Touchpoints At Chestnut
Inspection history, citations, penalties and survey trends for this long-term care facility in East Windsor, Connecticut.
- Location
- 171 Main St, East Windsor, Connecticut 06088
- CMS Provider Number
- 075436
- Inspections on file
- 27
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Touchpoints At Chestnut during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown did not have weekly skin assessments documented as required by facility policy. Despite care plans and risk assessments indicating the need for regular monitoring, there were significant gaps in the documentation of skin checks, which was confirmed by the DON during record review.
Multiple resident rooms were observed to have temperatures above 81°F, and several residents reported ongoing discomfort due to excessive heat over a period of weeks. Requests for portable air conditioners were not fulfilled in a timely manner, and the facility was unable to provide temperature logs for several days during a period of high outdoor temperatures. The Maintenance Director confirmed ongoing issues with the air conditioning system.
A resident with severe cognitive impairment and total dependence for care did not receive incontinence care or repositioning every two hours as required by the care plan and facility policy. Documentation and staff interviews confirmed that the resident was left saturated with urine for several hours, and care was not provided until a family member intervened. Facility policy mandates two-hour checks and care for incontinent residents unable to request assistance, which was not followed in this case.
Surveyors identified deficiencies in kitchen sanitation, food labeling, and monitoring practices, including unclean dry storage areas with debris and dead insects, improperly labeled and dated refrigerated food items, inadequate sanitizing solution levels, and dish machine rinse cycles not consistently reaching required temperatures. Documentation and verification of daily cleaning and temperature logs were frequently incomplete or missing, and staff could not provide clear explanations for these lapses.
The facility did not ensure nurse aides received or were properly tracked for the required 12 hours of annual education, including dementia care and abuse prevention. Education was delivered through self-directed poster boards and post tests, often completed in less time than credited, with answer keys available and no instructor present. There was no formal tracking of actual hours completed, and some nurse aides did not complete all required modules or have their competencies verified.
A resident with severe cognitive impairment was admitted without timely review and documentation of required admission paperwork, including resident rights, consent for treatment, and advance directives. The resident's representative did not review or sign these documents until about a month after admission, and the advance directive/code status consent was not signed until six months later, contrary to facility policy.
The facility did not consistently notify physicians or resident representatives when residents experienced significant changes, such as elevated blood glucose levels, returning from leave smelling of marijuana, or being found with smoking materials. In several cases, staff failed to follow physician orders and facility policy regarding notification and documentation, even when incidents were reported among staff or discussed in meetings. This lack of communication and documentation occurred despite clear expectations from the medical director and facility policies.
Two residents experienced failures in the timely reporting and investigation of abuse and neglect allegations. In one case, a resident alleged verbal abuse, including profanity and a racial slur, by a staff member during a smoking break, but the incident was not promptly reported to the state agency as required. In another case, a resident reported neglect after waiting several hours for incontinence care, but the concern was not properly documented or investigated, and key staff were unaware of the allegation. Facility policy requiring immediate reporting and investigation of such incidents was not followed.
A resident with significant care needs reported not receiving incontinence care for several hours after multiple requests for assistance. The facility did not conduct a thorough investigation, failed to document findings, and did not interview or remove involved staff as required by policy. Key staff were unaware of the incident, and the required investigative steps were not followed.
A resident with a new diagnosis of schizoaffective disorder did not receive a required PASARR rescreen after this change in mental health status. The facility's records and care plan reflected the updated diagnosis and use of psychotropic medications, but staff confirmed that only the original PASARR was on file and no new screening was completed as required.
A resident with significant care needs reported waiting five hours for incontinent care after a bowel movement, repeatedly calling for assistance without timely response. Despite the grievance being reported, no RN assessment was performed to check for injuries or complications, and key nursing staff were unaware of the incident. Required facility policy for assessment after a change in condition was not provided.
The facility failed to ensure appropriate care and documentation for multiple residents, including not completing RN assessments after a feeding tube dislodgement, not obtaining or recording weights as ordered, not documenting or following up on refusals of care, and not assessing or notifying providers when a resident repeatedly returned from leave smelling of marijuana. Facility policies and physician orders were not followed, and required documentation was missing.
