Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avery Nursing Home/noble Building during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was able to exit a secured unit unsupervised due to a nonfunctioning exit door alarm, resulting in a fall and injuries outside the building. Staff last observed the resident two hours before the incident, and the courtyard area contained multiple environmental hazards, including uneven pavement, unsecured stones, and an easily opened gate. The facility lacked a specific policy for wandering behaviors and could not explain the alarm failure or address the environmental risks, leading to an immediate jeopardy finding.
The facility did not assess, care plan, or document the need for placement of several residents on a secured unit, nor did it obtain required consents or demonstrate that this was the least restrictive setting. Residents with various cognitive and psychiatric conditions were placed on a locked unit without documented criteria, assessment, or consent, and facility leadership confirmed the absence of formal guidelines or documentation for such placements.
The facility did not provide documentation showing that required quarterly environmental rounds were completed for infection prevention and control during a specified period. The current Infection Preventionist reported that the previous nurse was responsible for these rounds and no records could be found for the timeframe in question, despite facility policy mandating regular completion and reporting of such rounds.
The facility did not ensure that residents were properly assessed for or offered pneumococcal and influenza vaccines, as required by policy. Several residents with cognitive impairment and chronic conditions had no documentation of vaccine assessment, administration, or refusal, and the Infection Preventionist acknowledged not fulfilling these responsibilities due to workload and being new to the role.
A resident with severe cognitive impairment and multiple medical conditions had clearly documented advance directive choices, including full code status and specific interventions, but the facility failed to ensure these choices were reflected in the physician's orders. Staff interviews and policy review confirmed that such orders should have been present and entered into the medical record, but this was not done.
The facility did not timely develop or update comprehensive care plans for multiple residents, resulting in care plans that failed to reflect current ADL, mobility, and skin integrity needs. In several cases, care plans were incomplete, not updated after significant changes, or did not address all areas identified in assessments, including after new wounds or falls occurred.
A resident with multiple chronic conditions was found self-administering medications that had been left at the bedside by an RN, despite not having a self-administration order. The RN routinely left medications for the resident to take later and documented administration in the MAR without observing ingestion, contrary to facility policy and professional standards.
A resident with multiple medical conditions did not receive prescribed artificial tears and wound care during a scheduled shift, despite documentation indicating otherwise. The resident reported the missed care, and subsequent review confirmed that the treatments were not administered as ordered, with the MAR inaccurately reflecting completion by an LPN.
Two residents experienced deficiencies in pressure ulcer care due to delayed documentation, lack of timely wound assessment, and failure to implement recommended nutritional interventions. One resident's pressure ulcer progressed from stage II to unstageable before being properly assessed by a wound physician, while another resident's dietary recommendation for protein supplementation was not implemented until a second request was made. Facility staff demonstrated inconsistent communication and documentation practices, and relevant policies were not followed.
A resident with significant mobility impairments and dependent on a Hoyer lift was transported alone in a reclining shower chair without a seatbelt, resulting in a fall when the chair was pushed over a raised threshold. Staff interviews revealed inconsistent understanding of transport requirements, and facility documentation lacked clear guidance or training on safe shower chair use.
Medication carts were found unlocked and unattended in the hallway, with one cart's drawer open and oxygen tubing on top. A resident was observed wandering near one of the unlocked carts while the charge nurse was not present to monitor them. Facility staff and policy confirmed that medication carts should be locked when not in use or out of direct view of nursing staff.
A resident with multiple dietary needs did not receive all menu choice items as listed on their meal ticket, with several items unavailable and no substitutions offered. Staff confirmed the unavailability and lack of communication regarding ordering, while the Dietician noted that substitutions should be provided. No documentation or policy was available to address the issue.
Two residents with moderately impaired cognition and multiple medical conditions were not administered or properly offered the COVID-19 booster vaccine despite having provided consent. Clinical records lacked documentation of vaccine administration or refusal, and the Infection Preventionist could not explain the omission, contrary to facility policy requiring vaccination opportunities for new admissions.
Several MDS assessments for multiple residents were not transmitted to CMS within the required 14-day period after completion. An LPN serving as the MDS Coordinator could not explain the delays, citing possible issues with a third-party company and potential system glitches. The facility's EMR system tracks due dates, but the required timelines were not met.
