Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Grimes Center during CMS and state inspections, most recent first.
Failure to Protect Resident from Verbal Abuse and Intimidation: A resident with dementia-related behavior issues was documented as verbally aggressive, intimidating, and using sexually explicit profanity toward another resident outside that resident’s room. The affected resident, who had bipolar disorder, anxiety, and borderline personality disorder, reported the altercation and later showed increased anger, paranoia, and distress. Facility records did not identify the other resident involved, and staff did not complete an incident report, investigation, or state report for the resident-to-resident abuse allegation.
Failure to Report Resident-to-Resident Verbal Abuse: A resident with dementia-related behavior issues sat outside another resident’s room, played loud music, and became verbally aggressive, intimidating, and used sexually explicit profanity after being told to turn it off. Staff removed the resident and spoke with both residents, but the event was not reported as a reportable abuse incident, and no incident report or investigation was completed despite policy requiring immediate reporting of abuse, intimidation, or resident-to-resident altercations.
Failure to investigate resident-to-resident verbal abuse: Staff knew one resident was verbally aggressive, intimidating, and used sexually explicit profanity toward another resident, but no incident report or full investigation was completed. The targeted resident later reported ongoing intimidation and retaliation concerns, and psych notes documented increased anger, paranoia, delusions, and distress. Facility records did not identify the other resident involved, and staff stated they did not report the event because they did not view it as abusive.
Failure to incorporate PASARR Level II recommendations into the care plan. A resident with bipolar disorder, psychotic disorder, borderline personality disorder, and a history of suicide attempts, homicidal ideation, violence, and substance abuse had a positive PASARR Level II that called for crisis intervention and a safety plan, but the record did not show the recommendations were reviewed, addressed, or added to the care plan. Interviews confirmed the MDS coordinator, SW, APRN, and psychologist were not aware of the PASARR findings or had not developed a formal safety plan.
A resident admitted with chronic diastolic CHF had physician-ordered CHF monitoring, including O2 sat checks, daily weights, edema checks, and monitoring for fatigue, SOB, cough, and lung sounds, but the care plan did not reflect the CHF diagnosis or related interventions. The admission MDS showed severe cognitive impairment and dependence on staff for ADLs, yet the care plan failed to include the CHF protocol.
Failure to Use Backboard During CPR: A resident with a trach, respiratory failure history, and full code status was found unresponsive in a recliner and staff initiated CPR after transferring the resident to bed, but no backboard or hard surface was used. Video and staff interviews showed the emergency cart arrived without a backboard attached, and multiple staff members confirmed CPR was performed without one. The physician present observed the absence of a backboard, and the CPR instructor stated a hard surface is needed for effective chest compressions.
Missed Daily Weight Documentation for Resident with CHF: A resident admitted with bilateral humerus fractures, AFib, and CHF had a physician order for daily weights and provider notification for significant weight gain, but the facility failed to document weights on multiple days. The care plan did not address CHF or daily weights, and the record lacked any explanation for the missed weights; the unit manager stated the resident’s pain initially made weighing difficult, but daily weights should have been done once movement was better tolerated.
Failure to apply a prescribed right-hand C-grip splint was identified for a resident with CVA, severe cognitive impairment, and limited ROM who required extensive ADL assistance. The splint was ordered for day-shift use after morning care, with instructions posted in the room, but observations showed the resident without the device on multiple occasions. NA staff said they were aware of the posted directions but did not routinely apply the splint, were unsure who was responsible, and had not been formally in-serviced; nursing staff also did not verify the device was in place or complete the expected skin check.
Failure to Implement EBP for Residents with Indwelling Devices and Chronic Wounds: Two residents were not placed on EBP despite having qualifying conditions. One resident had chronic bilateral foot wounds, a PICC/Hickman line, wound VAC care, and IV antibiotics; the other had ESRD and was dialyzed through a permacath. Nursing staff stated they were not aware the residents were on EBP or whether they met criteria, and the care plans and orders did not reflect EBP.
A resident with multiple blood disorders, cancer, and on medications known to increase bruising risk was admitted with existing bruises and developed further bruising during their stay. Despite clear documentation and staff awareness of the resident's high risk for bruising, the care plan did not include specific interventions to address this risk, contrary to facility policy.