Two residents with cognitive and physical impairments were repeatedly observed using smoking materials, including vaping and marijuana, inside the facility. Staff failed to consistently report these incidents, and management did not ensure care plans were updated or that appropriate supervision and interventions were implemented. The facility did not follow its own policies for smoking assessments, care plan revisions, or notification of responsible parties and medical providers, resulting in ongoing safety hazards.
A resident with a history of epilepsy, gastrostomy, and dysphagia experienced significant, unaddressed weight loss after admission. Despite documented weight declines and recommendations for supplements, the facility failed to consistently monitor the resident's weight, update the care plan, or provide timely nutritional assessments. Inconsistent dietitian coverage and lack of follow-up contributed to the deficiency.
A resident with a history of alcohol dependence and anxiety disorder was admitted following hospitalization for alcohol withdrawal. The facility failed to assess the resident's smoking status upon admission and did not provide the substance abuse support services recommended by the Level II PASARR, such as group therapy and recovery support groups. During the stay, the resident was repeatedly found with marijuana and smoking paraphernalia, and staff confirmed that no substance abuse support programs were available.
The facility did not ensure timely action on pharmacy consultant recommendations for three residents, resulting in missed or delayed medication management interventions such as stop dates for anticoagulants, appropriate medication forms for tube administration, monitoring for side effects of antipsychotics, and completion of recommended laboratory tests. Staff interviews and record reviews confirmed that pharmacy recommendations were not consistently reviewed, signed, or acted upon by providers as required by facility policy.
Two residents with significant dental needs were not scheduled for recommended outside dental consultations and extractions due to unclear staff responsibilities and lack of training in the referral process, resulting in delays in receiving necessary dental care.
A resident with quadriplegia and full dependence on staff was not assisted out of bed for lunch as ordered by a physician. When the resident requested help, a nurse aide refused, responded disrespectfully, and instructed the resident to get out of bed independently, despite the resident's inability to do so. The incident was documented in the aide's personnel file and confirmed through staff interviews, highlighting a failure to treat the resident with dignity and respect.
A resident with dementia and behavioral disturbances was physically struck in the nose by another resident with a history of behavioral issues after a verbal exchange and accidental contact in a hallway. Despite care plans and staff presence, the altercation was not prevented, resulting in pain and distress for the affected resident.
Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to ensure that weekly skin assessments were documented for two residents who were at risk for skin integrity issues. For one resident with a history of stroke, hemiplegia, incontinence, diabetes, and impaired mobility, the care plan required weekly skin checks and other interventions to prevent skin breakdown. However, there was no documentation of weekly skin observation tool assessments for this resident between February and late June, despite the resident being identified as very high risk for pressure sores on the Braden scale. The only documented skin assessments during this period were at the beginning and end of the timeframe, with a gap of several months in between. Similarly, another resident with chronic ulcer, osteomyelitis, and a history of stroke was also identified as at risk for skin breakdown, with care plan interventions including regular Braden/Norton assessments. For this resident, there was no documentation of weekly skin assessments between late April and mid-July, except for assessments at the start and end of the period. The Director of Nursing confirmed that she could not provide documentation of the required weekly skin assessments for either resident during the specified periods, despite facility policy directing that weekly head-to-toe skin checks be completed and documented.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for residents, as evidenced by observations of three resident rooms with temperatures exceeding 81 degrees Fahrenheit. Specifically, rooms were recorded at 82 and 83 degrees, and multiple residents reported that their rooms had been uncomfortably hot for two to three weeks. Residents expressed dissatisfaction with the temperature, with one resident stating they had requested a portable air conditioner from the Maintenance Director but had not yet received one. The Director of Maintenance confirmed ongoing issues with the air conditioning and chiller systems and acknowledged that requests for portable air conditioners were being prioritized. Additionally, the facility was unable to provide temperature logs for a four-day period during which outdoor temperatures ranged from 86 to 91 degrees Fahrenheit. Interviews with several residents confirmed persistent discomfort due to the heat, and the Maintenance Director verified that the temperature control issues had been ongoing. The lack of temperature documentation and unresolved maintenance concerns contributed to the deficiency in providing a safe, comfortable, and homelike environment for residents.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A resident with a history of stroke, left-sided hemiplegia, dysphagia, epilepsy, diabetes, and severe cognitive impairment was admitted with total dependence for activities of daily living and was always incontinent of bowel and bladder. The care plan and physician's orders required incontinence care and repositioning every two hours to maintain skin integrity and assist with wound healing. On the date in question, documentation and interviews revealed that the resident was not provided incontinence care or repositioned as required between 4:00 PM and 7:00 PM. The resident's family member discovered the resident saturated with urine at 7:00 PM, and facility records failed to show incontinence care provided between 12:21 PM and 10:19 PM that day. Staff interviews confirmed that the resident was checked at 4:00 PM and not again until the family member raised concerns at 7:00 PM. The nurse aide responsible did not return to the resident's room after the initial check, and the nurse confirmed the resident was wet when assessed. Facility policy and the Director of Nursing Services both indicated that incontinent residents unable to request care should be checked and changed every two hours, which was not done in this instance. The lack of timely incontinence care and repositioning was not in accordance with the resident's care plan and facility policy.
