Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westside Care Center during CMS and state inspections, most recent first.
Kitchen Construction Area Not Properly Sealed: Surveyors found a dish room renovation area with visible dust and debris on equipment, pipes, and flooring, while the temporary plastic barrier separating construction from the operational kitchen was torn and loosely taped with large gaps. A fan in the operational kitchen faced the damaged barrier and had visible dust and residue. The Dietary Director, DOR, and Administrator described ongoing dishwasher-related construction, including floor, plumbing, and electrical work, and no policy for construction debris management was provided.
Dirty HVAC units and an unclean laundry area were observed throughout the facility. A resident reported moldy air conditioners, and surveyors found a dining room mini split with a mildew odor, black debris, and black stains in the vents, along with multiple unit ACs with heavy dust and debris despite maintenance logs showing recent cleaning. In the laundry area, surveyors observed dirty and dusty surfaces, uncovered clean linens and resident clothing, soiled equipment, cobwebs, and other cluttered items; staff said housekeeping was responsible for the area and that some stored items belonged to expired residents.
Failure to prevent resident-to-resident abuse: Two residents with behavioral and psychiatric histories became involved in a dining room altercation after one confronted the other about a prior issue. Accounts of the event conflicted, including reports of a cane being swung, a push, and punches, while no staff directly witnessed the incident and the residents were only separated after staff arrived. The facility did not obtain detailed contemporaneous statements from either resident at the time of the event.
Incomplete Investigation of Resident-to-Resident Altercation: Two residents were involved in a physical altercation after one resident allegedly swung a cane at the other, leading to a push and punches. The facility separated the residents and initiated an investigation, but the record shows no detailed contemporaneous interviews from the involved residents and the investigation relied on conflicting witness accounts. Leadership later acknowledged they were not aware of the cane-related statement during the investigation, despite the abuse policy requiring allegations to be immediately and thoroughly investigated.
Failure to develop a timely comprehensive skin prevention care plan for a resident at risk for pressure injury. The resident had multiple comorbidities, was chairfast with substantial to maximum assistance for mobility and transfers, and had Braden scores showing mild risk and later no risk. The care plan addressed toileting, transfers, and position changes, but did not address skin breakdown risk. The resident later developed a blister/open area on the heel, and a nutrition note documented new DTI to both heels; APRN notes did not document left heel assessment.
A resident with OSA had a physician order for CPAP at bedtime, but the care plan was not revised to reflect the CPAP use. The MDS did not identify noninvasive respiratory treatment, and a regional clinical reimbursement and case management nurse confirmed the care plan should have been updated when the order was received. The facility policy required a comprehensive person-centered plan of care to be updated and revised.
A resident on hospice with chronic lung disease, dementia, muscle weakness, and depression did not have hospice-directed comfort meds maintained in the chart. Lorazepam and morphine orders for anxiety, restlessness, pain, and SOB expired without documented re-evaluation or a provider/hospice decision to discontinue, even though hospice documentation said the plan of care should continue. The care plan also did not identify the resident as receiving hospice care, and the hospice nurse was unaware the orders had been discontinued.
A resident with multiple comorbidities and limited mobility was identified as being at risk for pressure injuries, but the facility did not complete weekly skin checks or develop a preventative skin breakdown care plan. Heel wounds were later identified, including bilateral heel pressure injuries, and physician orders for treatment were delayed after the right heel blister was first noted. Documentation also lacked clear assessment of the left heel and did not establish when the wounds were first identified.
Failure to follow a resident’s no-Styrofoam dietary order. A resident with dementia and other behavioral diagnoses had a care plan and MD order for no Styrofoam, after the SLP observed the resident chewing on Styrofoam. During dining observations, the resident was served meals in Styrofoam containers and plates, while dietary staff reported the dishwasher had been broken and meals were being served in disposable Styrofoam containers. The DON/Dietary Services confirmed the resident was served in Styrofoam despite the order.
A resident’s breakfast was placed on an over-bed table that also held urinals and other items, and a nurse aide handled a hard-boiled egg with bare hands and very long nails while preparing a meal tray. The resident’s CPAP mask and bedside table were also observed unclean, with the mask not stored in a clean bag as ordered and dust visible on the table and machine.
A resident with Alzheimer’s disease, severe cognitive impairment, and total dependence for toileting and personal hygiene was observed receiving ADL care while fully visible from the hallway, with the room door and privacy curtain left open and no sheet or blanket covering the body. A NA removed a saturated brief by pulling and tugging it from under the resident, who was lying flat in bed, without asking the resident to roll or lift their buttocks, despite care instructions for gentle skin care. Interviews with a NA, an LPN, the ADNS, the Administrator, and the DNS confirmed that facility expectations and resident rights required closing doors/curtains during personal care and avoiding pulling briefs out from under residents.
A resident with dementia and severe cognitive impairment suffered a fall resulting in a head laceration and change in consciousness. Although emergency services and the provider were notified, only a single voicemail was left for the responsible party, with no documented follow-up attempts, contrary to facility policy requiring timely notification and documentation after a significant change in condition.
A resident with dementia and severe cognitive impairment was left unsupervised by a nursing assistant during an outpatient dental appointment. The staff member lost visual contact with the resident for several minutes while distracted by a phone call, resulting in the resident wandering away and being found two miles from the clinic. Facility policy required continuous line-of-sight supervision, which was not maintained.
