Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vanderman Place during CMS and state inspections, most recent first.
Surveyors identified that kitchen staff failed to consistently wear hair coverings, properly label and date food items, and discard expired foods. Expired and unlabeled food was found in both refrigerated and dry storage areas, and staff interviews confirmed these practices did not meet facility expectations.
Multiple residents were started on new psychotropic medications without timely or properly documented informed consent from themselves or their responsible parties. In several cases, consent was obtained only after significant delays, and forms were not always signed by the staff who obtained verbal consent. Staff interviews revealed confusion about the consent process and lack of familiarity with facility policy.
Three residents with dementia and wandering behaviors were able to access soiled utility rooms on multiple units, where surveyors observed uncovered trash, soiled linens, hazardous waste, and unsecured equipment, including an unlocked specimen refrigerator on an unstable surface. Staff acknowledged that the risk of wandering residents entering these rooms had not been previously addressed.
Surveyors found that medication rooms contained food, personal items, and unlabeled containers stored alongside medications, with surfaces stained and unclean. Staff could not identify the owners of personal belongings or explain the presence of residue. Additionally, a medication cart was left unlocked and unattended in a hallway while the responsible LPN was assisting a resident, contrary to facility policy requiring secure storage of medications.
Staff did not consistently perform hand hygiene or use required PPE when providing care to residents on precautions, including failing to sanitize hands after glove removal, improperly disposing of used gloves, and entering precaution rooms without PPE. An LPN also conducted a dressing change without appropriate hand hygiene and placed used gloves on a resident's bed, with clean supplies stored next to food items.
Multiple residents with cognitive and behavioral impairments were involved in physical altercations and verbal threats, including incidents where one resident struck another and a resident verbally threatened to strangle a roommate. Staff intervened after the events occurred, but the facility did not prevent the abuse or ensure residents were free from harm.
Staff did not immediately report or document a verbal threat of abuse made by one resident toward another, despite facility policy requiring prompt notification to the Administrator and DON. The incident, involving a cognitively impaired resident and a roommate with depression and anxiety, was not reported to leadership or external authorities until several hours later, and no immediate investigation or written statements were obtained.
A resident with multiple medical conditions was transferred to the hospital after vomiting dark black emesis. Although the provider and responsible party were notified of the transfer, there was no written notification or documentation provided regarding bed-hold options at the time of transfer, and staff interviews revealed a lack of process for ensuring this required notification.
A resident with dementia and wandering behaviors was involved in an aggressive incident that was not addressed by specific care plan interventions, despite prior knowledge of such behaviors. Another resident with right-sided paralysis repeatedly refused a physician-ordered hand splint, but staff were unclear about their responsibilities and the care plan did not address the refusals, leading to inconsistent application and monitoring of the splint.
A resident with dementia, anxiety, and diabetes who was frequently incontinent of bowel and bladder did not have their care plan updated to include the offering of a bowel and bladder retraining program or documentation of any refusals to participate. Although the care plan addressed incontinence and resistance to care, there was no evidence that retraining programs were offered or refused, as confirmed by nursing staff interviews and record review.
A resident with dementia, schizophrenia, and depression did not receive multiple prescribed medications and required care interventions on several occasions, with no documentation of refusal or reason for omission. The MAR and nursing notes lacked evidence that medications and treatments were administered or that refusals were recorded, contrary to facility policy and physician orders.
The facility did not provide staff with education about the COVID-19 vaccine or information on alternative locations to receive the vaccine when it was unavailable at the facility. An ADNS reported not being offered the vaccine, not receiving education about it, and not being informed of other options for vaccination. The facility was also unable to obtain the vaccine from the pharmacy for staff.
Two residents with physician orders and nursing evaluations supporting the use of bed rails did not have this intervention documented in their care plans. Despite observations confirming the use of bed rails and facility policy requiring such documentation, the care plans failed to include directives for side rail usage, as acknowledged by the DON.
The facility did not provide education or obtain informed consent for bed rail use for several residents with cognitive and physical impairments. Required bed and side rail safety audits were not performed at the mandated intervals, and audit documentation lacked dates. Additionally, a bed rail safety test was not conducted according to manufacturer guidelines, and a loose bed rail was observed, with maintenance staff unable to explain the omission.
