Village Green Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Connecticut.
- Location
- 23 Fair Street, Bristol, Connecticut 06010
- CMS Provider Number
- 075198
- Inspections on file
- 29
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Village Green Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with a right femur fracture had orders for PRN Oxycodone and scheduled Lyrica for pain management. Pharmacy records and proof of delivery showed that two 30-count blister packs of Oxycodone and two 30-count blister packs of Lyrica were delivered and signed for by an RN. Facility video showed the RN handing four blister packs to an LPN, who placed them on top of a hallway med cart, did not verify the quantity at hand-off, left the controlled drugs unsecured while administering another resident’s meds, and later documented receipt of only three blister packs (two Lyrica and one Oxycodone). CSDRs were completed for two Lyrica packs and only one Oxycodone pack, leaving one Oxycodone blister pack unaccounted for and demonstrating failure to follow the facility’s double-lock and immediate recording requirements for controlled substances.
A resident with severe cognitive impairment and multiple medical conditions fell out of bed and sustained serious injuries due to inadequate supervision and failure to call for help during a change in condition. Additionally, the facility's smoking area was found to have a non-flame-resistant canopy, posing a safety hazard.
A resident with cognitive impairment and urinary incontinence had their indwelling catheter bag visibly exposed, causing frustration. Despite a care plan and physician's order for Foley management, the urinary bag was not covered by the resident's pants. An LPN acknowledged the issue but was unsure why the Foley was loosely fitted and visible.
A facility failed to ensure a clean and sanitary environment in a resident's room, who had a neurological disorder and chronic respiratory failure. The resident's family reported infrequent housekeeping, leading to a pink stain and plastic caps from medical equipment remaining on the floor. Observations confirmed these issues, and the facility lacked documentation for daily cleanings and a housekeeping policy.
A resident's personal cigarette lighters were used by other residents without consent, violating the facility's policy on protecting personal belongings. The resident, who requires supervision while smoking and uses oxygen, had their lighters used by others, and the facility failed to provide separate lighters for each resident, leading to a breach of the abuse prohibition policy.
A facility failed to notify a resident's responsible party of the bed hold policy during a hospital transfer. The resident, with COPD and acute respiratory failure, was transferred due to increased respiratory secretions. The facility's policy required notification of bed hold conditions, but no documentation or notification was provided. Upon readmission, the resident's bed was prepared for another due to infection control needs, leading to a grievance about the handling of belongings. Staff interviews revealed uncertainty about notification requirements, contributing to the deficiency.
A facility failed to accurately code the MDS assessment for a resident with schizoaffective disorder bipolar type, who met PASRR requirements for a serious mental illness. The resident was incorrectly coded as not meeting these requirements, despite being at risk for complications related to psychotropic drugs. The Director of Social Services admitted the coding error was an oversight.
The facility failed to develop baseline care plans for two residents with respiratory conditions within 48 hours of admission, as required by policy. One resident with COPD and acute respiratory failure did not have a respiratory care plan initiated, despite a physician's order for oxygen therapy. Another resident with acute and chronic respiratory failure was admitted with a CPAP machine, but their care plan did not include respiratory care. The MDS Coordinator acknowledged the oversight, and the facility could not provide the Admission Nursing Assessment for the second resident.
The facility failed to conduct proper elopement evaluations for a resident with dementia, lacked a comprehensive care plan for a resident with a history of seizures, and did not develop a respiratory care plan for a resident with COPD and pneumonia. These deficiencies were identified through clinical record reviews and staff interviews, highlighting lapses in adherence to facility policies.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident with diabetes and dementia developed a pressure ulcer, but the care plan was not updated. Another resident with heart failure had conflicting weight monitoring orders, and the care plan was not revised. A third resident with a cervical spine injury had outdated care plan instructions for hand splints, which were no longer in use. Staff acknowledged these oversights, citing issues with record-keeping and communication.
A facility failed to ambulate a resident with COPD and CHF according to the care plan, leading to a deficiency. The resident, who required assistance for ambulation, was not ambulated during several shifts despite a physician's order. Interviews revealed concerns about staffing and documentation inconsistencies, with no recorded refusals from the resident to ambulate.
