Stamford Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Stamford, Connecticut.
- Location
- 53 Courtland Avenue, Stamford, Connecticut 06902
- CMS Provider Number
- 075061
- Inspections on file
- 27
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Stamford Care Center during CMS and state inspections, most recent first.
A resident with quadriplegia, severe cognitive impairment, and malnutrition developed worsening pressure wounds while dependent on staff for repositioning. Documentation showed many missed NA turning/repositioning entries, the resident was repeatedly observed lying on the back instead of following the turning schedule, and the pressure-relieving mattress was set to the wrong weight. Wound measurements showed enlargement of both the sacral stage 4 wound and the right lower back unstageable wound.
Unsafe and Uncomfortable Facility Temperatures: An LPN and residents were observed in cold rooms and common areas, with temperatures measured as low as 53 F in the lobby, 57.6 F at the nurses' station, and low 60s in hallways and dining areas. A resident in bed said, "I'm freezing," while the facility acknowledged awareness of the heating issue and had only been closing resident doors to preserve heat. Residents later reported they had complained about being uncomfortable and needing heat for at least two weeks before the survey.
Food was not consistently palatable or served at proper temperatures. Residents reported cold meals, tough meat, overcooked pork, repetitive chicken dishes, and poor flavor, and a resident council meeting noted ongoing concerns about food quality. Surveyors sampled a lunch tray and found bland mashed potatoes, watery lumpy gravy, and overcooked vegetables, while the RD also noted the meal lacked quality and flavor.
A resident council repeatedly reported late food trucks, cold meals, and delays in passing out trays. Observations showed breakfast and lunch carts arriving late to the 4th floor, with trays not fully delivered until well after the posted times; one resident said the food was disgusting and always cold, and another said cold breakfast was a common occurrence. The DON said she was unaware meals were consistently late or that some residents had only 3 hours between breakfast and lunch, while the Administrator noted the elevator had been out of service but meals still should have been delivered on time.
Food Storage and Sanitary Food Handling Deficiencies: Surveyors observed multiple dietary practice failures, including unlabeled prepared foods and frozen items, an open walk-in cooler door, uncovered roast beef cooling, raw chicken stored above bologna, and staff preparing food without required hair or beard restraints. Staff and the DON confirmed that temperatures, labeling, covering food, proper storage order, and sanitary attire were expected, but these practices were not being followed.
A facility failed to follow EBP for a resident with a PICC line when an LPN administered IV fluids without gown, gloves, or proper hand hygiene. The facility also left a peripheral IV in another resident’s hand beyond the ordered time frame, with no clear documentation of extension or site change, and an LPN failed to perform hand hygiene during a wound dressing change for a resident with a stage 4 sacral ulcer. In addition, the EBP tracking list did not match room signage, and staff incorrectly stated that residents with MDRO history did not need precautions despite the policy requiring EBP for MDRO colonization or infection.
Dignity and Meal Service Deficiencies: Two residents were assisted with meals by NAs who stood over them instead of sitting at eye level, despite facility policy requiring seated feeding for a more dignified dining experience. One resident was bedbound with dementia and functional quadriplegia, and another had severe cognitive impairment and needed meal assistance. In addition, meals were plated in disposable cardboard to-go containers and transported around the facility, with residents reporting cold, late, and poor-quality food; the RD and DON acknowledged the practice was undignified.
Failure to Investigate Allegation of Resident-to-Resident Abuse: A resident with severe cognitive impairment was found with bruising around both eyes and later told the ED that another resident had hit him/her in the face. The facility’s incident report noted bruises of unknown origin and later included the abuse allegation, but no investigation was identified in the A&I report. The DON stated the allegation was not investigated because she was unaware of it; another resident with dementia, anxiety, and depression was also reviewed for abuse.
A resident with anxiety disorder and bipolar disorder had a Level I PASRR that required a Level II if the resident stayed past 30 days, but the facility did not notify the state designated authority and no Level II was found in the record. The resident’s MDSs continued to show bipolar disorder, moderate cognitive impairment, total dependence for several ADLs, and use of antipsychotic, antianxiety, and antidepressant meds; staff stated the resident was self-pay and did not need a Level II.
