Villa Maria Nursing And Rehabilitation Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainfield, Connecticut.
- Location
- 20 Babcock Avenue, Plainfield, Connecticut 06374
- CMS Provider Number
- 075084
- Inspections on file
- 25
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Villa Maria Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
The facility did not consistently update or review resident care plans within the required timeframe following care conferences for three residents with complex medical and cognitive needs. Staff interviews confirmed that care plans were not revised as required and that care conferences were not always held quarterly, with no clear explanation for these lapses.
Multiple residents reported receiving cold food and insufficient portions, with direct temperature checks confirming that both hot and cold foods were served outside of safe and palatable temperature ranges. The Dietary Director acknowledged the issue, and observations showed that food not meeting temperature standards was still served to residents.
Two residents experienced deficiencies related to lack of timely physician notification: one resident with multiple comorbidities developed hypotension and respiratory symptoms after nitroglycerin administration, but staff did not notify the physician or reassess vital signs promptly; another resident did not receive prescribed Prozac for two days due to pharmacy delivery issues, and the LPN failed to notify the supervisor or physician about the missed doses.
Staff failed to promptly report allegations of sexual abuse and missing personal property involving three residents to the State Agency as required. In one case, a cognitively intact resident reported inappropriate behavior by a nurse aide, but the administrator did not notify authorities, dismissing the claim. In two other cases, residents' missing cell phones were reported to staff, but the incidents were not escalated or documented according to policy, resulting in delayed investigation and reporting.
A resident with multiple medical conditions and no cognitive impairment reported that a nurse aide exposed her breasts and acted inappropriately. The allegation was reported to supervisory staff and the Administrator, but no investigation was initiated, and the accused staff member remained on the facility schedule, contrary to policy. The incident was not addressed until brought to attention by surveyors.
Two residents experienced deficiencies in care when staff failed to follow professional standards and facility policy. In one case, a resident with obvious injuries from a fall was physically lifted by staff before EMS arrival, despite policy prohibiting movement prior to assessment. In another case, a resident with a significant change in condition, including hypotension and chest pain, did not receive an RN assessment or timely physician notification, and was sent for hemolytic treatment without appropriate evaluation.
A resident with end stage renal disease and multiple comorbidities experienced a significant change in condition, including chest pain and low blood pressure, but staff failed to communicate this to the dialysis center prior to the resident's scheduled treatment. Documentation and required information exchange between the facility and the dialysis center were not completed as required, resulting in the resident being sent to dialysis in an unstable condition and subsequently requiring emergency care.
A resident with lower limb wounds received wound care from an LPN who failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Interviews with facility leadership and review of policy confirmed that hand hygiene was required at these points, but the protocol was not followed, resulting in a deficiency.
Three residents with significant medical conditions did not have their COVID-19 vaccination status identified, were not offered the vaccine, and did not receive documented education about the vaccine. Care plans and health records lacked required information, and the Infection Preventionist confirmed that vaccination status and education were not tracked or provided, contrary to facility policy.
