Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fairview during CMS and state inspections, most recent first.
A resident with CHF, respiratory failure, edema, cognitive impairment, incontinence, and documented risk for pressure injury did not receive an accurate, comprehensive care plan reflecting their assessed needs. The admission MDS and PT/OT evaluations showed the resident was dependent for ADLs, required assist of two and a mechanical lift for bed mobility and transfers, and had poor activity tolerance with fatigue and SOB, yet the care plan and NA Kardex continued to direct assist of one and did not include the Hoyer lift. Braden assessments by staff scored only mild risk and did not match clinical documentation of bedfast status, very limited mobility, edema, incontinence, and open skin areas. Although nursing and a wound specialist documented multiple wounds, including a right lower leg wound and later coccyx moisture-associated skin damage and a stage 3 coccyx pressure injury, the skin care plan remained generalized, did not list specific wounds or wound MD treatments, and was not revised as new wounds developed, contrary to facility policies requiring individualized, measurable, and updated care plans based on comprehensive assessment.
A resident with CHF, respiratory failure, pulmonary edema, dementia, severe edema, incontinence, and dependence for bed mobility and transfers was repeatedly scored as only mildly at risk for pressure injuries on Braden evaluations completed by an LPN. Therapy and nursing documentation described the resident as bedfast most of the time, incontinent, requiring a mechanical lift or stander with assist of two, and having +3 pitting edema with some open areas, which supported a much lower Braden score and high risk status. The care plan carried over outdated interventions (assist of one for transfers) and did not fully reflect current PT/OT recommendations or the resident’s true functional status. Facility leadership confirmed that Braden tools completed by LPNs were not reviewed or co-signed by an RN, despite state practice standards that LPNs cannot independently perform nursing assessments, and the ADNS later acknowledged that the Braden scores were inaccurate and understated the resident’s risk.
A resident with multiple comorbidities, impaired mobility, incontinence, edema, and cognitive impairment was assessed with Braden scores indicating only mild pressure injury risk, despite therapy and nursing documentation showing dependence for bed mobility and transfers, bedfast status much of the time, and frequent incontinence. The care plan was carried over from a prior admission, remained vague, and did not reflect current therapy recommendations, existing open skin areas, or wound MD involvement, while the Kardex therefore did not direct care based on the resident’s actual condition. Turning and repositioning were considered standard of care but were not documented, staff could not clearly identify responsibility for ensuring these interventions, and the dietician was not notified of the development of a Stage 3 coccyx wound or the wound MD’s request for a dietary consult. The facility’s own pressure injury prevention policy required systematic risk assessment, individualized care planning, and appropriate pressure redistribution and moisture management, but inaccurate Braden assessments, non-specific care plans, and failure to implement and document preventive interventions contributed to the resident developing a Stage 3 pressure ulcer to the sacrum.
A resident with paraplegia who required staff assistance for transfers was not safely transferred when two nurse aides used a standard sling instead of the required full body sling, as specified in the care plan. During the transfer, the resident slid out of the sling and sustained a head injury, later diagnosed as a subdural hematoma. Staff interviews confirmed that the correct procedures and equipment were not used, leading to the resident's fall and injury.
A resident with severe cognitive impairment and risk for pressure ulcers did not have a physician's order specifying the required settings for a pressure redistribution air mattress. Staff set the mattress above the resident's actual weight and relied on estimation rather than precise adjustment, with no documentation that licensed staff checked the settings as required. The resident later developed two new unstageable wounds.
The facility failed to maintain proper food safety and sanitation standards in the Dietary Department. Open food items were not dated, and there was a heavy accumulation of dirt and dust in various areas. Additionally, the dishwasher was not operating at the correct temperatures, and staff failed to report or address these issues.
The facility failed to timely address pharmacy recommendations for two residents regarding psychotropic medications. One resident, with Alzheimer's and dementia, was prescribed PRN Trazodone without a stop date, despite multiple pharmacy recommendations. Another resident, with anxiety and insomnia, had delayed responses to recommendations for stop dates on PRN medications. The facility's policy lacked a specific timeframe for addressing these recommendations.