A resident with a stage 4 sacral pressure ulcer and moderate cognitive impairment had an air mattress that was not checked and documented every shift as ordered, and observations showed the mattress setting remained between 280 and 320 even though the order directed it be set to the resident’s weight. Another resident with CHF, DM2, AFib, severe cognitive impairment, and continuous oxygen needs was observed receiving O2 at 2 L/min instead of the ordered 3 L/min via NC, and an LPN confirmed the setting was incorrect.
A resident with Parkinson's disease, dementia, and anxiety disorder was identified as an elopement risk and had an active order for a Wander guard transmission device on the right ankle. During observation, the resident was sitting in the dining room without the device on either ankle, and the assigned LPN had not yet checked placement that shift. The resident stated the device had been removed months earlier, and the device could not be located in the room. The MD and DON confirmed that an active order meant the device needed to be on the resident and that staff were responsible for checking placement every shift.
Failure to Monitor Intake and Output for Resident on Fluid Restriction: A resident with ESRD on hemolytic treatments and a 1000 mL fluid restriction had intake documented on the MAR that was consistently below the ordered limit, yet nursing notes did not show accurate I&O monitoring or physician notification when the restriction was not met. The resident also had documented weight gain and fluctuations, while an I&O binder at the nurses' station did not contain the resident's worksheet. The dietitian and DON were unable to confirm how staff were maintaining accurate fluid monitoring.
Failure to monitor AV fistula function during dialysis care. A resident with ESRD, CKD stage 5, and DM with CKD had a care plan directing staff to check for AV shunt/fistula bruit and thrill and provide HD via the left AV fistula. However, the physician orders did not include this monitoring, the dialysis center notes did not document that the fistula was being checked for function, and the clinical record, nurse's notes, and MAR contained no evidence of bruit and thrill monitoring. The DON stated she did not know the resident had an AV fistula or whether bruit/thrill checks were being done.
A resident with severe mobility and cognitive deficits was not properly positioned or provided with the required two-person assistance during bed mobility. While a nurse aide adjusted the bed height without checking the resident's position or ensuring a second staff member was present, the resident slid off the bed and sustained a femur fracture.
Failure to Prevent Worsening Pressure Wounds
Penalty
Summary
The facility failed to provide services to prevent worsening of two pressure wounds for a dependent resident with quadriplegia, severe cognitive impairment, and malnutrition. The resident’s comprehensive MDS identified total dependence for toileting, transfers, and changing positions in bed, and the care plan included a reopened stage 4 sacral pressure ulcer and an unstageable pressure ulcer to the right upper back, with interventions for a low air loss mattress, turning and repositioning every 2 hours, and monitoring nutritional status. Record review showed the resident was at very high risk for pressure ulcers, with quarterly skin evaluations documenting a Braden Scale score of 8. The physician ordered an air mattress to be set to the resident’s weight and checked every shift, and ordered turning and repositioning every 2 hours. However, the Nurse Aid turning and repositioning documentation was incomplete, with 28 of 93 opportunities unsigned in January and 43 of 115 opportunities unsigned in February. The resident’s care card also directed that the low air loss mattress be checked every shift and that the resident be turned every 2 hours. Surveyor observations found the resident repeatedly positioned on his/her back during times when the facility’s turning and repositioning program indicated the resident should have been facing the door or the window. The pressure-relieving mattress was observed set to 160 pounds at normal pressure, and RN #1 stated the mattress should have been set to 91 pounds based on the resident’s current weight. Wound records showed the right lower back wound increased from 1 cm x 1.5 cm x 0 cm to 1 cm x 2 cm x 0 cm, and later to 2 cm x 2.2 cm x 0 cm. The sacral stage 4 wound remained unchanged initially at 1 cm x 0.2 cm x 0.3 cm, then increased to 2 cm x 2.2 cm x 0.3 cm. RN #1, the dietician, and the wound APRN all identified the resident’s worsening wounds in the context of missed turning and repositioning, an incorrectly set mattress, and poor nutritional status.