A resident with anxiety, schizoaffective disorder, and bipolar disorder was prescribed multiple antipsychotic medications, but staff failed to monitor and document behaviors as required by the care plan and facility policy. Reviews of orders, medication records, and nurse's notes showed no evidence of behavior monitoring, and staff interviews confirmed that such monitoring should have been in place.
A resident with complex medical conditions experienced a significant change in condition prior to a scheduled dialysis transport, displaying increased respirations, pallor, and weakness. While some vital signs were recorded, staff failed to document an oxygen saturation level, a full RN assessment, provider notification, and a physician's order for transfer to the ED, contrary to facility policy requiring thorough documentation of such events.
A resident with dementia, Parkinson's disease, and a history of behavioral disturbances and falls was identified as at risk for elopement, but the facility did not develop a care plan to address this risk. Multiple incidents occurred where the resident attempted or succeeded in leaving the facility, sometimes requiring police intervention, and the use of a Wanderguard device was not properly documented or incorporated into the care plan as required by policy.
A resident with Parkinson's disease, dementia, and a history of falls was identified as an elopement risk, but the facility did not obtain a timely physician's order for a Wanderguard or ensure staff monitored its placement and function as required by policy. The resident left the facility without being redirected, and documentation of device checks and care planning was lacking.
A resident with mental health diagnoses was moved to a new room due to issues with a roommate, but the facility failed to document the room change and did not provide or record required social service support during the transition, contrary to facility policy and staff responsibilities.
Deficiencies in Food Storage, Labeling, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations during a kitchen tour. A cook was seen in the kitchen without a required hair covering, and admitted to forgetting to put it back on after reentering the kitchen. In the walk-in refrigerator, several food items, including opened bags of waffles and cooked turkey, were found without proper labels indicating when they were opened or their use-by dates. Additionally, frozen burgers with a use-by date that had already passed were found in the walk-in freezer, and neither the administrator nor the cook could explain why these expired items had not been discarded. Further inspection of the dry storage room revealed ten cases of evaporated milk that had expired several months prior. Interviews with the Food Service Director confirmed that all kitchen staff are expected to check expiration dates, label and date food items once opened, and wear hair coverings at all times in the kitchen. Despite requests, the facility was unable to provide a food service policy during the survey.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from residents or their responsible parties prior to initiating new psychotropic medications for multiple residents. In several cases, residents with cognitive impairments or conservators were started on medications such as antidepressants and antipsychotics without documented consent. For example, one resident with severe cognitive impairment and a conservator began receiving an antidepressant, but there was no evidence that the conservator was informed or provided consent before the medication was administered. Consent was only obtained over 100 days after the medication was started, and the form was not properly signed by the staff member who obtained it. Other residents, including those with dementia, schizophrenia, and anxiety disorders, were also started on various psychotropic medications without timely or properly documented consent. In some instances, verbal consent was obtained long after the medications had been initiated, and forms lacked signatures from the staff who obtained the consent. Staff interviews revealed confusion and lack of awareness regarding the process for obtaining and documenting informed consent, with some staff members unaware of the facility's policy on psychotropic medications. The facility's own policy required that consent be obtained from the resident or responsible party when starting a psychoactive medication and that they be notified of any dose changes. However, the policy was not consistently followed, and staff responsible for obtaining consent were not always familiar with the procedures. Documentation and interviews confirmed that the deficiency was systemic, affecting multiple residents and involving delays and omissions in the consent process.