A resident with severe cognitive impairment and acute osteomyelitis experienced high pain levels when their prescribed Oxycodone was unavailable. An LPN administered acetaminophen, which did not relieve the pain, but did not notify the supervisor or physician about the ongoing pain or medication shortage. Key nursing and administrative staff were unaware of the situation, and the physician was not contacted to provide an alternative pain management option.
A resident with behavioral health needs was physically abused by another resident following a verbal altercation in the dining room. The incident escalated when one resident, using a motorized wheelchair, caused the other to fall and then struck them in the head with a cane, resulting in a laceration requiring sutures. Staff and therapy personnel witnessed the event, and facility policies prohibiting abuse were not effectively implemented to prevent this incident.
Two residents did not receive their prescribed medications within the facility's required timeframe, with administration occurring up to several hours late. An LPN reported heavy assignments as the cause and did not notify supervisors, while the RN and DON were unaware of the delays. Facility policy required medications to be given within 60 minutes of the scheduled time and for staff to report delays, but these steps were not followed.
A resident with severe pain and a history of osteomyelitis did not receive prescribed Oxycodone-APAP for over 32 hours due to the facility running out of the medication and lacking an emergency supply. Despite the resident reporting high pain levels and acetaminophen being ineffective, staff failed to notify supervisors or providers in a timely manner, and no alternative pain management was arranged. Poor communication and lack of adherence to pain management protocols resulted in the resident experiencing prolonged, unrelieved pain.
Two residents, both with intact cognition and behavioral health diagnoses, were involved in a physical and verbal altercation in a common area. One resident approached another, yelled, and punched them, leading to a physical struggle. Staff and witness statements confirmed the incident, which was substantiated as abuse, indicating a failure to protect residents from abuse as required by facility policy.
Following a physical altercation between two residents, the facility did not document the required 1:1 and Q15 minute monitoring for a resident as mandated by policy. Despite orders and care plan updates for close observation, there was no record in the clinical file or on monitoring flowsheets to confirm that these checks were performed.
The facility failed to maintain a homelike environment, with numerous issues such as damaged walls, broken furniture, and missing tiles observed across two units. Key staff, including the Regional Maintenance Director and Administrator, were unaware of these issues, indicating a breakdown in communication and oversight.
The facility failed to protect residents from physical abuse by other residents with known histories of altercations. A resident with adjustment disorder was hit in the face by another resident after a verbal argument, despite interventions to maintain a no-contact boundary. In another incident, the same resident was punched by a different resident after refusing to leave a room. Additionally, a resident with dementia and PTSD was pushed and injured by another resident during an argument. These incidents highlight the facility's deficiency in preventing resident-to-resident altercations.
The facility failed to protect residents from involuntary seclusion by not providing independent egress from a locked dementia unit. Residents who chose to live on the unit or did not meet the criteria were not given access codes to leave independently. The facility also failed to conduct required assessments and document discussions with residents or their representatives regarding their placement. Staff interviews revealed a lack of awareness and completion of necessary assessments.
The facility failed to maintain cleanliness in the nourishment refrigerator and food transport carts, leading to deficiencies in food safety and hygiene. Observations revealed unlabeled, expired, and partially eaten food items in the refrigerator, along with unsanitary conditions. Additionally, food transport carts used for serving meals were soiled and not properly cleaned. The dietary department was responsible for these tasks, but failed to adhere to the facility's policies, resulting in the observed deficiencies.
The facility failed to implement proper infection control measures for three residents requiring transmission-based precautions. Two residents with COVID-19 were observed in communal areas without masks, contrary to isolation orders. Another resident with MRSA did not have appropriate signage or PPE outside their room, increasing the risk of transmission. Staff interviews confirmed a lack of adherence to infection control protocols.
A resident with dementia and dysphagia was fed by a standing nurse aide, contrary to facility policy requiring staff to be seated at eye level. The resident, with severely impaired cognition and no natural teeth, was silent during the meal, and there was no dialogue. Staff interviews confirmed training to sit while feeding, indicating non-compliance with the policy.
A facility failed to accurately document a resident's advance directive, resulting in a discrepancy between the resident's DNR preference and the facility's records, which listed the resident as Full Code. Despite the resident's signed consent for DNR, the facility's documentation and physician's orders incorrectly identified the resident as Full Code, contrary to the facility's policies on advance directives and order transcription.
The facility failed to notify the physician or APRN of a resident's change in condition, did not inform a resident's representative of multiple smoking incidents, and neglected to document and communicate a resident's refusal of showers. These actions violated facility policies requiring timely notification and documentation of significant changes in residents' conditions.
Three residents in a facility did not receive their scheduled weekly showers, with one resident not showered for months due to an unsuitable bariatric chair, and another preferring showers over bed baths but not receiving them due to staffing issues. Additionally, a resident with a history of falls did not receive the required 72-hour neurological monitoring after an unwitnessed fall, highlighting deficiencies in care and documentation.
The facility failed to adhere to physician orders and facility policies, resulting in inadequate care for several residents. One resident did not receive an RN assessment after a change in condition, and weights were not obtained as ordered. Another resident was not monitored for fluid intake and output, and weights were inconsistently recorded. Additionally, neurological checks were not completed for a resident after an unwitnessed fall with a head strike, contrary to facility policy.
The facility failed to ensure safety for residents, including a smoker not using a required apron, a fan with exposed blades, and a cognitively impaired resident smoking indoors. Staff discretion and lack of documentation contributed to these deficiencies.
