Villa At Stamford, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Stamford, Connecticut.
- Location
- 88 Rockrimmon Road, Stamford, Connecticut 06903
- CMS Provider Number
- 075153
- Inspections on file
- 27
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Villa At Stamford, The during CMS and state inspections, most recent first.
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 Alzheimer's disease and severe cognitive impairment, who required maximum assistance with eating, had multiple instances of missing meal intake documentation over nearly a month. Despite facility policy and expectations for accurate recordkeeping, several breakfasts, lunches, and dinners were not recorded in the EMR, as confirmed by interviews with the dietician and DON.
A resident with a history of aggressive behaviors, including verbal and physical gestures, repeatedly directed negative actions toward another cognitively impaired resident. Despite staff awareness of these ongoing behaviors, care plans did not address the escalating conflict, resulting in a physical altercation where one resident struck the other. The lack of specific interventions and care plan updates contributed to the incident of resident-to-resident abuse.
A resident with hemiplegia/hemiparesis was involved in an abuse allegation where a family member reported a nursing assistant slapped the resident. The facility's investigation found no injuries and could not substantiate the claim. However, the social worker failed to document a follow-up visit with the resident, violating the facility's documentation policy.
The facility failed to follow dental orders for a resident needing a tooth extraction, resulting in multiple cancellations due to not discontinuing aspirin and lacking an Ativan order. Additionally, another resident with a surgical incision did not receive prescribed sulfadiazine cream treatment as ordered. Staff interviews revealed a breakdown in transcribing and administering physician orders, with the DNS acknowledging the failure to follow expected procedures.
A resident with COPD, dementia, and a psychotic disorder was found smoking in their room, but the responsible party was not notified until five days later. The facility's policy requires prompt notification of incidents, which was not followed in this case.
A resident with multiple mental health diagnoses did not receive a timely Level II PASRR screening after their short-term approval expired. The facility's social worker failed to submit the necessary screening, which was completed seven months late, despite the facility's policy requiring timely assessments for residents with short-term PASRR approvals.
The facility failed to update care plans for two residents after significant incidents. One resident, with a history of smoking, was found smoking in their room, but the care plan was not revised to include new interventions like a nicotine patch. Another resident, admitted for rehabilitation with a cervical fracture and an implanted loop recorder, did not have their care plan updated to include necessary interventions for the neck collar and surgical incision monitoring. Staff interviews revealed that care plans were not revised due to time constraints, despite facility policy requiring comprehensive care plans.
A resident with hemiplegia and other conditions did not have splints applied as per physician orders, leading to contracted limbs. Despite a care plan and orders for specific splints, observations showed they were not consistently used. Interviews with staff and the resident confirmed the inconsistency, and the facility's policy on orthotics was not followed, resulting in a deficiency in care.
A resident with a history of COPD and dementia was found smoking in their room, violating the facility's no-smoking policy. The resident accessed smoking materials brought by their spouse, highlighting lapses in supervision and documentation. Staff interviews revealed missing admission paperwork and incomplete incident reporting, contributing to the deficiency.
A facility failed to implement contact precautions for a resident with a multi-drug resistant organism (MDRO) infection, despite heavy wound drainage and treatment with intravenous antibiotics. The resident, who had lymphedema, sepsis, MRSA infection, and schizoaffective disorder, was only placed on enhanced barrier precautions (EBP). Staff interviews revealed a lack of communication and oversight in updating the resident's precautionary status, and a misunderstanding of the difference between EBP and contact precautions.
The facility did not complete annual performance evaluations for three nurse aides, as required by policy. Personnel files lacked documentation of 2023 evaluations. The DNS acknowledged the oversight, confirming it was her responsibility to ensure reviews on anniversary dates. Facility policy mandates annual written reviews by department supervisors, which were not conducted.
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.
Incomplete Meal Intake Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for a resident with Alzheimer's disease and anxiety who was at risk for weight loss. The resident was identified as being severely cognitively impaired and required maximum assistance with eating. Review of the resident's care plan directed staff to feed the resident meals. However, meal intake documentation was missing for multiple breakfasts, lunches, and dinners over a period of nearly one month. Specifically, several dates were identified where meal intakes were not recorded in the electronic medical record. Interviews with the dietician and the DON confirmed that it was the expectation for staff to document meal intakes accurately after each meal, and that the facility's policy required records to be accurate and based on resident information. The DON was unable to provide an explanation for the missing documentation. The deficiency was identified through clinical record review, facility documentation review, policy review, and staff interviews.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with a history of behavioral issues, including verbal and physical aggression, was not adequately protected from physical abuse by another resident. The resident, who had diagnoses such as impulse disorder, intellectual disabilities, schizophrenia, and delusional disorder, frequently directed negative comments, gestures, and spitting toward another resident with severe cognitive impairment. Multiple staff members, including LPNs, a social worker, and a psychiatric APRN, confirmed that the resident regularly expressed dislike and made threatening gestures toward the other resident, who typically did not react to these provocations. On the day of the incident, staff heard yelling in the hallway and observed both residents with raised arms. An LPN witnessed the cognitively impaired resident strike the resident with behavioral issues on the cheek after the latter had reportedly hit the former first. The resident who was struck exhibited distress, repeatedly hitting their own cheek and stating they had been hit. Documentation and interviews confirmed that the resident with behavioral issues admitted to hitting the other resident first because of personal dislike. Prior to this incident, the care plans for both residents did not specifically address the ongoing negative interactions and behaviors between them. Although staff were aware of the frequent verbal and non-verbal aggression, interventions to keep the residents separated or to address the specific conflict were not implemented in the care plans until after the physical altercation occurred. The lack of targeted interventions and failure to update care plans contributed to the occurrence of resident-to-resident physical abuse.