Two residents at an LTC facility experienced deficiencies in pressure ulcer care due to inconsistent completion of weekly skin checks and risk assessments. One resident developed a stage one pressure ulcer, while another had a stage II pressure injury that was not properly assessed upon readmission. Issues with electronic documentation and adherence to facility policies contributed to these deficiencies.
A facility failed to specify the location for treatment application for a resident with a feeding tube. The resident had a physician's order to cleanse a site and apply Bacitracin, but the order lacked location details. The care plan included interventions for enteral feeding tube care. The DNS acknowledged the oversight, and a new order was issued after surveyor inquiry.
A facility failed to provide proper respiratory care for a resident with a tracheostomy, leading to a deficiency. The resident, with COPD and other conditions, experienced increased congestion and secretions, but staff did not notify the physician or obtain a suctioning order. Additionally, the emergency equipment area was disorganized, with supplies in open boxes on the floor and cluttered surfaces, potentially hindering emergency response. Staff interviews revealed communication lapses and protocol non-adherence, contributing to the deficiency.
The facility failed to ensure annual competencies for nurse aides in 2023 and 2024, lacking documentation for three aides. The absence of a dedicated staff development nurse and the unavailability of the DNS contributed to this oversight. The facility was transitioning ownership, with a regional staff development nurse temporarily managing education and competencies.
The facility failed to complete annual performance evaluations for nurse aides in 2023 and 2024. The HR Director, responsible for notifying the DNS of due evaluations, fell behind in updating the tracking document, resulting in missed evaluations for three nurse aides. The facility also lacked policies related to performance evaluations.
The facility failed to follow Enhanced Barrier Precautions (EBP) for two residents, one with a foot lesion and another with a gastrostomy tube. Staff were unsure about EBP requirements, leading to a lack of proper signage and protective measures. The Infection Control Preventionist confirmed the need for EBP, but it was not implemented until after surveyor inquiry. Additionally, an LPN did not wear a gown during a dressing change, and the Director of Nursing acknowledged the oversight.
The facility failed to ensure call bells were within reach for two ventilator-dependent residents. One resident, with severe cognitive impairment, had a call bell placed out of reach, while another resident, who was alert, had a call bell on the floor and struggled to activate it. The facility's policy mandates that call lights be within reach at all times.
The facility failed to conduct annual safety evaluations for two therapeutic modality machines and did not post required oxygen signage for a resident with COPD and Congestive Heart Failure. The machines lacked safety evaluation stickers, and staff were unclear about responsibilities for posting oxygen signs, leading to non-compliance with facility policy.
A resident with a history of repeated falls experienced an unwitnessed fall and, despite physician orders and facility protocol, did not receive all required neurological checks at the specified intervals. Documentation showed that multiple checks were missed, indicating a failure to follow post-fall assessment procedures.
A resident with multiple drug-resistant organisms, including MRSA, ESBL, and C. auris, did not have proper transmission-based precautions implemented as required. A respiratory therapist was observed exiting the room after providing ventilator and tracheostomy care while still wearing soiled gloves, then touched personal items and documented care before removing gloves and performing hand hygiene, contrary to facility policy and infection control protocols.
The facility did not ensure complete and accurate documentation of care for three residents, including those with dementia, heart failure, and chronic kidney disease. Wound care, medication administration, and other treatments were not consistently recorded in the medical records, despite staff interviews confirming the care was provided but not documented. This failure to document care as required by facility policy led to incomplete clinical records.
A resident with multiple wounds and significant medical needs received wound care from an LPN who failed to follow proper infection control practices, including double-gloving, not performing hand hygiene, and not treating each wound as a separate procedure. Interviews revealed the LPN was unaware of correct protocols, and facility policy confirmed these actions were not in compliance.
A resident with dysphagia was given regular milk instead of the prescribed nectar-thick consistency, leading to choking and respiratory distress. The nursing assistant assumed the milk was pre-thickened and did not verify its consistency. The resident was hospitalized with acute hypoxic respiratory failure and aspiration pneumonia. The facility's investigation revealed a lack of communication between dietary and nursing staff and no policy on following physician orders.
