Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Springs At East Hill, The during CMS and state inspections, most recent first.
A resident admitted with malnutrition and dysphagia did not receive ordered J-tube feeding for over 11 hours because nursing staff could not locate the formula and supplies, and failed to notify the provider as required by facility policy. Interviews and documentation confirmed that the formula and supplies were present in the facility but not used, and no timely notification to the APRN or physician occurred.
A resident with a J-tube and orders for continuous enteral feeding did not receive the prescribed tube feeding for over 11 hours after admission because nursing staff could not locate the formula and supplies, despite these items being present in the facility. Staff did not contact the APRN or physician to establish an alternate plan, resulting in a significant delay in providing ordered nutrition.
The facility failed to ensure that all licensed staff had valid CPR certification, with 13 LPNs lacking certification. Miscommunication between the DNS and HR led to a lack of tracking, resulting in RN #2 working 79 shifts without a valid CPR card. The facility's policy requires CPR certification, but it was not enforced.
The facility failed to ensure that all licensed nursing and supportive nursing personnel had the appropriate IV training, certification, and competencies. An RN and an LPN provided IV care to a resident without having the necessary certifications on file. Additionally, the facility did not complete IV competency validation for nurse aides in 2024, as required by their policies.
The facility failed to conduct 90-day and annual performance evaluations for nurse aides in 2023 and 2024, and did not provide mandatory education for 2024. The Director of HR and DNS acknowledged the lapses, with personnel files showing missing evaluations and education records. Critical topics like infection control and resident rights were not covered.
A facility failed to verify the Infection Preventionist's certification upon hire, leading to a deficiency identified during a survey. The RN, responsible for infection control, had completed a certification course in 2019 but lacked documentation. Miscommunication between the DNS and Human Resources led to the oversight, which was only addressed after the survey.
A facility failed to create a baseline care plan for a resident with significant cardiac and respiratory issues, including recent coronary artery bypass surgery and a pneumothorax. The resident required a Lifevest device, but the care plan did not document these needs. An LPN cited workload as a reason for the oversight, acknowledging that the care plan should have included these critical health needs as per facility policy.
The facility failed to create comprehensive care plans for two residents, one with depression, anxiety, and aortic dissection, and another with MRSA bacteremia and a PICC line for antibiotic treatment. The care plans lacked necessary interventions for medications and specialized treatments due to the MDS coordinator's workload and lack of support, leading to deficiencies in addressing the residents' medical needs.
The facility failed to obtain weights for a resident as per physician's orders, leading to delayed identification of fluid overload. Another resident was not provided with a physician's order or staff training for a Lifevest device, and respiratory assessments were inconsistently documented. Additionally, a third resident did not receive the second step of a PPD test for TB as ordered, indicating lapses in admission procedures and monitoring.
A resident with severe protein-calorie malnutrition was not weighed as per physician's orders, leading to a 12.5% weight loss over 16 days. Despite the resident's awareness and collaboration with staff, there was no documentation of weight refusals. Interviews revealed a lack of communication and documentation regarding weight monitoring, contributing to the oversight in addressing the resident's nutritional needs.
A resident with chronic respiratory conditions did not have their oxygen and nebulizer tubing changed weekly as ordered by a physician. The tubing was last changed 12 days prior to observation, contrary to the facility's policy and physician's directive. Interviews with staff revealed a lack of adherence to the protocol and possible gaps in documentation practices.
A facility failed to train staff on the use of a Lifevest device for a resident admitted after cardiac surgery. The resident, who required the device for cardiac monitoring, managed the device independently due to staff's lack of training. Interviews revealed that staff, including the DNS, LPNs, NAs, and therapy staff, were not educated on the device, and the care plan lacked interventions for the resident's cardiac needs. The facility's assessment claimed adequate resources for staff education, yet no policies or procedures for the Lifevest were available.
The facility failed to consistently complete shift-to-shift controlled drug counts, as observed during a survey. On multiple dates, the change of shift inventory record for controlled drugs was missing nurse signatures across all shifts on a specific unit. Interviews revealed that staff were unaware of the missing signatures, despite the facility's policy requiring accurate counts and signatures at each shift change.
