West Hartford Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in West Hartford, Connecticut.
- Location
- 130 Loomis Dr, West Hartford, Connecticut 06107
- CMS Provider Number
- 075278
- Inspections on file
- 22
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at West Hartford Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found expired medications, undated opened containers, and staff personal items improperly stored in two medication rooms. An LPN confirmed responsibility for discarding expired medications and dating items, but some items were not dated or removed. The DON stated that all medications should be labeled and personal items stored in designated staff areas, in accordance with facility policy.
Two out of three ice machines were found with a black substance buildup inside, despite logs and tags indicating monthly and annual cleaning had been performed. Observations and interviews with environmental services staff confirmed the unsanitary condition, and facility policy requiring daily inspections and regular cleaning was not followed.
The facility did not maintain consistent records of required monthly water flushes for showers, tubs, faucets, and eyewash stations as outlined in its water management plan. Although some flushing was performed, documentation was lacking due to staff oversight and extended absences, and the water management policy did not specify preventative measures. This resulted in a deficiency related to the facility's infection prevention and control program.
A resident with cognitive impairment and behavioral health diagnoses alleged rough care by a CNA. The facility notified the physician and family and conducted an internal investigation, but did not notify local law enforcement as required by policy, citing the resident's history of similar accusations. The incident was ultimately determined to be unsubstantiated.
A resident was not adequately prepared for a safe transfer or discharge, as the facility did not ensure the process met the individual's needs and preferences.
A resident with multiple medical conditions was discharged after not returning from a leave of absence, but was not provided with written notice of discharge or informed of their right to appeal. Facility staff did not document that the resident wished to be discharged or that a medical provider was involved in the decision, and interviews confirmed that required notifications were not given.
A resident with quadriplegia and a sacral pressure ulcer did not have their care plan updated to reflect changes in wound status and treatment, including the discontinuation of PICO wound therapy and progression to a stage 4 ulcer. The care plan continued to list outdated interventions and did not include the resident's preferences or documentation of turning and repositioning, contrary to facility policy.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as observed and documented by surveyors.
A resident with a central line for antibiotic therapy did not receive IV flushes in the correct order as per physician orders and facility policy. An LPN administered heparin before saline after disconnecting the antibiotic, instead of following the required saline-then-heparin sequence. The facility's SASH protocol and IV management policy were not followed, as confirmed by staff interviews and record review.
A resident with obstructive sleep apnea was using a CPAP machine, but the facility failed to ensure that the physician's order included the required machine settings as specified by facility policy. The order only indicated the times for use, and staff could not explain the omission of the settings.
A resident with severe cognitive impairment and on hospice care did not have a comprehensive end-of-life care plan developed or revised for an extended period, and the facility failed to coordinate with the hospice provider or obtain timely hospice certification paperwork. The only intervention documented was to honor the resident's and family's wishes, and the hospice provider was not included in care plan meetings, contrary to facility policy.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failure to ensure treatment and supports for daily living were delivered safely.
Expired and Unlabeled Medications, Improper Storage of Personal Items in Medication Rooms
Penalty
Summary
Surveyors observed that in two of four medication rooms, expired medications and biologicals were not discarded as required, and some items were not labeled with the date they were opened. Specifically, in the Bliss unit medication room, expired Polydent Antibacterial Denture Cleaner and hand cream were found, as well as an open box of denture cleaner and an open container of Thick and Easy powder, both lacking the date of opening. Zinc tablets with a valid expiration date were also present, but the open items were not properly labeled. An LPN confirmed that all nurses are responsible for discarding expired medications and dating items when opened, but was unsure why some items were not dated. The hand cream was believed to be a staff member's personal item. In the Reflection unit medication room, an open container of Thick and Easy powder was also found without a date of opening. The Director of Nursing Services (DNS) confirmed that all medications should be labeled and dated once opened, and that personal items for staff should be stored in designated areas such as lockers or closets, not in medication rooms. Facility policies require expired medications to be removed and destroyed, and all opened containers to be dated, but these procedures were not followed in the observed instances.