Unsecured Soiled Utility Rooms Accessible to Wandering Residents
Penalty
Summary
The facility failed to prevent access to soiled utility rooms on three units for residents with a history of wandering. Clinical record reviews identified three residents diagnosed with Alzheimer's disease or dementia, all of whom exhibited wandering behaviors and were noted to be oblivious to their own safety. Observations revealed that the soiled utility rooms on each unit could be accessed by simply pushing the door handle, making them easily accessible to residents. Inside these rooms, surveyors found uncovered garbage cans, soiled linen bags, hazardous waste containers, and equipment. On one unit, a specimen refrigerator was found unlocked and placed on an unstable surface, which tipped forward when the door was opened. Other units contained additional hazards such as a vacuum cleaner, a pipe-snaking machine, and a hopper with no lid. Staff interviews confirmed that the potential for wandering residents to enter these rooms had not been previously considered, and the rooms remained unsecured at the time of the observations.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies in the storage and security of drugs and biologicals in the facility. In the medication rooms on two separate wings, food and personal items such as an opened protein drink, unlabeled water bottles, tumblers, mugs, jackets, a backpack, and a purse were found stored alongside or near medications. The medication refrigerator contained a non-medical drink with no resident label, and the shelves were stained with residue. Additional issues included sticky and stained surfaces in the medication rooms, unlabeled and possibly expired medication containers, and personal belongings stored in areas designated for medication storage. Staff interviewed were unable to identify the owners of many of these items or explain the presence of residue and stains, and there was no policy provided for the storage of personal belongings in medication rooms. In a separate incident, a medication cart was observed left unlocked and unattended in a hallway outside a resident's room, with no licensed staff in the immediate area. A nurse aide was present but did not alert the responsible LPN, who later stated she had left the cart unlocked when responding to assist a resident. The facility's policy requires medication storage and preparation areas to be kept clean, safe, and sanitary, and for medications to be stored securely and separately from food, but these requirements were not met during the observations.
Failure to Ensure Proper Hand Hygiene and PPE Use During Resident Care
Penalty
Summary
Staff failed to consistently perform proper hand hygiene and use appropriate personal protective equipment (PPE) as required by the facility's infection prevention and control program. Observations revealed that nurse aides exited a resident room under Enhanced Barrier Precautions (EBP) without completing hand hygiene and one aide was seen carrying a used glove in the hallway. The charge nurse also left the same room without performing hand hygiene. Interviews indicated a lack of awareness among staff regarding the requirements for EBP and the use of hand sanitizer, as well as confusion about the application of PPE for residents on precautions. In another instance, two nurse aides entered a room with a droplet precaution sign without donning any PPE, stating they believed it was unnecessary for simply delivering a meal, despite facility policy and leadership confirming PPE was required. Additionally, during a dressing change for a resident with lymphedema and neuropathy, an LPN failed to perform hand hygiene after removing gloves and before donning new gloves, and disposed of used gloves on the resident's bed rather than in a sanitary manner. Clean dressing supplies were placed on an overbed table alongside food items, and the LPN was unaware of the need for hand hygiene between glove changes. Interviews with facility leadership confirmed that hand hygiene should have been performed after glove removal, and facility policy directed staff to wash hands after removing gloves.
Failure to Prevent Resident-to-Resident Abuse and Verbal Threats
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations and verbal threats. In one case, a resident with hemiplegia, hemiparesis, aphasia, and anxiety, who had mild cognitive impairment, was involved in a physical altercation with a cognitively intact roommate. The altercation escalated from an argument over closet space to physical contact, with one resident grabbing the other's arm and being struck in the face in return. Staff witnessed the incident and intervened, but the altercation had already occurred. Another incident involved a resident with vascular dementia and impaired mobility who was struck in the face by another resident known to wander into other rooms. The cognitively impaired resident could not recall the event, but staff confirmed the altercation occurred after hearing distress and intervening. The wandering resident had a history of entering other residents' rooms, and the incident took place when the resident entered the room and pulled the other resident's hair. A further deficiency was noted when a resident with dementia, Parkinson's disease, and confusion was verbally threatened by a roommate with a history of depression and anxiety. The confused resident was found yelling and attempting to get out of bed, prompting the roommate to threaten to strangle them. Staff separated the residents and monitored the situation, but the verbal abuse had already taken place. In all cases, the facility's failure to prevent these incidents and ensure residents were free from abuse constituted a deficiency.
Failure to Timely Report and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
Staff failed to immediately report an episode of verbal abuse between two residents, as required by facility policy. One resident, who had diagnoses including dementia and Parkinson's disease and was cognitively impaired, was admitted to the facility and shared a room with another resident diagnosed with major depression and anxiety. During the night, the cognitively impaired resident became agitated and began yelling, prompting the roommate to threaten to strangle them. Staff present at the time separated the residents by moving the agitated resident to the lounge and monitored them for safety. Despite the clear verbal threat, staff did not immediately notify the Administrator or the Director of Nursing Services (DNS) as required. The charge nurse and nursing supervisor were aware of the incident but did not document the altercation in either resident's clinical record, nor did they request written statements from staff involved. The DNS was not informed of the incident until the following morning, more than seven hours after it occurred, and only learned of it during a routine arrival at the facility. Facility policy mandates that all allegations or observations of abuse be reported immediately to the Administrator and DNS, with subsequent notification to the physician and initiation of an immediate investigation. The incident should also have been reported to the state agency and local law enforcement within two hours. These steps were not followed, resulting in a delay in both internal and external reporting and investigation of the abuse allegation.