Unsafe and Uncomfortable Facility Temperatures
Penalty
Summary
The facility failed to provide safe and comfortable air temperature levels in resident rooms and common areas. During an initial tour, an LPN on the 1st Floor East hallway was observed dressed in a winter hat, two sweaters, and a scarf and stated that it was freezing on the 1st floor and always like this at night. In a resident room, a resident was in bed under three blankets with the room heating system running at the highest possible setting, yet the probe thermometer measured 69.8 F and the resident stated, "I'm freezing." The Administrator acknowledged the facility was aware of the heating issue and said the intervention had been to close resident doors to preserve heat within rooms. Additional observations showed cold temperatures throughout the facility, including 57.6 F at the 1st Floor East nurses' station, 61.3 F in the hallway where housekeeping staff remained in a winter coat while cleaning, 53 F in the 1st Floor lobby, 64 F at the entrance to the 1st Floor East dining room, 61 F in the 2nd Floor East dining room, 59 F in the 2nd Floor East hallway, 65 F in the 4th Floor hallway, and 63 F in the elevator used for resident transport. Residents were observed wearing winter coats while eating breakfast or sitting in common areas. The Maintenance Director stated the facility was aware of heating issues, but temperature logs had not reflected the low temperatures observed, and the Administrator later stated this was the first time temperature issues had been identified. Residents later reported they had raised concerns about being uncomfortable and needing heat for at least two weeks before the survey began.
Food Not Served at Appetizing Temperature or Palatable Quality
Penalty
Summary
The facility failed to provide appetizing and palatable food, with repeated resident complaints documented in Resident Council minutes and during interviews. Residents reported that meat was not tender and hard to chew, food was delivered cold, pork was overcooked, and chicken meals were repetitive with the same seasoning. Several residents interviewed described the food as terrible, disgusting, low quality, and always cold, and a Resident Council meeting with 13 residents identified that the quality of food was lacking and often cold. Surveyors requested a lunch test tray and sampled the meal, finding it unappetizing and not palatable. The mashed potatoes lacked flavor, the roast beef was served with watery, lumpy, separating gravy, and the vegetables were watery and overcooked cauliflower, broccoli, and green beans; no dessert was provided. The Regional Dietary Director also tried the meal and noted the vegetables were overcooked and the instant mashed potatoes tasted like boxed potatoes. Facility policy required nourishing, palatable food at proper temperatures, food preparation methods that conserve flavor and appearance, and meals served at preferable temperatures.
Late Meal Delivery and Cold Food Service
Penalty
Summary
Meals and snacks were not served at regularly scheduled intervals, and the facility did not consistently provide timely meal delivery to residents on the 4th floor and other units. Resident Council minutes dated 10/27/25, 11/21/25, and 12/24/25 documented resident concerns that food trucks were late, meals took too long to be delivered, food was cold, and food was not passed out when it reached the unit destination. The 1/27/26 Resident Council minutes noted continued concerns about meals arriving cold and late, and the Dietary Food Director responded by stating tray delivery timing would be adjusted. On 2/8/26 and 2/9/26, observations and facility documentation showed breakfast and lunch carts arriving later than the posted delivery schedules for the 4th floor. On 2/8/26, breakfast arrived at 9:03 AM when it was scheduled for 7:30 AM to 8:00 AM, and the last breakfast tray was not delivered until 9:42 AM; residents reported the food was cold and late, and one resident stated this had been happening for about a week. Lunch on 2/8/26 arrived at 12:45 PM, later than the posted 12:00 PM to 12:30 PM window, and dinner was scheduled to arrive 6 hours and 18 minutes to 6 hours and 48 minutes after the last breakfast tray, with the time between dinner and the prior evening's meal documented as 17 hours and 12 minutes. On 2/9/26, breakfast plating began later than expected because a cook arrived late, lunch plating began 43 minutes late, and the lunch cart arrived at 12:42 PM, later than the posted schedule. The DON stated she was not aware meals were consistently served late or that some residents only had 3 hours between breakfast and lunch, and the Administrator stated the elevator had not been functioning since 2/3/25, though meals still should have been delivered in a timely manner.
Food Storage and Sanitary Food Handling Deficiencies
Penalty
Summary
The dietary department failed to store, prepare, and serve food in accordance with professional standards when surveyors found multiple food safety issues during the kitchen tour. The outside thermometer on the milk cooler showed 55 degrees Fahrenheit, and staff could not locate a thermometer inside the cooler at first to verify the milk temperature. In Refrigerator #1, trays of sandwiches and desserts on individual plates were not labeled with a preparation date or expiration date. The walk-in cooler door was propped open with a cart, four large roast beef chunks were cooling uncovered, and a pan of chicken thighs in marinade was stored above packages of bologna. The walk-in freezer contained onion rings and tater tots without labels showing when they were opened or when they expired. Staff preparing breakfast were also observed without hair nets, hats, or beard restraints as required. Additional observations showed a dietary aide in the food preparation area with a tray of salads on the counter without a beard restraint. Interviews with dietary staff and the Dietary Director confirmed that cooler, refrigerator, and freezer temperatures were supposed to be checked daily, food items were supposed to be covered while cooling, raw meat was supposed to be stored on a lower shelf, and foods were supposed to be labeled with open and expiration dates. The Dietary Director also stated that staff were expected to wear hair nets and beard restraints in the kitchen, but these practices were not being followed at the time of the observations.