A resident with vascular dementia and a history of falls had a clip alarm in place, but the facility failed to update the care plan and NA care card to reflect this intervention. Observations confirmed the use of the alarm, but staff interviews revealed that the documentation was not updated as required by the facility's policy.
A resident with cognitive impairment and dependency on staff for personal hygiene was found with unclean and lengthy fingernails, contrary to their care plan and facility policy. The facility's policy required routine nail care during ADL and on weekly bath days, but the responsible NA did not document any reason for the oversight, and attempts to contact them were unsuccessful.
The facility failed to follow physician orders for two residents regarding compression stockings and heel offloading, and did not provide necessary 1-to-1 assistance during meals for another resident. Observations showed non-compliance with orders, lack of updated care cards, and inadequate supervision during meals, leading to deficiencies in care.
A resident with a pressure ulcer on the coccyx did not receive proper infection control during a dressing change. An LPN failed to perform hand hygiene after changing gloves, violating the facility's clean dressing technique policy. The resident had a history of Parkinson's disease and cognitive decline, and the care plan included specific interventions for pressure ulcer management.
A resident with Alzheimer's and dementia was prescribed PRN Trazodone for anxiety without a stop date, contrary to CMS guidelines. Despite pharmacy recommendations to include a stop date, the prescriber did not address this in a timely manner, and the facility lacked a policy for stop dates on psychotropic medications.
A resident with dysphagia, paraplegia, and osteoporosis did not receive follow-up dental treatment for an upper denture due to a lack of communication and coordination within the facility. The resident's request was not documented, and necessary treatment for root tips was not pursued. The Unit Secretary failed to seek an alternative dental provider or inform the DNS, resulting in the resident not receiving the desired dental care.
A resident with dementia attempted to pull another resident out of bed, causing injuries. Despite the facility's policy requiring notification of Adult Protective Services (APS) within three days, the Director of Nursing (DON) did not report the incident, citing a lack of awareness of state guidelines and believing the situation did not warrant notification.
The facility failed to maintain a safe and sanitary environment in three shower rooms, with issues such as open bleach wipes, broken tiles, and soiled toilets. Staff interviews revealed a lack of awareness and responsibility for maintaining cleanliness and safety, with the Director of Maintenance unaware of some issues and relying on a ticket system for repairs.
Failure to Develop and Update Comprehensive Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple medical conditions and identified risk factors. The resident was admitted with acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, and dementia, and was placed on a sodium-restricted diet. The admission MDS identified moderately impaired cognition, dependence on staff for toileting, bathing, transfers, position changes, and wheelchair mobility, frequent bowel and bladder incontinence, risk for pressure ulcers/injuries, use of pressure-reducing devices, and use of anticoagulant and diuretic medications. These assessments triggered care areas including nutritional status, pressure ulcer, cognitive loss/dementia, ADL functional/rehabilitation potential, and urinary incontinence. Despite these findings, the resident’s care plan did not accurately reflect the resident’s functional and skin status or the therapy recommendations. The care plan dated 12/2 identified a self-care deficit related to ADLs and activity intolerance and directed an assist of one for bed mobility and transfers, and documented the resident as non-ambulatory. These interventions were carried over from a previous admission and did not incorporate the physical and occupational therapy evaluations completed on 11/29, which documented that the resident required an assist of two for bed mobility, sit-to-lying, lying-to-sitting, and sit-to-stand, and that transfers were not attempted due to medical condition. Therapy notes further indicated the resident required a mechanical Hoyer lift for transfers, had poor activity tolerance, fatigue, shortness of breath with activity, and decreased O2 saturation, yet the care plan and nurse aide care card continued to direct an assist of one and did not include the Hoyer lift. The care plan was not updated to reflect subsequent therapy documentation that the resident required an assist of two for safety during transfers and had a new level of ability with fatigue and shortness of breath. The facility also failed to accurately assess and care plan the resident’s skin integrity and pressure injury risk. On admission, nursing notes documented multiple skin issues, including a right shin abrasion, red/blanchable buttocks, bruising, edema to bilateral lower extremities, and later a right lower leg wound treated by a wound specialist. Braden Scale assessments completed by facility staff scored the resident at 16 and 17 (mild risk), indicating no sensory impairment, occasional moisture, chairfast status with frequent slight position changes, and adequate or probably inadequate nutrition. However, based on the admission assessment, therapy assessments, and nursing notes, the surveyor’s Braden scoring indicated the resident should have been classified as high risk, with very limited sensory perception, bedfast activity, very limited mobility, probably inadequate nutrition, and friction/shear as a problem. The care plan for “risk for potential impairment to skin integrity” remained generalized, did not identify the resident’s open wounds, did not incorporate the wound physician’s specific treatment orders, and was not revised when new coccyx moisture-associated skin damage and a stage 3 coccyx pressure wound were identified. Interviews with MDS and nursing leadership confirmed that open areas and wound MD involvement should have been reflected in the care plan, that Braden assessments were not accurate, and that interventions in the care plan did not align with assessments or therapy recommendations, contrary to facility policies requiring individualized, measurable, and updated care plans based on comprehensive assessment and risk factors.