Deficiencies in Kitchen Sanitation, Food Labeling, and Monitoring Practices
Penalty
Summary
The facility failed to maintain the kitchen's dry storage areas in a clean and sanitary condition, as evidenced by observations of debris, dead insects, dried pasta, and powdery substances scattered throughout the storage rooms and under shelving. Multiple mouse and insect glue traps were present, and cleaning schedules did not specifically assign or document regular cleaning of these areas. The Dietary Director and staff were unable to provide documentation or clear explanations regarding the cleaning assignments or verification of completed cleaning tasks for these areas. Additionally, the facility did not ensure that previously opened refrigerated items were properly labeled and dated. Packages of meat and bags of what appeared to be raw chicken were found in the walk-in refrigerator without clear identification or date markings. The Dietary Director was unable to confirm the contents or the dates when the items were prepared or opened, and there was confusion regarding the labeling system in use. This lack of proper labeling and dating of perishable food items is contrary to facility policy and food safety standards. The facility also failed to maintain appropriate sanitizing solution levels and dish machine rinse temperatures. Testing of the sanitizing solution in the pot sink and sanitizing bucket revealed levels below the required 200 PPM, and the test strips used were found to be expired. The high temperature dish machine did not consistently reach the required rinse temperature of 180°F, with multiple documented instances of substandard temperatures and missing temperature logs. Daily monitoring sheets for sanitizer levels, dish machine temperatures, and food temperatures were frequently incomplete or missing, and staff did not consistently initial or verify these logs as required by facility policy.
Failure to Provide and Track Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to provide and accurately track the required 12 hours of annual education for nurse aides, including essential topics such as dementia care and abuse prevention. Interviews with the ADNS and RN responsible for staff education revealed that the annual mandatory education was delivered primarily through poster boards and post tests in the staff break room, with no formal tracking system for the actual hours completed by each nurse aide. The staff development nurse and the corporate regional educator both acknowledged that they did not monitor the actual time spent on education modules, instead assigning predetermined credit hours regardless of the time staff actually spent on the material. Multiple nurse aides reported that the mandatory education and dementia training took significantly less time than the hours credited, often completing the material in 15 to 60 minutes. The education was self-directed, with answer keys available for copying, and there was no instructor present to answer questions or verify understanding. Some nurse aides did not complete all required modules, and there was no observation or verification of competency for skills, as staff simply signed off on forms themselves. The corporate COO confirmed awareness of issues with the staff education and competency process during the year in question. A review of the facility assessment indicated that the facility's staffing plan required nurse aide competency in areas such as dementia management and abuse prevention, with training to be completed during orientation and annually. However, the facility was unable to provide a policy for mandatory staff education or documentation verifying that nurse aides received the full 12 hours of required education. The lack of a structured, monitored education program and insufficient documentation led to the deficiency.
Failure to Provide Timely Notice of Rights and Secure Admission Consents
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed of their rights, rules, and responsibilities upon admission. Specifically, the clinical record did not show that the required admission paperwork—including the bed hold policy, contraband policy, consent for treatment, advance directive/code status consent, smoking policy, resident rights, influenza vaccination consent and education, and the facility admission agreement—was reviewed with the resident representative at the time of admission. Additionally, there was no documentation of a signed advance directives/code status consent form at admission. The resident in question was admitted with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, and had severely impaired cognition, requiring moderate assistance with activities of daily living. The resident was hospitalized for alcohol withdrawal prior to admission and was initially identified as full code regarding resuscitation status. However, the care plan and physician orders regarding code status were inconsistent and not supported by timely, signed documentation from the resident or their representative. Interviews with facility staff revealed that the social worker was responsible for reviewing administrative paperwork, while the RN supervisor was responsible for clinical paperwork. The social worker acknowledged that, due to the resident's cognitive impairment, paperwork was reviewed with the resident's representative, but this did not occur until approximately one month after admission. Furthermore, the signed documents were not placed in the resident's paper chart or uploaded to the electronic record. The advance directive/code status consent form was not signed until six months after admission, contrary to facility policy requiring this to be completed upon admission.