A nurse aide failed to notify the charge nurse after observing purple discoloration to a resident's groin and upper inner thighs, despite the resident's complex medical history and facility policy requiring immediate reporting of significant changes in condition. The issue was discovered after the resident was hospitalized and the bruising was reported by hospital staff.
The facility did not ensure that their designated Infection Control Nurse, RN #4, completed the required CDC Infection Prevention Course. Although RN #4 had completed a certificate of achievement course in infection control, she had not finished two modules or taken the final exam for the CDC course. The Administrator and DNS were unaware of this incomplete training. RN #4 was the sole certified infection control nurse since her hire date.
The facility failed to complete advanced directive forms for three residents, resulting in incomplete documentation and lack of proper signatures and witness verification as required by policy.
The facility failed to notify the Office of the State LTC Ombudsman when three residents were transferred to the hospital. Interviews revealed a lack of awareness and miscommunication regarding the correct procedure for notifying the Ombudsman, and the facility did not provide a policy on the notification process.
The facility failed to provide adequate supervision for a resident, resulting in a fall and fracture, and did not ensure consistent monitoring for another resident with recurrent falls. Staffing issues and inconsistent documentation contributed to these deficiencies.
A resident with Alzheimer's, dementia, dysphagia, and diabetes experienced significant weight loss over several months. Despite documented weight decreases, the dietitian did not reassess the resident or bring the issue to the interdisciplinary team for intervention until months later, violating facility policy.
The facility failed to provide adequate nursing staff for a resident with multiple falls, leading to inconsistent 1:1 monitoring. Despite a care plan intervention, the resident was often left unsupervised due to staffing issues, resulting in multiple falls. Staff interviews confirmed that monitoring levels fluctuated based on staffing availability, and the DNS was unaware of these adjustments.
The facility failed to monitor targeted behaviors for a resident on antipsychotic medication. Despite directives to document specific behaviors, the behavior flow sheets were not individualized, and documentation was inconsistent. This failure to properly monitor and document behaviors led to a deficiency in care.
An LPN failed to properly sanitize a glucometer and perform hand hygiene as per facility policy, leading to a deficiency in infection control practices. The LPN did not know the correct procedure and did not allow for the required dwell time for sanitization, necessitating intervention from a supervisor.
A resident with a history of heart conditions did not receive anticoagulant medication for 13 days due to a missed INR test, resulting in a significant medication error. The facility's policy required INR testing per physician's order, but the nursing staff failed to follow up, leading to the resident missing the medication. The resident's INR level was found to be below the therapeutic range when tested later.
Failure to Protect Resident from Verbal Abuse and Intimidation
Penalty
Summary
The facility failed to protect a resident from verbal abuse and intimidation by another resident who was on a different unit. The other resident, who had diagnoses including dementia with agitation, adjustment disorder, and anxiety disorder, was documented as having behavior issues, verbal aggression, profanity toward other residents, and a history of antagonizing and intimidating others. Facility notes showed that this resident had been verbally aggressive toward another resident on the morning of 9/7/25, and later records described additional aggressive and intimidating behavior involving other residents, including use of sexually inappropriate profanity. The affected resident had diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder, with intact cognition and use of a walker and wheelchair. The resident’s care plan identified psychosocial risk related to depression, anxiety, psychosis, PTSD, and borderline personality disorder. Facility documentation and staff interviews showed that the resident reported a verbal altercation in which the other resident was sitting outside the room playing loud music, became yelling and profane when asked to turn it off, and intimidated the resident. The resident later reported that the other resident was attempting to retaliate, and psychiatric documentation noted increased anger, delusions, anxiety, paranoia, and distress following the events. The record did not contain additional documentation identifying the other resident involved in the incident, and the facility did not complete an incident report or investigation for the resident-to-resident altercation. Interviews showed that the DNS was not aware of reportable event reports for the incidents, and the SW and ADNS stated they did not complete an investigation or report to the state agency because they did not believe the incident required reporting. Staff interviews also confirmed that the resident involved in the aggressive behavior frequently traveled to other units and had ongoing issues with yelling and antagonizing the affected resident, while the facility policy required immediate reporting, documentation, and investigation of abuse, intimidation, and resident-to-resident altercations.