A resident with hepatic encephalopathy and liver failure experienced a significant medication error due to incorrect transcription of Lactulose orders, leading to hospitalization for acute encephalopathy. The error was discovered after the resident showed increased lethargy and altered mental status. Facility staff interviews revealed confusion over the correct dosage, and the facility's policies for handling medication orders were not adequately followed.
The facility failed to document education on the benefits and side effects of the influenza vaccine for three residents before administration. An LPN provided the Vaccine Information Statement (VIS) but did not record this in the clinical records, contrary to facility policy. The Regional Director of Infection Control was unaware that documentation was required.
Kitchen Construction Area Not Properly Sealed
Penalty
Summary
The facility failed to ensure that a section of the kitchen undergoing construction was appropriately sealed off from food preparation and storage areas to prevent the spread of infection. During a tour of the kitchen with the Dietary Director, surveyors observed an area under construction in the dish room that contained visible dust and debris on stainless steel equipment, surrounding pipes, and portions of the tile floor. The temporary plastic barrier separating the construction area from the operational kitchen was torn in several places and held with loose or partially detached tape, leaving large visible gaps between the construction area and the adjacent kitchen. A fan was positioned in the operational portion of the kitchen facing the torn barrier, and the fan casing and blades had visible dust and residue. The Dietary Director stated the dish room was being renovated for a replacement dishwasher and that work had included the floor, plumbing, and electrical. The Director of Maintenance said the barrier had been intact when he last worked and thought it may have been torn when a contractor brought the new dishwasher over the weekend. The Administrator stated construction had begun on 5/7/2026, included removal of part of the floor, and that the facility would be cleaning the dust and debris from the unsealed construction area after the surveyor's inquiry. No policy for management of construction debris was provided.
Dirty HVAC Units and Unclean Laundry Area
Penalty
Summary
The facility failed to honor residents’ right to a safe, clean, comfortable, and homelike environment by not maintaining multiple air conditioners in a clean and sanitary manner. During an interview on the B wing, a resident stated that the facility’s air conditioners were moldy. When the dining room wall-mounted mini split was turned on, a distinct mildew smell was noted, and soft black debris was seen coming from the vents and landing on the piano below. Inspection of the unit showed black stains inside the vents and additional black debris, and there were 8 residents in the dining room at the time, including 3 residents seated adjacent to the unit. Facility staff and documentation reflected inconsistent maintenance of the air conditioners. The Administrator and DNS observed the dining room mini split with black debris and stains, while the Director of Maintenance stated the unit may have been overlooked and that an outside company serviced the air conditioners, though he was not sure when they last came. The Monthly HVAC P.M. maintenance log indicated the first- and second-floor dining room and nursing unit HVAC units were cleaned monthly, with filters cleaned and coils inspected on two documented dates. However, the next day, an observation of all four nursing units identified 8 ceiling-mounted air conditioners with thick visible dust on the filters and black stains and debris in the vents, including units in all four nursing units. The Director of Housekeeping stated monthly maintenance included cleaning the outside and vacuuming the filters and said he had cleaned all air conditioners on the documented dates, but also stated he had cleaned the dining room mini split only after being notified of the observed debris and stains. The laundry area was also observed to be unclean and cluttered with multiple items and surfaces in disrepair or covered with dust. Surveyors observed a dirty pitcher with dried substance, a clean mop head on the floor, uncovered clothes and medical equipment in the same room as clean laundry dryers, uncovered sheets and towels on a rack, thick dust on pipes, dirty curtains waiting to be cleaned, a yellow mop bucket with rags and liners, an old washing machine frame filled with a trash bag containing used clothing and other items, a visibly soiled open door to an outside area, uncovered racks of resident clothing, dusty blinds, a dusty air conditioner, a dirty mop, uncovered bins with resident clothing items, cobwebs on windowsills, an inactive wired phone system in the storage area, and a wall-mounted fan with dust on the blades. Staff stated housekeeping was responsible for the laundry area, and a housekeeper said the items in the washing machine room belonged to expired residents and had been there for at least over 1 month. The facility’s personal laundry and handling policy required clean linen to be covered for storage and transport, but the observed laundry area included uncovered clean items and soiled conditions.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident-to-resident altercation occurred in the dining room and the residents were not kept separated before the interaction escalated into a physical confrontation. One resident had diagnoses including anxiety, major depression, PTSD, and bipolar disorder and was documented as cognitively intact and independent with activities of daily living. The other resident had depressive episodes, was cognitively intact, and had a care plan noting verbal aggression during periods of frustration or emotional dysregulation. The incident involved a dispute that began after one resident confronted the other about an event from months earlier. Facility documentation and staff interviews described the altercation differently, including reports that one resident swung a cane, pushed the other resident, and that the other resident punched back. A witness statement also described an open palm to the shoulder. No injuries were found, but the residents were separated only after staff arrived on scene. The record also reflects that no staff saw the incident directly, and the facility did not obtain detailed contemporaneous statements from the residents at the time of the event. The investigation records, nursing notes, and psychosocial documentation show that the facility later reviewed the event and documented that both residents felt safe and were on amicable terms. However, at the time of the incident, the facility failed to prevent the resident-to-resident abuse and relied on incomplete and conflicting accounts of what occurred. The report also notes that staff later indicated the residents had been transported or cared for by staff at the time, and that the exact staff who separated the residents was not documented in the incident reports.