Inaccurate Braden Scoring and Lack of RN Oversight for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pressure injury risk assessments met professional standards of quality for a resident with multiple serious medical conditions. The resident was admitted with acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, gait and mobility abnormalities, difficulty walking, cognitive communication deficit, and dementia. An LPN completed Braden Scale evaluations on two occasions, assigning scores of 16 and 17, which indicated only mild risk for pressure injury development. These Braden assessments documented no sensory impairment, occasional moisture, chairfast status with frequent slight independent position changes, and either inadequate or adequate nutrition, with friction and shear listed as a potential problem. In contrast, other clinical documentation at and shortly after admission described the resident as significantly more impaired. Physical therapy and occupational therapy evaluations identified the resident as dependent with assist of two for bed mobility and sit-to-stand, requiring a mechanical lift (Hoyer) or stander with assist of two for transfers, and ambulation only with therapy. Nursing documentation and an advanced skilled evaluation described the resident as bedfast most of the time, incontinent of urine and bowel, using adult briefs and a bedpan, with +3 pitting edema in all extremities and some open areas requiring ace wraps. The admission MDS documented that the resident was dependent for toileting, bathing, transfers, position changes, and wheelchair mobility, frequently incontinent of bowel and bladder, and at risk for pressure ulcers/injuries. Based on these records, the surveyor’s Braden scoring using the same tool yielded a significantly lower score, indicating high risk for pressure injury development. The facility also failed to ensure that Braden assessments completed by an LPN were reviewed by an RN, despite state scope-of-practice requirements that LPNs contribute to, but not independently perform, nursing assessments. The DNS and RN supervisor confirmed that Braden scales were completed and locked by the LPN without RN co-signature or review, and that the RN supervisor did not review LPN documentation for accuracy or consistency. The ADNS later acknowledged that the Braden assessments for this resident were not accurate, that the score should have been lower, and that there were inconsistencies and conflicting documentation in the clinical record. The facility’s own policy required licensed nurses to conduct Braden risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and the ADNS stated that the Braden score directs interventions for pressure injury prevention. However, the resident’s care plan carried over prior interventions that did not reflect current PT recommendations for mechanical lift transfers and assist of two for bed mobility, and the resident was provided only a pressure-reducing mattress rather than an overlay or air mattress, further illustrating the disconnect between the resident’s documented condition and the Braden assessments used to guide care. Additionally, the resident’s care plan for self-care deficit and skin integrity risk did not accurately incorporate the updated functional status and transfer needs identified by therapy. The care plan continued to direct assist of one for bed mobility and transfers and described the resident as non-ambulatory based on prior admission information, failing to reflect the current requirement for mechanical lift transfers with assist of two. While the care plan for skin integrity risk included general interventions such as keeping skin clean and dry, providing a pressure-relieving/reducing mattress, frequent turning and repositioning, and encouraging nutrition and hydration, it did not appear to be driven by an accurate Braden risk level. Interviews with nursing leadership confirmed that Braden assessments were not being reviewed or co-signed by an RN when completed by an LPN, and that the facility relied on these unreviewed scores to direct pressure injury prevention interventions for this high-risk resident. The CT LPN Practice Act and state statute cited in the report specify that LPNs may participate in all phases of the nursing process under the direction of an RN and may collect, report, and record data, but cannot independently perform the nursing assessment. Despite this, the DNS and RN supervisor stated that Braden scales were considered evaluations rather than assessments and therefore did not require RN review or co-signature. This practice resulted in inaccurate Braden scoring for a resident with significant mobility, continence, and edema issues, and the ADNS ultimately agreed that the Braden assessments did not accurately reflect the resident’s status and that the resident’s risk for pressure injury development was greater than documented. The combination of inaccurate Braden scoring, lack of RN oversight of LPN-completed assessments, and care plans that did not align with current therapy and nursing findings led to the identified deficiency in ensuring services met professional standards of quality. The facility’s own