A resident with dementia and a history of right leg fractures, who required a hinged knee brace and assistive device for transfers, was assisted by two nurse aides after a shower without the knee brace being reapplied and without use of the designated device. The resident's knees buckled during the transfer, resulting in a fall and an acute proximal tibia fracture. Staff interviews revealed the aides did not review the care plan or Kardex and were unaware of the specific transfer requirements.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Timely Update and Review Resident Care Plans
Penalty
Summary
The facility failed to review and revise resident care plans (RCPs) and did not conduct care plan conferences as required for three sampled residents. For one resident with diagnoses including malignant neoplasm, chronic heart failure, and PTSD, the care plan was not updated within 5-7 days following several resident care conferences, despite the resident having no cognitive impairment and requiring significant assistance with daily activities. Interviews with facility staff confirmed that care plans were not updated in a timely manner after multiple care conferences, and staff could not provide reasons for these delays. Another resident, diagnosed with dementia, diabetes, and anxiety, had severe cognitive impairment and required moderate assistance with personal care. The care plan for this resident was also not updated within the required timeframe after several care conferences. Additionally, there was a significant gap between care conferences, exceeding the required quarterly schedule, which staff attributed to a change in staffing but could not otherwise explain. A third resident with hemiplegia, diabetes, and moderate cognitive impairment also experienced delays in care plan updates following care conferences. Facility policy requires care plans to be developed within 7 days of the comprehensive MDS and updated at least quarterly, but this was not consistently followed. Staff interviews confirmed the lapses in timely care plan updates and the inability to account for the missed deadlines.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported receiving cold food, including cold toast, coffee, eggs, and meat that was sometimes raw. One resident stated that he remained hungry after meals due to insufficient food portions. Direct temperature checks conducted by surveyors and the Dietary Director revealed that hot foods such as chicken nuggets and French fries were served below the recommended palatable temperature of 140°F, with recorded temperatures as low as 116.0°F and 96.2°F, respectively. Cold food items, such as coleslaw, were found to be served at 57.1°F, exceeding the safe maximum of 45°F for cold foods. Observations indicated that the coleslaw was not promptly removed from plates after it was found to be above the safe temperature, and it continued to be delivered to residents. The Dietary Director acknowledged the temperature issues, attributing the heat loss to inadequate plate lids. The Administrator confirmed awareness of resident complaints regarding cold food. Review of the facility's food preparation and serving policy showed a requirement to maintain proper hot and cold temperatures during food service, which was not met during the survey period.
Failure to Notify Physician of Change in Condition and Medication Omission
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident, who was alert and oriented, experienced chest pain and was administered nitroglycerin as ordered. Following this, the resident developed hypotension, with blood pressure readings dropping to 80/40 and remaining low for several hours. Despite these abnormal findings and the resident presenting with increased lethargy, mild shortness of breath, and diminished lung sounds, there was no documentation that the physician or hemolytic center was notified of these changes. Nursing staff did not reassess vital signs in a timely manner, and the resident was sent to hemolytic treatment without physician notification. Upon return, the resident was found to be unstable and was sent to the emergency room, where they were admitted for hypoxic respiratory failure and exhibited stroke-like symptoms. In a separate incident, the facility failed to notify the physician when a prescribed medication was not available for administration to another resident. The resident, who was cognitively intact and required psychotropic medication for depression, did not receive Prozac as ordered on two consecutive days due to the medication not being delivered by the pharmacy. The responsible LPN did not notify the nursing supervisor, contact the pharmacy, or inform the physician about the missed doses. The MAR and nursing notes did not provide an explanation for the missed medication administration, and the issue was only addressed after the RN supervisor was informed by the LPN on the following day. Facility policy required immediate reporting of changes in condition to the unit manager or shift supervisor, assessment and documentation of the resident's status, and prompt notification of the physician for non-emergent changes. Additionally, policy required that discrepancies or omissions in medication delivery be reported to the pharmacy and charge nurse. In both cases, staff failed to follow these policies, resulting in a lack of timely physician notification for significant changes in condition and medication administration issues.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property to the State Agency as required by policy and regulation. In one instance, a resident with a history of malignant neoplasm, chronic heart failure, and post-traumatic stress disorder, who was cognitively intact, reported that a nurse aide had exposed herself and engaged in inappropriate behavior. The resident communicated this to another nurse aide, who then reported it to a registered nurse and the facility administrator. Despite these reports, the administrator did not notify the State Agency, dismissing the incident as a hallucination, and the nurse aide in question continued to work, only being removed from the resident's care assignment. Multiple staff interviews confirmed knowledge of the allegation, but no timely report was made to authorities as required by the facility's abuse policy. In another case, two residents with chronic medical and psychiatric conditions reported missing cell phones. One resident reported the missing phone to the Therapeutic Recreation Director, who searched for the phone but did not escalate the issue to the administrator or complete a grievance. The Director of Environmental Services was also informed but did not file a report, assuming the issue had already been addressed. The second resident reported the missing phone to a nurse aide, who searched for the phone but did not report the incident, believing others were already aware. In both cases, the missing property was not reported to the appropriate supervisory staff or the State Agency in a timely manner, as required by facility policy. Interviews with facility leadership, including the Director of Nursing and the administrator, revealed that staff were expected to report such incidents immediately, but this did not occur. The facility's abuse prohibition policy clearly directed staff to report any knowledge of abuse, neglect, or misappropriation of property to supervisors and the State Agency within specified timeframes. Despite this, staff failed to follow reporting protocols, resulting in delayed notification and investigation of the allegations.