Infection Control Failures With EBP, IV Site Management, and Hand Hygiene
Penalty
Summary
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for a resident with a PICC line and active infections. Resident #22 had diagnoses including acute osteomyelitis of the left ankle and foot, cellulitis of the left lower foot, and Klebsiella pneumoniae infection. The resident’s care plan identified impaired skin integrity, a limb alert related to IV access, and IV antibiotic therapy for 6 weeks. A physician order directed EBP during high-contact care for residents with indwelling medical devices such as a PICC line, and an EBP sign was posted on the room door with PPE available outside the room. During observation, an LPN entered the room carrying an IV bag and administered the resident’s IV fluid without first putting on PPE. The LPN stated that the resident was on EBP precautions and acknowledged that she should have worn a gown and gloves and performed hand hygiene, but had missed steps. The Infection Preventionist and DON both confirmed that gown and gloves should have been used during IV administration for this resident. The facility also failed to manage a peripheral IV site for another resident according to the ordered time frame and infection control expectations. Resident #23, who had dementia, adult failure to thrive, and functional quadriplegia, had a peripheral IV in the right hand that remained in place beyond the 5 to 7 day period referenced in the care plan. Observations showed the IV still present 12 and 13 days after insertion, with the dressing secured only by tape and lacking a date. The record did not show a new order extending the site time frame or documentation that the site had been changed, and the DNS and APRN were unable to explain why the IV remained in place. The facility further failed to perform hand hygiene during wound care for a resident with a stage 4 sacral pressure ulcer. Resident #108 had a stage 4 sacral wound, legal blindness, and low back pain, and the wound order directed cleansing, application of calcium alginate, and a foam dressing every 8 hours and as needed. During the dressing change, an LPN removed the old dressing and then placed on new gloves and cleansed the wound without first cleansing or sanitizing her hands. The LPN acknowledged the missed hand hygiene step, and the DON stated that hand hygiene should occur after removal of the old dressing and before applying clean gloves. In addition, the infection control tracking process was inaccurate and incomplete. During the facility tour, multiple room signs indicated residents required EBP, but the Infection Preventionist’s current EBP list did not include those room numbers. The Infection Preventionist also provided a list of residents with a history of MDROs and stated that residents with MDRO history did not need precautions because they were colonized. The DON gave the same explanation, although the EBP policy stated that residents colonized or infected with an MDRO should be placed on EBP and that the Infection Preventionist keeps an ongoing list of such residents and distributes it to other disciplines.
Dignity and Meal Service Deficiencies
Penalty
Summary
The facility failed to assist residents to eat in a dignified manner and failed to ensure appropriate food plating for a dignified dining experience. Resident #23 had diagnoses including unspecified dementia, functional quadriplegia, and adult failure to thrive, and was dependent on staff for eating. During observation, the resident was in bed with the head of the bed raised while breakfast was on the bedside tray table, and a nurse aide stood on the side of the bed, above eye level, while feeding the resident. The nurse aide stated she normally sat down when feeding residents but no chair was available, and acknowledged she should have been sitting per facility policy. Resident #128 had vascular dementia, hypertension, and pain in the joints of the left hand, and required setup or clean-up assistance with eating. During observation, the resident was seated at a table in the dining room while a nurse aide stood next to the resident, above eye level, and assisted with breakfast. The nurse aide stated she always stood when feeding residents because it was easier and she thought it was permissible. After surveyor inquiry, the nurse aide moved an empty chair next to the resident and assisted while sitting down. The ADNS stated staff should follow the ADL policy and resident care plan when assisting residents to eat, and that both nurse aides should have been seated because standing was an undignified way to assist with meals. The facility also plated meals in disposable cardboard to-go containers because the elevator was not functioning and kitchen staff transported meals outside and around the facility to the units. Residents reported the food was terrible, always late and cold, disgusting, low quality, and always cold. Observations showed breakfast delivered in disposable cardboard containers and served on plastic trays, while later lunch was observed on porcelain plates with lids and warming bases, and then again lunch was observed plated into disposable cardboard containers. The Regional Dietary Director stated the disposable containers were used to make it easier on staff, but acknowledged it was an undignified dining experience and that the cardboard containers affected food quality and temperatures. The DON and Administrator stated they were not aware meals were being served in disposable cardboard containers and both identified that this was undignified.