The facility failed to notify the Ombudsman of hospital transfers for two residents. One resident had two hospital leaves in May and June, and another was transferred in October, without notifications being sent. The social worker responsible was unaware of the requirement, and the facility's policy for monthly reporting was not followed.
A resident with multiple sclerosis and mobility impairments, who required assistance with toileting, was told by a nurse aide to go to the bathroom independently. The resident attempted to do so and soiled themselves, as the aide failed to provide the necessary help, violating the resident's right to dignity and respect.
A resident with cognitive impairment and significant care needs was subjected to repeated sexually inappropriate comments by a nursing assistant during a scheduled shower, in the presence of the resident's spouse and other staff. Despite being instructed not to provide care to the resident after the incident was reported, the nursing assistant proceeded to shower the resident. Facility investigation confirmed the occurrence of verbal sexual abuse.
A resident with cognitive impairment and significant care needs was subjected to sexually inappropriate comments by a nursing assistant. Despite a directive from the DNS to remove the staff member from the resident's care, the nursing assistant continued to provide care to the resident after the allegation was reported, in violation of facility policy requiring immediate removal of accused staff from resident contact.
A resident with dementia and mobility issues was mistreated by an LPN, who was observed being rough and verbally inappropriate during a transfer. The incident was witnessed by another LPN and an RN, leading to the LPN's termination. The facility's failure to protect the resident from mistreatment constitutes a deficiency.
Failure to Notify Provider of Inability to Administer Ordered Tube Feeding
Penalty
Summary
The facility failed to ensure timely notification of the medical provider when a resident was unable to receive ordered tube feeding upon admission. The resident, admitted with diagnoses including protein-calorie malnutrition and dysphagia, had orders for J-tube feeding with a specific formula and rate. Upon admission, nursing staff were unable to locate the required tube feeding formula and administration supplies, resulting in the resident not receiving the prescribed feeding for approximately 11 and a half hours. Documentation shows that the formula and supplies were present in the facility but not found or used by the staff on duty. Nursing staff did not notify the APRN or physician about the inability to provide the ordered feeding, as confirmed by interviews and review of the medical record. Both the evening and night shift nurses acknowledged awareness of the issue but did not contact the medical provider or document any notification. Facility policy required immediate consultation with the physician when treatment could not be provided as ordered, but this was not followed. The deficiency was identified through clinical record review, staff interviews, and policy review.
Delay in Initiation of Ordered Tube Feeding Due to Supply and Communication Failures
Penalty
Summary
A deficiency occurred when a resident admitted with protein-calorie malnutrition and dysphagia, and with a J-tube for enteral feeding, did not receive tube feeding as ordered by the physician. Upon admission, the resident had physician orders for Vital AF 1.2 at 55 ml per hour for 22 hours daily via J-tube, with hourly water flushes. Nursing staff documented that the prescribed tube feeding formula and necessary administration supplies were not available upon the resident's arrival, resulting in a delay in initiating the tube feeding. Although the resident arrived with some containers of the formula, staff were unable to locate the appropriate supplies and did not start the feeding as ordered. The resident went approximately 11 and a half hours without the ordered tube feeding, missing about 660 ml of nutrition. During this period, staff were able to administer medications and flush the J-tube as ordered, but the enteral nutrition was not provided. Interviews revealed that the on-call APRN or physician was not contacted to establish an alternate plan when the feeding could not be started, despite facility policy requiring appropriate treatment for residents with feeding tubes. The feeding and supplies were later found to have been present in the facility, but not located or used by the nursing staff at the time of need.
Failure to Ensure CPR Certification for Licensed Staff
Penalty
Summary
The facility failed to ensure that all licensed staff had valid, current CPR certification, as required by their policy. A review of CPR certification records revealed that only 2 RNs and 2 LPNs had valid CPR certification, while 13 LPNs did not. Interviews with the Director of Nursing Services (DNS) and Human Resources (HR) personnel indicated a lack of clarity regarding responsibility for tracking CPR certifications. The DNS believed it was the nurses' responsibility to update their CPR cards and provide copies to DNS and HR, while HR personnel indicated that the DNS was responsible for tracking certifications. The Administrator was under the impression that HR was responsible for ensuring all licensed nursing staff were CPR certified. Further investigation revealed that RN #2, who was hired without a valid CPR certification, worked the 11:00 PM to 7:00 AM shift as the only nurse on duty for 79 out of 112 days. RN #2 indicated that he was CPR certified at a hospital in 2021, but his certification expired in 2023, and he had lost the expired card. Despite the facility's policy requiring CPR certification to be obtained and tracked, RN #2 was not asked to provide his CPR card since his hire. The facility's failure to track and ensure current CPR certification for all licensed staff represents a significant deficiency in compliance with their own policies and state regulations.