Failure to Investigate and Remove Staff Following Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with diagnoses including malignant neoplasm of the head, face, and neck, congestive heart failure, and post-traumatic stress disorder. The resident, who was cognitively intact and dependent on staff for personal hygiene and transfers, reported that a nurse aide had exposed her breasts and behaved inappropriately. The resident informed another nurse aide, who reported the incident to a registered nurse and the Administrator. Despite this, the Administrator dismissed the allegation as a hallucination and did not initiate an investigation. The nurse aide accused of abuse continued to work in the facility and was only removed from the resident's care assignment, not from the facility schedule. Multiple staff interviews confirmed that the allegation was reported up the chain of command, but neither the Director of Nursing Services nor the State Agency was notified at the time. The facility's abuse reporting policy required immediate notification of the Administrator, a thorough investigation, and removal of the alleged perpetrator from resident contact pending investigation. These steps were not followed, as the staff member remained on the schedule and the incident was not investigated until prompted by surveyor inquiry. The failure to act according to policy resulted in a lack of protection for the resident and a delay in addressing the abuse allegation.
Failure to Follow Professional Standards in Resident Assessment and Post-Fall Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate incidents involving two residents. In the first incident, a resident with a history of dementia, depression, heart failure, and hypertension, who was at risk for falls, experienced a fall in the dining room. The resident was found on the floor with a head injury, visible deformity of the left wrist, and hip pain. Despite the presence of obvious injuries, including a shortened leg indicative of a hip fracture and a visible wrist deformity, three staff members physically lifted the resident from the floor to a chair before emergency medical services arrived. This action was contrary to the facility's policy, which directs staff not to move a resident with suspected injury until evaluated by a physician or EMS. Interviews with staff and review of facility policy confirmed that the resident should not have been moved, and the Director of Nursing was unable to explain why this occurred. In the second incident, another resident with end stage renal disease, diabetes, hypertension, and a history of stroke-like events, experienced a change in condition characterized by chest pain, hypotension, increased lethargy, mild shortness of breath, and diminished lung sounds. The resident was administered nitroglycerin for chest pain, but subsequent blood pressure readings revealed abnormally low values. Despite these findings, there was no documentation that a Registered Nurse assessed the resident or that the physician was notified of the change in condition. The resident was sent for hemolytic treatment without further assessment or notification to the treatment center regarding the change in condition. Interviews with LPNs and review of the clinical record confirmed that no RN assessment or provider notification occurred during this period. Both incidents demonstrate failures to follow established standards of practice and facility policies regarding the assessment and management of residents with injuries or changes in condition. The deficiencies were identified through observations, record reviews, staff interviews, and review of facility policies, which clearly outlined the required procedures that were not followed in these cases.