A resident with a history of muscle weakness, repeated falls, and impaired cognition, who was dependent on staff for bed mobility, slid off a low air-loss mattress during personal care and sustained multiple fractures, ultimately passing away at the hospital. Staff interviews revealed inconsistent understanding and application of the required assistance level, and the care plan was not updated in a timely manner to reflect the resident's changing needs.
A resident with multiple risk factors for falls and impaired cognition slid off a low air-loss mattress during care and sustained multiple fractures. After the fall, a nursing assistant and an LPN moved the resident prior to assessment by an RN, contrary to professional standards and facility policy. The resident was later transferred to the hospital and passed away. Staff interviews confirmed the resident was repositioned and changed on the floor before RN assessment, and the RN was not informed of these actions.
The facility did not update care plans for multiple residents following physical altercations, despite incidents involving residents with severe cognitive impairment and behavioral symptoms. In each case, care plans were not revised to include interventions to protect those involved or prevent future incidents, contrary to facility policy and regulatory requirements.
A resident with Alzheimer's disease experienced an incident where a nursing assistant was reported to be rough during a transfer. Although an assessment found no injuries, the nursing supervisor failed to document the assessment in the medical record, contrary to facility policy.
Failure to Supervise Wandering Resident and Maintain Safe Environment
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, severe cognitive impairment, muscle weakness, legal blindness, and bone density disorder was not adequately supervised despite being identified as at risk for wandering and/or elopement. The resident's care plan included interventions such as increased staff supervision, quarterly elopement assessments, and the use of exit alarms. However, on the night in question, the resident was last seen by staff at 2:00 AM and was found outside the building at 4:00 AM, having sustained abrasions, bruises, and a hematoma after a fall. The exit door alarm, which was supposed to alert staff if the door was opened, did not sound, and staff were unable to determine how long the resident had been outside. Interviews with staff revealed that the resident was known to ambulate independently and wander throughout the unit, especially during the day, and was generally redirectable. On the night of the incident, the nurse's aide had last assisted the resident to the bathroom at 2:00 AM and then returned to the nurse's station, where she could see down the hallway. The aide did not hear any alarm from the exit door and only discovered the resident outside after hearing yelling at 4:00 AM. The exit door, which should have been secured with an alarm, was found to be nonfunctional at the time of the incident, although it was reported to be working when tested later that day. The facility did not have a specific policy for residents with wandering behaviors, and the only relevant policy directed staff to report missing residents and ensure adequate safeguards for resident safety. Environmental observations identified additional hazards in the courtyard area accessible from the unit, including uneven pavement, unsecured stones with sharp edges, loose rocks creating tripping hazards, a steep drop-off, and an easily opened gate leading to a pathway toward a main road. The courtyard was intended to be accessible only under staff supervision, but the physical environment was not free from accident hazards, and the exit door alarm system failed to function as required. The facility was unable to explain why the alarm did not sound or why environmental hazards were not addressed, resulting in a finding of immediate jeopardy.
Failure to Assess, Care Plan, and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to properly assess, care plan, and document the placement of residents on a secured unit, as well as to obtain necessary consents and demonstrate that this setting was the least restrictive option. Observations over multiple days confirmed that the secured unit, identified as Station 2, required a code for egress, effectively restricting residents' ability to leave. For three sampled residents with varying cognitive and psychiatric diagnoses, there was no evidence in their clinical records, care plans, or physician orders that their placement on the secured unit was assessed, justified, or consented to by the residents or their representatives. For one resident with schizophrenia, bipolar disorder, and dementia, care plans and physician orders did not mention secured unit placement, and psychiatric notes indicated the resident was not a danger to self or others. Another resident with Alzheimer's dementia and schizoaffective disorder was assessed as not at risk for elopement, yet was placed on the secured unit without documentation of criteria or consent. A third resident with Lewy Body dementia and severely impaired cognition was also not assessed as an elopement risk, but was placed on the secured unit, with no documentation supporting the need for this level of restriction. Interviews with facility leadership, including the DNS, ADNS, and Medical Director, revealed a lack of established criteria or documented process for determining placement on the secured unit. The facility assessment did not identify the existence of a secured unit or criteria for placement, and the facility was unable to provide requested documentation such as placement consents or assessments. Residents interviewed were aware of their inability to leave the unit, and staff interviews confirmed that decisions for placement were made without formal guidelines or documentation.
