The resident was subsequently diagnosed with a right humerus fracture and required additional interventions, including a sling, non-weight bearing status, use of a Hoyer lift for transfers, pain management, and therapy evaluation. The facility's policy and staff interviews confirmed that a gait belt should have been used during the transfer, but it was not, directly leading to the deficiency.
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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