Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Stamford Care Center during CMS and state inspections, most recent first.
A resident with quadriplegia, severe cognitive impairment, and malnutrition developed worsening pressure wounds while dependent on staff for repositioning. Documentation showed many missed NA turning/repositioning entries, the resident was repeatedly observed lying on the back instead of following the turning schedule, and the pressure-relieving mattress was set to the wrong weight. Wound measurements showed enlargement of both the sacral stage 4 wound and the right lower back unstageable wound.
Unsafe and Uncomfortable Facility Temperatures: An LPN and residents were observed in cold rooms and common areas, with temperatures measured as low as 53 F in the lobby, 57.6 F at the nurses' station, and low 60s in hallways and dining areas. A resident in bed said, "I'm freezing," while the facility acknowledged awareness of the heating issue and had only been closing resident doors to preserve heat. Residents later reported they had complained about being uncomfortable and needing heat for at least two weeks before the survey.
Food was not consistently palatable or served at proper temperatures. Residents reported cold meals, tough meat, overcooked pork, repetitive chicken dishes, and poor flavor, and a resident council meeting noted ongoing concerns about food quality. Surveyors sampled a lunch tray and found bland mashed potatoes, watery lumpy gravy, and overcooked vegetables, while the RD also noted the meal lacked quality and flavor.
A resident council repeatedly reported late food trucks, cold meals, and delays in passing out trays. Observations showed breakfast and lunch carts arriving late to the 4th floor, with trays not fully delivered until well after the posted times; one resident said the food was disgusting and always cold, and another said cold breakfast was a common occurrence. The DON said she was unaware meals were consistently late or that some residents had only 3 hours between breakfast and lunch, while the Administrator noted the elevator had been out of service but meals still should have been delivered on time.
Food Storage and Sanitary Food Handling Deficiencies: Surveyors observed multiple dietary practice failures, including unlabeled prepared foods and frozen items, an open walk-in cooler door, uncovered roast beef cooling, raw chicken stored above bologna, and staff preparing food without required hair or beard restraints. Staff and the DON confirmed that temperatures, labeling, covering food, proper storage order, and sanitary attire were expected, but these practices were not being followed.
A facility failed to follow EBP for a resident with a PICC line when an LPN administered IV fluids without gown, gloves, or proper hand hygiene. The facility also left a peripheral IV in another resident’s hand beyond the ordered time frame, with no clear documentation of extension or site change, and an LPN failed to perform hand hygiene during a wound dressing change for a resident with a stage 4 sacral ulcer. In addition, the EBP tracking list did not match room signage, and staff incorrectly stated that residents with MDRO history did not need precautions despite the policy requiring EBP for MDRO colonization or infection.
Dignity and Meal Service Deficiencies: Two residents were assisted with meals by NAs who stood over them instead of sitting at eye level, despite facility policy requiring seated feeding for a more dignified dining experience. One resident was bedbound with dementia and functional quadriplegia, and another had severe cognitive impairment and needed meal assistance. In addition, meals were plated in disposable cardboard to-go containers and transported around the facility, with residents reporting cold, late, and poor-quality food; the RD and DON acknowledged the practice was undignified.
Failure to Investigate Allegation of Resident-to-Resident Abuse: A resident with severe cognitive impairment was found with bruising around both eyes and later told the ED that another resident had hit him/her in the face. The facility’s incident report noted bruises of unknown origin and later included the abuse allegation, but no investigation was identified in the A&I report. The DON stated the allegation was not investigated because she was unaware of it; another resident with dementia, anxiety, and depression was also reviewed for abuse.
A resident with anxiety disorder and bipolar disorder had a Level I PASRR that required a Level II if the resident stayed past 30 days, but the facility did not notify the state designated authority and no Level II was found in the record. The resident’s MDSs continued to show bipolar disorder, moderate cognitive impairment, total dependence for several ADLs, and use of antipsychotic, antianxiety, and antidepressant meds; staff stated the resident was self-pay and did not need a Level II.
A resident with a stage 4 sacral pressure ulcer and moderate cognitive impairment had an air mattress that was not checked and documented every shift as ordered, and observations showed the mattress setting remained between 280 and 320 even though the order directed it be set to the resident’s weight. Another resident with CHF, DM2, AFib, severe cognitive impairment, and continuous oxygen needs was observed receiving O2 at 2 L/min instead of the ordered 3 L/min via NC, and an LPN confirmed the setting was incorrect.