Failure to Document Quarterly Environmental Rounds for Infection Control
Penalty
Summary
The facility failed to provide documentation that environmental rounds were conducted on a quarterly basis as required by their policy. Review of records with the Infection Preventionist revealed no evidence that environmental rounds were completed for the first quarter of 2024, specifically for the months of January, February, and March. The current Infection Preventionist, who began her role in June 2024, stated that it was the responsibility of the previous infection control nurse to ensure completion of these rounds and was unable to locate any documentation for the period in question. Facility policy requires that environmental rounds be conducted regularly by charge nurses, supervisors, departmental heads, and the infection control practitioner, with a report generated to identify areas of noncompliance.
Failure to Assess and Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly assessed for and offered pneumococcal and influenza vaccinations, as evidenced by the review of clinical records, facility policies, and staff interviews. For all five sampled residents, there was a lack of documentation indicating that the pneumococcal vaccine was assessed, offered, or administered, and in some cases, the influenza vaccine was not offered or documented as received. The Infection Preventionist acknowledged that it was her responsibility to ensure residents were up to date with vaccinations but admitted to not having done so due to being new to the role and busy with other tasks. Specific examples include residents with moderately to severely impaired cognition and multiple comorbidities such as anemia, hypertension, hyperlipidemia, schizoaffective disorder, vascular dementia, and diabetes mellitus. For these residents, records failed to show that vaccines were offered, administered, or refused, and in some cases, there was no assessment of prior vaccination history. The Infection Preventionist also noted difficulties in obtaining consent from responsible parties but did not document attempts or refusals related to the vaccines. Facility policy required that all residents be assessed for vaccination status upon admission and that vaccines be offered if not previously received. However, the review found that these procedures were not followed, as evidenced by missing documentation and lack of vaccine administration or offers. The Infection Preventionist had not completed planned audits to identify and address these gaps, resulting in the deficiency.
Failure to Document Advance Directive Choices in Physician Orders
Penalty
Summary
The facility failed to ensure that a physician's order was present to reflect a resident's wishes regarding cardiopulmonary code status, hospitalization, and intravenous fluids, as indicated in the resident's advance directive. The resident in question had diagnoses including dementia, hypertension, and muscle weakness, and was identified as having severely impaired cognition and requiring maximal assistance with daily activities. The care plan and an Advance Directive Consent Form, signed by the responsible party and physician/APRN, clearly documented the resident's election for full code status (CPR), hydration by IV fluids, nutrition by feeding tube, hospitalization to prolong life, and antibiotic therapy, with a refusal of comfort measures. Despite these documented choices, a review of the physician's orders over the relevant period did not reveal any orders addressing the resident's code status or the other elected interventions. Interviews with nursing staff and facility leadership confirmed that the code status should be reflected in the physician's orders and that it is the responsibility of nursing supervisors to ensure these orders are obtained and entered into the electronic medical record. The facility's own policy also requires that the physician write appropriate orders to indicate code status, to be verified by nursing upon admission. However, this process was not followed, resulting in the absence of required physician orders for the resident's advance directive choices.
Failure to Develop, Review, and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans within the required timeframe and did not ensure that care plans were reviewed and revised to reflect residents' current conditions. For one new admission, the interdisciplinary care plan meeting was not held, and the comprehensive care plan was not completed within 21 days as required by facility policy. The baseline care plan did not address all areas triggered by the admission MDS assessment, such as activities of daily living, rehabilitation potential, urinary incontinence, falls, dehydration, and pressure ulcers. The responsible RN acknowledged the care plan was overdue and incomplete, and could not provide a reason for the delay. Another resident's care plan was not updated to reflect changes in their activities of daily living (ADL) status, specifically regarding transfer and mobility needs. Despite physician orders and therapy notes indicating the need for a Hoyer lift with two-person assist, the care plan inaccurately described the resident as transferring and ambulating independently. The care plan was only updated after a fall occurred, and staff interviews confirmed that the care plan did not accurately reflect the resident's status prior to the incident. For a resident with pressure injuries, the care plan was not reviewed or revised when new skin issues developed, including a sacral pressure ulcer and a left heel wound. Documentation showed that the care plan did not reflect the resident's current skin status until after surveyor inquiry, despite multiple nursing notes and wound care interventions. Staff interviews confirmed that care plans should be updated following significant changes, but this was not done in a timely manner for the resident who developed new wounds.
Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including muscle weakness, glaucoma, hypertensive heart and chronic kidney disease, was observed self-administering medications that had been left at the bedside by a registered nurse. The resident was cognitively intact and received several medications daily, as documented in the care plan and physician's orders. Despite this, the resident did not have an order permitting self-administration of medications. The nurse reported routinely leaving medications at the bedside because the resident preferred to take them later, and confirmed that she did not observe the resident taking the medications, even though she had signed off on the medication administration record (MAR) as if the medications had been administered. Further interviews with facility staff, including the nurse manager, confirmed that medications should not have been left at the bedside and that staff are required to observe residents taking their medications unless there is a specific self-administration order in place. The facility failed to provide a medication administration policy when requested. The facility's own policy on self-administration states that such practice is only permitted if the interdisciplinary team determines it is safe, which had not occurred in this case.
Failure to Administer Ordered Treatments and Medications
Penalty
Summary
A resident with a history of hereditary syndrome of bilateral lacrimal glands, dry eye disorder, and malignant melanoma of the right upper eyelid did not receive prescribed treatments during a specific shift. The resident was cognitively intact, required assistance with toileting, and was independent with eating. Physician orders included administration of artificial tears to both eyes twice daily and a specific wound care regimen for the right leg. On the evening in question, the resident reported not receiving either the artificial tears or the wound care treatment, despite using the call bell and being told someone would return, which did not occur. The resident subsequently reported the missed care to the next shift, at which point the wound care was completed, but the eye drops were not administered as the nurse was unaware they had been missed. Documentation on the Medication Administration Record (MAR) indicated that the treatments had been provided by the LPN assigned to the earlier shift, but interviews and physical evidence (the unchanged dressing) confirmed the care was not performed as ordered. The facility's policy required licensed nurses to perform dressing changes as ordered by the physician.
Failure to Document and Intervene Timely for Pressure Ulcers and Nutritional Needs
Penalty
Summary
The facility failed to ensure proper documentation and timely intervention for pressure ulcers in two residents, resulting in deficiencies in pressure ulcer care and prevention. For one resident with Parkinson's disease and significant mobility limitations, a pressure ulcer on the sacrum/coccyx was first identified as an excoriation and later documented as a stage II pressure ulcer. However, there was no evidence of weekly monitoring or assessment of the wound, and the wound was not referred to the wound care team or physician for nearly two months. During this period, the wound progressed to a stage III ulcer and later became unstageable due to necrosis, with the first wound physician assessment occurring only after significant deterioration. Facility documentation and communication practices were inconsistent, with staff interviews revealing confusion about notification procedures and a lack of clear documentation in the APRN communication book. Another resident, who was at risk for skin breakdown due to decreased mobility and other medical conditions, developed two new stage III pressure wounds. The dietician made a recommendation for increased protein supplementation to promote wound healing, but this recommendation was not implemented until nearly a month later, after a second recommendation was made. There was no documentation of the original dietary recommendation in the resident's chart or the APRN communication book, and staff interviews indicated uncertainty about the process for handling dietary recommendations. The facility was unable to provide a policy outlining how such recommendations should be processed, despite having a protocol that required the dietician to assess and recommend nutritional supplementation as appropriate. Facility policy required regular documentation of wound appearance, weekly progress notes, and prompt referral to the wound care team for wounds not improving within 2-3 weeks. The policy also outlined specific documentation requirements for wound site, stage, size, and appearance, as well as procedures for reporting and treating acquired wounds. Despite these policies, the facility failed to follow its own protocols, resulting in delayed assessment, inadequate documentation, and lack of timely intervention for pressure ulcers and related care needs.
Resident Fall Due to Inadequate Supervision During Shower Chair Transport
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including hemiplegia, muscle weakness, and a history of stroke, was transported in a reclining shower chair by a single nursing assistant. The resident required extensive assistance for mobility and transfers, as documented in clinical records and therapy notes, and was non-ambulatory, requiring a Hoyer lift with two staff for transfers. Despite these needs, the resident was moved alone in the shower chair, which did not have a seatbelt, and fell when the chair was pushed over a raised threshold, resulting in the resident hitting the back of their head. Interviews with staff revealed inconsistent knowledge and unclear policies regarding the number of staff required to transport residents in different types of shower chairs. Some staff believed two people were needed for certain chairs, especially for residents requiring a Hoyer lift, while others were unsure or could not specify requirements. The staff member involved in the incident acknowledged forgetting the two-person requirement and transported the resident alone, leading to the fall. Facility documentation and interviews indicated a lack of formal education or competency assessments regarding the use of shower chairs, except in response to incidents. The facility's bathing and grooming policy did not specify staff requirements for transporting residents in shower chairs, and the care card for the resident did not provide guidance for safe transport in the chair. This lack of clear procedures and staff training contributed to the unsafe transport and subsequent accident.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on Station 2, including both the 2 South and 2 North carts, were left unlocked and unattended in the hallway, with one cart's drawer slightly open and oxygen tubing packets placed on top. At the time of observation, a resident was wandering in the hallway near one of the unlocked carts, while the charge nurse was in the nurses' office and unable to see the carts. Interviews with nursing staff and the Assistant Director of Nursing Services confirmed that facility policy requires medication carts to be locked when not in use or out of the nurse's direct view. Review of the facility's medication storage policy further indicated that only licensed nursing personnel should have access to locked medication carts, which are to remain locked at all times when not in use or in direct view.