Failure to Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to immediately report a resident-to-resident verbal abuse incident involving two residents on different units. One resident had diagnoses including dementia with agitation, adjustment disorder, and anxiety disorder, and the care plan identified a risk for behavior issues related to mental illness and cognitive deficits. The other resident had diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder, with intact cognition and a care plan identifying psychosocial risk related to depression, anxiety, psychosis, PTSD, and borderline personality disorder. The incident occurred when one resident was sitting outside the other resident’s room, playing loud music, and became verbally aggressive, intimidating, and used sexually explicit profanity after being told to turn the music off. Facility staff removed the resident from the area, and nursing staff later spoke with both residents. Documentation showed the resident who was targeted reported the other resident was attempting to retaliate, and later psychiatric notes described increased anger, paranoia, delusions, and distress following the events. The record also reflected that staff were aware of ongoing antagonizing and intimidating behavior by the resident who initiated the confrontation. Despite the nature of the event and the facility policy requiring immediate reporting of abuse, intimidation, or mental anguish, the incident was not reported to the state agency as a reportable event. Interviews showed the DNS was not aware of any reportable event for the incident, the SW did not complete an incident report or investigation, and the ADNS did not complete an investigation or incident report and did not feel the event required reporting because the targeted resident did not identify additional issues. Facility policy required immediate reporting, incident documentation, investigation, and notification for abuse-related events and resident-to-resident altercations.
Failure to Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to complete a thorough investigation and failed to protect a resident from further potential abuse after another resident sat outside the resident’s room, played loud music, and became verbally aggressive, intimidating, and sexually explicit toward the resident. The involved resident had diagnoses including dementia with agitation, adjustment disorder, and anxiety disorder, and the record identified a history of behavior issues, mental illness, and cognitive deficits. Facility documentation showed prior behavior concerns involving profanity, intimidation, and attempts to target other residents, but the clinical record did not contain complete documentation identifying the other resident involved in the incidents or a full incident investigation. The resident who was targeted had diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder, with intact cognition and use of a walker and wheelchair. The record documented that the resident reported a verbal altercation with another resident and stated that the other resident made a vulgar comment, intimidated the resident, and was later attempting to retaliate. Psychologist documentation later noted that the resident reported multiple incidents with the other resident, including verbal altercations and attempts to intimidate, and that these events contributed to worsening symptoms, including increased anger, paranoia, delusions, and distress. Interviews with the DNS, SW, ADNS, APRN, psychologist, and RN showed that staff were aware of the incidents but did not complete an incident report or a formal investigation for the resident-to-resident altercation. The SW stated she did not complete an incident report because the issue was addressed and did not report the incident to the state agency because she did not view it as abusive. The ADNS similarly stated she did not ask follow-up questions or complete an investigation or incident report because the resident did not identify additional issues. The facility policy required immediate reporting, documentation, notification, and investigation of abuse or mistreatment, including interviewing witnesses and the accused person, but those steps were not completed for the incident.
Failure to Incorporate PASARR Level II Recommendations Into Care Plan
Penalty
Summary
The facility failed to incorporate recommendations from a positive PASARR Level II determination into the resident assessment and care plan for a resident admitted with diagnoses including borderline personality disorder, anxiety disorder, and bipolar disorder. The annual MDS identified intact cognition, continence, independence with toileting and transfers, and active diagnoses including bipolar disorder and psychotic disorder with daily antipsychotic medication, but it did not identify the resident as having a serious mental illness under the state PASARR process. The care plan addressed psychosocial risk related to depression, anxiety, psychosis, PTSD, and borderline personality disorder, but it did not include the resident’s history of suicidal ideation, suicide attempts, homicidal ideation, harm-directed behaviors, or substance abuse. The clinical record showed that the resident had a history of suicide attempts, homicidal ideation, physical violence toward strangers, and longstanding cocaine and illicit substance use documented in psychiatric treatment notes since admission. An initial psychiatric evaluation documented prior suicide attempts, a history of homicidal ideation, and chronic cocaine dependence, and the treatment plan included a verbal contract to notify someone if violent thoughts occurred and to begin talk therapy and substance abuse support. A psychotherapy assessment also documented drug use since the teen years, active crack cocaine use, a history of violence, and the resident’s report of being triggered, with therapy planned four times monthly including substance abuse counseling, relapse prevention, psychosocial education, and cognitive behavioral therapy. The record did not show that the care plan was revised to reflect these issues or that the PASARR Level II recommendations were reviewed, addressed, or implemented after the positive determination. The PASARR identified additional diagnoses including cocaine use, opioid use, alcohol abuse, suicide attempts, and attempts at harming others, and recommended crisis intervention and a safety plan with monitoring for increased symptoms or behavior changes and steps for the resident and staff to take. Interviews with the MDS Coordinator, SW, APRN, and Psychologist confirmed that the PASARR recommendations were not reviewed or formally incorporated into the resident’s care plan, and that no formal crisis intervention or safety plan had been developed or documented.