Unsecured Controlled Substances and Missing Oxycodone Blister Pack
Penalty
Summary
The deficiency involves the facility’s failure to secure and account for controlled substances in accordance with its own Controlled Substance Administration & Accountability policy. A resident admitted with a right femur fracture had physician orders for Oxycodone 5 mg every four hours as needed for pain and Lyrica (Pregabalin) 200 mg twice daily for nerve pain, and the resident’s care plan included administration of pain medication as ordered. Pharmacy documentation showed that two 30-count blister packs of Oxycodone 5 mg and two 30-count blister packs of Lyrica 200 mg were delivered for this resident and signed for by an RN. The facility’s documentation identified that Controlled Substance Disposition Records (CSDRs) were created for two 30-count Lyrica blister packs and only one 30-count Oxycodone blister pack, despite the pharmacy packing slips and proof of delivery indicating that two Oxycodone blister packs had been delivered. A reportable event completed by the DNS documented that video review showed the RN receiving four blister packs (two Lyrica and two Oxycodone) from the pharmacy driver and delivering them to an LPN, who was observed on video with all four blister packs at the nursing station and then at the medication cart. However, only three blister packs (two Lyrica and one Oxycodone) were documented as received by the LPN. In interview, the LPN stated she was working the 11:00 PM to 7:00 AM shift when the RN brought the controlled substances to her unit. She reported that the RN placed the blister packs on top of her medication cart in the hallway, that she did not verify the number of blister packs at the time of transfer because she was in a rush, and that she left the controlled substances unsecured on top of the cart while she went to administer another resident’s medication. She later returned and signed in only three blister packs into the controlled substance records. The DNS described the facility’s process, which requires the supervisor and unit nurse to verify each blister pack at hand-off, immediately record the medications on the appropriate drug disposition record, and store patient-specific controlled substances under double lock, and confirmed that controlled substances should not be left unattended and should always be secured. One 30-count blister pack of Oxycodone remained unaccounted for.
Failure to Prevent Resident Fall and Smoking Area Hazard
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent a fall with major injury for a resident who exhibited a change in condition. The resident, who had a history of cerebrovascular accident with right-sided hemiparesis, epilepsy, and chronic respiratory failure with a tracheostomy, was severely cognitively impaired and required assistance with activities of daily living. During a bed change, the resident began moving around excessively, and the nurse aide, who was at the head of the bed, did not call for help when the resident showed signs of distress. As a result, the resident fell out of bed, sustaining a severe comminuted fracture of the right maxillary sinus and orbital floor, as well as a corneal abrasion. The incident was witnessed by nursing staff, and the resident was sent to the emergency department for evaluation. The nurse aide's failure to call for help and the positioning at the head of the bed, rather than the side, contributed to the inability to prevent the fall. The Director of Nursing Services identified the root cause as the nurse aide not calling for help when the resident began moving around and showing signs of distress. The facility did not provide a policy for nurse aide reporting of a change of condition. Additionally, the facility failed to ensure the designated smoking area was free from accident hazards. A canopy made of cloth-like material, which was not flame-resistant, was placed in the smoking area. The Director of Maintenance acknowledged the canopy was a replacement for one damaged in a storm, and it was removed after surveyor inquiry. The facility did not provide a policy for ensuring a safe environment.
Failure to Maintain Dignity in Urinary Device Management
Penalty
Summary
The facility failed to handle a resident's urinary collecting device in a dignified manner, as observed in the case of Resident #26. The resident, who has diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia, and a history of falls, was identified as cognitively impaired and requiring assistance with personal hygiene and toileting. Despite a care plan and physician's order for managing the resident's urinary incontinence and Foley catheter, an observation revealed that the resident's indwelling catheter bag was visible from the hallway, causing the resident frustration. The resident expressed concern that the urinary bag was not covered by their pants, and an LPN confirmed that the situation was inappropriate but was unsure why the Foley was loosely fitted and visible.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the room of a resident who was admitted with a neurological disorder and chronic respiratory failure. The resident, who was cognitively intact and dependent on activities of daily living, had a tracheostomy, an enteral feeding tube, and a urinary catheter. During an interview, the resident's family member reported that housekeeping services were infrequent, sometimes taking several days to clean spills. An observation confirmed the presence of a pink stain on the floor and several plastic caps from medical equipment scattered around the room. Further observations with the Housekeeping Director revealed that while the pink stain had been removed, the plastic caps remained. The Housekeeping Director stated that rooms are cleaned daily, including dust mopping and wet mopping, and that debris should be swept up and discarded. However, the facility did not maintain quality control documentation for daily room cleanings, and no policy on housekeeping or daily room cleaning was provided upon request. The room was scheduled for a deep cleaning, but the lack of documentation and oversight contributed to the deficiency in maintaining a clean environment.
