Summit At Plantsville Center For Health & Rehabili
Inspection history, citations, penalties and survey trends for this long-term care facility in Plantsville, Connecticut.
- Location
- 261 Summit Street, Plantsville, Connecticut 06479
- CMS Provider Number
- 075420
- Inspections on file
- 32
- Latest survey
- April 27, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Summit At Plantsville Center For Health & Rehabili during CMS and state inspections, most recent first.
The facility failed to revise and implement a behavior-focused care plan and care card after multiple physical altercations between two cognitively impaired residents on a secured unit. One resident with dementia, anxiety, and violent behavior had known triggers related to fear of theft and unfamiliar people, while another resident with dementia and wandering behavior was newly admitted. Despite documented verbal and physical altercations, including incidents where one resident struck and pushed the other causing injury, the written care plan and care card were not updated to include specific behavioral triggers, de-escalation strategies, or clear directions to keep the two residents separated. Instead, staff relied on temporary 1:1 monitoring, periodic checks, and verbal communication in huddles, leaving some staff, including an NA unfamiliar with the residents, without written guidance on maintaining safe distance or managing interactions, which preceded another physical altercation in one resident’s room.
A resident with dementia, anxiety, and a history of violent behavior had a care plan noting potential physical aggression and general interventions such as reassurance and monitoring, but the plan and care card were not updated with specific, measurable strategies after the resident pushed another cognitively impaired resident, causing a fall and head injury. Despite this initial altercation and temporary one-to-one monitoring, the written interventions remained unchanged, and staff continued to rely on existing generic directions. Later, when the same two residents encountered each other again in one resident’s room, another physical altercation occurred. A NA on duty reported not receiving specific instructions about keeping the two residents apart or how to manage them when in close proximity, while the DON reported relying on verbal staff huddles rather than revising the written care plan and care card.
A resident with dementia and a history of falls was observed by a nurse aide and an LPN sleeping in the dining room, contrary to the care plan directive to encourage sleeping in the resident's own bedroom. Staff did not intervene, and the resident later fell while attempting to walk, sustaining multiple pelvic fractures. Facility policy required implementation of person-centered care plans, which was not followed in this instance.
A resident with dementia and multiple comorbidities suffered a fall and reported severe pain, but did not receive as-needed acetaminophen for pain relief during the hour before hospital transfer. Both the LPN and RN present observed the resident's distress but did not administer pain medication, despite facility policy and an active PRN order. Hospital evaluation later revealed multiple pelvic fractures.
A resident with dementia and mobility deficits, care planned for two-person assist during transfers, was transferred by a single nurse aide. During the transfer, the resident became combative and sustained a laceration to the left shin after hitting the wheelchair, requiring sutures. Facility records and interviews confirmed the care plan was not followed.
A medication cup containing multiple pre-poured medications for a resident was left unsecured on top of a medication cart in the hallway when an LPN walked away to assist another resident, leaving the cart unattended and out of sight. The ADON confirmed that this action was against facility policy, which requires medications to be secured or under visible control at all times.
A resident with multiple medical conditions sustained a head injury when a Hoyer lift tipped during a transfer to a shower chair. The incident occurred because staff were unable to fully open the lift's legs for stabilization due to space constraints and obstacles in the room, resulting in the lift striking the resident's forehead. Staff interviews confirmed that environmental limitations prevented proper use of the lift, and the facility's policy requiring full stabilization was not followed.
A resident with Alzheimer's and hemiparesis was injured when a nursing assistant failed to respect the resident's request to slow down while pushing their wheelchair. The resident's hand was caught between the wheelchair and doorframe, resulting in redness and an x-ray. The facility's investigation confirmed the NA's failure to adhere to the resident's request and the need for caution, violating the resident's right to dignity and respect.