Incomplete Investigation of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to conduct a thorough resident-to-resident abuse investigation after an altercation between two residents in the dining room. One resident had diagnoses including anxiety, major depression, PTSD, and bipolar disorder, and was documented as cognitively intact with no mood or behavioral symptoms on the quarterly MDS. The other resident had depressive episodes, was also cognitively intact, and had some depressive symptoms but no behavioral symptoms on the annual MDS. Both residents were described in care plans as generally independent and socially engaged, with one resident noted to have a history of verbal aggression during frustration or emotional dysregulation. The incident report documented that the two residents were involved in a physical altercation with no injuries found. Staff separated the residents and placed both on 15-minute checks. The RN supervisor completed an investigation sheet stating the residents had an altercation related to an incident from months earlier, and staff interviews did not identify any staff who saw the event, although one staff member indicated another resident had witnessed it. A physician order was entered for neurological checks and psychiatric referral, and social work and psychiatric follow-up notes later documented that the residents were on amicable terms and felt safe in the facility. The deficiency centered on the investigation process itself. The resident witness statement later documented that one resident said the other swung a cane at him/her, prompting a push and punches during the interaction. Another interview with the RN who responded to the commotion stated that when she entered the dining room, she saw one resident on the floor and was told that the other resident had attempted to hit him/her with a cane, leading to the cane being grabbed and used to strike back. Facility leadership stated they were not aware of this cane-related account during the investigation and acknowledged that no detailed interviews were taken and documented from the involved residents at the time of the incident. The facility policy required allegations of abuse to be reported immediately and thoroughly investigated, but the investigation relied on incomplete and conflicting accounts rather than a full contemporaneous statement from the residents involved.
Failure to Develop Timely Skin Breakdown Prevention Care Plan
Penalty
Summary
The facility failed to develop a timely comprehensive, preventative care plan for a resident at risk for skin breakdown, and the resident developed a pressure ulcer on the heels. The resident had diagnoses including displaced fracture of the right femur, end stage renal disease, diabetes mellitus, and congestive heart failure. The nursing admission assessment documented warm, moist skin, a surgical incision on the right hip, and a bruise on the right iliac crest. A Braden Scale completed on 3/18/2026 showed a score of 18, indicating mild risk, with chairfast activity and potential friction and shear concerns due to needing assistance with movement. No focuses or interventions were documented with that assessment. A later Braden Scale on 3/25/2026 showed a score of 19, indicating no risk. The baseline care plan dated 3/19/2026 addressed assistance with position changes and toileting, and the care plan for limited mobility included bed-level toileting and mechanical lift transfers with 2 staff, but it did not address the resident's risk for skin breakdown or pressure ulcer development. The admission MDS identified the resident as cognitively intact, requiring substantial to maximum assistance with bed mobility and transfers, and noted the resident was at risk for pressure ulcers with an interdisciplinary care plan to be developed. An APRN visit note dated 4/01/2026 documented a blister on the right heel after the resident complained of heel pain while on a specialized treatment chair outside the facility; the area was open on examination, and the APRN requested skin prep, pressure-relieving boots, an air mattress, and wound physician follow-up. A nutrition note dated 4/02/2026 documented new deep tissue injuries to both heels. Another APRN note dated 4/02/2026 described the right heel as a superficial open spot and again noted a boot and air mattress, but there was no documentation about left heel skin integrity in either APRN note. Physician orders addressing complete skin checks, Braden scale monitoring, and individualized interventions were dated after the heel injury was identified.
Care Plan Not Revised for CPAP Use
Penalty
Summary
The facility failed to revise Resident #5’s care plan to address the use of CPAP. Resident #5 had a diagnosis of obstructive sleep apnea, and a physician’s order dated 2/09/2026 directed staff to apply CPAP at bedtime with settings at 12:0 and remove it in the morning. The annual MDS assessment identified the resident as cognitively intact and did not indicate that the resident received noninvasive respiratory treatment with CPAP. During an interview and clinical record review on 06/18/2026, the regional clinical reimbursement and case management nurse confirmed that the physician order had been in place for 146 days and stated that the resident’s care plan should have been revised when the order was received to accurately reflect the resident’s needs. The facility policy on care planning stated that the facility was to develop a comprehensive person-centered plan of care and update and revise it.
Hospice comfort medications were not maintained
Penalty
Summary
The facility failed to provide and continue hospice-directed comfort care medications for a resident with chronic lung disease, dementia, muscle weakness, and depression who had been admitted to hospice under a physician order. The resident’s hospice admission note directed discontinuation of blood draws, rehabilitation therapies, vitamin B12, and vitamin D3, and also started atropine drops, lorazepam Intensol oral concentrate for anxiety and restlessness, and morphine sulfate concentrate for pain or shortness of breath. The resident’s care plan identified DNR, DNI, DNH, and nurse may pronounce death, but it did not identify the resident as receiving hospice care despite the active hospice admission. Review of the clinical record showed the lorazepam and morphine orders were not re-evaluated and reordered by the physician, and the record did not reflect active hospice comfort medication orders for those medications. The ADNS stated there was no documented reason for discontinuation and no provider or hospice notes showing a decision to stop them. Hospice documentation indicated the plan of care should continue and medications were not to be discontinued, yet the lorazepam and morphine orders expired. The hospice nurse stated hospice was unaware the orders had been discontinued, and the DON stated nursing supervisors were responsible for reviewing, maintaining, and entering hospice orders because hospice staff did not have EMR access. After surveyor inquiry, new physician orders for lorazepam and morphine were entered.