Misuse of Resident's Personal Belongings
Penalty
Summary
The facility failed to protect a resident's personal belongings, specifically cigarette lighters, from being used by other residents without consent. Resident #41, who has a history of nicotine dependence and requires supervision while smoking, had their personal lighters used by other residents. The facility's policy mandates that smoking materials be maintained by staff to ensure supervision and safety, especially since Resident #41 also uses oxygen. Despite this, observations revealed that a nurse aide used Resident #41's lighter to light another resident's cigarette, and the lighter was later returned to the medication room without proper consent from Resident #41. Further investigation showed that the facility did not have separate lighters for each resident, as only Resident #41's lighters were found in the smoking bin. Interviews with staff confirmed that lighters labeled with Resident #41's name were used by other residents, and the facility's social worker indicated that lighters should be labeled as 'Facility' for communal use. The facility's policy on abuse prohibition defines misappropriation of patient property as the deliberate temporary use of a patient's belongings without consent, which was violated in this instance.
Failure to Notify Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party of the bed hold policy when a resident was transferred to the hospital. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and acute respiratory failure, was transferred to the hospital due to increased respiratory secretions. Although the facility's policy required notification of the bed hold policy upon transfer, there was no documentation or notification provided to the responsible party. The facility's policy, as per Connecticut State Agencies Section 17-134 d-79, mandates informing residents and their representatives of the conditions under which a bed is reserved, but this was not adhered to in this case. The resident was readmitted to the facility after the hospital stay, but the bed had been prepared for another resident due to an infection control issue. The facility's administrator and staff were aware of the situation, and the responsible party was encouraged to file a grievance regarding the handling of the resident's belongings. Interviews with staff revealed uncertainty about the requirement for written notification of the bed hold policy, although it was included in the Admission Agreement packet. The facility's failure to provide the necessary notification and documentation led to the deficiency identified in the report.
Inaccurate MDS Coding for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for a resident identified with a serious mental illness. The resident, diagnosed with schizoaffective disorder bipolar type, was determined to meet Preadmission Screening and Resident Review (PASRR) assessment requirements for a serious mental illness as per the report dated 12/11/18. However, the annual MDS assessment inaccurately coded the resident as '0', indicating they did not meet PASRR requirements for a serious mental illness. The care plan noted the resident was at risk for complications related to psychotropic drugs, with interventions to monitor mental status and obtain psychiatric evaluations as ordered. The Director of Social Services, responsible for MDS coding related to PASRR criteria, acknowledged the coding error as an oversight during an interview on 3/12/25. The MDS 3.0 Resident Assessment Instrument (RAI) Manual directs that a '1' should be coded if the PASRR level II screening determined the resident had a serious mental illness.
Failure to Develop Baseline Respiratory Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan to meet the essential respiratory care needs of two residents within 48 hours of their admission, as required by their policy. Resident #224, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and acute respiratory failure, had a physician's order for oxygen therapy via a trach mask. However, no respiratory care plan was initiated during the resident's stay, despite the facility's policy mandating a baseline care plan within 48 hours of admission. This oversight was confirmed during an interview and record review with RN #4. Similarly, Resident #274, who had acute and chronic respiratory failure with hypoxia and hypercapnia, was admitted with a physician's order for respiratory therapy using a CPAP machine. The baseline care plan for this resident did not include respiratory care, focusing instead on skin infection risk, ADL/self-care deficit, and nutritional problems. The MDS Coordinator acknowledged that the respiratory care should have been included in the care plan. Additionally, the facility was unable to provide a copy of the Admission Nursing Assessment for this resident, and the MDS was not completed before the resident was transferred back to the hospital.