Care Plan Missing CHF Interventions
Penalty
Summary
The facility failed to ensure Resident #38’s care plan reflected the resident’s congestive heart failure diagnosis and the ordered CHF protocol. Resident #38 was admitted with diagnoses including bilateral humerus fractures, atrial fibrillation, and chronic diastolic CHF. Physician orders directed CHF monitoring measures including oxygen saturation every shift, daily weights, edema checks to the abdomen, legs, ankles, and feet every shift, and monitoring for fatigue, shortness of breath, cough, and lung sounds every shift. The admission MDS identified severely impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and dependence on staff for eating, bathing, and toileting, but the care plan did not identify CHF or related interventions.
Failure to Use Backboard During CPR
Penalty
Summary
The facility failed to use a hard surface, or backboard, beneath a resident during CPR in accordance with current American Heart Association guidelines. The resident was admitted with diagnoses including malignant neoplasm of the glottis and a history of acute and chronic respiratory failure with tracheostomy placement. The quarterly MDS identified the resident as cognitively intact, independent with bed mobility, transfers, and ambulation, and receiving tracheostomy care. The care plan identified a potential for altered respiratory status related to the tracheostomy and history of respiratory failure, and the resident’s advance directives indicated full code status. On the morning of the event, the resident was found unresponsive in a recliner in the room. Staff transferred the resident into bed and initiated CPR while emergency medical services were dispatched. The record states that high-flow oxygen was delivered via Ambu bag and an AED was applied, with no shock advised. EMS arrived and continued resuscitation efforts, including suctioning via the trach and orally, interosseous fluids, epinephrine, bicarbonate, and later use of a LUCAS device. The resident was intubated and later pronounced dead. The death certificate listed mucous plugging, tracheostomy, and laryngeal cancer as the cause of death. Facility video and staff interviews showed the emergency cart was brought to the room without a backboard attached, and the backboards on the units were observed next to the carts rather than attached to them. Multiple staff members who responded to the emergency stated they did not use a backboard during CPR. The physician present during the event observed that no backboard was in use and stated staff should have utilized one during CPR. The facility’s CPR policy did not include the requirement for a hard surface during CPR, and the certified CPR instructor stated that a resident must be placed on a hard surface in a clinical setting to deliver effective chest compressions.
Missed Daily Weight Documentation for Resident with CHF
Penalty
Summary
Failure to provide treatment and care according to orders, resident preferences, and goals occurred for Resident #38 when the facility did not obtain and document daily weights as ordered. Resident #38 was admitted in January 2026 with diagnoses including bilateral humerus fractures, atrial fibrillation, and chronic diastolic congestive heart failure. The physician ordered daily weights at 6:30 AM and to notify the MD/APRN for a weight gain of 3 lbs. or more in one day or 5 lbs. in one week. The admission MDS identified severely impaired cognition, frequent bowel incontinence, occasional bladder incontinence, and dependence on staff for eating, bathing, and toileting. Review of the clinical record showed that daily weights were not documented on 1/17, 1/18, 1/19, 1/20, 1/22, 1/25, and 1/28/26, and there was no documentation explaining why the weights were not obtained on those dates. The care plan did not identify interventions related to congestive heart failure or the need for daily weights. During interview, the unit manager stated that weights were difficult to obtain during the first few days after admission because of the resident’s bilateral humerus fractures and pain with movement, but after 3 to 4 days the resident could tolerate more movement and daily weights should have been completed; the manager also stated that if weights could not be obtained, the reason should have been documented and the provider notified.