Incomplete Documentation Following Abuse Allegation
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate following an allegation of abuse. The resident, who was admitted with hemiplegia/hemiparesis after a cerebral infarction, was reported by family to have been slapped by a nursing assistant. An assessment was conducted with no injuries noted, and the facility's investigation could not substantiate the allegation. However, the clinical record did not include documentation of a follow-up visit by social services after the incident. The social worker admitted to seeing the resident for a follow-up support visit but failed to document the encounter, stating she forgot to write a note. The Director of Nursing Services confirmed that the social worker should have documented the visit. The facility's Charting and Documentation Policy requires all observations and services performed to be documented in the resident's clinical record, which was not adhered to in this case.
Failure to Follow Dental and Medical Orders
Penalty
Summary
The facility failed to follow dental orders for a resident requiring a tooth extraction. The resident, who had a history of dysphagia and other conditions, was scheduled for a tooth extraction to facilitate the fitting of dentures. However, the facility did not discontinue the resident's aspirin as ordered by the dentist, nor did they have an order in place for Ativan to manage the resident's anxiety prior to the procedure. This oversight led to multiple cancellations of the dental procedure, delaying the resident's dental care and denture fitting. Another deficiency involved a resident with a surgical incision who required treatment with 1 percent sulfadiazine cream. The physician's order specified that the cream should be applied twice daily to the resident's left chest. However, the treatment administration record did not reflect that the cream was administered as ordered, indicating a failure to follow the physician's directive. This lapse in care was identified during a review of the treatment records and confirmed through staff interviews. Interviews with facility staff, including LPNs and the DNS, revealed that there was a breakdown in the process of transcribing and administering physician orders. The DNS acknowledged that the orders were not followed as expected, and the facility's policies required that all medications be administered according to written orders from licensed prescribers. These deficiencies highlight a failure in the facility's processes to ensure that residents receive the prescribed care and treatment.
Failure to Notify Responsible Party of Smoking Incident
Penalty
Summary
The facility failed to notify the responsible party of a resident who was found smoking in their room, which is a violation of the facility's policy on reporting incidents. The resident, who has diagnoses including chronic obstructive pulmonary disease, dementia, and a psychotic disorder with delusions, was found smoking in their room with their spouse present. The nursing note documented that the resident was educated on the smoking policy, a room search was conducted, and a new order for a Nicotine patch was obtained. However, the reportable event report did not indicate that the resident's responsible party was notified of the incident. Interviews revealed that the responsible party was not informed of the incident until five days later, via an email from a social worker. The Director of Nursing Services (DNS) acknowledged that the responsible party should have been notified at the time of the incident and that the reportable event report was not completed until two days after the incident due to her being busy. The facility's policy requires that all incidents be promptly investigated and reported, with the family being notified and the date/time of notification documented on the reportable event form.
Failure to Complete Timely PASRR Screening for Resident
Penalty
Summary
The facility failed to complete a necessary Preadmission Screening and Resident Review (PASRR) for a resident with multiple mental health diagnoses, including paranoid personality disorder, delusional disorder, post-traumatic stress disorder, and major depressive disorder. The resident, who had intact cognition and was dependent on a wheelchair for mobility and all activities of daily living, was initially given a short-term approval without specialized services, which required a follow-up Level II screening. However, this screening was not completed until seven months after the short-term approval had expired. The deficiency was identified during a review of the resident's clinical records and interviews with facility staff. The social worker responsible for the PASRR process acknowledged that she should have submitted the resident for a Level II screening following the expiration of the short-term approval. The facility's policy required the social worker to complete a new level screen and level of care assessment if a resident was admitted with a short-term or time-sensitive PASRR. Despite this policy, the necessary screening was delayed, resulting in a failure to comply with the required procedures for residents with mental health needs.