Deficiencies in Care Planning and Risk Assessment
Penalty
Summary
The facility failed to conduct proper elopement evaluations and maintain an updated care plan for a resident with dementia and a history of wandering. Resident #2, who was diagnosed with dementia with behavioral disturbances, had an elopement evaluation that did not indicate a score to determine the level of risk for elopement. Despite having a history of wandering and elopement, the resident's Wander guard bracelet was discontinued without a clear rationale. The acting Director of Nursing Services was unaware of the frequency of elopement evaluations and how the risk of elopement is determined, indicating a lack of adherence to the facility's policy. Another deficiency involved Resident #124, who had a history of epilepsy but did not have a comprehensive care plan addressing seizure precautions. The resident was severely cognitively impaired and required assistance with activities of daily living. Despite a reportable event where the resident's body started to flop, indicating a possible seizure, the care plan lacked specific interventions for seizure management. The Nurse Practitioner acknowledged that a seizure protocol should have been in place, and the Director of Nursing Services confirmed that the care plan should have included padded rails for safety. Lastly, the facility failed to develop a comprehensive respiratory care plan for Resident #224, who had diagnoses including COPD, pneumonia, and acute respiratory failure. Although there were physician's orders for oxygen therapy and tracheostomy care, there was no evidence of a respiratory care plan during the resident's stay. The facility's policy required a comprehensive care plan to be developed within seven days of admission, but this was not adhered to, as confirmed by the acting Director of Nursing Services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for three residents, leading to deficiencies in their care. Resident #24, diagnosed with type 2 diabetes mellitus and vascular dementia, developed a stage 1 pressure ulcer on the left heel. Despite a treatment order to apply skin prep and elevate heels, the care plan was not updated to reflect this new condition. The wound nurse acknowledged the oversight, citing issues with electronic record-keeping and Wi-Fi connectivity, which led to a reliance on paper documentation. Resident #38, with diagnoses including encephalopathy, chronic systolic congestive heart failure, and end-stage renal disease, had conflicting physician orders regarding weight monitoring. The care plan included daily weights as an intervention for heart issues, but the orders specified weights only after specialized treatment. The MDS Coordinator admitted the care plan should have been revised to align with the new orders but failed to do so until prompted by the surveyor. Resident #324, admitted with a cervical spine injury, had a care plan indicating the use of hand splints, which were no longer in use following multiple hospitalizations. Despite signage and care cards indicating splint use, there were no active physician orders for them. The Director of Rehabilitation confirmed that splints would not be ordered without a proper evaluation, and the MDS Coordinator acknowledged the care plan should have been updated to reflect the discontinuation of the orthotic device.
Failure to Ambulate Resident as Per Care Plan
Penalty
Summary
The facility failed to ensure that Resident #8 was ambulated according to the plan of care, which led to a deficiency in the resident's rehabilitation and restorative care. Resident #8, who has diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and anxiety, was identified as cognitively intact and required maximal assistance with personal care. The care plan specified assistance for stand pivot transfers and ambulation with a rolling walker. However, the Treatment Administration Records (TAR) showed that Resident #8 did not ambulate during four shifts in March 2025, despite a physician's order directing ambulation with assistance every shift. Interviews with Resident #8 and staff revealed a lack of adherence to the ambulation schedule. Resident #8 expressed concerns about insufficient staff to assist with ambulation, leading to a perceived decline in mobility. Nursing Assistant #7 and LPN #5 indicated that ambulation schedules were documented but not consistently followed. The Director of Rehabilitation Services confirmed that staff from various departments were responsible for assisting with ambulation but could not explain the missed ambulation sessions. The nurse's notes for March 2025 did not document any refusal from Resident #8 to ambulate, highlighting a gap in the facility's documentation and execution of the care plan.
Inconsistent Skin Assessments Lead to Pressure Ulcer Deficiencies
Penalty
Summary
The facility failed to ensure consistent completion of weekly skin checks and skin risk assessments for two residents, leading to deficiencies in pressure ulcer care. Resident #24, diagnosed with type 2 diabetes mellitus and vascular dementia, was identified as at risk for pressure ulcers. Despite this, there were multiple weeks where no skin checks were documented, and a Braden Scale assessment was not completed as required. This lack of consistent monitoring resulted in the development of a stage one pressure ulcer on the resident's left heel, which was not promptly addressed in the care plan. Similarly, Resident #47, who had diagnoses including type II diabetes and neoplasm of the colon, experienced lapses in weekly skin assessments. The resident was readmitted with a stage II pressure injury, yet the admission assessment failed to include a comprehensive description of the wound. Additionally, the Braden Risk Assessment was not completed on readmission or weekly thereafter for the first month, as per facility policy. This oversight in documentation and assessment contributed to inadequate pressure ulcer management. Interviews with the wound nurse and facility administrator revealed ongoing issues with the electronic scheduler and documentation processes, which contributed to the inconsistencies in skin assessments. The facility's policies for skin integrity and wound management were not adhered to, resulting in a failure to provide adequate pressure ulcer prevention and care. The lack of a policy for weekly skin checks further compounded the issue, as staff were unable to consistently track and document the necessary assessments.