Failure to Investigate Allegation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. Resident #36, who had unspecified dementia, depression, anxiety disorder, and a BIMS score of 6 indicating severe cognitive impairment, was found with dark red bruising around both eyes. The resident stated, "I don't know what happened." The resident was later transferred to the hospital for evaluation of redness around the eyes, and the emergency department documented facial trauma and that the resident stated he/she had been hit in the face by another resident and was unsure when it happened. The facility's incident reporting documented bruises of unknown origin and later added a summary including the allegation of resident-to-resident abuse. The facility's A&I report recorded that Resident #36 stated that a girl with long hair hit her and her roommate hit her, but the report did not identify an investigation into the allegation. The Director of Nurses stated that she and the ADNS were responsible for ensuring abuse allegations were thoroughly investigated, but also stated that an investigation was not completed because she was unaware of the resident-to-resident abuse allegation. Resident #30, who had vascular dementia with agitation, anxiety disorder, and major depressive disorder, was also reviewed for abuse and had care plan interventions related to verbally abusive behaviors.
Failure to Complete PASRR Level II Assessment
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program and failed to refer for services as needed for one resident with diagnoses of anxiety disorder and bipolar disorder. The resident was admitted with a Level I PASRR that noted bipolar disorder and directed that a Level II PASRR must be completed if the resident remained in the facility past 30 days. The resident’s comprehensive MDS assessments continued to identify bipolar disorder, and a later quarterly MDS showed moderate cognitive impairment with total dependence for oral hygiene, toileting hygiene, eating, and bathing, along with use of antipsychotic, antianxiety, and antidepressant medications. Review of the clinical record did not identify a completed PASRR Level II assessment. The Social Worker stated that the Level II PASRR was not in the record because the facility never sent notification to the state designated authority when the resident’s initial 30 days had been completed, and the resident was 173 days past due. The Social Worker also stated that the resident was self-pay and therefore did not require a PASRR Level II screen to be completed.
Failure to Follow Ordered Air Mattress and Oxygen Settings
Penalty
Summary
The facility failed to follow the physician’s order for Resident #108’s specialty air mattress. Resident #108 had a stage 4 sacral pressure ulcer, legal blindness, low back pain, and moderate cognitive impairment, and the care plan included use of an air mattress with settings checked and documented every shift. The physician’s order directed staff to check the air mattress for proper functioning and settings and set it to the resident’s weight every shift, but the clinical record and monthly MAR/TARs for January and February 2026 did not show the mattress was checked for functioning, settings, or weight every shift as ordered. Observations on 2/8/26 and 2/9/26 showed the air mattress setting remained between 280 and 320. The DNS confirmed the mattress was set at 300 and stated the facility practice was to set the mattress per the resident’s weight, noting the resident’s current weight was 184 pounds, but also acknowledged the physician’s order directed the mattress to be set to the resident’s weight and not per preference. The facility policy stated nursing would adjust specialty mattress settings per manufacturer instructions and that the settings would be checked and documented every shift. The facility also failed to follow the physician’s order for Resident #132’s oxygen therapy. Resident #132 had CHF, type 2 diabetes, atrial fibrillation, severe cognitive impairment, and required continuous oxygen therapy per the MDS. The physician’s order directed oxygen at 3 liters per minute via nasal cannula as needed, but observations showed the resident receiving oxygen at 2 liters per minute while lying in bed with the head of the bed elevated. The LPN stated the oxygen setting was incorrect, had not checked it at the beginning of the shift, and would change it to 3 liters per minute. The DNS confirmed oxygen should be set according to the physician’s order and that the assigned nurse was responsible for ensuring the correct setting.