Failure to Notify Physician and Resident Representatives of Significant Changes and Incidents
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in resident status and incidents as required by policy and physician orders. For one resident with diabetes, there were multiple documented instances where blood glucose readings exceeded the threshold set by the physician's order, which required immediate physician notification. Despite this, nursing staff did not notify the physician or document such notifications in the clinical record, even though the physician expected to be informed to provide additional insulin coverage. Interviews with nursing staff confirmed that notifications were not made, and the Director of Nursing Services (DNS) stated that her expectation was for staff to follow the physician's order and document all notifications. For another resident with chronic kidney disease who frequently left the facility for dialysis and with family, staff repeatedly noted the resident returned smelling of marijuana. Although this was reported among staff and discussed in meetings, there was no documentation of physician notification, assessment, or notification to the dialysis center, as required by facility policy. The physician was not made aware of these ongoing issues, despite his expectation to be notified due to potential drug interactions with prescribed medications. The facility also lacked documentation of smoking assessments, education, or agreements for this resident, contrary to its own smoking policy. A third resident with a history of substance use and impaired cognition was involved in multiple incidents of suspected smoking and possession of smoking paraphernalia within the facility. Documentation showed that room searches were conducted and smoking materials were found, but there was a lack of evidence that the physician or the resident's representative was notified in most cases. The facility's own policies required such notifications and documentation, but interviews with staff and review of records confirmed these steps were not consistently followed. The only documented notification to the resident's representative occurred after a policy violation that led to discussions of discharge planning.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse involving a resident with a history of hemiplegia, hemiparesis, and depression. During a supervised smoking break, the resident alleged that a nurse aide used profanity and a racial slur towards them. The resident reported the incident to the administrator, but the administrator did not immediately recognize or act upon the allegation of verbal abuse. The charge nurse was informed by the resident that the aide had used a racial slur, but did not escalate the report to the RN Supervisor as required, choosing instead to wait for the resident to calm down before seeking further details. The administrator only became fully aware of the specific allegation the following day, at which point the state agency was notified and an investigation was initiated, outside the required reporting timeframe. In a separate incident, another resident with chronic osteomyelitis and a diaphragmatic hernia reported a concern of neglect after waiting several hours for incontinence care. The resident filed a grievance stating that they called for assistance multiple times over a five-hour period before receiving care. The social worker documented the grievance and reported it to nursing and administration, but the Director of Nursing Services (DNS) was unaware of the concern and could not locate documentation of an investigation. The administrator, upon learning of the allegation, spoke with the resident and the assigned aide, but determined that the information did not require reporting to the state agency, despite facility policy requiring immediate reporting of all allegations of mistreatment. Both incidents demonstrate failures in the facility's process for reporting and investigating allegations of abuse and neglect. The facility's own policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported to the state agency immediately, but in both cases, the required notifications and investigations were either delayed or not completed according to policy. Documentation was incomplete or missing, and key staff members were not always aware of the allegations or the required procedures for handling them.
Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of neglect involving a resident with chronic osteomyelitis and a diaphragmatic hernia. The resident, who required assistance with activities of daily living and was incontinent, reported calling for help after a bowel movement and not receiving assistance for five hours, despite multiple requests. The resident's grievance was documented, but the investigation process was incomplete. Key facility staff, including the Director of Nursing Services (DNS), social worker, and administrator, were responsible for investigating such allegations. However, the DNS was unaware of the incident, and the administrator could not provide documentation of a completed investigation, including staff or resident statements or a summary of findings. The administrator also could not identify the staff involved or explain why the DNS was not included in the investigation. Staff members who worked during the incident were not interviewed as part of the investigation, nor were they removed from the schedule pending the outcome, as required by facility policy. Interviews with staff assigned to the resident on the day of the incident revealed that they were not informed of the allegation, were not asked to provide statements, and did not receive any education related to the event. The facility's policy required immediate reporting and thorough investigation of all allegations of neglect, including removal of the alleged abuser from resident care, but these steps were not followed. Attempts to interview additional staff involved were unsuccessful.