policy for pressure injury prevention and management required licensed nurses to conduct Braden risk assessments at specified intervals and with significant changes in condition, but the implementation of this policy did not include RN validation of LPN-completed Braden tools. Interviews showed that leadership staff were either unable or unwilling to confirm the accuracy of the resident’s initial Braden scores at the time of survey, and only upon further review did the ADNS acknowledge that the scores were inaccurate and should have been lower. The surveyor’s independent Braden scoring, based on the admission assessment, PT and OT assessments, and nursing notes, demonstrated that the resident’s true risk level was high, underscoring the discrepancy between the facility’s documented Braden scores and the resident’s actual clinical condition as recorded elsewhere in the chart. Overall, the deficiency centers on the facility’s failure to ensure that Braden pressure injury risk assessments were accurate, consistent with other clinical documentation, and performed within the appropriate scope of practice, as well as the failure to ensure RN oversight of LPN-completed Braden tools. This resulted in care planning and interventions that were not properly aligned with the resident’s actual risk for pressure injury development, as evidenced by conflicting documentation regarding mobility, continence, edema, and skin status, and by leadership’s acknowledgment that the Braden scores were not accurate and that the resident’s risk was greater than documented.
Failure to Accurately Assess Pressure Injury Risk and Implement Preventive Measures
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess a resident’s pressure injury risk and to implement appropriate preventive measures, resulting in the development of a Stage 3 pressure ulcer to the sacrum. The resident was admitted with multiple significant diagnoses, including acute on chronic diastolic congestive heart failure, acute and chronic respiratory failure with hypoxia, pulmonary edema, muscle weakness, gait and mobility abnormalities, difficulty walking, cognitive communication deficit, and dementia. On admission, the Braden Scale assessment completed by an LPN scored the resident at 16 (mild risk), documenting no sensory impairment, chairfast status with frequent independent position changes, occasional moisture, probable inadequate nutrition, and friction/shear as a potential problem. Nursing admission notes, however, documented multiple skin issues, including red/blanchable buttocks, edema to both lower extremities, incontinence, and bedfast status most of the time, while therapy evaluations documented that the resident was dependent for bed mobility and transfers, required a mechanical lift, and had poor activity tolerance with desaturation and shortness of breath. Subsequent documentation continued to show inconsistencies between the resident’s actual condition and the Braden assessments and care plan. A later Braden assessment scored the resident at 17 (still mild risk), again indicating no sensory impairment, chairfast status with frequent independent position changes, occasional moisture, and adequate nutrition, despite the admission MDS identifying moderately impaired cognition, dependence for toileting, transfers, and position changes, frequent bowel and bladder incontinence, and use of pressure-reducing devices. Therapy notes described the resident as incontinent without awareness, requiring extensive assistance for mobility and transfers, and needing a mechanical lift or stander with two-person assist. The care plan carried over interventions from a previous admission, directing assist of one for bed mobility and transfers and non-ambulatory status, and did not reflect current therapy recommendations or the resident’s actual dependence. The skin integrity care plan was generalized, did not identify existing open skin areas or wound MD involvement, and did not individualize interventions based on the resident’s specific risks and condition. As the resident’s condition deteriorated, documentation showed increased edema, bedfast status, incontinence, and prolonged time in bed, but the facility did not demonstrate implementation or documentation of turning and repositioning or other enhanced interventions. Nursing advanced skilled evaluations later identified moisture-associated skin damage to the right and left coccyx that was painful and burning, with specific wound measurements, and interventions limited to position changes. A wound physician subsequently assessed the coccyx wound as a Stage 3 pressure injury with exposed subcutaneous tissue, moderate serosanguineous exudate, and associated factors including edema, pain, COVID-positive status, incontinence, and decreased activity. Interviews with staff revealed that turning and repositioning were considered a standard of care but were not documented, that there was no clear identification of who ensured these interventions were completed, and that Braden assessments for this resident were later acknowledged by the ADNS as inaccurate. The dietician reported not being notified of the Stage 3 wound or the wound MD’s request