Lack of IV Certification and Competency in Nursing Staff
Penalty
Summary
The facility failed to ensure that all licensed nursing and supportive nursing personnel had the appropriate IV training, certification, and competencies. Specifically, 7 out of 17 licensed nurses, including an RN and an LPN, did not have an IV therapy certification on file. The RN provided care for a resident with a PICC line, performing tasks such as flushing the line on multiple occasions, while the LPN administered IV Daptomycin via a PICC to the same resident. The RN had previous IV training in an emergency department setting but lacked certification for long-term care and could not recall completing any competencies or skill demonstrations at the facility. The Human Resources Director was unaware of her responsibility to obtain and track IV certifications, and the DNS acknowledged that it was ultimately her responsibility to ensure the certifications and competencies were completed. Additionally, the facility failed to provide IV competency validation for nurse aides in 2024. The DNS admitted that due to a lack of residents requiring IV therapy recently, annual IV therapy education and competency evaluations for nurse aides were overlooked. The facility's policies require that nurse aides receive IV education initially, yearly, and as needed, with competency determined by the facility. The DNS recognized her oversight in not completing the necessary education and competencies for the nurse aides.
Failure to Conduct Performance Evaluations and Mandatory Education
Penalty
Summary
The facility failed to conduct 90-day and annual performance evaluations for nurse aides in 2023 and 2024, as well as the mandatory annual education for 2024. The Director of HR acknowledged that the 90-day evaluations were not completed due to department heads being busy, and the annual evaluations were also not conducted. The Director of HR was responsible for tracking and notifying department heads of upcoming evaluations, but the process was not followed through. The DNS confirmed that she was behind on annual evaluations for the nursing department and was unsure about the 90-day evaluations for new hires. Personnel files for five nurse aides revealed missing evaluations for the specified periods. Additionally, the facility did not provide the mandatory education for nursing staff in 2024. The DNS was unable to present documentation of completed mandatory education for the year. Personnel files for the nurse aides showed no record of the required education, which included various critical topics such as infection control, resident rights, and emergency procedures. Despite requests, the facility could not provide a policy for mandatory annual education for nurses and nurse aides.
Infection Preventionist Certification Oversight
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a registered nurse (RN), had completed specialized training in infection prevention and control. The RN was hired on October 23, 2024, and during a survey conducted on January 6, 2025, the facility could not provide documentation that the RN had completed the necessary training or certification. The RN had previously completed an Infection Preventionist certification course in 2019 but was unable to provide documentation of this due to the certificate being located five hours away. The RN had been working at the facility for approximately 90 days, dedicating over 40 hours per week to infection control responsibilities, yet had not been asked for her credentials upon hire. Interviews with the Director of Nursing Services (DNS) and the Human Resources Director revealed a lack of communication and responsibility regarding the verification of the RN's credentials. The DNS assumed that the Human Resources department was responsible for obtaining the certification documentation, while the Human Resources Director believed it was the responsibility of the DNS or the Administrator. This oversight was only identified during the survey, and the RN subsequently provided a certification dated January 9, 2025. The facility's policy requires the Infection Preventionist to be qualified by education, training, experience, or certification, which was not initially verified in this case.