Failure to Complete PASARR Rescreen After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) rescreen was completed for a resident following a new diagnosis of schizoaffective disorder. The resident had an initial Level 2 PASARR evaluation that determined they met the criteria for nursing home level-of-care but did not require specialized mental health services, and no further evaluations were required unless there was a change in condition related to mental illness. Despite the resident later being diagnosed with schizoaffective disorder, this significant change in mental health status was not reported or followed up with a new PASARR screening as required by facility policy and federal/state procedures. Review of the clinical record showed that the resident's primary diagnosis was updated to schizoaffective disorder, and the care plan included interventions for multiple mental health conditions, including the use of psychotropic medications. However, the annual MDS did not identify a serious mental illness or intellectual disability as a Level II PASARR condition. Interviews with facility staff confirmed that the only PASARR on file was the original one, and that a new Level 1 and potentially Level 2 PASARR should have been completed after the new diagnosis. The lack of timely PASARR rescreening following the change in mental health diagnosis constituted the deficiency.
Failure to Conduct RN Assessment After Reported Delay in Incontinent Care
Penalty
Summary
A resident with chronic osteomyelitis, a diaphragmatic hernia, and urinary incontinence reported waiting five hours for incontinent care after a bowel movement. The resident, who required assistance with transfers and perineal care, called for help multiple times over a five-hour period, but staff did not respond until much later. The incident was documented in a grievance report, and the resident was cognitively intact at the time. The baseline care plan and physician's orders indicated the resident's need for significant assistance with mobility and toileting. Despite the resident's report of delayed care, there was no evidence that an RN assessment was conducted to evaluate for potential injuries or complications resulting from the delay. The Director of Nursing Services (DNS) was not aware of the allegation, and the LPN on duty was not informed of the untimely care concern. Facility policy for assessment following a change of condition was requested but not provided. The failure to conduct an RN assessment after the reported delay in care constituted a lapse in meeting professional standards of quality.
Failure to Provide Care and Documentation per Orders and Standards
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and professional standards for multiple residents. For one resident with a history of epilepsy, gastrostomy, and dysphagia, the facility did not complete or document an RN assessment after the dislodgement of a feeding tube, nor did they notify the provider on the day of the incident. There was also a lack of documentation regarding the resident’s removal or self-discontinuation of the G-tube, and weights were not consistently obtained or recorded as ordered by the physician. The clinical record showed significant gaps in weight monitoring, and weights provided by therapy staff were not entered into the resident’s clinical record. Interviews confirmed that staff did not document or communicate key events, and the facility’s own policies on weight monitoring and documentation were not followed. Another resident with congestive heart failure and severe protein calorie malnutrition had a physician’s order for daily weights, which were not consistently obtained or documented on numerous days over several months. When the resident refused weights, there was no documentation of education, re-approach, or notification to the physician or APRN, despite repeated refusals. The care plan did not address refusals of care, and interviews with staff and leadership confirmed that documentation and follow-up were inconsistent or absent. The facility’s policies and guidelines for inotrope therapy, which emphasize the importance of daily weights, were not adhered to in this case. A third resident, with chronic kidney disease and a history of returning from leave of absence or dialysis smelling of marijuana, did not receive care in accordance with professional standards. There was no documentation of assessments upon return, notification to the physician or dialysis center, or education provided to the resident regarding the impact of drug use. The facility also failed to maintain required documentation such as a smoking agreement or smoking assessment, and did not document room searches or the retrieval of smoking materials. Interviews revealed that staff were aware of the issue but did not consistently document or communicate it, and the facility’s smoking policy requirements were not met.