Failure to Apply Prescribed Hand Splint
Penalty
Summary
The facility failed to ensure that a prescribed right C-grip hand splint was applied for a resident with cerebral infarction, severe cognitive impairment, limited ROM in the upper and lower extremities, and dependence on two staff for bed mobility, transfers, and dressing. The quarterly MDS and care plan identified the resident’s mobility limitations and need for ADL assistance, and a physician’s order directed the right C-grip hand splint to be applied every day shift after morning care for up to four hours. The resident’s room also had posted instructions showing the splint was to be applied after morning care, with staff directed to check that straps were not tight, follow numbered application steps, inspect skin for breakdown, and notify the supervisor with questions. Observation showed the resident up and dressed in a wheelchair on 1/27/26 and again up in a chair on 1/28/26 without the prescribed right-hand C-grip in place. The nurse aide care card did not include the splint schedule or related care, and NA #2 stated she was aware of the posted directions but did not routinely apply the device, was unsure who was responsible for placing it, did not know where to find it, had not been formally in-serviced, and had not reported the issue. RN #2 stated nurse aides were responsible for applying the device and nursing staff were responsible for ensuring application and skin checks, while the DNS expected aides to apply the splint and notify nursing for refusal or inability to locate it. LPN #5 stated she did not verify the splint on 1/29/26 because no concerns were reported.
Failure to Implement EBP for Residents with Indwelling Devices and Chronic Wounds
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for a resident with chronic bilateral foot wounds and an indwelling PICC/Hickman line. The resident had diagnoses including non-pressure chronic ulcers of both heels and midfoot with bone involvement, required daily wound care and wound VAC treatment, and was receiving IV antibiotics. The admission MDS identified intact cognition, substantial assistance needs for several activities of daily living, a foot infection, surgical wound care, and IV access, but the physician orders and care plan did not direct or include EBP. The resident’s record also showed a history of bilateral foot debridement, a left calcaneal biopsy showing acute osteomyelitis, ED transfer for necrotic heel wounds with purulent drainage, surgery for right foot incision and drainage, and later OR treatment with debridement, biological grafts, and negative pressure wound therapy. The resident was discharged to short-term rehab on IV Unasyn and Vanco. During interviews, nursing staff stated they were not aware the resident was on EBP or whether the resident met criteria for EBP. The facility also failed to ensure EBP was implemented for a resident receiving hemodialysis through a permacath. The resident had end-stage renal disease, dependence on renal dialysis, intact cognition, and required substantial assistance with personal care. The physician order directed transparent dressing changes for the permacath, and the care plan addressed the dialysis access site, but EBP was not in place. Staff interviews confirmed the resident was not on EBP and that the resident’s permacath was being used for dialysis because the AV fistula was not in use.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Bruising
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with appropriate interventions for a resident at risk for bruising. The resident had multiple complex diagnoses, including blood disorders, lymphoma, anemia, amyloidosis, and was taking medications such as Brukinsa (Zanubrutinib) and an antiplatelet, both of which increase the risk of bruising. Upon admission, the resident was noted to have multiple bruises and discoloration, and subsequent medical notes documented further bruising and purpura of unknown etiology, with concerns raised about medication side effects and possible trauma. Despite these findings and the resident's high risk for bruising, the care plan only addressed impaired skin integrity related to decreased mobility and incontinence, without specific interventions for bruising risk. Interviews with clinical staff, including the APRN and DNS, confirmed that the resident was at increased risk for bruising due to their diagnoses and medications, and that a comprehensive care plan addressing this risk should have been in place. The facility's care plan policy requires a care plan based on identified needs, strengths, and preferences, including measurable goals and interventions, but this was not followed for the resident in question. The deficiency was identified through review of clinical records, facility documentation, and staff interviews.