Failure to Develop Baseline Care Plan for Resident with Cardiac and Respiratory Issues
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident with significant cardiac and respiratory issues. Resident #226 was admitted following a hospital stay for coronary artery bypass surgery and experienced a spontaneous pneumothorax requiring chest tube placement. The resident was also discharged with a Lifevest device, a wearable defibrillator for continuous heart monitoring. Despite these critical conditions, the baseline care plan did not document the resident's cardiac or respiratory diagnoses, recent surgery, pneumothorax, or the need for the Lifevest device. An interview with the LPN responsible for MDS assessments and care plan updates revealed that due to workload, there was a delay in reviewing and individualizing care plans. The LPN acknowledged that the baseline care plan should have included the resident's specific needs, such as respiratory and cardiac monitoring and the use of the Lifevest device, as indicated in the hospital discharge documentation. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including necessary healthcare information to provide effective, person-centered care, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #9 was admitted with diagnoses including depression, anxiety, and aortic dissection, and was on medications such as Lexapro, Alprazolam, and Heparin. Despite these conditions and a history of falls, the care plan did not include interventions for the use of antidepressant, antianxiety, and anticoagulant medications, nor did it address the resident's fall risk. The MDS coordinator, responsible for creating the care plan within 21 days of admission, acknowledged the oversight, citing workload and lack of coverage as reasons for the delay. Resident #224 was admitted with MRSA bacteremia, chronic kidney disease, and diabetes, and was receiving Daptomycin via a PICC line. The care plan failed to include interventions related to the intravenous medication or the PICC line, which was crucial for the resident's long-term antibiotic treatment. The MDS coordinator admitted to falling behind on updating care plans due to her dual role as a medical records clerk, which impacted her ability to ensure care plans were individualized to residents' needs. The facility's policy mandates the development of a comprehensive care plan within seven days of the comprehensive assessment, including measurable objectives and timetables to meet residents' needs. However, the care plans for both residents did not meet these requirements, as they lacked specific interventions for their medical conditions and treatments. This deficiency was attributed to the MDS coordinator's workload and the absence of adequate support, resulting in incomplete care plans that did not address the residents' specialized needs.
Deficiencies in Weight Monitoring, Device Management, and TB Testing
Penalty
Summary
The facility failed to obtain weights for Resident #224 as per the physician's order upon admission. The resident was admitted with a diagnosis of MRSA bacteremia and required specific weight monitoring for Daptomycin dosing. However, the initial weight was not documented until two days after admission, showing a significant weight loss from the hospital's recorded weight. This oversight led to a delay in identifying the resident's fluid overload condition, which was only addressed after a notable weight gain was observed. For Resident #226, the facility did not secure a physician's order for the use of a Lifevest device, a critical cardiac monitoring tool, nor did they provide staff training on its operation. The resident, who had undergone major cardiac surgery, was left to manage the device largely independently, including battery changes, despite having physical limitations. Additionally, the facility failed to consistently document respiratory assessments as ordered, with gaps in the clinical record for several days. Resident #9 did not receive the second step of a two-step PPD test for tuberculosis as ordered upon admission. The facility's policy required this test to be completed to ensure the resident was free from active TB, but the second test was not administered or documented. This lapse in following physician orders and facility policy highlights a deficiency in the facility's admission procedures and monitoring of new residents.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order for weight monitoring for a resident diagnosed with severe protein-calorie malnutrition. Resident #7, who was admitted with conditions including dysphagia, hyponatremia, Myelodysplastic Syndrome, and severe malnutrition, was to be weighed on admission, daily for three days, weekly for four weeks, and then monthly. However, the facility did not complete the required weekly weights from 12/14/24 through 12/30/24, resulting in a significant weight loss of 12.5% during this period. The care plan for Resident #7 identified nutritional problems but failed to address refusals of care. Despite the resident's awareness of their weight loss and collaboration with facility staff, there was no documentation of weight refusals. Interviews with the dietitian and nursing staff revealed that the resident had not refused care or weights, and the dietitian adjusted nutritional supplements only after the weight loss was identified. The facility's weight policy mandates that weights be documented and appropriate follow-up initiated if weight changes occur, but this was not adhered to in Resident #7's case. Interviews with facility staff, including LPNs and the DNS, indicated a lack of communication and documentation regarding the resident's weight monitoring. The DNS expected weights to be completed per physician orders, and the APRN anticipated weight loss due to the resident's medical conditions but expected adherence to the weight monitoring order. The failure to obtain and document the resident's weights as ordered contributed to the oversight in addressing the resident's nutritional needs in a timely manner.