Failure to Prevent and Address Unauthorized Smoking and Substance Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with a history of tobacco and substance use. One resident, with hemiplegia, hemiparesis, and depression, was repeatedly observed by staff vaping in their room and bathroom, in violation of the facility's smoking policy. Despite these observations, there was a lack of consistent reporting to management, and the Director of Nursing Services (DNS) was not made aware of the incidents. The care plan for this resident did not initially address the ongoing unauthorized use of smoking materials, and staff interviews revealed that management was aware of the behavior but did not take effective action. Another resident, with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, was involved in multiple incidents of smoking and possession of smoking paraphernalia within the facility. Documentation showed that this resident was found with marijuana, a lighter, and a smoking pipe on several occasions, and was observed smoking in both their room and a facility bathroom. The facility failed to notify the resident's physician or conservator after these incidents, did not revise the care plan to address the repeated policy violations, and did not consistently document or implement increased supervision or other interventions. Staff interviews indicated that the issue of residents smoking, including marijuana use, was ongoing and that reporting and follow-up were inconsistent or lacking. Facility policy required smoking assessments upon admission and after significant changes, as well as care plan updates and supervision for residents with smoking risks. However, the facility did not adhere to these requirements, as evidenced by the lack of smoking assessments, care plan revisions, and documentation of interventions following repeated incidents. The facility also failed to consistently notify responsible parties and medical providers, and did not maintain adequate records of investigations or actions taken in response to the observed hazards, resulting in a failure to protect residents from accident hazards related to unauthorized smoking and substance use.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status and weight of a resident with a history of epilepsy, gastrostomy, and dysphagia, who was dependent on staff for care and had a G-tube for enteral nutrition. Upon admission, the resident weighed 173.6 lbs, but within a week, a significant weight loss of 9.4 lbs (5.4%) was documented. The dietitian recommended nutritional supplements and an appetite stimulant, but there was no evidence that the stimulant was started, and no follow-up weights or nutritional assessments were performed in the subsequent weeks. After a hospitalization and readmission, the resident's weight continued to decline, with a further loss of 21 lbs (12.1%) since admission. Despite this, there were no documented weights or nutritional assessments for the entire month following readmission, and the care plan was not revised to address the ongoing weight loss. Interviews revealed that the facility lacked consistent, in-person dietitian coverage, with periods of only remote coverage and uncertainty among staff about who was responsible for nutritional oversight. Staff also reported that diet slips and diet change forms were not being signed off by a dietitian for newly admitted residents. Facility policy required weights to be obtained on admission and monthly, with additional monitoring and interventions for significant weight changes. However, the resident did not receive the required monitoring or timely interventions after multiple episodes of significant weight loss. Interviews with staff and the resident confirmed that weight monitoring was inconsistent, and the lack of dietitian presence contributed to the failure to reassess and update the nutritional care plan as required.
Failure to Implement PASARR Recommendations for Substance Abuse Support
Penalty
Summary
A deficiency occurred when the facility failed to implement Level II PASARR recommendations for a resident with a diagnosed substance abuse disorder. The resident was admitted with a history of alcohol dependence, anxiety disorder, and repeated falls, and had recently been hospitalized for alcohol withdrawal. Upon admission, the resident's smoking status was not assessed, and subsequent clinical records did not document any smoking assessments. Despite a physician's order for supervised smoking and care plan interventions for safety risk evaluations, the admission MDS did not identify current tobacco use, and there was no evidence that the recommended substance abuse support services were provided. The Level II PASARR identified that the resident required specific services, including participation in a support group for substance abuse recovery (such as Alcoholics Anonymous), group therapy with a trained therapist, and the appointment of a guardian conservator for health and safety decisions. While the care plan acknowledged these recommendations, the facility did not offer group counseling or substance abuse support programs. Interviews with facility staff confirmed that the recommended services were not available, and there was no documentation of the resident receiving these supports. During the resident's stay, multiple incidents occurred involving the possession and use of marijuana and smoking paraphernalia, as well as violations of the facility's smoking and safety policies. Room searches revealed marijuana, a smoking pipe, and a pocketknife in the resident's possession. Despite these findings and the clear recommendations from the PASARR, the facility did not provide the required substance abuse support services, contributing to ongoing behavioral and safety concerns.