Failure to Provide Written Bed-Hold Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their responsible party regarding the reason for transfer/discharge to the hospital, as well as information about bed-hold policies. The resident involved had diagnoses including GERD without bleeding, gastrostomy status, dysphagia, and cerebral infarction, and was assessed as having moderate cognitive difficulty. Following an incident where the resident vomited a large amount of dark black emesis, the provider and responsible party were notified, and the resident was sent to the hospital. However, there was no documentation in the clinical record indicating that the resident or responsible party was informed in writing about the bed-hold options at the time of transfer. Interviews with facility staff, including the ADNS, Administrator, and Business Office Manager, revealed a lack of clarity and process regarding written notification of bed-hold policies upon hospital transfer. The ADNS was unaware of the process, and the Administrator could not demonstrate how written notification was provided at the time of transfer. Although bed-hold information was included in the admission packet, there was no evidence of a specific form or documentation used to track or confirm that this information was provided in writing during the transfer event, as required by facility policy.
Failure to Develop and Implement Person-Centered Care Plans for Behavioral and Positioning Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For one resident with dementia, anxiety disorder, and Alzheimer's disease, the care plan noted wandering and intrusive behaviors but did not include specific interventions for known aggressive behaviors, despite documentation of an incident where the resident hit another resident. Staff interviews confirmed that the behaviors were known prior to the incident and should have been addressed in the care plan, but appropriate interventions were not included or updated as required by facility policy. For another resident with right-sided paralysis and a physician's order to wear a right-hand splint, the care plan required the splint to be worn continuously and for staff to assist as needed. However, records showed multiple refusals by the resident to wear the splint, and staff were inconsistent in offering or reminding the resident to use it. Interviews revealed confusion among staff regarding responsibility for applying the splint and a lack of awareness about the need to remind the resident, despite the physician's order. The care plan did not address the resident's refusals, and the facility's policy required nursing staff to ensure proper use and care of splinting devices.
Failure to Update Care Plan for Bowel and Bladder Retraining
Penalty
Summary
The facility failed to ensure that the care plan for a resident with bowel and bladder incontinence was updated to include the offering of a bowel and bladder retraining program, as well as documentation of any refusals to participate in such a program. The resident in question had diagnoses including unspecified dementia with behavioral disturbances, anxiety, and diabetes, and was assessed as moderately cognitively impaired. The Minimum Data Set (MDS) assessment indicated frequent incontinence of both bowel and bladder, while the care plan noted incontinence related to impaired mobility and cognition, with interventions such as two-hour checks and observation of incontinence patterns. The care plan also documented resistance to care, including refusals of weights, medication, and care. Despite these findings, there was no evidence in the clinical record or care plan that the resident was offered a voiding trial or a bowel and bladder retraining program, nor was there documentation of the resident refusing participation in such programs. Interviews with nursing staff confirmed that while the care plan addressed resistance to care, it did not specifically mention offering or refusal of retraining programs. This lack of documentation and action led to the deficiency cited in the report.