Failure to Update Care Plans for Residents After Incidents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents following significant incidents. Resident #23, diagnosed with chronic obstructive pulmonary disease, dementia, and a psychotic disorder, was found smoking in their room, which violated the facility's smoking policy. Despite the incident, the care plan was not updated to reflect the new interventions, such as the use of a nicotine patch, to address the unauthorized smoking behavior. Interviews with staff, including the Director of Nursing and a Social Worker, revealed that the care plan had not been revised due to time constraints, despite the facility's policy requiring an interdisciplinary team to develop individualized care plans. Resident #45, admitted for short-term rehabilitation following a cervical vertebrae fracture, required the use of an Aspen neck collar and had an implanted loop recorder. The care plan failed to include necessary interventions for the use of the neck collar and the monitoring of the surgical incision related to the loop recorder. Nursing notes did not reflect monitoring for signs of infection at the incision site. Interviews with an LPN and the Director of Nursing Services indicated that the care plan should have addressed these needs, but it was not updated to include the physician's instructions for care and monitoring. The facility's policy mandates that the interdisciplinary team is responsible for creating comprehensive care plans for each resident. However, in both cases, the care plans were not updated to reflect the residents' current needs and interventions following significant incidents, highlighting a deficiency in the facility's care planning process.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a resident, who had specific physician orders for splint use, had the splints in place daily as required. The resident, diagnosed with hemiplegia, hemiparesis, legal blindness, rheumatoid arthritis, and vascular dementia, was observed multiple times without the necessary splints on their upper extremities. Despite the care plan and physician's orders specifying the use of various splints, including a left elbow splint, right resting hand splint, and left-hand carrot splint, these were not consistently applied during morning care. Interviews with the resident revealed that the splints had not been placed for some time, and the resident had not refused their use. Observations confirmed the absence of splints on several occasions, and staff interviews indicated a lack of consistent application of the splints. Nursing staff and nursing assistants were both responsible for ensuring the splints were applied, yet there was a failure to do so, as evidenced by the resident's contracted limbs and the absence of splints during observations. The facility's policy on the use of orthotics for contracture management was not adhered to, as splints were not applied according to the individualized wearing schedule. The policy required splints to be removed every two hours for skin inspection and reapplication, but this was not consistently followed. The therapy director and other staff interviews highlighted a lack of adherence to the care plan and physician's orders, contributing to the deficiency in care for the resident.
Inadequate Supervision Leads to Resident Smoking Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from smoking in their room, which posed a significant safety hazard. The resident, who had a history of chronic obstructive pulmonary disease, dementia, and a psychotic disorder, was found smoking in their room despite the facility's no-smoking policy. The resident's care plan indicated they required supervision for personal care, but the incident revealed a lapse in monitoring. The resident's spouse had brought smoking materials, which the resident accessed, leading to the incident. Interviews with staff highlighted several procedural lapses. The Nursing Supervisor noted the incident but did not complete the Accident and Incident report promptly. The Director of Nursing acknowledged that the resident should have been treated as a new admission due to their extended absence from the facility, which would have required updated admission paperwork, including acknowledgment of the no-smoking policy. However, the necessary documentation was missing, and the care plan was not updated following the incident. The facility's policies on reportable events and smoking were not adequately enforced. The Admissions Director could not locate the signed no-smoking agreement for the resident, and the Social Worker failed to document discussions with the resident and their spouse about the dangers of smoking. The facility's failure to implement and document preventive measures and update care plans contributed to the deficiency, as did the lack of a timely investigation into the incident.
Failure to Implement Contact Precautions for Resident with MDRO
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident actively infected with a multi-drug resistant organism (MDRO). The resident, identified as having lymphedema, sepsis, Methicillin Resistant Staphylococcus Aureus (MRSA) infection, and schizoaffective disorder, was not placed on contact precautions despite having a wound with heavy drainage. The resident's care plan included enhanced barrier precautions (EBP) due to a lower extremity wound, but the facility did not update the precautions to contact precautions as recommended by the Centers for Disease Control and Prevention (CDC) for residents with active infections and uncontained drainage. The resident's clinical records showed a wound culture with heavy growth of pseudomonas aeruginosa and moderate growth of MRSA, and the resident was treated with intravenous antibiotics. Despite this, the facility's infection control tracking sheet and physician's orders for April 2024 only indicated EBP, not contact precautions. Interviews with staff, including the Infection Preventionist and Director of Nursing Services, revealed a lack of communication and oversight in updating the resident's precautionary status, even though the resident exhibited behaviors such as refusing dressing changes and having copious wound drainage. The facility's policies on multidrug-resistant organisms and contact precautions were not followed, as the resident's condition warranted contact precautions due to the inability to contain wound drainage and the resident's non-compliance with care. Staff interviews confirmed that the resident was never placed on contact precautions, and there was a misunderstanding among staff regarding the difference between EBP and contact precautions. This oversight in implementing the correct precautions contributed to the deficiency identified by the surveyors.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three nurse aides, as required by their policy. The personnel files of the nurse aides, hired on various dates, did not contain documentation of a performance evaluation for the year 2023. During an interview, the Director of Nursing Services (DNS) acknowledged the oversight and confirmed that it was her responsibility to ensure that annual performance reviews were conducted on each employee's anniversary date. The facility's policy mandates that all employees undergo a written annual review by their department supervisor on their anniversary date, which was not adhered to in these cases.
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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