Failure to Act on Pharmacy Consultant Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that physicians or advanced practice registered nurses (APRNs) acted upon pharmacy consultant recommendations in a timely manner for three residents reviewed for unnecessary medications. For one resident with multiple complex diagnoses, including diabetes, stroke, epilepsy, and gastrostomy, the pharmacy consultant made several recommendations over multiple months regarding medication management, such as adding stop dates for anticoagulants, switching medication forms for easier administration via feeding tube, and monitoring for side effects. Despite these recommendations, there was no documentation that the physician or APRN responded to or acted upon them within the expected timeframe, as required by facility policy. Interviews with facility staff confirmed that the process for following up on pharmacy recommendations was inconsistent, with forms not always being reviewed, signed, or returned by the responsible providers. Another resident with a history of stroke, diabetes, and heart failure was started on an antipsychotic medication, and the pharmacy consultant recommended baseline and ongoing monitoring for side effects, as well as laboratory testing for lipid profiles. The clinical record review revealed that these recommendations were not completed, and the forms were not signed or dated by the provider. Interviews with nursing and pharmacy staff confirmed that the recommendations were not reviewed or acted upon, and the required monitoring and laboratory tests were not documented in the resident's record. A third resident with bipolar disorder and hyperlipidemia was receiving an antipsychotic medication, and the pharmacy consultant recommended ordering a lipid profile and HbA1C due to the risk of diabetes and dyslipidemia. Although the prescriber agreed with the recommendations, only the HbA1C was completed, and there was no documentation that the lipid profile was ordered or completed. Facility staff interviews indicated that the process for ensuring completion of pharmacy recommendations was not consistently followed, resulting in missed or delayed actions on important medication management recommendations.
Failure to Schedule and Follow Up on Dental Referrals
Penalty
Summary
The facility failed to follow through on recommendations for outside dental consultations for two residents who required specialized dental care. One resident, with a history of multiple sclerosis, paraplegia, and cardiomegaly, was fully dependent on staff for oral hygiene and had documented dental issues including tooth decay and mobile teeth. Despite a dental provider's note indicating the need for an outside dental appointment for specific teeth, the resident was not scheduled for the recommended consultation for several months. Interviews revealed that the staff responsible for scheduling such appointments was unclear about their responsibilities and had not received adequate training on the referral process, resulting in the delay. Another resident, diagnosed with type 2 diabetes, reduced mobility, and requiring a mechanically altered diet, was identified as having significant dental issues, including cavities and broken teeth. The dental provider recommended referral to an oral surgeon for extractions prior to denture fabrication. However, the resident was not scheduled for the necessary dental extractions, and staff interviews indicated confusion and lack of clarity regarding the process for scheduling follow-up appointments. The staff member responsible for appointments had only recently taken on this role and had not been fully trained, contributing to the oversight. Facility policy required assistance with making appointments and arranging transportation for medical and professional services, including dental care. Despite this, the lack of clear procedures and staff training led to failures in ensuring timely dental services for the residents, as recommended by consulting dental providers.
Failure to Honor Resident Dignity and Physician Orders During Transfer Request
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, contracture of the left hand, and chronic pain syndrome, who was fully dependent on staff for all activities of daily living and required transfer via a Hoyer lift, was not assisted out of bed for lunch as per physician's orders. The resident requested assistance from a nurse aide to be transferred to a wheelchair before lunch, but the aide refused, stating she was busy and instructed the resident to get out of bed independently, despite the resident's inability to do so due to their medical condition. The resident reported this interaction to a registered nurse supervisor, and documentation confirmed that the aide responded in a rude and disrespectful manner, failed to follow the physician's order, and was insubordinate to the supervising nurse. The clinical record did not document the negative interaction, but the aide's personnel file included a corrective action record for the incident, noting the refusal to assist the resident and the disrespectful communication. The aide had a history of multiple disciplinary actions related to care issues. Interviews with facility staff confirmed awareness of the incident and the expectation that all residents be treated with dignity and respect. The facility's policy directs that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with dementia, epilepsy, anxiety disorder, and depressive disorder was involved in a physical altercation with another resident who had a history of behavioral problems, including being inconsiderate to roommates and intentionally disturbing others. The incident occurred when the first resident was waiting at the nurse's medication cart and accidentally touched the second resident, who was attempting to pass by in a wheelchair. The second resident responded by shouting and then physically striking the first resident in the nose. The facility's documentation indicated that both residents had care plans addressing their behavioral issues, with interventions such as monitoring behaviors, documenting observed incidents, and intervening to protect the rights and safety of others. Despite these interventions, the altercation occurred, resulting in the first resident experiencing pain and discomfort, though no visible trauma was noted upon assessment. Staff present at the scene attempted to intervene but were unable to prevent the physical contact, and one staff member was injured while separating the residents. Interviews with the involved resident and staff confirmed the sequence of events, with the resident expressing feelings of embarrassment and fear following the incident. The facility's abuse policy prohibits abuse, neglect, and mistreatment by anyone, including other residents. The report documents that the facility failed to protect the resident from physical abuse by another resident with a known history of altercations.
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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