Failure to complete skin checks, plan for pressure injury risk, and timely treat heel ulcers
Penalty
Summary
The facility failed to complete weekly skin checks, failed to develop a preventative skin breakdown care plan for a resident identified as being at risk, and delayed physician orders for treatment after pressure ulcers were identified. The resident had diagnoses including a displaced right femur fracture, end stage renal disease, diabetes mellitus, and congestive heart failure. On admission, the resident had a surgical incision on the right hip and a bruise on the right iliac crest. A Braden Scale completed shortly after admission showed mild risk, and the admission MDS identified the resident as at risk for pressure ulcers and stated the facility would proceed with interdisciplinary care planning. However, the care plan did not address the resident’s risk for skin breakdown or pressure ulcer development. The record showed no weekly skin assessments after admission until more than three weeks later, when the first weekly skin observation tool documented bilateral heel deep tissue injuries. The facility’s pressure ulcer prevention policy required a complete head-to-toe skin check on admission and weekly thereafter, Braden scoring on admission and weekly for four weeks, and individualized interventions for residents at risk. Interviews with the DNS and MDS nurse confirmed that weekly skin assessments were not completed after admission until the later skin observation, and that no preventative care plan could be located before the pressure ulcers were found. The DNS also stated the resident was admitted without pressure ulcers. The resident later complained of heel pain while receiving specialized treatment outside the facility, and an APRN noted a blister on the right heel that had opened and requested follow-up for skin prep, pressure-relieving boots, an air mattress, and wound physician evaluation. The note did not indicate whether the left heel was observed. Additional documentation identified new deep tissue injuries to both heels, but physician orders for the heel wounds were not entered until three days after the right heel blister was noticed. The wound specialist later documented a new stage 2 pressure ulcer on the left heel and a new stage 2 pressure ulcer on the right heel, with decreased lower-extremity sensation due to diabetes noted in the evaluation.
Failure to Follow No-Styrofoam Dietary Order
Penalty
Summary
The facility failed to follow dietary guidelines and restrict the use of Styrofoam products during dining for a resident with dementia, speech disorder, restlessness, agitation, and bipolar disorder. The resident’s MDS identified cognitive impairment and need for set-up assistance with eating, and the care plan and physician order both directed that no Styrofoam products be used for the resident. The Speech-Language Pathologist stated she placed the no-Styrofoam order after observing the resident chewing on Styrofoam and said she provided oral education to staff at that time. During dining observations, the resident was served meals in Styrofoam containers despite the no-Styrofoam order. On one observation, a nurse’s aide was seen clearing the resident’s lunch, which had been served in a Styrofoam box. On another observation, dietary staff were transporting Styrofoam lunch containers from the steam table to residents, and the resident was again served using Styrofoam products. The Director of Dietary Services confirmed the resident had been served in a Styrofoam container and plate and stated nursing and nurse aides were responsible for ensuring residents received meals according to dietary interventions. The facility also reported the dishwasher had been broken since 12/25, resulting in meals being served in disposable Styrofoam containers.
Infection Control Lapses During Meal Service and CPAP Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not maintain sanitary conditions during resident meal service and equipment care for Resident #5. Resident #5 had diagnoses including spinal stenosis and paraplegia, and the annual MDS indicated the resident was cognitively intact. The care plan stated the resident required extensive 2-person assistance for bed mobility, was dependent for dressing and toileting, and was independent for eating once the meal tray was set up. During an observation, two empty urinals and an open bag of snacks were on the resident’s over-the-bed table when breakfast was brought in, and the nurse aide placed the meal on the same table next to the urinals after the resident asked for it to be placed on the lap instead. The report also documented that Resident #5 was wearing a CPAP mask when awakened for medication administration, and the CPAP machine on the bedside table was uncovered with a dust-like substance on it. The physician order directed the CPAP mask to be wiped clean with soap and water and bagged after use, but the mask was observed without proper storage and the bedside table was dusty. In a separate observation at the nurse’s station, a nurse aide was peeling a hard-boiled egg for a resident using bare hands while wearing very long nails; the nursing supervisor stated the aide should not have handled the egg that way and then directed the aide to don gloves and wash hands before continuing. The supervisor also stated the peeled egg should not be served and that a new hard-boiled egg would be obtained.
Failure to Maintain Resident Privacy and Dignity During ADL Care
Penalty
Summary
The deficiency involves a failure to maintain a resident’s privacy and dignity during the provision of ADL care. Resident #2 had Alzheimer’s disease, a BIMS score of 3/15 indicating severe cognitive impairment, no behaviors, and was dependent on staff for toileting, bed mobility, and personal hygiene. The resident’s care plan and NA care list directed assistance of one staff for bed mobility, personal hygiene, and total dependence for brief changes at bed level, with instructions to protect sensitive skin and avoid scrubbing. During a surveyor observation, NA #1 was providing ADL care at the bedside while the room door and bedside curtain facing the hallway were left open, leaving Resident #2 fully visible from the hallway. The surveyor observed Resident #2 lying supine in bed, undressed, without a shirt or pants, and not covered by any sheet, blanket, towel, or bath blanket. The resident’s chest was exposed, and NA #1’s body only partially blocked the view of the hips/groin area. The surveyor further observed NA #1 pulling and tugging a moderately to heavily saturated adult brief out from under the resident’s hips while the resident remained flat on their back; NA #1 was not heard asking the resident to roll over or lift their buttocks during the brief removal. Subsequent interviews with NA #1, an LPN, the ADNS, the Administrator, and the DNS confirmed that facility expectations and the resident’s rights required closing the door and/or privacy curtain during personal care and that briefs should not be pulled or tugged out from under a resident lying flat, particularly given the need for gentle skin care. The facility’s Residents’ Rights policy also stated residents had a right to privacy when receiving personal and medical care and treatment.