Failure to Administer Medications and Perform Required Care as Ordered
Penalty
Summary
The facility failed to administer medications and perform required care interventions according to physician's orders for a resident diagnosed with unspecified dementia, paranoid schizophrenia, and depression. The resident was assessed as cognitively impaired and required significant assistance with daily activities. The care plan included administration of multiple psychotropic medications and monitoring for therapeutic effects and side effects, as well as completion of behavior monitoring sheets every shift. However, review of the Medication Administration Records (MAR) for May 2025 revealed that several medications, including Haloperidol, Melatonin, Mirtazapine, Trazadone, Guaifenesin ER, Acetaminophen Extra Strength, and Morphine, were not administered as ordered on specific dates. There was no documentation in the nursing notes indicating that the resident refused these medications. Additionally, the MAR indicated that other required care interventions, such as administration of Ensure Plus, pain assessments, assessments for shortness of breath, monitoring for signs and symptoms of antidepressant use, and application of compression stockings or ace wraps, were not performed on certain dates. Again, there was no documentation of refusal by the resident. Facility policy requires that medications be administered as prescribed and that any refusals or withheld doses be properly documented on the MAR. An interview with the ADNS confirmed the expectation for accurate documentation of medication administration and refusals.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that staff were provided with education regarding the COVID-19 vaccination and information about alternative locations to receive the vaccine if it was not available at the facility. During an interview, the Infection Control Nurse, who also serves as the Assistant Director of Nursing Services (ADNS), stated that they were not offered the COVID-19 immunization, did not receive any education about the vaccine, and were not informed about where the vaccine could be obtained if the facility was unable to provide it. The ADNS further indicated that the facility was unable to obtain the COVID-19 vaccine from the pharmacy for staff use. This deficiency was identified through a review of the facility's Infection Control Program, facility documents, and staff interviews.
Care Plans Lacked Bed Rail Usage Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents included directives for the use of bed rails, despite physician orders and nursing evaluations indicating their necessity. One resident with dementia and contractures had a physician order for half side rails and a nursing evaluation recommending bilateral side rails as enablers to promote independence. However, the resident's care plan did not document the use of side rails. Similarly, another resident with dementia and anxiety disorder had a physician order for bilateral quarter side rails and a nursing evaluation supporting their use, but the care plan lacked any mention of side rail usage. Observations confirmed that bed rails were in use for both residents, yet their care plans did not reflect this intervention. The Director of Nursing acknowledged that the care plans should have included side rail usage and could not explain the omission. Facility policy required documentation of side rail use on the resident's plan of care following evaluation, but this was not followed for the residents in question.
Failure to Obtain Bed Rail Consents, Inadequate Audits, and Improper Safety Testing
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of bed rails for four residents with varying degrees of cognitive impairment and physical dependency. Clinical record reviews revealed that, despite physician orders and care plans indicating the use of side rails or grab bars, there was no documentation that residents or their representatives were educated on the risks and benefits, nor that consent was obtained prior to bed rail implementation. Interviews with the DON confirmed the absence of consent forms and education documentation, attributing the lack of paperwork to changes made by a previous DON. Additionally, the facility did not adhere to its own policy regarding the frequency and documentation of bed and side rail safety audits. Audit forms for the residents' beds lacked dates, and the Director of Maintenance acknowledged that audits were performed annually and on a random basis, rather than at the required six-month intervals. There was also no documentation of the specific dates audits were conducted, contrary to facility policy that mandates biannual assessments and proper record-keeping. Further deficiencies were observed in the performance of bed rail safety tests. During an observation, a bed rail was found to be loose, and the Director of Maintenance did not accurately perform the manufacturer-recommended entrapment test for a specific safety zone. Instead, the wrong test procedure was used, and the required zone was not assessed, with the Director unable to explain how the bed could be considered compliant without this critical test being completed.
Failure to Monitor Behaviors for Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that behavior monitoring was completed for a resident receiving antipsychotic medications. The resident had diagnoses including anxiety disorder, schizoaffective disorder, and bipolar disorder, and was prescribed multiple antipsychotic medications such as Aripiprazole, Cariprazine, and Seroquel. The resident's care plan required staff to monitor for side effects and effectiveness of psychotropic medications every shift and to document occurrences of target behavior symptoms per facility protocol. However, a review of physician's orders, medication administration records, and nurse's notes over a two-month period did not show any evidence that behavior monitoring was ordered or performed as required. Interviews with facility staff, including a psychiatric APRN and the ADNS, confirmed that behavior monitoring should have been in place for the resident due to the use of several antipsychotic medications. Both staff members acknowledged the absence of documented behavior monitoring and indicated that such monitoring is necessary to guide treatment and assess the resident's condition. Facility policies also directed that behavioral symptoms be identified, evaluated, and documented, and that the effectiveness of antipsychotic medications be observed and reported. Despite these requirements, the facility did not obtain a physician's order for behavior monitoring or ensure that staff documented target behaviors every shift for the resident on antipsychotic medications.