A resident with Parkinson's disease, dementia, and anxiety disorder was identified as an elopement risk and had an active order for a Wander guard transmission device on the right ankle. During observation, the resident was sitting in the dining room without the device on either ankle, and the assigned LPN had not yet checked placement that shift. The resident stated the device had been removed months earlier, and the device could not be located in the room. The MD and DON confirmed that an active order meant the device needed to be on the resident and that staff were responsible for checking placement every shift.
Failure to Monitor Intake and Output for Resident on Fluid Restriction: A resident with ESRD on hemolytic treatments and a 1000 mL fluid restriction had intake documented on the MAR that was consistently below the ordered limit, yet nursing notes did not show accurate I&O monitoring or physician notification when the restriction was not met. The resident also had documented weight gain and fluctuations, while an I&O binder at the nurses' station did not contain the resident's worksheet. The dietitian and DON were unable to confirm how staff were maintaining accurate fluid monitoring.
Failure to monitor AV fistula function during dialysis care. A resident with ESRD, CKD stage 5, and DM with CKD had a care plan directing staff to check for AV shunt/fistula bruit and thrill and provide HD via the left AV fistula. However, the physician orders did not include this monitoring, the dialysis center notes did not document that the fistula was being checked for function, and the clinical record, nurse's notes, and MAR contained no evidence of bruit and thrill monitoring. The DON stated she did not know the resident had an AV fistula or whether bruit/thrill checks were being done.
A resident with severe mobility and cognitive deficits was not properly positioned or provided with the required two-person assistance during bed mobility. While a nurse aide adjusted the bed height without checking the resident's position or ensuring a second staff member was present, the resident slid off the bed and sustained a femur fracture.
Failure to Prevent Worsening Pressure Wounds
Penalty
Summary
The facility failed to provide services to prevent worsening of two pressure wounds for a dependent resident with quadriplegia, severe cognitive impairment, and malnutrition. The resident’s comprehensive MDS identified total dependence for toileting, transfers, and changing positions in bed, and the care plan included a reopened stage 4 sacral pressure ulcer and an unstageable pressure ulcer to the right upper back, with interventions for a low air loss mattress, turning and repositioning every 2 hours, and monitoring nutritional status. Record review showed the resident was at very high risk for pressure ulcers, with quarterly skin evaluations documenting a Braden Scale score of 8. The physician ordered an air mattress to be set to the resident’s weight and checked every shift, and ordered turning and repositioning every 2 hours. However, the Nurse Aid turning and repositioning documentation was incomplete, with 28 of 93 opportunities unsigned in January and 43 of 115 opportunities unsigned in February. The resident’s care card also directed that the low air loss mattress be checked every shift and that the resident be turned every 2 hours. Surveyor observations found the resident repeatedly positioned on his/her back during times when the facility’s turning and repositioning program indicated the resident should have been facing the door or the window. The pressure-relieving mattress was observed set to 160 pounds at normal pressure, and RN #1 stated the mattress should have been set to 91 pounds based on the resident’s current weight. Wound records showed the right lower back wound increased from 1 cm x 1.5 cm x 0 cm to 1 cm x 2 cm x 0 cm, and later to 2 cm x 2.2 cm x 0 cm. The sacral stage 4 wound remained unchanged initially at 1 cm x 0.2 cm x 0.3 cm, then increased to 2 cm x 2.2 cm x 0.3 cm. RN #1, the dietician, and the wound APRN all identified the resident’s worsening wounds in the context of missed turning and repositioning, an incorrectly set mattress, and poor nutritional status.
Unsafe and Uncomfortable Facility Temperatures
Penalty
Summary
The facility failed to provide safe and comfortable air temperature levels in resident rooms and common areas. During an initial tour, an LPN on the 1st Floor East hallway was observed dressed in a winter hat, two sweaters, and a scarf and stated that it was freezing on the 1st floor and always like this at night. In a resident room, a resident was in bed under three blankets with the room heating system running at the highest possible setting, yet the probe thermometer measured 69.8 F and the resident stated, "I'm freezing." The Administrator acknowledged the facility was aware of the heating issue and said the intervention had been to close resident doors to preserve heat within rooms. Additional observations showed cold temperatures throughout the facility, including 57.6 F at the 1st Floor East nurses' station, 61.3 F in the hallway where housekeeping staff remained in a winter coat while cleaning, 53 F in the 1st Floor lobby, 64 F at the entrance to the 1st Floor East dining room, 61 F in the 2nd Floor East dining room, 59 F in the 2nd Floor East hallway, 65 F in the 4th Floor hallway, and 63 F in the elevator used for resident transport. Residents were observed wearing winter coats while eating breakfast or sitting in common areas. The Maintenance Director stated the facility was aware of heating issues, but temperature logs had not reflected the low temperatures observed, and the Administrator later stated this was the first time temperature issues had been identified. Residents later reported they had raised concerns about being uncomfortable and needing heat for at least two weeks before the survey began.