for a dietary consultation. The facility’s own pressure injury prevention policy required systematic risk assessment using the Braden tool in conjunction with other risk factors, individualized care planning, and appropriate pressure redistribution and moisture management, but the facility failed to ensure accurate assessment, specific and current care planning, implementation of recommended referrals, and documentation of preventive interventions for this resident. The facility’s policy also assigned responsibility to the ADNS for reviewing documentation related to skin assessments, pressure injury risks, and compliance, and for modifying interventions as needed. Interviews with the MDS staff indicated that all residents were considered at some risk and should have a care plan for potential skin impairment, with open areas and wound MD involvement reflected in the care plan. However, the MDS staff could not explain why this resident’s wounds and mobility status were not updated in the care plan, and one MDS staff member acknowledged that care plans were vague. The ADNS later confirmed that the resident’s Braden assessments were not accurate and that documentation did not demonstrate that turning and repositioning were being completed, and stated that a lower Braden score would have prompted consideration of an overlay or air mattress. The facility ultimately failed to ensure that the resident’s pressure injury risk was correctly assessed, that the care plan accurately represented the resident’s status and needs, that the Kardex directed care appropriately, and that referrals and preventive interventions were implemented and documented, leading to the development of a Stage 3 pressure ulcer to the sacrum.
Failure to Use Correct Mechanical Lift Sling Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when a resident with paraplegia, chronic pain, weakness, and anxiety disorder, who required staff assistance for transfers, was not safely transferred using the appropriate equipment. The resident's care plan specified the use of a small full body mechanical lift sling for transfers due to their high risk for falls. On the day of the incident, two nurse aides attempted to transfer the resident using a standard sling instead of the required full body sling because the correct sling could not be located. One aide was aware of the care plan instructions but did not seek assistance to find the correct sling and proceeded with the transfer using the available standard sling. During the transfer, the resident began to slide out of the standard sling, and the staff attempted to lower the resident to the floor. The resident complained of moderate pain to the right backside of the head and was found to have a small bump and a skin tear. Shortly after the incident, the resident experienced a change in level of consciousness and was transferred to the emergency department. Initial CT scans were negative, but a follow-up scan revealed a small subdural hematoma. Interviews with the involved nurse aides revealed that both were aware, or should have been aware, of the requirement to use the full body sling as indicated on the resident's care card. One aide admitted to not using the correct sling and not asking for help, while the other assumed the correct sling was in use based on visual cues. The facility's mechanical lift transfer policy required staff to ensure the proper sling size was used and that slings were securely attached before and during transfers, but these procedures were not followed, resulting in the resident's fall and injury.
Failure to Specify and Document Pressure Mattress Settings for Resident at Risk for Pressure Injuries
Penalty
Summary
A deficiency was identified when the facility failed to ensure a physician's order specified the settings for a pressure redistribution air mattress for a resident with multiple diagnoses, including dementia, weakness, and risk for pressure injuries. The resident was dependent on staff for bed mobility and transfers, had severely impaired cognition, and was at risk for pressure ulcers. Physician orders directed staff to check the function of the air mattress every shift and evaluate for bottoming out, but did not specify the required mattress settings based on the resident's weight. During observation, the air mattress was set above 160 pounds, despite the resident's recorded weight being 122.2 pounds, and there were no markers to identify the exact setting. Staff estimated the dial position rather than using a precise setting, and there was no documentation that licensed staff were checking the settings as required. Interviews with facility leadership confirmed that the air mattress settings should be based on the resident's weight and that inaccurate settings could increase the risk for skin breakdown. The facility's policy required support surfaces to be used according to physician orders and checked each shift for proper functioning. However, the lack of specific orders for mattress settings and absence of documentation verifying checks contributed to the deficiency. The resident subsequently developed two new unstageable wounds to both feet, as documented by a wound care specialist.