Failure to Update Behavior Care Plan After Repeated Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to revise and implement a resident-specific care plan and care card with clear behavioral interventions after repeated resident-to-resident physical altercations on a secured unit. One resident (Resident #1), admitted in April 2025 with dementia, anxiety disorder, and violent behavior, was identified as severely cognitively impaired and having the potential to be physically aggressive related to progressive cognitive impairment. The care plan noted that this resident expressed fear that others might steal personal belongings, especially the remote control, and that behavior escalated when unfamiliar individuals were present. Interventions included proactively introducing new staff and residents and monitoring for danger to self and others, while the care card only directed staff to assist with hand hygiene and monitor for agitation and restlessness. Another resident (Resident #2), admitted in March 2026 with dementia, cognitive communication deficit, and post-traumatic stress disorder, was also severely cognitively impaired and had wandering behavior. Shortly after admission, nursing notes documented arguments between the two residents, with staff separating them several times. On 3/22/26, a reportable event documented that a verbal altercation between the two residents turned physical when Resident #1 struck Resident #2 on the left cheek, causing bruising, swelling, and a small laceration. A one-to-one monitor was initiated for Resident #1 and Resident #2’s room was changed. The care plan for Resident #1 was updated to include one-to-one monitoring and psychiatric consultation, but the care card remained unchanged and did not include specific triggers, de-escalation strategies, or instructions to keep the two residents apart. On 3/28/26, another reportable event documented that yelling was heard in the hallway and a nurse witnessed the two residents standing in close proximity, yelling at each other. Resident #1 struck Resident #2, Resident #2 struck back, and Resident #1 then pushed Resident #2, who fell and struck the head on the floor, sustaining a small laceration. A one-to-one monitor was again assigned to Resident #1, but the care plan still did not identify additional interventions to prevent further altercations with other residents, and the care card continued to list only hand hygiene and monitoring for agitation and restlessness. The one-to-one monitor was discontinued the next day, and 15-minute checks were implemented for Resident #1, but no changes were made to the care card through 4/9/26. On 4/10/26, another reportable event documented that Resident #2 entered Resident #1’s room. A nursing assistant, who had only worked with Resident #1 twice before and was unfamiliar with Resident #2, followed Resident #2 into the room to redirect and locate a walker. Resident #1 yelled at Resident #2 to get out of the room, and when Resident #2 touched Resident #1’s walker, Resident #1 punched Resident #2 in the face. Resident #2 punched back, and the two residents continued to exchange punches until another nursing assistant intervened and redirected Resident #2 out of the room. The nursing assistant reported that, although a shift report was received, there were no specific instructions that these two residents needed to be kept at a safe distance or how to manage them when in close proximity, and the assistant was unaware of their prior altercations. The Director of Nursing Services stated that staff huddles and direct reports were used to communicate issues between the residents and acknowledged that the care plan and care card for Resident #1 were not updated with specific interventions, while relying on huddles and medication adjustments instead.
Failure to Update Care Plan After Resident-to-Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to update a cognitively impaired resident’s comprehensive care plan with specific, measurable interventions after a physical altercation, despite known aggressive behaviors. Resident #1, admitted in April 2025 with dementia, anxiety disorder, and violent behavior, was identified on a quarterly MDS as severely cognitively impaired, needing partial assistance with bathing and hygiene, and able to ambulate with supervision. The resident’s care plan dated 3/25/26 already noted potential for physical aggression related to progressive cognitive impairment and included general interventions such as reassuring the resident about personal belongings, proactively introducing new staff and residents, and monitoring and reporting signs of danger to self and others. The resident care card from 3/22/26 through 3/27/26 listed only assistance with hand hygiene and monitoring for agitation and restlessness. On 3/28/26, an LPN heard yelling and witnessed Resident #1 push another cognitively impaired resident (Resident #2), causing a fall and head strike that resulted in a small laceration and transfer to the hospital. Although a one-to-one monitor was assigned to Resident #1 and later discontinued, the resident’s care plan and care card were not updated with additional, specific interventions to deter or prevent further altercations with other residents. From 3/28/26 through 4/9/26, the care card interventions remained unchanged from those in place before the first altercation. On 4/10/26, Resident #2 entered Resident #1’s room, and Resident #1 yelled at and punched Resident #2, who then hit Resident #1 back. A nursing assistant working that shift reported having worked with Resident #1 only twice before, being unfamiliar with Resident #2, and not receiving specific instructions about keeping the two residents apart or managing them in close proximity, and the DNS acknowledged relying on staff huddles rather than updating the resident’s care plan and care card with specific interventions after the initial incident.
Failure to Implement Care Plan Intervention for Fall Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident identified as a potential fall risk. The resident, who had diagnoses including dementia, muscle weakness, anxiety, and major depressive disorder, was noted in the care plan to have a behavior of sleeping in the dining room at bedtime. The care plan directed staff to encourage the resident to sleep in their own bedroom. However, on the night of the incident, both a nurse aide and an LPN observed the resident sleeping in the dining room with the lights off but did not wake the resident or encourage them to return to their room as required by the care plan. Subsequently, the resident attempted to walk and fell, resulting in multiple minimally displaced pelvic fractures. Documentation confirmed that the resident was found on the floor in front of a chair, reported significant pain, and was transferred to the hospital for evaluation and treatment. Interviews with staff and facility leadership confirmed that the care plan intervention was not followed, and the facility's policy required that person-centered care plans be implemented by qualified staff.