Food Not Served at Appetizing Temperature or Palatable Quality
Penalty
Summary
The facility failed to provide appetizing and palatable food, with repeated resident complaints documented in Resident Council minutes and during interviews. Residents reported that meat was not tender and hard to chew, food was delivered cold, pork was overcooked, and chicken meals were repetitive with the same seasoning. Several residents interviewed described the food as terrible, disgusting, low quality, and always cold, and a Resident Council meeting with 13 residents identified that the quality of food was lacking and often cold. Surveyors requested a lunch test tray and sampled the meal, finding it unappetizing and not palatable. The mashed potatoes lacked flavor, the roast beef was served with watery, lumpy, separating gravy, and the vegetables were watery and overcooked cauliflower, broccoli, and green beans; no dessert was provided. The Regional Dietary Director also tried the meal and noted the vegetables were overcooked and the instant mashed potatoes tasted like boxed potatoes. Facility policy required nourishing, palatable food at proper temperatures, food preparation methods that conserve flavor and appearance, and meals served at preferable temperatures.
Late Meal Delivery and Cold Food Service
Penalty
Summary
Meals and snacks were not served at regularly scheduled intervals, and the facility did not consistently provide timely meal delivery to residents on the 4th floor and other units. Resident Council minutes dated 10/27/25, 11/21/25, and 12/24/25 documented resident concerns that food trucks were late, meals took too long to be delivered, food was cold, and food was not passed out when it reached the unit destination. The 1/27/26 Resident Council minutes noted continued concerns about meals arriving cold and late, and the Dietary Food Director responded by stating tray delivery timing would be adjusted. On 2/8/26 and 2/9/26, observations and facility documentation showed breakfast and lunch carts arriving later than the posted delivery schedules for the 4th floor. On 2/8/26, breakfast arrived at 9:03 AM when it was scheduled for 7:30 AM to 8:00 AM, and the last breakfast tray was not delivered until 9:42 AM; residents reported the food was cold and late, and one resident stated this had been happening for about a week. Lunch on 2/8/26 arrived at 12:45 PM, later than the posted 12:00 PM to 12:30 PM window, and dinner was scheduled to arrive 6 hours and 18 minutes to 6 hours and 48 minutes after the last breakfast tray, with the time between dinner and the prior evening's meal documented as 17 hours and 12 minutes. On 2/9/26, breakfast plating began later than expected because a cook arrived late, lunch plating began 43 minutes late, and the lunch cart arrived at 12:42 PM, later than the posted schedule. The DON stated she was not aware meals were consistently served late or that some residents only had 3 hours between breakfast and lunch, and the Administrator stated the elevator had not been functioning since 2/3/25, though meals still should have been delivered in a timely manner.
Food Storage and Sanitary Food Handling Deficiencies
Penalty
Summary
The dietary department failed to store, prepare, and serve food in accordance with professional standards when surveyors found multiple food safety issues during the kitchen tour. The outside thermometer on the milk cooler showed 55 degrees Fahrenheit, and staff could not locate a thermometer inside the cooler at first to verify the milk temperature. In Refrigerator #1, trays of sandwiches and desserts on individual plates were not labeled with a preparation date or expiration date. The walk-in cooler door was propped open with a cart, four large roast beef chunks were cooling uncovered, and a pan of chicken thighs in marinade was stored above packages of bologna. The walk-in freezer contained onion rings and tater tots without labels showing when they were opened or when they expired. Staff preparing breakfast were also observed without hair nets, hats, or beard restraints as required. Additional observations showed a dietary aide in the food preparation area with a tray of salads on the counter without a beard restraint. Interviews with dietary staff and the Dietary Director confirmed that cooler, refrigerator, and freezer temperatures were supposed to be checked daily, food items were supposed to be covered while cooling, raw meat was supposed to be stored on a lower shelf, and foods were supposed to be labeled with open and expiration dates. The Dietary Director also stated that staff were expected to wear hair nets and beard restraints in the kitchen, but these practices were not being followed at the time of the observations.