Failure to Communicate Resident Status to Dialysis Center
Penalty
Summary
The facility failed to ensure appropriate communication and documentation with the dialysis (hemolytic) treatment center for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident required regular dialysis treatments and had a care plan in place that specified the need for communication with the dialysis center regarding medications, treatments, and coordination of care. However, a review of records from November 2024 through June 2025 revealed a lack of documentation from the dialysis center and no evidence that facility staff had communicated essential information such as diagnoses, current medications, dietary needs, assistance required for activities of daily living, fluid needs, or changes in condition. On one occasion, the resident experienced a significant change in condition, including chest pain, administration of nitroglycerin, and a drop in blood pressure. Despite these changes, the nurse on the following shift did not recheck vital signs or inform the dialysis center of the resident's unstable condition before sending the resident for treatment. Upon arrival at the dialysis center, the resident was noted to be lethargic, short of breath, and hypotensive, prompting the dialysis center to administer treatment at a minimal level and monitor the resident closely. After returning from dialysis, the resident remained unstable and was sent to the emergency department. Interviews with facility staff and the dialysis center nurse confirmed that there was no communication from the facility regarding the resident's change in condition. The facility's own communication tool and policy required that information about recent medications, signs of infection, and changes in condition be shared with the dialysis center, but this was not done. The Director of Nursing acknowledged that required documentation and communication had not been completed since the resident's admission.
Failure to Ensure Proper Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified in the facility's infection prevention and control program related to improper hand hygiene during wound care for a resident with multiple lower limb wounds, including cellulitis, chronic ulcers, and deep tissue injuries to both heels. The resident required significant assistance with mobility and had physician orders for daily wound care on both heels. During an observed wound care procedure, an LPN failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Specifically, the LPN removed gloves and donned new gloves multiple times without performing hand hygiene, despite being interrupted and acknowledging the correct procedure. Further interviews with facility leadership, including the Director of Nursing Services and the Infection Preventionist, confirmed that hand hygiene should be performed before care, with each glove change, and after care is complete. Review of the facility's policy also indicated that staff are required to wash or sanitize hands after removing soiled dressings and before applying clean dressings. The observed failure to follow these protocols during wound care led to the identified deficiency.
Failure to Identify, Offer, and Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to identify, offer, and document COVID-19 vaccination status and education for three residents with various medical conditions, including cellulitis, lymphedema, diabetes, end stage renal disease, protein calorie malnutrition, Alzheimer's disease, rheumatic tricuspid insufficiency, and chronic kidney disease. For each resident, the care plans and electronic health records did not reflect COVID-19 vaccination status, documentation of vaccine education, or evidence that the vaccine was offered. Additionally, there were no physician orders related to COVID-19 vaccination for these residents. During an interview and review of records with the Infection Preventionist, it was confirmed that the vaccination status and education for these residents had not been obtained or provided, and none of the residents appeared on the vaccination log. The Infection Preventionist indicated that staff were no longer required to offer or track COVID-19 vaccination for residents. This was inconsistent with the facility's own policy, which required education, offering the vaccine, and documentation of these actions.
Failure to Apply Required Knee Brace and Use Assistive Device Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to apply a required hinged knee brace to a resident's right leg prior to assisting the resident to stand, which resulted in the resident's leg buckling and a subsequent fall. The resident, who had a history of dementia, a lower end right femur fracture, osteoarthritis of the right knee, and generalized weakness, was dependent on staff for transfers and had physician orders and care plan interventions specifying the use of a hinged knee brace during weight-bearing activities and transfers. The care plan also required the use of a specific assistive device and assistance from two staff members for transfers. On the day of the incident, two nurse aides assisted the resident with a shower and removed the knee brace for the shower. After the shower, they attempted to help the resident stand to dry off without reapplying the knee brace and without using the designated assistive device. As the resident was assisted to stand, the knees buckled twice, and the aides lowered the resident to the floor. The resident was subsequently found to have sustained an acute fracture of the proximal tibia and required transfer to the hospital for evaluation and treatment. Interviews and facility documentation confirmed that the nurse aides did not review the resident's care requirements in the Kardex and were unaware of the orders for the knee brace and assistive device. The Director of Nursing confirmed that the aides failed to follow the plan of care, which led to the resident's fall and injury. Facility policies required staff to provide care in accordance with the resident's care plan and to prevent decline in functional status.
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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