Failure to Timely Notify Responsible Party After Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to notify the responsible party in a timely manner following a significant change in condition for a resident with dementia and severe cognitive impairment. The resident, who was at risk for falls and required specific interventions such as wearing grippy socks, experienced a witnessed fall resulting in a head laceration and a change in level of consciousness. Emergency services were called, and the resident was transferred to the hospital. Documentation showed that the provider was notified at 5:15 AM, but the responsible party was only left a voicemail at 9 AM, with no evidence of further attempts to reach them. Interviews with nursing staff revealed inconsistencies and lack of clarity regarding who was responsible for notifying the family, with some staff assuming others had made the call. The facility's policies required timely notification and documentation of all attempts to contact the responsible party, especially after a serious injury. However, the clinical record and interviews confirmed that only a single voicemail was left, and no additional follow-up or documentation of further attempts was found.
Resident Left Unsupervised During Outpatient Appointment
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes mellitus, and a history of stroke was not adequately supervised during an outpatient dental appointment. The resident was identified as severely cognitively impaired and had demonstrated behaviors such as frustration and anger, with interventions in place to allow adequate response time and anticipate needs. Despite an exit-seeking risk assessment indicating no known risk factors for exit-seeking, the resident was disoriented. During the dental appointment, the resident was accompanied by a nursing assistant (NA) who, after the appointment, waited outside the clinic with the resident for transportation. While waiting, the resident moved around the area, including using the bathroom twice and sitting or standing near the NA. At one point, the NA was distracted by a phone call regarding transportation and lost visual contact with the resident for approximately five minutes. Upon realizing the resident was missing, the NA searched the clinic and surrounding area before notifying facility staff. The incident was escalated to the facility administration, and local authorities were contacted to assist in the search. The resident was eventually found unharmed at a gas station two miles from the clinic and was transported to the emergency department for evaluation. The facility's policy required staff to maintain close proximity and line-of-sight supervision of residents during appointments, which was not followed in this instance, resulting in the resident being left unsupervised.
Failure to Notify Physician of Unavailable Pain Medication and Ineffective Alternative
Penalty
Summary
The facility failed to notify the physician when a resident's prescribed pain medication, Oxycodone 5-325 mg, was unavailable, and when the alternate pain medication administered, acetaminophen, was ineffective. The resident, who had acute osteomyelitis of the left ankle and foot and severe cognitive impairment, experienced pain levels ranging from five to ten. On the day in question, the resident reported a pain level of nine, received acetaminophen, and subsequently reported that the medication was ineffective, with pain remaining at eight. Despite this, the physician was not informed of the unrelieved pain or the unavailability of the prescribed Oxycodone, and no alternative pain management was sought. Interviews with facility staff revealed that the LPN did not notify the supervisor or the physician about the medication shortage or the resident's ongoing pain. The nurse supervisor, ADNS, and DON all confirmed they were not informed of the situation, and the Medical Director stated that he would have expected to be notified to provide an alternative medication. Facility policy required assessment and physician notification in the event of a significant change in condition, which did not occur in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with bipolar disorder and anxiety, who was alert and oriented, was not protected from physical abuse by another resident. The incident began with a verbal altercation in the dining room over condiments, escalating when one resident, who used a motorized wheelchair and had a history of anxiety and depression, drove towards the other, causing them to fall. While on the floor, the resident who had fallen attempted to use their cane defensively, but the other resident took the cane and struck them in the head, resulting in a significant laceration that required emergency medical attention and sutures. Multiple staff members, including a social worker, physical therapy assistant, and certified occupational therapy assistant, witnessed or responded to the altercation. Their accounts confirmed that the altercation escalated quickly from a verbal dispute to physical violence, with the use of a cane as a weapon. The staff intervened after the incident had already resulted in injury, and both residents were subsequently separated and evaluated. Facility documentation and policies reviewed indicated that residents are to be free from abuse by anyone, including other residents. Despite these policies, the facility failed to prevent the physical abuse that occurred during the altercation, resulting in harm to one of the residents. The deficiency was identified through clinical record reviews, staff interviews, and facility documentation.
Failure to Administer Medications Timely per Facility Policy
Penalty
Summary
The facility failed to administer medications in accordance with its own policy for two of three residents reviewed for medication administration. For one resident with diagnoses including schizoaffective disorder, major depressive disorder, and Crohn's disease, the care plan required medications to be given as ordered and monitored for effectiveness. Physician orders specified exact times for multiple medications, but documentation showed that these medications were administered between one hour and fifty-three minutes to over two hours after the scheduled times. Another resident, diagnosed with metabolic encephalopathy, traumatic brain injury, and adjustment disorder, also had specific medication orders with scheduled administration times. Observations and record reviews revealed that this resident's medications were administered two and a half to three and a half hours past the scheduled times. Both residents had care plans and physician orders that required timely administration of medications, but these were not followed as per facility policy. Interviews with staff indicated that the late administration of medications was due to heavy resident assignments and was a known issue within the facility. The LPN responsible did not notify supervisors about the delays, and the RN and Director of Nursing were unaware of the ongoing problem. Facility policy required medications to be administered within sixty minutes of the scheduled time and for staff to notify supervisors if unable to do so, but these procedures were not followed.