Failure to Specify Treatment Location for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure that staff obtained a treatment order specifying the location for the application of treatment for a resident with a feeding tube. The resident, who had diagnoses including dysphagia and gastrostomy status, had a physician's order dated 1/14/2025 to cleanse a site daily with normal saline, apply Bacitracin, and cover with a dressing. However, the order did not specify the location for this treatment. The care plan indicated the resident had an enteral feeding tube and included interventions such as keeping the head of the bed elevated during feeding and monitoring the skin surrounding the gastrostomy tube site. During a clinical record review and interview, the Director of Nursing Services (DNS) acknowledged the missing location in the order and stated that staff should not assume the location is the G-tube site. Following surveyor inquiry, a new physician's order was issued specifying the application of treatment to the G-tube site.
Deficiency in Respiratory Care and Equipment Organization
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident with a tracheostomy, leading to a deficiency in care. The resident, diagnosed with COPD, pneumonia, acute respiratory failure, and neoplasm of the larynx, required oxygen therapy and was at risk for Multiple Drug-Resistant Organisms. Despite a physician's order for oxygen therapy, the facility staff did not notify the physician of a change in the resident's condition when the resident experienced increased congestion and respiratory secretions. The staff also failed to obtain a physician's order for suctioning when the resident presented with thick green mucous, which was a deviation from the facility's policy requiring provider notification for such changes. Additionally, the facility did not maintain an organized and accessible emergency equipment area at the resident's bedside. Observations revealed disarray, with treatment supplies stored in open cardboard boxes on the floor, a suction machine, and other items cluttering the tabletop and shelf. The presence of an open trach mask and tubing, along with multiple Ambu bags, further indicated a lack of organization and readiness in the emergency equipment area. This disorganization could have impeded timely access to necessary equipment in an emergency. Interviews with facility staff, including the APRN, LPN, and RN, highlighted a lack of communication and adherence to protocols. The APRN expected the nursing staff to notify the physician of the resident's condition change, but this did not occur. The LPN and RN involved were unaware of the need for a physician's order for suctioning and did not notify the physician of the resident's condition change. The facility's failure to follow its policies and maintain an organized emergency equipment area contributed to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Complete Annual Competencies for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual competencies were completed for nurse aide staff for the years 2023 and 2024. Specifically, there was no documentation of annual competencies for 2023 for one nurse aide, and for 2024, two nurse aides lacked documentation of completed competencies. The facility's employee listing indicated the hire dates for the nurse aides involved, with one having been employed since 2000, another since 2012, and the third hired in late 2023. The absence of a dedicated staff development nurse and the unavailability of the Director of Nursing Services (DNS) contributed to the lack of oversight in ensuring the completion of these competencies. During an interview, the Infection Control Nurse acknowledged the absence of documentation or tracking sheets for the nurse aides' annual competencies. The facility was undergoing a change in ownership, and a regional staff development nurse from the new owner was expected to manage education and competencies temporarily. The facility's clinical competency validation checklist for 2023/2024 outlined specific competencies required for nurse aides, including hand hygiene, PPE use, and various care procedures. The facility assessment emphasized the necessity of staff training and competencies to provide appropriate care for the resident population.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for nurse aide staff for the years 2023 and 2024. Specifically, the facility did not provide documentation of completed annual performance evaluations for three nurse aides: one hired in 2000, another in 2012, and a third in 2023. The Director of Human Resources (HR) was responsible for notifying the Director of Nursing Services (DNS) when evaluations were due, but admitted to falling behind in updating the tracking document due to workload, resulting in a lack of notification to the DNS. The Director of HR maintained the evaluation schedule on an Excel document, which was not updated regularly, leading to missed evaluations. The facility also failed to provide any policies related to annual performance evaluations when requested. The HR Director confirmed that the DNS did not track evaluations independently, relying solely on HR notifications, which were not provided due to the HR Director's backlog.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) guidelines for two residents, leading to deficiencies in infection prevention and control. Resident #46, who had a lesion on the right dorsal foot, was not placed on EBP as required by a physician's order. Observations revealed that there was no EBP signage on the resident's door, and the staff, including the Wound Care Nurse and RN #2, were unsure if the resident should be on EBP. It was later confirmed by the Infection Control Preventionist that the resident should have been on EBP, but this was not implemented until after surveyor inquiry. Similarly, Resident #224, who had a gastrostomy tube, was also not managed according to EBP guidelines. Although there was a physician's order for EBP, the signage was blocked, and LPN #11 did not wear a gown during the dressing change, which was required. The resident reported increased drainage and tenderness around the gastrostomy site, and the LPN acknowledged the need to notify the APRN for evaluation. The Director of Nursing Services confirmed that the signage and personal protective equipment should have been visible and that the LPN should have worn a gown during the procedure.