Infection Control Failures With EBP, IV Site Management, and Hand Hygiene
Penalty
Summary
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy for a resident with a PICC line and active infections. Resident #22 had diagnoses including acute osteomyelitis of the left ankle and foot, cellulitis of the left lower foot, and Klebsiella pneumoniae infection. The resident’s care plan identified impaired skin integrity, a limb alert related to IV access, and IV antibiotic therapy for 6 weeks. A physician order directed EBP during high-contact care for residents with indwelling medical devices such as a PICC line, and an EBP sign was posted on the room door with PPE available outside the room. During observation, an LPN entered the room carrying an IV bag and administered the resident’s IV fluid without first putting on PPE. The LPN stated that the resident was on EBP precautions and acknowledged that she should have worn a gown and gloves and performed hand hygiene, but had missed steps. The Infection Preventionist and DON both confirmed that gown and gloves should have been used during IV administration for this resident. The facility also failed to manage a peripheral IV site for another resident according to the ordered time frame and infection control expectations. Resident #23, who had dementia, adult failure to thrive, and functional quadriplegia, had a peripheral IV in the right hand that remained in place beyond the 5 to 7 day period referenced in the care plan. Observations showed the IV still present 12 and 13 days after insertion, with the dressing secured only by tape and lacking a date. The record did not show a new order extending the site time frame or documentation that the site had been changed, and the DNS and APRN were unable to explain why the IV remained in place. The facility further failed to perform hand hygiene during wound care for a resident with a stage 4 sacral pressure ulcer. Resident #108 had a stage 4 sacral wound, legal blindness, and low back pain, and the wound order directed cleansing, application of calcium alginate, and a foam dressing every 8 hours and as needed. During the dressing change, an LPN removed the old dressing and then placed on new gloves and cleansed the wound without first cleansing or sanitizing her hands. The LPN acknowledged the missed hand hygiene step, and the DON stated that hand hygiene should occur after removal of the old dressing and before applying clean gloves. In addition, the infection control tracking process was inaccurate and incomplete. During the facility tour, multiple room signs indicated residents required EBP, but the Infection Preventionist’s current EBP list did not include those room numbers. The Infection Preventionist also provided a list of residents with a history of MDROs and stated that residents with MDRO history did not need precautions because they were colonized. The DON gave the same explanation, although the EBP policy stated that residents colonized or infected with an MDRO should be placed on EBP and that the Infection Preventionist keeps an ongoing list of such residents and distributes it to other disciplines.
Dignity and Meal Service Deficiencies
Penalty
Summary
The facility failed to assist residents to eat in a dignified manner and failed to ensure appropriate food plating for a dignified dining experience. Resident #23 had diagnoses including unspecified dementia, functional quadriplegia, and adult failure to thrive, and was dependent on staff for eating. During observation, the resident was in bed with the head of the bed raised while breakfast was on the bedside tray table, and a nurse aide stood on the side of the bed, above eye level, while feeding the resident. The nurse aide stated she normally sat down when feeding residents but no chair was available, and acknowledged she should have been sitting per facility policy. Resident #128 had vascular dementia, hypertension, and pain in the joints of the left hand, and required setup or clean-up assistance with eating. During observation, the resident was seated at a table in the dining room while a nurse aide stood next to the resident, above eye level, and assisted with breakfast. The nurse aide stated she always stood when feeding residents because it was easier and she thought it was permissible. After surveyor inquiry, the nurse aide moved an empty chair next to the resident and assisted while sitting down. The ADNS stated staff should follow the ADL policy and resident care plan when assisting residents to eat, and that both nurse aides should have been seated because standing was an undignified way to assist with meals. The facility also plated meals in disposable cardboard to-go containers because the elevator was not functioning and kitchen staff transported meals outside and around the facility to the units. Residents reported the food was terrible, always late and cold, disgusting, low quality, and always cold. Observations showed breakfast delivered in disposable cardboard containers and served on plastic trays, while later lunch was observed on porcelain plates with lids and warming bases, and then again lunch was observed plated into disposable cardboard containers. The Regional Dietary Director stated the disposable containers were used to make it easier on staff, but acknowledged it was an undignified dining experience and that the cardboard containers affected food quality and temperatures. The DON and Administrator stated they were not aware meals were being served in disposable cardboard containers and both identified that this was undignified.