Ice Machines Not Maintained in Sanitary Condition
Penalty
Summary
Surveyors observed that two out of three ice machines in the facility were not maintained in a sanitary condition. Specifically, a black substance was found built up on the inner edges of the Unit 1 ice machine during an inspection. Documentation attached to the machine, including a cleaning schedule log and a service provider label, indicated that the last recorded cleaning was in June, and annual maintenance was performed in March. However, the presence of visible buildup suggested that cleaning and sanitization were not performed as required. Further observations and interviews with the Physical Plant Director and the Regional Director of Environmental Services confirmed the black buildup inside the ice machines on both Unit 1 and Unit 2. Although each machine had tags indicating yearly maintenance and monthly cleaning checklists with staff initials, the black substance was still present. The Regional Director acknowledged that housekeeping was responsible for cleaning the machines and that the buildup was unacceptable. Facility policy required daily visual inspections, monthly cleaning, and annual thorough cleaning and sanitization, but there was no evidence of prior staff training for this task, and the required standards were not met.
Failure to Document and Implement Water Flushing per Water Management Plan
Penalty
Summary
The facility failed to maintain records of monthly water flushes as required by its water management plan. An environmental assessment identified risk areas for opportunistic pathogens and recommended flushing uncommonly used tubs, showers, and faucets for 3 to 5 minutes, with documentation to be kept in the service records. The water management plan also required monthly flushing of eyewash stations. Despite these requirements, a review of facility documents revealed that the last documented water flushing occurred several months prior, and there was no consistent documentation of flushing activities for tubs, sinks, or showers. The Director of Physical Plant acknowledged performing the flushes but admitted to not always documenting them due to other responsibilities and periods of extended leave. During the Director's absence, the Special Projects Supervisor covered some duties but did not consistently document or recall all required flushing activities. Additionally, the facility's water management plan policy lacked specific preventative measures to prevent the growth of opportunistic pathogens, and meeting minutes indicated that flushing documentation was not reviewed during water plan meetings. While water testing for opportunistic pathogens was completed and results were negative, the facility did not have a reliable system in place to ensure and document that all required water flushing tasks were performed according to the plan. This lack of documentation and inconsistent implementation of the water management plan's requirements led to the identified deficiency.
Failure to Notify Law Enforcement After Abuse Allegation
Penalty
Summary
The facility failed to notify local law enforcement following an allegation of abuse involving a resident with dementia, paranoid personality disorder, anxiety, and depression. The resident, who had moderately impaired cognition and required significant assistance with daily activities, alleged that a certified nurse aide provided rough care during an evening shift. The incident was documented on a State of Connecticut Reportable Event form, and the physician and the resident's family were notified. The facility administrator initiated an internal investigation by interviewing staff the following day. Despite the facility's abuse policy directing that allegations be reported to local law enforcement when appropriate, the police were not notified. The administrator stated that the decision not to contact law enforcement was based on the resident's history of accusatory behaviors and frequent calls to the police department. The internal investigation concluded that the allegation was unsubstantiated, but the required notification to law enforcement was not made as outlined in facility policy.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Provide Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide written notice of discharge and did not inform a resident of their right to appeal prior to discharge. The resident, who had diagnoses including anxiety, heart failure, and dysphagia, was cognitively intact and required varying levels of assistance with activities of daily living. The resident went on a leave of absence (LOA) with a responsible party, with the expectation to return on a specified date. Documentation showed that the resident and responsible party communicated changes in the return date, but there was no indication that the resident expressed a desire to be discharged or that a medical provider was involved in the discharge decision. When the resident did not return at the agreed-upon time, facility staff informed the responsible party that the resident was considered discharged against medical advice (AMA) for violating LOA protocol. There was no evidence that a written discharge notice was provided or that the resident was informed of their right to appeal the discharge. Interviews with the responsible party and social worker confirmed that neither written notification nor information about appeal rights was given prior to the discharge, and the facility's documentation did not reflect involvement of a medical provider in the discharge process.