Call Bell Accessibility Deficiency for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, both of whom were dependent on ventilators. Resident #40, who had severe cognitive impairment and required substantial assistance with mobility, was observed with a call bell placed two feet away on a tray table, out of reach. During the observation, the resident was unable to move their arms and was mouthing words to request pain medication. An LPN confirmed that the call bell should have been within the resident's reach. Resident #325, who was alert and able to communicate needs, was found with a call bell on the floor next to the bed. A nursing assistant, unfamiliar with the resident's ability to call, indicated that the call bell should have been clipped to the sheets. Although the resident attempted to use the call bell, they were unable to fully activate it. The nursing assistant suggested that the resident might benefit from an adaptive call bell that is easier to push. The facility's policy requires that all residents have a call light or alternative communication device within reach at all times when unattended.
Deficiencies in Equipment Safety Evaluation and Oxygen Signage
Penalty
Summary
The facility failed to ensure that two therapeutic modality machines in the Therapy Department were evaluated annually for safety in 2022 and 2023. During an observation, it was noted that the machines lacked stickers indicating the last safety evaluation. The Maintenance Director was unable to provide service documents for the evaluations and confirmed that the machines had not been serviced. The equipment servicing company was contacted to schedule a service visit, and the machines were removed from use until they could be serviced. Additionally, the facility failed to post signage indicating oxygen use for a resident with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure, who was receiving oxygen therapy. Observations revealed that there was no sign outside the resident's room, and interviews with staff indicated confusion over responsibility for posting the sign. The facility's policy requires a 'No smoking - Oxygen in use' sign in areas where high-pressure cylinders are stored, but this was not adhered to in the resident's case.
Failure to Complete Neurological Checks After Unwitnessed Fall
Penalty
Summary
A resident with a history of fibromyalgia and repeated falls was identified as being at risk for falls, with a care plan in place that included interventions such as assistance with ambulation and transfers, and the initiation of frequent neurological and bleeding evaluations per facility protocol in the event of a fall. The resident experienced an unwitnessed fall after attempting to go to the bathroom without staff assistance, resulting in a physician's order to continue neurological checks. Review of the neurological evaluation documentation revealed that the required neurological checks were not completed in full according to the facility's protocol. Specifically, several checks at 15-minute, 30-minute, and hourly intervals were missed following the fall. Facility policy and the neurological procedure required thorough and timely documentation of neurological status after unwitnessed falls, but these were not adhered to for this resident.
Failure to Implement Required Transmission-Based Precautions for MDROs
Penalty
Summary
A deficiency was identified when staff failed to implement required transmission-based precautions for a resident with multiple drug-resistant organisms (MDROs). The resident had chronic respiratory failure requiring ventilator support, dementia, ALS, epilepsy, and was colonized or infected with ESBL, MRSA at the tracheostomy site, and Candida auris. Physician orders and care plans directed the use of contact precautions and enhanced barrier precautions, including the use of gown and gloves during high-contact care and device care such as tracheostomy and ventilator management. On observation, a respiratory therapist (RT) was seen exiting the resident's room after providing ventilator and tracheostomy care, still wearing gloves used during care. The RT touched her eyeglasses, used a pen, and documented on a clipboard while still wearing the soiled gloves, and only removed the gloves and performed hand hygiene after these activities. The RT acknowledged she should have removed gloves and performed hand hygiene before exiting the room but did not do so. Facility policy and the infection control nurse confirmed that all staff were required to remove PPE and perform hand hygiene before leaving a resident's room, especially in the context of an MDRO outbreak. Facility documentation and interviews confirmed that all ventilator unit residents were on contact precautions due to an active outbreak of Carbapenem-resistant Acinetobacter baumannii and Candida auris. The infection control nurse stated that staff had previously received education on these requirements, and facility policies directed removal of PPE and hand hygiene upon room exit. The failure to follow these protocols was directly observed and confirmed through staff interview and policy review.