Failure to Report Change in Resident's Skin Condition
Penalty
Summary
A deficiency occurred when a nurse aide observed purple discoloration to the groin and upper inner thighs of a resident with multiple complex medical diagnoses, including Waldenstrom macroglobulinemia, myeloproliferative disease, lymphoplasmacytic lymphoma, amyloidosis, post-traumatic stress disorder, delirium, and depressive disorder. The resident was noted to have moderately impaired cognition, was frequently incontinent, dependent with transfers, and required substantial assistance with activities of daily living. Despite observing the change in skin condition during care, the nurse aide did not report this significant change to the charge nurse, as required by facility policy. The failure to report the change in condition was discovered after the resident was sent to the hospital for abnormal bloodwork, where hospital staff identified bruising in the vaginal area and notified the facility. The facility's Director of Nursing confirmed that the nurse aide should have immediately reported the observed discoloration to the charge nurse, in accordance with facility expectations and policy. The facility's policy requires all significant changes in a resident's condition to be reported to the physician and family.
Infection Preventionist Certification Incomplete
Penalty
Summary
The facility failed to ensure a certified Infection Preventionist was employed, as evidenced by the review of documentation and interviews conducted during the survey. RN #4, designated as the Infection Control Nurse, had completed a certificate of achievement course in infection control in April 2022, which included various topics related to infection prevention. However, it was noted that RN #4 had not completed the final exam associated with a more extensive CDC Infection Control Training course, despite taking several modules. The Administrator and DNS were unaware of this incomplete training, and RN #4 was the only nurse certified for infection control since her hire date in June 2022. During an interview and review of the Infection Control curriculum with RN #4, it was revealed that she had not completed two modules and had never taken the final test to secure a certificate of completion for the CDC Infection Prevention Course. Subsequent to the surveyor's inquiry, RN #4 completed the outstanding modules, took the test, and obtained a certificate certifying completion of the CDC Infection Prevention Course.
Failure to Complete Advanced Directive Forms
Penalty
Summary
The facility failed to ensure the advanced directive forms were completed for three residents. Resident #53 was readmitted with diagnoses including dementia and end-stage renal disease. Despite being alert and oriented, the facility did not discuss the code status with the resident, and the consent form was only signed by one nurse without a witness. The care plan indicated the resident was a full code, but there was no physician's order for the code status, and the advanced directive form lacked proper signatures and documentation of attempts to contact the resident's representative. Resident #58, who had a stroke and moderately impaired cognition, was readmitted to the facility. The resident's representative requested a full code status, but the consent form was signed by only one nurse without a witness. Although a physician's order directed the resident to be a full code, the advanced directive form was incomplete, and there was no documentation of a second witness as required by the facility's policy. Resident #70, admitted with heart failure and severely impaired cognition, had a full code status per the hospital discharge summary. However, the facility did not discuss the code status with the resident's conservator, and the advanced directive form was blank. Despite the conservator visiting the facility, there was no documentation of the conversation or attempts to obtain the advanced directive within the first day or two following admission. The facility's policy required the advanced directive and physician order form to be completed upon admission, which was not adhered to in these cases.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when three residents were transferred to the hospital. Resident #1, who was admitted with chronic kidney disease, myocardial infarction, and atherosclerotic heart disease, was transferred to the hospital on two occasions in February and March 2024. The Action Summary for these periods did not reflect that the Ombudsman was notified of these transfers. Similarly, Resident #18, admitted with congestive heart failure, atrial fibrillation, and chronic kidney disease, was transferred to the hospital twice in March 2024, and the Ombudsman was not notified as required. Resident #71, admitted with Wegener's granulomatosis, epilepsy, and chronic pain syndrome, was transferred to the hospital in November 2023, and again, the Ombudsman was not notified. Interviews with the facility's Administrator, Director of Nursing Services (DNS), and medical record staff revealed a lack of awareness and miscommunication regarding the correct procedure for notifying the Ombudsman. The medical record staff indicated that discharges to the hospital were uploaded to the Ombudsman’s office monthly but were unaware that the incorrect Action Summary was being sent. The facility did not provide a policy regarding the notification process, indicating a systemic issue in ensuring compliance with notification requirements.