Failure to Update Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a pressure ulcer was updated to accurately reflect the resident's current status and treatment interventions. The resident, who had diagnoses including a sacral pressure ulcer and quadriplegia, was initially care planned for being at risk for pressure ulcers with interventions such as pressure redistribution devices, skin protectants, and daily skin evaluations. The care plan also noted an unstageable pressure ulcer with an intervention for wound clinic services and PICO wound therapy. However, after the PICO therapy was discontinued and the wound progressed to a stage 4 ulcer, the care plan was not updated to reflect these changes. The intervention to use PICO therapy remained in the care plan even though it had been discontinued two months prior, and the care plan continued to list the ulcer as unstageable rather than stage 4. Further, the resident's preferences regarding time out of bed and repositioning, as well as the actual wound care interventions being provided, were not reflected in the care plan. The facility wound nurse confirmed that the care plan was not current and that documentation of turning and repositioning was not included, despite facility policy requiring individualized care plans for residents with pressure ulcers. The policy also required that turning and repositioning be documented in the care plan and that licensed nurses update the care plan as necessary, which was not done in this case.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency were not provided in the report.
Improper Administration of IV Flushes Following Antibiotic Therapy
Penalty
Summary
Licensed staff failed to administer saline and heparin intravenous flushes according to facility policy and standard of care for a resident with a central line receiving antibiotic therapy. The resident, who was cognitively intact and had an artificial hip joint infection with an open hip wound, had physician orders specifying the use of a central line for intermittent infusions. The orders directed that the central line be flushed with 10 mL of saline before medication administration, and after medication administration, flushed with 10 mL of saline followed by 5 mL of heparin. However, observation revealed that an LPN flushed the central line first with 5 mL of heparin and then with 10 mL of saline, contrary to the prescribed order and facility protocol. Interviews with the LPN and the Director of Nursing Services (DNS) confirmed that the facility uses the SASH protocol (Saline, Antibiotic, Saline, Heparin) for central line maintenance, which was also reflected in the facility's IV management policy. The LPN admitted to possibly misreading the order and was unsure why the sequence was reversed. The DNS was also unable to explain the deviation from protocol. The deficiency was identified through observations, staff interviews, and review of facility policy and resident records.
Failure to Document CPAP Settings in Physician Orders
Penalty
Summary
The facility failed to ensure that respiratory equipment settings for a resident with obstructive sleep apnea were obtained and accurately reflected in the physician's orders. The resident, who was cognitively intact, was using a CPAP machine as part of their treatment. The admission Minimum Data Set (MDS) did not indicate the use of CPAP, and the initial physician's order specified only the times for the CPAP to be turned on and off, without including the required machine settings. During observation, the CPAP machine was present at the bedside, but a review of the clinical record and facility policy revealed that the necessary settings were missing from the physician's order. Facility staff were unable to explain why the settings had not been obtained and documented as required by policy. The facility's policy stated that physician orders for CPAP should include the settings, oxygen flow rate if used, and the time period for use, but this was not followed in the resident's case.
Failure to Coordinate and Document Hospice Care Planning
Penalty
Summary
A deficiency was identified in the facility's management of hospice services for a resident with severe cognitive impairment and a diagnosis of unspecified dementia with behavioral disturbance. The resident was admitted with advanced directives specifying do not resuscitate, do not intubate, do not hospitalize, and to provide comfort care. Despite being on hospice care, the only intervention documented in the care plan was to honor the resident's and family's wishes, with no further revisions or comprehensive end-of-life care planning. The facility failed to develop a care plan that coordinated services between the hospice provider and the facility, and did not initiate an end-of-life (hospice) care plan for over 95 days after hospice admission. Additionally, the facility did not ensure timely receipt of hospice renewal orders and plans of care, as there was no 90-day re-certification paperwork available after a certain date. The hospice provider was not routinely invited to participate in care plan meetings for hospice residents, and the required documentation for hospice certification periods was only obtained after surveyor inquiry, well after the resident had been on hospice services. These actions and omissions were not in accordance with the facility's own policy, which required comprehensive, coordinated care planning in collaboration with the hospice agency.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
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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