Failure to Provide Menu Choice Items and Substitutions
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hyperlipidemia, dysphagia, and gastro-esophageal reflux disease was not provided with all menu choice items as listed on their meal ticket. The resident, who was cognitively intact and on a mechanically altered, therapeutic diet, received only a hot dog, apple juice, and water during a meal, while other listed items such as baked beans, chips, and pickles were unavailable. No substitutions were offered, and the resident reported that the kitchen was frequently out of stock of multiple items. Staff serving the meal confirmed the unavailability of the menu items and were unsure of the reason, noting they did not handle ordering. Further investigation revealed that the Food Service Director was unaware that the items had not been ordered or delivered, and there was no documentation indicating the items were out of stock. The Dietician acknowledged hearing resident concerns about not receiving chosen menu items and stated that appropriate substitutions should be offered when items are unavailable. Additionally, there were no notes from the monthly food committee meetings, and the facility was unable to provide a policy regarding food ordering and menu choices.
Failure to Administer or Document COVID-19 Booster Vaccination for Eligible Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccine was administered or properly offered to two residents who were eligible and had provided consent. One resident, admitted with diagnoses including anxiety, hypertension, and depression, had moderately impaired cognition and was not up to date with COVID-19 vaccination. Although this resident gave consent for the COVID-19 Pfizer-BioNTech vaccine, there was no documentation of consent for the 2024-2025 booster, nor any record that the vaccine was administered or refused. Review of clinical records and immunization consent forms did not show evidence that the booster was offered or given, and the Infection Preventionist could not explain why the vaccine was not administered. Another resident with schizoaffective disorder, anemia, and nutritional deficiency, also with moderately impaired cognition, was similarly not up to date with COVID-19 vaccination. Consent for the 2024-2025 COVID-19 vaccine was obtained from the responsible party, but there was no documentation that the vaccine was administered or refused. The Infection Preventionist acknowledged responsibility for obtaining consents and administering vaccines but was unable to provide a reason for the failure to offer or administer the booster. Facility policy required that new admissions be offered vaccination after a clinic, but this was not followed for these residents.
Late Submission of MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for five sampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) within the required 14-day timeframe following the completion of the assessments or care plans. Specifically, the quarterly and annual MDS assessments for these residents were submitted between seven and fourteen days late, as evidenced by a review of the facility's transmittal records. The electronic medical record (EMR) system in use at the facility compiles a list of due dates for MDS assessments, and the policy requires submission within 14 days of completion, but this protocol was not followed for the residents in question. During an interview, the MDS Coordinator, an LPN, was unable to provide a clear explanation for the late submissions. She indicated that a third-party company assists with MDS processing and sometimes reports that assessments have been submitted when, in fact, they have not. The LPN also mentioned the possibility of a system glitch contributing to the issue. The Resident Assessment Instrument Manual was referenced, confirming the requirement for timely submission of comprehensive and other MDS assessments.