Inadequate Supervision and Monitoring Leading to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall resulting in a fracture for Resident #40. Despite being identified as at risk for falls and having interventions in place, Resident #40 experienced an unwitnessed fall in the shower, leading to a displaced fracture at the proximal humerus. The facility did not have documentation that Resident #40 was assessed by therapy to shower independently, and the nursing assistant left the resident alone in the shower, contrary to the expected supervision protocol. This lapse in supervision directly contributed to the resident's fall and subsequent injury. The facility also failed to ensure appropriate observation and monitoring for Resident #37, who had multiple recurrent falls. Despite being identified as requiring 1:1 monitoring after several unwitnessed falls, the facility's documentation revealed significant gaps in the monitoring records. Resident #37 experienced numerous falls without consistent 1:1 monitoring or documented checks, and the facility's staffing issues led to fluctuating levels of supervision. The facility's policy did not require physician orders for frequent monitoring, and the DNS was unaware that staffing shortages were affecting the implementation of the monitoring interventions. Interviews with staff, including the DNS and APRN, confirmed that the facility's monitoring practices were inconsistent and often altered due to staffing issues. The DNS acknowledged that neurological checks should have been completed for unwitnessed falls but were not consistently documented. The facility's failure to provide continuous and adequate monitoring for Resident #37, despite the known risk of falls, resulted in repeated incidents of unwitnessed falls and injuries, highlighting a significant deficiency in the facility's fall prevention and monitoring protocols.
Failure to Follow Up on Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure the dietitian followed up on significant weight loss for a resident diagnosed with Alzheimer's disease, dementia, dysphagia, and diabetes. The resident, who had severely impaired cognition and required meal setup, experienced a notable weight loss over several months. Despite the resident's weight being documented as consistently decreasing, the dietitian did not reassess the resident or bring the issue to the interdisciplinary team for intervention until months later. The resident's weight dropped from 236 lbs. to 219.5 lbs., representing an 8.2% weight loss over a short period. The facility's policy required the dietitian to assess residents experiencing significant weight changes and to update care plans with new interventions. However, the dietitian did not follow this protocol, as there was no documentation of assessment or intervention after the resident's weight loss was noted on multiple occasions. The dietitian's last assessment was on 12/13/23, and the next assessment did not occur until 3/8/24, despite the resident's ongoing weight loss. This failure to act contravened the facility's policy and contributed to the deficiency identified in the report.
Inadequate Staffing and Monitoring for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to provide close monitoring for a resident with multiple falls. Resident #37, who had diagnoses including repeated falls, muscle weakness, and dementia, was admitted to the facility and required substantial assistance with daily activities. Despite a care plan intervention for 1:1 monitoring due to a high risk of falls, the facility did not consistently provide this level of supervision. Observations on multiple occasions revealed that the assigned nursing assistant was either not present or was attending to other residents, leaving Resident #37 unsupervised. Interviews with staff confirmed that due to staffing issues, the level of monitoring fluctuated and was not always in line with the care plan requirements. The facility's daily nursing roster and staffing sheets indicated that Resident #37 was supposed to be on 1:1 monitoring, but this was not consistently implemented. On one occasion, the nursing assistant assigned to Resident #37 was observed assisting another resident, and on another occasion, the same nursing assistant was seen attending to Resident #37's roommate, leaving Resident #37 unsupervised. Staff interviews revealed that the facility often adjusted the monitoring levels based on staffing availability, which sometimes resulted in Resident #37 being monitored less frequently than required. The Director of Nursing Services (DNS) and other staff members acknowledged the staffing issues and the inconsistency in monitoring but did not take adequate steps to address the problem. The facility's policy on falls required that residents at risk for falls have appropriate fall prevention measures in place, including 1:1 sitters when necessary. However, the DNS admitted that she was not aware that the staff had adjusted Resident #37's monitoring based on staffing issues and that the monitoring intervention was not always being carried out. The Advanced Practice Registered Nurse (APRN) also confirmed that the monitoring level was determined based on the resident's risk but was not aware that it was being altered due to staffing shortages. The facility's failure to provide consistent 1:1 monitoring for Resident #37, as required by the care plan, led to multiple falls and demonstrated a significant deficiency in ensuring resident safety.