Deficiencies in Food Safety and Sanitation in Dietary Department
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the Dietary Department. During a tour, it was observed that open food items in the walk-in freezer, refrigerator, and dry storage room were not dated, which is against the facility's policy. The Assistant Dietary Manager acknowledged that it was her responsibility to ensure that open items were dated and labeled correctly, but she had overlooked the non-dated items. Additionally, the facility's Date Marking for Food Safety policy requires that food be clearly marked with the date it was opened and the date it should be consumed or discarded, which was not adhered to. The facility also failed to maintain sanitary conditions in the kitchen and dish room. There was a heavy accumulation of dirt, dust, and dead insects on the windowsill and window tracking near the walk-in freezer and refrigerator. A brown substance was splattered on the door frame and ceiling tiles in the dish room, and fans over the 3-bay sink area and clean dish rack were covered in dust. The inside of a convection oven had crumbs and a dried splattered substance, and a bin of flour and a jug of molasses were noted to be dirty. The Assistant Dietary Manager admitted that there was a cleaning schedule in place, but she failed to ensure that the areas were clean. Furthermore, the facility did not ensure that the dishwasher was operating at the correct temperatures. Logs showed that the wash and rinse temperatures were consistently below the required levels, and there was no follow-up on these low temperatures. Dietary Aide #1, who was responsible for recording the temperatures, was unsure of which gauge to read and did not report the low temperatures. Similarly, Dietary Aide #2 continued to use the dishwasher despite low temperature readings. The Assistant Dietary Manager acknowledged that the aides should have reported the low temperatures and that she should have been notified to take corrective action.
Failure to Address Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for the use of psychotropic medications for two residents. Resident #23, diagnosed with Alzheimer's disease and dementia, was receiving hospice services and was prescribed Trazodone as needed for anxiety and agitation. Despite pharmacy recommendations on multiple occasions to include a stop date for the PRN Trazodone, the facility did not address these recommendations in a timely manner. The pharmacy consultant communicated the need for a stop date on 4/29/24, 5/30/24, and 6/27/24, but the prescriber did not respond until 7/3/24, and even then, the order was not consistently updated to include a stop date. Resident #48, with diagnoses of generalized anxiety disorder, depression, and insomnia, was prescribed Hydroxyzine and Trazodone as needed. The pharmacy consultant recommended on 1/23/24 that a stop date be provided for these medications or that they be discontinued, in accordance with CMS guidelines. This recommendation was not addressed until 4/23/24, 91 days later, when the psychiatric APRN discontinued the PRN Trazodone and added a stop date for Hydroxyzine. The facility's policy required staff to act upon all medication regimen review recommendations, but it did not specify a timeframe for doing so. Interviews with the Director of Nursing Services and the pharmacist revealed that there was no specific timeframe in the facility's policy for addressing pharmacy recommendations, although the pharmacist expected recommendations to be addressed within 14 days. The lack of timely response to pharmacy recommendations for both residents indicates a deficiency in the facility's medication management practices, particularly in ensuring compliance with CMS guidelines for psychotropic medications.