Failure to Investigate Allegation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of resident-to-resident abuse involving two residents. Resident #36, who had unspecified dementia, depression, anxiety disorder, and a BIMS score of 6 indicating severe cognitive impairment, was found with dark red bruising around both eyes. The resident stated, "I don't know what happened." The resident was later transferred to the hospital for evaluation of redness around the eyes, and the emergency department documented facial trauma and that the resident stated he/she had been hit in the face by another resident and was unsure when it happened. The facility's incident reporting documented bruises of unknown origin and later added a summary including the allegation of resident-to-resident abuse. The facility's A&I report recorded that Resident #36 stated that a girl with long hair hit her and her roommate hit her, but the report did not identify an investigation into the allegation. The Director of Nurses stated that she and the ADNS were responsible for ensuring abuse allegations were thoroughly investigated, but also stated that an investigation was not completed because she was unaware of the resident-to-resident abuse allegation. Resident #30, who had vascular dementia with agitation, anxiety disorder, and major depressive disorder, was also reviewed for abuse and had care plan interventions related to verbally abusive behaviors.
Failure to Complete PASRR Level II Assessment
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program and failed to refer for services as needed for one resident with diagnoses of anxiety disorder and bipolar disorder. The resident was admitted with a Level I PASRR that noted bipolar disorder and directed that a Level II PASRR must be completed if the resident remained in the facility past 30 days. The resident’s comprehensive MDS assessments continued to identify bipolar disorder, and a later quarterly MDS showed moderate cognitive impairment with total dependence for oral hygiene, toileting hygiene, eating, and bathing, along with use of antipsychotic, antianxiety, and antidepressant medications. Review of the clinical record did not identify a completed PASRR Level II assessment. The Social Worker stated that the Level II PASRR was not in the record because the facility never sent notification to the state designated authority when the resident’s initial 30 days had been completed, and the resident was 173 days past due. The Social Worker also stated that the resident was self-pay and therefore did not require a PASRR Level II screen to be completed.
Failure to Follow Ordered Air Mattress and Oxygen Settings
Penalty
Summary
The facility failed to follow the physician’s order for Resident #108’s specialty air mattress. Resident #108 had a stage 4 sacral pressure ulcer, legal blindness, low back pain, and moderate cognitive impairment, and the care plan included use of an air mattress with settings checked and documented every shift. The physician’s order directed staff to check the air mattress for proper functioning and settings and set it to the resident’s weight every shift, but the clinical record and monthly MAR/TARs for January and February 2026 did not show the mattress was checked for functioning, settings, or weight every shift as ordered. Observations on 2/8/26 and 2/9/26 showed the air mattress setting remained between 280 and 320. The DNS confirmed the mattress was set at 300 and stated the facility practice was to set the mattress per the resident’s weight, noting the resident’s current weight was 184 pounds, but also acknowledged the physician’s order directed the mattress to be set to the resident’s weight and not per preference. The facility policy stated nursing would adjust specialty mattress settings per manufacturer instructions and that the settings would be checked and documented every shift. The facility also failed to follow the physician’s order for Resident #132’s oxygen therapy. Resident #132 had CHF, type 2 diabetes, atrial fibrillation, severe cognitive impairment, and required continuous oxygen therapy per the MDS. The physician’s order directed oxygen at 3 liters per minute via nasal cannula as needed, but observations showed the resident receiving oxygen at 2 liters per minute while lying in bed with the head of the bed elevated. The LPN stated the oxygen setting was incorrect, had not checked it at the beginning of the shift, and would change it to 3 liters per minute. The DNS confirmed oxygen should be set according to the physician’s order and that the assigned nurse was responsible for ensuring the correct setting.
Ordered Wander Guard Device Not in Place for Elopement-Risk Resident
Penalty
Summary
The facility failed to ensure that Resident #11, who had Parkinson's disease, unspecified dementia, anxiety disorder, and was identified on the MDS and care plan as an elopement risk/wanderer, had the ordered anti-wandering transmission device in place. The resident's care plan directed placement of a Wander guard transmission device on the right ankle and checking placement every shift, and the physician's order in effect on 2/9/26 directed the device to be checked every night shift and worn on the right ankle. However, during observation on 2/9/26 at 11:29 AM, Resident #11 was sitting in the dining room without a Wander guard device on either ankle. During interview and record review, the assigned LPN stated it was the nurse's responsibility to ensure residents with a Wander guard order had the device in place and acknowledged she had not yet checked placement that shift. Resident #11 stated, "I took that off months ago," and the LPN searched the room but could not locate the device. The Medical Director stated that an active order meant the device needed to be on the resident, and the DON stated it was the unit nurse's responsibility to check and document placement every shift. The facility's elopement prevention policy stated the Wander guard is to be worn 24 hours a day and that the licensed nurse should initiate an emergency CCP meeting if the resident removes or refuses the device.