Failure to Accurately Document Resident Care and Treatments
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for three residents reviewed for quality of care. For one resident with dementia and a history of pressure ulcers, physician orders required specific wound care interventions to be performed and documented every day and evening shift. However, review of the Treatment Administration Record (TAR) revealed that wound care was not documented on several occasions across multiple months. Interviews with LPNs responsible for the care confirmed that while the care was reportedly provided, documentation was omitted due to forgetfulness. The Director of Nursing (DON) stated that nursing staff are expected to document care accurately and timely in the electronic medical record, as outlined in the facility's documentation policy. For another resident with heart failure and an open wound, physician orders directed specific wound care and medication administration. The TAR and Medication Administration Record (MAR) showed missing documentation for wound care and administration of Tylenol on multiple days. Interviews with LPNs revealed that the care and medication were provided but not documented, and staff acknowledged the omission. The facility's policy requires concise, clear, and timely documentation of care provided, which was not followed in these instances. A third resident with chronic kidney disease and heart failure also had missing documentation for ordered treatments, including application of splints and wound care. The responsible LPN confirmed that treatments were completed but not documented. The DON and Director of Nursing Services (DNS) both indicated that care should have been documented according to physician orders and facility policy. The failure to document care as provided resulted in incomplete and inaccurate clinical records for these residents.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
A deficiency was identified when wound care for a resident with chronic kidney disease, heart failure, severe cognitive impairment, and dependence on staff for activities of daily living was not performed according to accepted infection control practices. During an observed wound care procedure, an LPN wore two pairs of gloves on each hand, removed only the outer layer after handling soiled dressings, and then proceeded to apply clean dressings without performing hand hygiene or changing gloves as required. The LPN also treated both wounds consecutively without treating each as a separate procedure, contrary to facility policy and standard infection control protocols. Interviews with the LPN revealed a lack of knowledge regarding proper glove use, hand hygiene, and the correct sequence for wound care procedures. The LPN stated she wore two pairs of gloves because the gloves tore easily and was unsure about when to change gloves or perform hand hygiene. Review of facility policy and interviews with the wound nurse and Director of Nursing Services confirmed that only one pair of gloves should be worn, gloves should be changed, and hand hygiene performed after removing soiled dressings and before applying clean dressings, and that each wound should be treated as a separate procedure.
Failure to Provide Correct Liquid Consistency Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide a resident with dysphagia the correct liquid consistency as per physician orders, leading to a serious incident. The resident, who had a history of cerebrovascular infarction with hemiplegia and hemiparesis, dysphagia, and vascular dementia, was on a mechanically altered diet requiring thickened liquids. On the day of the incident, the resident was given regular milk instead of the prescribed nectar-thick consistency, resulting in choking and respiratory distress. The incident occurred when a nursing assistant (NA) fed the resident milk that was not thickened, assuming it was pre-thickened by the kitchen staff. The NA did not verify the consistency of the milk before serving it to the resident, which led to the resident coughing and subsequently experiencing respiratory distress. The resident was cyanotic and displayed signs of choking, prompting immediate intervention by the nursing and respiratory teams, who performed the Heimlich maneuver and provided suction and oxygen before transferring the resident to the hospital. The hospital confirmed the resident had acute hypoxic respiratory failure and aspiration pneumonia, necessitating treatment with antibiotics and respiratory support. The facility's investigation revealed that the kitchen had sent regular milk with a thick-it packet due to a backorder of pre-thickened milk, and there was a lack of communication between dietary and nursing staff regarding this change. The facility did not have a policy on following physician orders, which contributed to the oversight in providing the correct liquid consistency to the resident.
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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