Failure to Change Respiratory Tubing Weekly
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of oxygen and nebulizer tubing for Resident #174, who was diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, Covid-19, and dementia. The resident was admitted to the facility with these conditions and required oxygen therapy and nebulizer treatments. A physician's order specified that the oxygen and nebulizer tubing should be changed weekly on Wednesday night shifts. However, observations on January 6th revealed that the tubing had not been changed since December 25th, indicating a lapse of 12 days without the required change. Interviews with facility staff, including an LPN and the DNS, confirmed that the tubing should have been changed on January 1st, as per the physician's order. The DNS acknowledged that the nurse responsible for changing the tubing should not have signed off on the task if it was not completed. Additionally, an RN indicated a lack of clarity on where to document the tubing change, suggesting a possible gap in training or communication. The facility's policy on respiratory equipment changes emphasizes the importance of changing equipment weekly to prevent infections, yet this protocol was not followed in this instance.
Lack of Staff Training on Lifevest Device for Resident
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and educated on the use of a specialized device, the Lifevest, for a newly admitted resident, Resident #226. This resident was admitted following major cardiac surgery, which included coronary artery bypass surgery and the removal of pacemaker/defibrillator wires. During the hospital stay, the resident experienced a pneumothorax requiring a chest tube, and upon discharge, was required to use a Lifevest device, a wearable defibrillator. However, the facility's care plan did not include interventions related to the resident's cardiac or respiratory issues, nor did it mention the Lifevest device. Interviews with various staff members, including the Director of Nursing Services (DNS), Licensed Practical Nurses (LPNs), Nurse Aides (NAs), and Physical and Occupational Therapy staff, revealed a lack of training and education on the Lifevest device. The DNS confirmed that no training had been provided to the staff regarding the Lifevest prior to or after the resident's admission. The resident had been managing the device independently, including monitoring and changing the battery, despite having mild arthritis and overall weakness from surgery, which made these tasks challenging. Staff members were aware of the device but had not received formal training or instructions on its use. The facility's failure to provide training and education on the Lifevest device was further highlighted by the absence of physician's orders related to the device's monitoring and battery changes. The facility's assessment claimed the ability to provide person-centered care and sufficient resources for staff education, yet no policies or procedures regarding the Lifevest were available. The lack of documentation and training posed a risk to the resident's well-being, as the Lifevest is critical for monitoring and treating potential cardiac events.
Failure to Complete Shift-to-Shift Controlled Drug Counts
Penalty
Summary
The facility failed to ensure that shift-to-shift controlled drug counts were consistently completed, as observed during a survey. On multiple dates in January 2025, the change of shift inventory record for controlled drugs was missing nurse signatures across all shifts on the Short End unit. This deficiency was identified during an observation of the medication carts with an RN, who was unaware of the missing signatures until the surveyor pointed them out. Interviews with an LPN, the RN, the Director of Nursing Services (DNS), and the Administrator revealed that none were aware of the missing signatures, although they all acknowledged the expectation that nurses should count narcotics at each shift change and sign the narcotic count sheet. The facility's policy requires that all Scheduled II-IV medications be accounted for at the end of each shift, with any discrepancies promptly investigated. The policy specifies that both the oncoming and off-going medication-distributing associates are responsible for counting the controlled medications and signing the controlled medication count/key sign-out sheet after verifying the count's accuracy. Despite this policy, the facility did not adhere to these procedures, resulting in the observed deficiency.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding hospital transfers for two residents. Resident #2 was admitted to the facility and experienced hospital leaves on two occasions, in May and June 2024, without the Ombudsman being notified. The facility's documentation, including the Emergency Transfers document and the Long-Term Care Ombudsman Program Notification Details, did not reflect these notifications. Interviews with the social worker (SW #1) revealed a lack of awareness about the requirement to report unplanned discharges to the hospital to the Ombudsman, which she only learned about a month prior to the interview. The Administrator confirmed the expectation for monthly reporting of all resident transfers to the Ombudsman. Similarly, Resident #23 was transferred to the hospital in October 2024, but the facility failed to notify the Ombudsman. The emergency transfers form did not include notifications for any resident hospital transfers from June 2024 through November 2024. Interviews with SW #1, the Director of Nursing Services (DNS), and the Administrator confirmed that SW #1 was responsible for these notifications, but they were not being done monthly. The facility's policy requires that emergency transfer notices be sent to the Ombudsman, either individually or in a list format on a monthly basis, but this was not adhered to.