Failure to Document Assessment and Provider Notification During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure complete and accurate documentation for a resident with multiple complex diagnoses, including acute and chronic respiratory failure, congestive heart failure, and chronic kidney disease, who experienced a significant change in condition. The resident became pale, cold, and complained of blurry vision and weakness while awaiting transport for dialysis. Although vital signs were recorded, including blood pressure, heart rate, temperature, and respirations, there was no documentation of an oxygen saturation (SpO2) level, a full RN assessment, or provider notification in the clinical record. Additionally, there was no documented physician's order for the transfer to the emergency department (ED). Interviews with nursing staff revealed that while some assessments and notifications may have occurred, they were not documented as required by facility policy. The nursing supervisor acknowledged assessing the resident and obtaining an oxygen level, as well as notifying the provider and obtaining a transfer order, but admitted these actions were not recorded due to the hectic circumstances. Facility policy directs that all care, assessments, and provider communications related to a change in condition must be documented in the resident's medical record, which was not followed in this instance.
Failure to Develop Elopement Risk Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a care plan addressing elopement risk for a resident with multiple diagnoses, including Parkinson's disease, dementia with behavioral disturbances, adjustment disorder, and a history of repeated falls. Despite an Elopement Risk Evaluation identifying the resident as at risk, and multiple documented incidents where the resident attempted or succeeded in leaving the facility—sometimes requiring police intervention—there was no care plan in place to address this risk. The clinical record also lacked timely physician orders for the use of a Wanderguard device, and the care plan was not updated to reflect the use of this device as required by facility policy. Nursing notes documented several episodes where the resident was unable to be redirected, became agitated or aggressive, and exited through various doors, often accompanied by staff and sometimes resulting in police involvement. Interviews confirmed that the resident had exited the facility on multiple occasions and that a care plan for elopement risk should have been developed following the initial risk assessment. Facility policies required care plans to contain necessary information for resident care and for the use of Wanderguard devices to be reflected in the care plan, which was not done in this case.
Failure to Timely Obtain Physician Order and Monitor Wanderguard for Elopement Risk
Penalty
Summary
A deficiency occurred when the facility failed to obtain a timely physician's order for a Wanderguard device after a resident was identified as being at risk for elopement. The resident, who had diagnoses including Parkinson's disease, dementia with behavioral disturbances, adjustment disorder, and a history of repeated falls, was assessed as an elopement risk on 6/24/24. Despite this assessment, there was no care plan addressing elopement risk, and the clinical record lacked documentation or physician's orders for the Wanderguard, as well as instructions for staff to check its placement and functionality, from the time of risk identification through 9/10/24. On 9/7/24, the resident attempted to leave the facility and was not able to be redirected by staff, resulting in police involvement before the resident returned. Documentation showed that a Wanderguard was applied after this incident, but prior orders did not specify the device's location or ensure that checks were carried over to the Treatment Administration Record (TAR). Facility policy required a physician's order, care plan updates, and regular checks of the Wanderguard's placement and function, none of which were consistently documented or implemented for this resident.
Failure to Document and Provide Social Service Support During Room Change
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a room change for a resident with major depressive disorder and conversion disorder was properly documented and that social service support was provided during the transition. The resident, who had intact cognition and required moderate assistance for transfers and ambulation, was moved to a new room after expressing agitation about a roommate's disruptive behaviors. Nursing notes indicated the resident's distress and subsequent adjustment to the new room, but there was no corresponding documentation from social services regarding the room change or support provided at the time of the move. Further review revealed that social service notes for the relevant month did not mention the room change until several days after it occurred, and even then, the change was not documented. Interviews with facility staff confirmed that social services are responsible for handling, documenting, and following up on all room changes, including communication with families and ensuring resident adjustment. The facility's policy also requires specific documentation of room transfers, which was not present in this case.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Willimantic
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Josephs Living Center, Inc. | 2.2 mi | ★★★★★ | 2 | 0 |
| Douglas Manor | 3.6 mi | ★★★★★ | 7 | 0 |
| Mansfield Center For Nursing And Rehabilitation | 5.5 mi | ★★★★★ | 5 | 0 |
| Complete Care At Harrington Court | 11 mi | ★★★★★ | 8 | 1 |
| Apple Rehab Colchester | 11.1 mi | ★★★★★ | 6 | 0 |
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