Failure to Assess and Provide Appropriate Assistance During Bed Mobility Results in Resident Fall and Major Injuries
Penalty
Summary
A deficiency occurred when staff failed to ensure a timely and appropriate assessment of a resident's bed mobility needs during care, resulting in a fall with major injuries. The resident had a history of muscle weakness, repeated falls, anxiety disorder, and type 2 diabetes with neuropathy, and was identified as having moderately impaired cognition and being dependent on staff for bed mobility and transfers. The care plan indicated the resident was at risk for falls and required positioning in the middle of the bed before turning, with an update specifying a two-person assist during care after a previous fall. On the day of the incident, a nursing assistant was providing personal care and turned the resident onto their left side, at which point the resident slid off the side of a low air-loss mattress and landed on the floor. The assistant attempted to prevent the fall but was unsuccessful. Interviews revealed that the resident's ability to assist with bed mobility was inconsistent, and while some staff considered a two-person assist safer, the care plan had not been updated to consistently require this level of assistance prior to the incident. The last therapy evaluation for activities of daily living had been conducted several months prior, and no functional status changes had been reported to trigger a reassessment. Following the fall, the resident was found to have sustained multiple fractures, including bilateral femur and rib fractures, and subsequently passed away at the hospital. The facility's fall policy required assessment for fall risks and implementation of safeguards, but the lack of timely reassessment and inconsistent application of assistance levels during care contributed to the incident. Interviews with staff indicated uncertainty regarding the appropriate level of assistance needed for the resident, and the care plan interventions were not consistently aligned with the resident's fluctuating capabilities.
Failure to Follow Professional Standards in Post-Fall Care
Penalty
Summary
The facility failed to ensure that care and services provided to a resident were in accordance with accepted professional standards, specifically in the management of a fall with major injuries. The resident involved had multiple diagnoses, including muscle weakness, repeated falls, anxiety disorder, and type 2 diabetes with neuropathy, and was identified as having moderately impaired cognition and being dependent on staff for bed mobility and transfers. The resident was assessed as high risk for falls, with a care plan in place that included interventions such as ensuring the resident was positioned in the middle of the bed before turning and providing assistance of two during care. On the day of the incident, during morning care, the resident was turned onto their left side and slid off the side of a low air-loss mattress, landing on the floor with both legs extended and the right leg externally rotated. Staff interviews revealed that after the fall, the resident was initially in a sitting position with their back against the bed, but was subsequently moved by a nursing assistant and an LPN prior to assessment by a registered nurse (RN). The staff repositioned the resident to a lying position and straightened their legs, and later changed the resident's brief by turning them back and forth on the floor, despite the RN's directive not to move the resident until assessed. The RN was not informed that the resident had been moved prior to her assessment. The resident was later transferred to the emergency department, where multiple fractures were identified, including bilateral femur fractures and rib fractures. The resident became lethargic and was pronounced dead later that day. Facility policy directed that residents should be assessed for fall risks and that after any fall, an investigation and care plan review should occur. However, the staff did not follow professional standards by moving the resident prior to RN assessment after a fall with suspected fractures.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to update the care plans for several residents following physical altercations, as required by policy and regulation. In one incident, a resident with vascular dementia and severe cognitive impairment entered another resident's room, leading to a physical confrontation where both residents struck each other. Although one resident's care plan was updated after the incident, the other resident's care plan was not revised to include interventions to protect the resident or prevent recurrence. In another event, two residents with Alzheimer's disease and dementia, both with significant cognitive impairment, were involved in a physical altercation near the nurse's station. One resident kicked the other, who then pushed back, resulting in a scrape injury. Review of their care plans showed that neither was updated following the incident to address the altercation or implement measures to prevent future occurrences. Interviews with facility staff, including the Assistant Director of Nurses and the Director of Nurses, confirmed that care plans were not consistently updated after these incidents. Facility policy requires the interdisciplinary team to implement and revise care plans based on residents' needs and events, but this was not followed in the cases reviewed.
Incomplete Documentation Following Abuse Allegation
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate following an allegation of abuse. The resident, who was admitted with Alzheimer's disease and had severe cognitive impairment, was involved in an incident where a nursing assistant was reported to have been rude and rough during a transfer. The incident was reported by another nursing assistant, and a subsequent assessment by the nursing supervisor found no injuries or distress in the resident. However, the nursing supervisor did not document this assessment in the resident's medical record, which is a requirement according to the facility's policy. The facility's policy mandates that upon receiving reports of physical abuse, the nursing supervisor should direct the charge nurse to examine the resident and document the findings in the medical record. Despite this policy, the assessment conducted by the nursing supervisor was not recorded, leading to an incomplete clinical record. Interviews with the acting Director of Nursing and the Assistant Director of Nursing Services confirmed that the assessment should have been documented, but they were unaware of why it was not done.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hartford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Hill Care Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Parkville Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Chelsea Place Care Center Llc | 2.4 mi | ★★★★★ | 8 | 1 |
| Jefferson House | 2.6 mi | ★★★★★ | 0 | 0 |
| West Hartford Health & Rehabilitation Center | 2.9 mi | ★★★★★ | 22 | 0 |
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