Ordered Wander Guard Device Not in Place for Elopement-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident #11, who had Parkinson's disease, unspecified dementia, anxiety disorder, and was identified on the MDS and care plan as an elopement risk/wanderer, had the ordered anti-wandering transmission device in place. The resident's care plan directed placement of a Wander guard transmission device on the right ankle and checking placement every shift, and the physician's order in effect on 2/9/26 directed the device to be checked every night shift and worn on the right ankle. However, during observation on 2/9/26 at 11:29 AM, Resident #11 was sitting in the dining room without a Wander guard device on either ankle. During interview and record review, the assigned LPN stated it was the nurse's responsibility to ensure residents with a Wander guard order had the device in place and acknowledged she had not yet checked placement that shift. Resident #11 stated, "I took that off months ago," and the LPN searched the room but could not locate the device. The Medical Director stated that an active order meant the device needed to be on the resident, and the DON stated it was the unit nurse's responsibility to check and document placement every shift. The facility's elopement prevention policy stated the Wander guard is to be worn 24 hours a day and that the licensed nurse should initiate an emergency CCP meeting if the resident removes or refuses the device.
Failure to Monitor Intake and Output for Resident on Fluid Restriction
Penalty
Summary
The facility failed to follow physician orders to monitor intake and output accurately for a resident receiving hemolytic treatments and a 1000 mL fluid restriction. Resident #48 had hypertensive chronic kidney disease stage 5, dependence on hemolytic treatments, and diabetes with chronic kidney disease. The care plan identified a potential for fluid volume overload related to end stage renal disease on hemolytic treatments and directed staff to monitor, document, and report signs and symptoms of fluid overload, including sudden weight gain. The physician ordered a 1000 mL fluid restriction in 24 hours and monitoring of intake and output, with notification of the physician if the restriction was not met. Review of the MAR for January and early February showed daily recorded intakes that were all below 1000 mL, including several days with 0 mL, but nursing progress notes did not identify fluid intakes or physician notification when the fluid restriction minimum was not met. A dietician note documented a 5% weight change of 9.3 pounds and later noted the resident's weight increased from 174.16 pounds to 179.01 pounds, with the resident continuing to come in over the target weight. Observation found an intake and output binder at the nursing station, but no worksheet for Resident #48 was present. The dietician stated she relied on electronic documentation entered by NAs, but the recorded MAR amounts could not accurately reflect the resident's actual intake because of the weight fluctuations and weight gain. The DON stated she needed to check the intake and output and fluid restriction policies and was unable to identify how intake and output or fluid restriction amounts were being maintained by nursing staff.
Failure to Monitor AV Fistula Function During Dialysis Care
Penalty
Summary
The facility failed to monitor the AV fistula site for function for Resident #48, whose diagnoses included hypertensive chronic kidney disease stage 5, dependence on dialysis, and diabetes with chronic kidney disease. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 14 and needing varying levels of assistance with activities of daily living. The care plan dated 12/16/25 directed staff to check for AV shunt/fistula bruit and thrill and to provide hemodialysis via the left AV fistula every Tuesday, Thursday, and Saturday, but the physician orders from 1/15/26 through 2/10/26 directed dialysis transport only and did not include monitoring of the AV fistula for bruit and thrill. Observation on 2/8/26 identified an AV fistula in the left upper arm. Review of the pre- and post-dialysis treatment center notes dated 1/10/26, 1/15/26, 1/17/26, 1/20/26, 1/24/26, and 1/27/26 showed an area for AV fistula monitoring was available, but staff did not document that the fistula was being monitored for function as required by the care plan. Review of the clinical record, nurse's notes, and MAR from 1/15/26 through 2/10/26 found no documentation of bruit and thrill monitoring. The DON stated on 2/10/26 that she did not know whether the resident had an AV fistula and was unaware if a bruit or thrill was being monitored for function.
Failure to Ensure Safe Positioning and Adequate Staff Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with significant physical and cognitive impairments, including hemiplegia, vascular dementia, and functional quadriplegia, was not safely positioned in bed and did not receive the required two-person assistance for bed mobility as outlined in the care plan. The resident was dependent on staff for all mobility and personal care needs. During a morning shift, a nurse aide adjusted the height of the resident's bed without first ensuring the resident was in a safe position. The resident was on their side, near the edge of the bed, and the aide did not realize this before raising the bed. As the bed was being adjusted, the resident slid off the bed and landed on the floor in a sitting position. The incident was witnessed, and the resident was unable to verbally express pain due to aphasia. The resident was subsequently sent to the hospital, where imaging revealed an acute comminuted and mildly displaced fracture of the proximal right femur. Staff interviews confirmed that the aide did not check the resident's position or have a second staff member present, as required by the care plan, prior to adjusting the bed.
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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