Failure to Assist Resident with Toileting Results in Loss of Dignity
Penalty
Summary
A resident with multiple sclerosis, generalized muscle weakness, and mobility impairments required moderate assistance with transfers and toileting, as documented in the care plan and MDS assessment. The resident was identified as needing the assistance of one staff member for activities of daily living and ambulation, and was frequently incontinent of bowel and occasionally incontinent of bladder. Despite these documented needs, a nurse aide failed to provide the required assistance when the resident requested help to use the bathroom. Instead, the aide instructed the resident to go to the bathroom independently. As a result of not receiving the necessary assistance, the resident attempted to ambulate to the bathroom alone and soiled themselves in the process. Facility documentation, including a grievance form and an accident and incident report, substantiated that the aide did not honor the resident's request in a timely manner and failed to assist as required. The facility's policy on resident rights directs that all staff must treat residents with respect and dignity at all times, which was not upheld in this instance.
Failure to Protect Resident from Verbal Sexual Abuse by Staff
Penalty
Summary
A resident with moderately impaired cognition, metabolic encephalopathy, retroperitoneal hematoma, generalized muscle weakness, and requiring assistance with personal care was subjected to verbal sexual abuse by a nursing assistant (NA). The resident's care plan and physician's orders specified scheduled showers and encouraged participation in care. During an interaction in the resident's room, the NA made sexually inappropriate comments about how the resident would be showered, including explicit references to the resident's body and sexual arousal, in the presence of the resident's spouse and other staff. Multiple staff members, including another NA, an LPN, and the RN supervisor, either overheard or were informed of the inappropriate comments. The resident's spouse expressed discomfort with the NA's behavior and reported the incident to facility leadership. Despite being directed by the RN supervisor not to provide care to the resident following the incident, the NA proceeded to shower the resident that evening. Facility documentation and interviews confirmed that the NA repeated the inappropriate comments multiple times and that the incident was witnessed by staff and the resident's spouse. The facility's investigation substantiated the allegation of verbal sexual abuse, confirming that the resident was not protected from abuse as required by policy and regulation.
Failure to Suspend Staff After Alleged Verbal Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to suspend an employee after an allegation of verbal sexual abuse toward a resident. The resident, who had diagnoses including metabolic encephalopathy, retroperitoneal hematoma, generalized muscle weakness, and required assistance with personal care, was the subject of a complaint made by the resident's spouse. The complaint detailed that a nursing assistant made sexually inappropriate comments to the resident in the presence of others. Despite the direction from the Director of Nursing Services (DNS) to remove the nursing assistant from the resident's care assignment for the remainder of the shift, the nursing assistant proceeded to provide a shower to the resident that evening. Facility policy required that any staff member accused of abuse be removed from contact with all residents until the investigation was concluded. However, interviews and documentation confirmed that the nursing assistant continued to have contact with the resident after the allegation was reported, contrary to policy. The investigation substantiated the allegation of verbal sexual abuse, and the failure to immediately suspend the staff member after the allegation constituted the deficiency.
Resident Mistreatment by LPN
Penalty
Summary
The facility failed to protect a resident from mistreatment, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident with dementia and mobility issues. The resident required moderate assistance from two staff members for transfers and could ambulate up to 200 feet with assistance. During an incident, an LPN was observed being rough with the resident, including placing her hand on the resident's face in a cupping motion and roughly placing the resident into a wheelchair. This behavior was witnessed by another LPN and a Registered Nurse (RN), who intervened during the transfer. The incident was reported and investigated by the facility, which substantiated the allegation of abuse. The facility's policy on abuse and neglect defines physical abuse to include actions such as hitting, slapping, and pinching, and verbal abuse as the use of disparaging and derogatory terms. The LPN involved in the incident did not respond to the facility's attempts to contact her and was subsequently terminated from employment. The facility's failure to ensure the resident was free from mistreatment constitutes a deficiency in providing a safe environment for residents.
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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 Southbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pomperaug Woods Health Center | 0.8 mi | ★★★★★ | 1 | 0 |
| River Glen Health Care Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Lutheran Home Of Southbury Inc | 2 mi | ★★★★★ | 5 | 0 |
| Stone Bridge Center For Health & Rehabilitation | 7.3 mi | ★★★★★ | 2 | 0 |
| Complete Care At Middlebury | 7.4 mi | ★★★★★ | 1 | 0 |
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