Failure to Provide Timely Pain Medication Due to Unavailability and Poor Communication
Penalty
Summary
A deficiency occurred when a resident with acute osteomyelitis of the left ankle and foot, who was prescribed both acetaminophen and Oxycodone-APAP for pain management, was not provided with adequate pain relief due to the unavailability of their prescribed narcotic pain medication. The resident's care plan required administration of analgesics as ordered and monitoring of effectiveness, but the facility ran out of Oxycodone-APAP and also had no emergency supply available. Despite the resident reporting significant pain, ranging from 5 to 10 on a pain scale, and acetaminophen being ineffective, the resident did not receive Oxycodone for over 32 hours. Nursing staff were aware of the medication shortage and the resident's unrelieved pain but failed to notify the nurse supervisor or provider in a timely manner. The LPN did not inform the supervisor or request an alternative pain medication from the provider, and the nurse supervisor was not made aware of the resident's ongoing pain or the lack of Oxycodone. The Assistant Director of Nursing and Director of Nursing were also not notified about the resident's unrelieved pain after acetaminophen administration. The on-call nurse practitioner service was contacted for a refill, but the urgency of the resident's pain was not communicated, and the refill was not ordered as a stat, resulting in a delay in medication delivery. Documentation and interviews confirmed that the facility's pain management policy, which includes both pharmacologic and non-pharmacologic interventions, was not followed. The lack of communication among staff and with providers, as well as the failure to ensure medication availability, led to the resident experiencing prolonged, unrelieved pain. The medical director stated that unresolved pain should have prompted notification and consideration of alternative medications.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by an altercation between two residents in the first-floor dining room. One resident, with a history of fibromyalgia and mood disorder, and another resident, with diagnoses including a sternal fracture, Tourette's disorder, and ADD, were involved. The first resident, who had a care plan noting a tendency to yell and threaten others when upset, approached the second resident, yelled at them, and punched them in the face. The second resident responded by placing the first resident in a headlock to prevent further assault. Witnesses, including staff, confirmed the sequence of events, and the incident was substantiated through consistent statements. Prior to the incident, the first resident's care plan included interventions such as psychiatric therapy, medication management, and strategies to separate them from others if bothered. Despite these interventions, the resident was able to approach and physically assault another resident in a common area. The second resident, who was sitting at a table coloring, was confronted and physically attacked without provocation, leading to a physical struggle between the two. The facility's abuse policy prohibits abuse, exploitation, and mistreatment of residents by anyone, including other residents. However, the incident demonstrates a failure to prevent resident-to-resident abuse, as the first resident was able to engage in both verbal and physical aggression toward the second resident. The event was witnessed by staff, and the facility's documentation and interviews confirm that the altercation occurred and was substantiated as abuse.
Failure to Document Required Close Observation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to complete and document required 1:1 and every fifteen-minute (Q15) checks for a resident following a resident-to-resident abuse incident, as mandated by facility policy. After an altercation in which one resident was punched by another in the dining room, both residents were immediately separated and placed on 1:1 observation. Psychiatry later evaluated both residents, discontinued 1:1, and initiated Q15 checks. However, there was no documentation in the clinical record or on the required monitoring flowsheets to show that these checks were performed for the affected resident. The resident involved had diagnoses including a sternal fracture, Tourette's disorder, and ADD, and was assessed as alert, oriented, and cognitively intact. The care plan and physician orders reflected the need for close observation following the incident. Despite these directives and the facility's policy requiring documentation of such monitoring, the Director of Nursing Services and Administrator were unable to locate any records of the 1:1 or Q15 checks for the resident on the day of the incident. The facility's policy specifies that initiation and ongoing monitoring must be documented in the clinical record or on designated flowsheets, which was not done in this case.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed during a survey on two of its four units. The survey identified numerous issues, including damaged, chipped, stained, or marred bedroom walls and radiators, broken or missing furniture knobs, damaged window blinds, cracked ceilings, and missing or broken floor and wall tiles. These deficiencies were noted in multiple rooms across both A and B wings, indicating a widespread issue with the facility's maintenance and upkeep. Interviews with the facility's staff, including the Regional Maintenance Director, Administrator, and Interim DNS, revealed a lack of awareness regarding these issues. The Regional Maintenance Director mentioned that the facility was in the process of transitioning to a computerized maintenance log system and that staff were responsible for reporting maintenance problems. However, the lack of awareness among key staff members suggests a breakdown in communication and oversight, contributing to the failure to address these environmental deficiencies in a timely manner.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #97 from physical abuse by other residents with known histories of altercations. Resident #97, who was admitted with adjustment disorder, anxiety, and mood disorders, was involved in a physical altercation with Resident #217. After a verbal argument, Resident #217 entered Resident #97's room and hit them in the face, causing swelling and pain. Despite interventions to maintain a no-contact boundary, the altercation occurred, indicating a lapse in monitoring and enforcement of safety measures. In another incident, Resident #97 was involved in an altercation with Resident #71. Resident #97 was in Resident #7's room when Resident #71 asked them to leave. After Resident #97 refused and knocked over a cup of milk, Resident #71 punched Resident #97 in the face. This incident highlights the facility's failure to prevent resident-to-resident altercations, despite the known behavioral issues of the residents involved. Resident #59, who has dementia, PTSD, and a traumatic brain injury, was also a victim of physical abuse by another resident, Resident #73. During an argument in the dining room, Resident #73 pushed Resident #59, causing them to fall and sustain a head injury. The facility's inability to prevent this altercation, despite Resident #73's known history of explosive behavior, demonstrates a deficiency in protecting residents from abuse.