Failure to Update Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for a resident with a history of falls and vascular dementia, upon the initiation of a clip alarm. The resident's care plan, dated June 30, 2024, did not include the use of a clip alarm as an intervention, despite the resident being identified as a fall risk. Observations on July 9 and July 11, 2024, confirmed the presence of a clip alarm attached to the resident's sweatshirt while seated in a chair. However, the Nurse Aide (NA) Assignment sheet, last updated on April 8, 2024, and the resident's care card did not document the use of the clip alarm. Interviews with staff, including a nurse aide and a registered nurse, revealed that the clip alarm was used on both the resident's bed and chair, but this was not documented in the care plan or the NA care card. The Director of Nursing Services (DNS) acknowledged the need for the clip alarm due to the resident's fall history but was unsure when it was initiated. The DNS also confirmed that the documentation should have been updated by the nursing staff responsible for implementing the alarm. The facility's Comprehensive Care Plan policy requires that staff be notified of their roles and responsibilities for interventions, initially and when changes are made, which was not adhered to in this case.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure that a resident's fingernails were clean and trimmed, as required by their care plan and facility policy. The resident, who was moderately cognitively impaired and dependent on staff for personal hygiene, was observed with unclean and lengthy fingernails. The resident expressed that the nurse aides had not cut their fingernails in the past few weeks, despite the care plan's directive to maintain short nails to prevent skin impairment. The facility's policy required routine nail care during activities of daily living and on a regular schedule with weekly bath days. However, the assigned nurse aide responsible for the resident's care on the designated shower day did not document any reason for failing to perform the nail care. Attempts to contact the responsible nurse aide were unsuccessful, indicating a lapse in adherence to the facility's nail care policy and documentation procedures.
Failure to Follow Physician Orders and Provide Required Care
Penalty
Summary
The facility failed to adhere to physician orders for two residents regarding the application of compression stockings and heel offloading. Resident #6, who had a history of cerebral infarction, hyperlipidemia, and hypertension, was observed multiple times without the prescribed compression stockings, despite documentation indicating they were applied. The nurse responsible for documentation admitted to signing off on the application without verifying it, and the facility lacked a specific policy for compression stockings, relying instead on the expectation that orders be followed. Resident #25, diagnosed with stroke, peripheral artery disease, and diabetes mellitus, was not provided with the required heel offloading as per physician orders. Observations showed the resident's heel was flat on the mattress, contrary to the directive to keep it elevated. The care card used by nurse aides was not updated to reflect the physician's order, and staff were unaware of the symbols and instructions on the card. Additionally, weekly skin assessments were not completed as required, with two out of four assessments missing in June. Resident #82, with dementia and dysphagia, was not provided with the necessary 1-to-1 assistance during meals. Observations showed the resident left alone with a meal tray within reach, contrary to the APRN's orders for supervision. The care card contained contradictory instructions, and staff documentation inaccurately reflected the resident's independence in eating. Interviews with staff revealed a misunderstanding of the supervision requirements, and the facility's policy was not followed, leading to the resident being unsupervised during meals.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to maintain proper infection control practices during a dressing change for a resident with a pressure ulcer. The resident, who had diagnoses including Parkinson's disease, generalized muscle weakness, abnormal posture, and age-related cognitive decline, was identified to have a stage 2 pressure injury on the coccyx upon transfer from the hospital. The resident's care plan noted an unstageable pressure ulcer and included interventions such as administering treatments as ordered, monitoring nutritional status, and documenting changes in skin status. During an observation of the treatment, an LPN donned personal protective equipment and removed the soiled dressing from the resident's coccyx wound. However, the LPN failed to perform hand hygiene after changing gloves, which is a breach of the facility's policy for clean dressing technique. The LPN attempted to open a clean foam dressing with the same gloved hands used to remove the soiled dressing, prompting the surveyor to intervene. The facility's policy requires removing gloves, washing hands, and putting on clean gloves when transitioning from dirty to clean tasks.
Failure to Include Stop Date on PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to include a stop date on an as-needed (PRN) psychotropic physician order for a resident diagnosed with Alzheimer's disease and dementia, who was receiving hospice services. The resident was prescribed Trazodone, an antidepressant, to be administered every 8 hours as needed for anxiety and agitation. However, the physician's order did not specify a stop date, which is a requirement according to CMS guidelines. The resident's Medication Administration Records (MAR) showed that Trazodone was administered multiple times over several months without a stop date being added to the order. Despite pharmacy reviews and recommendations on multiple occasions, including on 4/29/24 and 6/27/24, to include a stop date for the PRN Trazodone, the prescriber did not address these recommendations in a timely manner. The facility's Director of Nursing Services (DNS) was verbally informed of the need for a stop date, but the issue persisted until the Advanced Practice Registered Nurse (APRN) eventually responded to the pharmacy's recommendations. The facility lacked a policy for including stop dates on psychotropic medications, contributing to the oversight.