Failure to Monitor Intake and Output for Resident on Fluid Restriction
Penalty
Summary
The facility failed to follow physician orders to monitor intake and output accurately for a resident receiving hemolytic treatments and a 1000 mL fluid restriction. Resident #48 had hypertensive chronic kidney disease stage 5, dependence on hemolytic treatments, and diabetes with chronic kidney disease. The care plan identified a potential for fluid volume overload related to end stage renal disease on hemolytic treatments and directed staff to monitor, document, and report signs and symptoms of fluid overload, including sudden weight gain. The physician ordered a 1000 mL fluid restriction in 24 hours and monitoring of intake and output, with notification of the physician if the restriction was not met. Review of the MAR for January and early February showed daily recorded intakes that were all below 1000 mL, including several days with 0 mL, but nursing progress notes did not identify fluid intakes or physician notification when the fluid restriction minimum was not met. A dietician note documented a 5% weight change of 9.3 pounds and later noted the resident's weight increased from 174.16 pounds to 179.01 pounds, with the resident continuing to come in over the target weight. Observation found an intake and output binder at the nursing station, but no worksheet for Resident #48 was present. The dietician stated she relied on electronic documentation entered by NAs, but the recorded MAR amounts could not accurately reflect the resident's actual intake because of the weight fluctuations and weight gain. The DON stated she needed to check the intake and output and fluid restriction policies and was unable to identify how intake and output or fluid restriction amounts were being maintained by nursing staff.
Failure to Monitor AV Fistula Function During Dialysis Care
Penalty
Summary
The facility failed to monitor the AV fistula site for function for Resident #48, whose diagnoses included hypertensive chronic kidney disease stage 5, dependence on dialysis, and diabetes with chronic kidney disease. The quarterly MDS identified the resident as cognitively intact with a BIMS score of 14 and needing varying levels of assistance with activities of daily living. The care plan dated 12/16/25 directed staff to check for AV shunt/fistula bruit and thrill and to provide hemodialysis via the left AV fistula every Tuesday, Thursday, and Saturday, but the physician orders from 1/15/26 through 2/10/26 directed dialysis transport only and did not include monitoring of the AV fistula for bruit and thrill. Observation on 2/8/26 identified an AV fistula in the left upper arm. Review of the pre- and post-dialysis treatment center notes dated 1/10/26, 1/15/26, 1/17/26, 1/20/26, 1/24/26, and 1/27/26 showed an area for AV fistula monitoring was available, but staff did not document that the fistula was being monitored for function as required by the care plan. Review of the clinical record, nurse's notes, and MAR from 1/15/26 through 2/10/26 found no documentation of bruit and thrill monitoring. The DON stated on 2/10/26 that she did not know whether the resident had an AV fistula and was unaware if a bruit or thrill was being monitored for function.
Failure to Ensure Safe Positioning and Adequate Staff Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with significant physical and cognitive impairments, including hemiplegia, vascular dementia, and functional quadriplegia, was not safely positioned in bed and did not receive the required two-person assistance for bed mobility as outlined in the care plan. The resident was dependent on staff for all mobility and personal care needs. During a morning shift, a nurse aide adjusted the height of the resident's bed without first ensuring the resident was in a safe position. The resident was on their side, near the edge of the bed, and the aide did not realize this before raising the bed. As the bed was being adjusted, the resident slid off the bed and landed on the floor in a sitting position. The incident was witnessed, and the resident was unable to verbally express pain due to aphasia. The resident was subsequently sent to the hospital, where imaging revealed an acute comminuted and mildly displaced fracture of the proximal right femur. Staff interviews confirmed that the aide did not check the resident's position or have a second staff member present, as required by the care plan, prior to adjusting the bed.
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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 Stamford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ark Healthcare & Rehabilitation At St. Camillus | 1 mi | ★★★★★ | 14 | 0 |
| Edgehill Health Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Civita Care Center At Long Ridge | 3.4 mi | ★★★★★ | 1 | 0 |
| Waveny Care Center | 4.8 mi | ★★★★★ | 12 | 0 |
| Nathaniel Witherell, The | 5.7 mi | ★★★★★ | 3 | 0 |
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