Failure to Monitor Targeted Behaviors for Antipsychotic Medication
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident on antipsychotic medication. Resident #16, who was admitted with diagnoses including bipolar disorder, dementia, depressive episodes, and anxiety, was receiving antipsychotics and antidepressants. The care plan included monitoring for side effects and considering dose reduction when clinically appropriate. However, the facility did not document targeted behaviors as required by the physician's order dated 2/21/24, which directed documentation on a behavior monitoring flow sheet every shift. The psychiatric APRN progress notes and physician progress notes indicated specific behaviors to monitor, such as disorganized behaviors, delusions, and restlessness. Despite these directives, the behavior flow sheets were not individualized for Resident #16's specific behaviors. The documentation was inconsistent, with some shifts missing signatures and others signed off by nursing assistants instead of licensed nurses. The DNS confirmed that the behavior monitoring was not tailored to Resident #16's specific needs and that the computerized template used was not individualized. Review of the facility's Antipsychotic Drug Use Indications Policy revealed that antipsychotic drugs should only be used for specific conditions and behaviors, which must be documented. The facility's failure to consistently and accurately document targeted behaviors for Resident #16, as required by the physician's order and facility policy, led to the deficiency. This lack of proper monitoring and documentation could potentially impact the resident's care and the appropriateness of continued medication use.
Failure to Sanitize Glucometer and Perform Hand Hygiene
Penalty
Summary
The facility failed to ensure proper sanitization of the glucometer and adherence to hand hygiene protocols. During an observation, an LPN obtained a blood sugar reading for a resident and placed the glucometer on the medication cart without sanitizing it. The LPN then performed hand hygiene but did not sanitize her hands again after touching the glucometer before preparing insulin for administration. When questioned by the surveyor, the LPN admitted to not knowing the facility's policy for glucometer cleaning. The LPN then attempted to clean the glucometer with a Sani-Purple wipe but did not allow for the required dwell time before using it again. The supervisor had to intervene to instruct the LPN on the correct procedure, which includes a total dwell time of 4 minutes for proper sanitization. Further interviews revealed that agency staff, including the LPN in question, receive an overview of facility policies upon initial entrance, but the LPN failed to follow these protocols. The facility's policy for cleaning and disinfecting the glucometer includes using Sani-wipes or Purple Cap Wipes PDI with a dwell time of 2 minutes. The manufacturer's recommendations for the glucometer suggest using a germicidal bleach wipe with a total dwell time of 2 minutes. Despite these guidelines being available on the medication carts, the LPN did not adhere to them, leading to the deficiency in infection control practices.
Failure to Administer Anticoagulant Due to Missed INR Test
Penalty
Summary
The facility failed to ensure a laboratory test was obtained per physician's order for a resident receiving anticoagulant medication, resulting in a significant medication error. The resident, who had a history of prosthetic heart valve, endocarditis, atherosclerotic heart disease, and congestive heart failure, was admitted in January 2023. The care plan required administering anticoagulant as ordered and scheduling laboratory tests to monitor coagulation factors. However, the resident did not receive the anticoagulant medication, Coumadin, for 13 days due to a missed laboratory test for INR on 2/7/23, which was not followed up by the nursing staff. The resident's Medication Administration Record (MAR) showed that Coumadin was not administered from 2/7/23 to 2/19/23. The INR test, which was supposed to be conducted on 2/7/23, was not performed, and the resident's INR level was found to be below the therapeutic range when tested on 2/20/23. The facility's policy required licensed nursing staff to perform INR testing per physician's order, but this was not adhered to, leading to the medication error. Interviews with the involved staff revealed a lack of follow-up on the INR test, contributing to the resident missing 13 days of anticoagulant therapy.
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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 New Haven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Center For Nursing & Rehabilitation | 0.6 mi | ★★★★★ | 20 | 1 |
| West Haven Center For Nursing & Rehabilitation | 2.4 mi | ★★★★★ | 2 | 0 |
| Leeway, Inc | 2.5 mi | ★★★★★ | 10 | 0 |
| Mary Wade Home, The Incorporated | 2.5 mi | ★★★★★ | 4 | 0 |
| Whitney Center | 2.7 mi | ★★★★★ | 0 | 0 |
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