Failure to Follow Up on Dental Treatment for a Resident
Penalty
Summary
The facility failed to follow up on dental treatment for a resident with diagnoses including dysphagia, paraplegia, and osteoporosis. The resident was cognitively intact and required assistance with oral and personal hygiene. The care plan identified oral health problems related to missing teeth and denture placement, with interventions to coordinate dental care and consult with a dietitian if chewing or swallowing issues arose. Despite a facility agreement with a dental service provider, the resident's request for an upper denture was not documented, and necessary treatment for root tips was not pursued. The resident expressed uncertainty about the status of the upper denture after the previous dental group left the facility. The Unit Secretary was aware the resident did not want to return to a community dentist seen earlier in the year but did not seek an alternative provider or communicate the issue to Social Services or the Director of Nursing Services (DNS). The DNS was unaware of the resident's preference and indicated that she would have taken action had she known. The lack of communication and follow-up resulted in the resident not receiving the desired dental treatment.
Failure to Report Resident Altercation to APS
Penalty
Summary
The facility failed to notify Adult Protective Services (APS) of a resident-to-resident altercation involving two residents. Resident #50, who has dementia, insomnia, and anxiety, was identified as moderately cognitively impaired and at risk of wandering. On the night of the incident, Resident #50 was found attempting to pull Resident #55 out of bed, causing discolored areas on Resident #55's face. Resident #55, who has dementia, contracture, and weakness, was severely cognitively impaired and dependent on staff for assistance. Despite the altercation and the facility's policy requiring APS notification within three days, the Director of Nursing Services (DNS) did not report the incident to APS, citing a lack of awareness of state guidelines and a belief that the situation did not warrant notification. The incident was documented in a Reportable Event form, and staff interviews confirmed the details of the altercation. LPN #7 heard yelling and found Resident #50 in Resident #55's room, attempting to remove Resident #55 from the bed. The DNS admitted to not notifying APS in similar past situations and was unaware of the facility's policy requirements. The facility's Resident Abuse policy clearly states the need to report such incidents to APS within three days, highlighting a deficiency in following established protocols for reporting suspected abuse or neglect.
Facility Fails to Maintain Safe and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a homelike, sanitary, and safe environment in three of its six shower rooms. During an initial tour, several issues were identified in Shower Room A on the second floor, including an open container of bleach wipes, chipped tiles and paint, broken blinds leaning against the wall, a walker left on shower equipment, and a commode stored behind the tub. In Shower Room B, a foot cradle was left on the floor, a basin and empty coat hanger were on the sink, and the toilet was soiled with brown stains. Shower Room C had broken trim hanging along the doorway, an unsecured drain cover, and unidentified substances in the corners of the floor. Interviews with staff revealed a lack of awareness and responsibility for maintaining the cleanliness and safety of the shower rooms. An LPN acknowledged the hazards posed by the equipment and conditions in the shower rooms, while a nursing assistant noted the presence of broken blinds during a resident's bath. The Director of Maintenance admitted to being unaware of some of the issues, such as the broken tile, and explained that environmental rounds are conducted monthly but do not include common areas. The maintenance process relies on staff reporting issues through a ticket system, which may contribute to delays in addressing deficiencies.
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What surveyors actually found near you
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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 Groton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beechwood Health & Rehabilitation Center | 1.4 mi | ★★★★★ | 3 | 0 |
| Harbor Village North Health And Rehabilitation Cen | 2 mi | ★★★★★ | 22 | 0 |
| Complete Care At Groton Regency | 2.7 mi | ★★★★★ | 13 | 0 |
| New London Sub-acute And Nursing | 2.9 mi | ★★★★★ | 22 | 3 |
| Greentree Manor Nursing And Rehabilitation Center | 3.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.