Failure to Provide Timely Pain Management After Resident Fall
Penalty
Summary
A resident with a history of dementia, muscle weakness, anxiety, and major depressive disorder experienced a fall in the dining room during the night. The resident was found on the floor, complaining of severe pain (rated 8 out of 10) in the right thigh, and exhibited limited range of motion due to pain. Despite having an active order for acetaminophen as needed for pain, the clinical record and Medication Administration Record (MAR) showed no documentation that pain medication was administered during the hour the resident waited to be transferred to the hospital. Both the charge nurse (LPN) and the Nursing Supervisor (RN) were present, observed the resident's pain, and acknowledged in interviews that the resident was in significant distress, but neither provided pain relief prior to transfer. Hospital imaging later confirmed the resident had sustained multiple minimally displaced pelvic fractures. Interviews with facility staff, including the APRN and Assistant Director of Nursing, confirmed that pain management should have been provided according to facility policy, which directs staff to evaluate and medicate for new or acute pain. The failure to administer pain medication was not in accordance with the facility's pain management policy and resulted in the resident remaining in severe pain for an extended period.
Failure to Follow Two-Person Transfer Protocol Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including dementia with agitation, Alzheimer's Disease, anxiety, and weakness, and was dependent on staff for transfers, was not assisted by two staff members during a transfer as required by the care plan. The care plan specified that the resident needed a two-person assist for transfers due to functional mobility deficits and a history of being resistive to care. Despite these directives, a nurse aide attempted to transfer the resident alone, without the assistance of a second staff member. During the solo transfer attempt, the resident became agitated and combative, which resulted in the resident hitting their left lower leg on the wheelchair and sustaining a laceration. The injury required medical attention, including transfer to the emergency department and the placement of sixteen sutures. Facility documentation and interviews confirmed that the care plan was not followed, and the transfer was conducted by only one staff member, contrary to established protocols.
Unattended Pre-Poured Medications Left on Medication Cart
Penalty
Summary
A medication cup containing pre-poured medications for one resident was left unsecured on top of a medication cart in the hallway when the charge nurse, an LPN, walked away to assist another resident with putting on shoes. The medication cart was left unattended and not within the nurse's line of sight, while several residents were observed sitting nearby in the hallway. The incident was observed during a facility tour with the Assistant Director of Nursing (ADON), who acknowledged the presence of the unattended medication cup on the cart. Review of the medication administration record confirmed that the cup contained multiple medications, including citalopram, empaglifozin, folic acid, loratadine, Norvasc, risperidone, apixaban, Entresto, metformin, Senokot S, and vitamin B12, all intended for a specific resident. Both the LPN and the ADON confirmed in interviews that medications should not be left unattended or unsecured, and facility policy requires medications to be kept secured in a locked area or under visible control at all times.
Resident Head Injury Due to Improper Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe mechanical lift (Hoyer lift) transfer for a resident with multiple medical conditions, including atrial fibrillation, neuropathy, muscle wasting, and a right hand contracture. The resident required substantial assistance with bed mobility and was dependent on staff for transfers. During a transfer to a shower chair, the Hoyer lift tipped and struck the resident on the forehead, resulting in a bump, bruising, and subsequent headaches. The incident was witnessed by two nursing assistants, and the resident was later evaluated for a head contusion and worsening ecchymosis around the eyes. The transfer was complicated by environmental constraints in the resident's room. The large shower chair could not fit next to the bed, requiring staff to position it in the doorway. Staff had to maneuver the Hoyer lift past the resident's roommate and other obstacles, such as a bedside table that could not be moved due to the roommate's objections. As a result, the Hoyer lift legs could not be fully opened for stabilization, contrary to the facility's mechanical lift policy and manufacturer guidelines. This lack of proper stabilization led to the lift tipping during the transfer process. Interviews with staff involved in the incident confirmed that space limitations and the inability to fully open the Hoyer lift legs contributed to the accident. The Director of Nursing Services was unaware of the environmental challenges staff faced during transfers in this room. The facility's policy required the Hoyer lift legs to be locked in the maximum open position for stability and resident safety, which was not possible in this situation due to the room's layout and obstacles.
Failure to Respect Resident's Request Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by an incident involving a nursing assistant (NA) and a resident with Alzheimer's and left-sided hemiparesis. The resident, who had moderate cognitive impairment and was dependent on assistance for activities of daily living (ADLs) and transfers, was being pushed in a wheelchair by NA #1. Despite the resident's request for the NA to slow down, the NA continued to push the wheelchair quickly, resulting in the resident's hand getting caught between the wheelchair wheel and the doorframe, causing redness and necessitating an x-ray. The facility's investigation confirmed that the NA did not heed the resident's request to slow down and was not careful when maneuvering through the doorway, leading to the resident's injury. The Director of Nursing Services (DNS) acknowledged that the NA should have slowed down and been more cautious. The facility's Residents' Rights policy emphasizes the right of residents to be treated with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this incident.
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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