Failure to Provide Independent Egress in Locked Dementia Unit
Penalty
Summary
The facility failed to protect residents from involuntary seclusion by not providing them with independent egress from a locked dementia unit. Four residents, who either voluntarily chose to reside on the unit or did not meet the criteria for placement, were not given access codes or other means to leave the unit independently. The facility's policy required that residents who choose to live in a secured unit and do not meet the criteria must have access to the method of opening doors independently, but this was not adhered to. The facility also failed to conduct initial and ongoing assessments as per the Greater Hartford Memory Care Center Program guidelines. The social worker was not educated on the required assessments, and the clinical records lacked documentation of discussions with residents or their representatives regarding their placement in the locked unit. Additionally, there was no documentation of the residents' involvement in the decision for placement, whether the placement was the least restrictive approach, or the impact and reaction of the residents to their placement. Interviews with facility staff revealed that the social worker had never seen or completed the required assessments, and the Director of Recreation, who was supposed to oversee the program, was unaware of its requirements. The facility's failure to document and assess the residents' placement in the locked unit, as well as to provide them with independent egress, resulted in a deficiency in protecting residents' rights to be free from involuntary seclusion.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary nourishment refrigerator and food transport carts, leading to deficiencies in food safety and hygiene. During an observation, it was noted that the first-floor nourishment refrigerator contained various food items that were not labeled or dated, including partially eaten and expired items such as sherbet cups, sausages, and watermelon. Additionally, the refrigerator and freezer were found to have unsanitary conditions, with a large black frozen substance and orange and brown spots. Interviews with RN #5 and the Director of Dietary revealed that the dietary department was responsible for cleaning and discarding unlabeled or expired food items, but this was not consistently done. Furthermore, the food transport carts used to serve meals were observed to be soiled with stains and caked-on filth. The dietary aide placed plates of food on these dirty carts, which had not been properly cleaned. The Director of Dietary acknowledged the unclean state of the carts and stated that the dietary staff were responsible for maintaining their cleanliness. The facility's policies outlined the responsibilities for labeling, dating, and discarding food items, as well as maintaining cleanliness, but these were not adhered to, resulting in the observed deficiencies.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for three residents requiring transmission-based precautions. Resident #64 and Resident #79, both diagnosed with COVID-19, were observed in communal areas without masks, contrary to physician orders for isolation and droplet/contact precautions. Despite the presence of signage and PPE carts, staff did not enforce these precautions, citing the residents' cognitive and behavioral issues as barriers. Observations revealed that staff were not wearing appropriate PPE, and residents were exposed to potential infection risks in communal dining areas. Resident #368, diagnosed with MRSA bacteremia, did not have appropriate signage or PPE outside their room to indicate the need for contact precautions. The resident was placed in a shared room with another resident who had no history of MRSA, contrary to the facility's policy and medical director's guidance. This oversight in implementing contact precautions increased the risk of MRSA transmission to the roommate and others. Interviews with facility staff, including the Infection Control Nurse and Medical Director, confirmed a lack of adherence to infection control protocols. Staff were unaware of the residents' non-compliance with isolation orders and the absence of necessary precautions for Resident #368. The facility's policies on droplet and contact precautions were not followed, leading to potential exposure and spread of infections among residents and staff.
Failure to Feed Resident in a Dignified Manner
Penalty
Summary
The facility failed to feed Resident #317 in a dignified manner, as per the facility's policy. Resident #317, who was admitted with diagnoses including dementia and dysphagia, was observed being fed by a nurse aide who was standing while the resident was seated on a low-positioned bed. This resulted in the resident's head being at the nurse aide's mid-chest level, contrary to the facility's policy that requires staff to be seated at eye level with the resident during feeding. The resident, who had severely impaired cognition and was edentulous, was silent during the meal, and there was no dialogue between the resident and the nurse aide. Interviews with the RN and DNS confirmed that nurse aides had been trained to sit while feeding residents, indicating a failure to adhere to the training and policy.
Failure to Document Resident's Advance Directive Accurately
Penalty
Summary
The facility failed to accurately document a resident's life support choices, leading to a discrepancy between the resident's advance directive and the facility's records. Resident #103, who was admitted with diagnoses including hypertension, COPD, endocarditis, and heart valve disorders, had a Full Code status during a hospital admission. However, upon admission to the facility, the resident signed an Advance Directive/Code Status Consent indicating a DNR (Do Not Resuscitate) preference. Despite this, the Care Conference signature sheet and the November 2024 Physician's Orders incorrectly identified the resident as Full Code. Interviews and record reviews revealed that the Director of Nursing Services (DNS) acknowledged the oversight, noting that the resident's DNR status should have been updated in the physician's orders. The facility's policy requires that any advance directive documents be reviewed and included in the medical record upon admission or any time thereafter. Additionally, the Physician's Orders-Transcription policy mandates that physician orders be transcribed by a licensed nurse and followed through in accordance with quality standards. The failure to update the resident's code status as per their advance directive represents a deficiency in adhering to these policies.
Failure to Notify Physician and Representatives of Changes in Condition and Policy Violations
Penalty
Summary
The facility failed to notify the physician or APRN of a change in condition for a resident who was admitted with diagnoses including congestive heart failure, seizures, diabetes, and hypertension. The resident experienced increased tremors and weakness, requiring assistance from two staff members to return to bed. Despite the change in condition, the RN supervisor did not contact the physician or APRN directly, instead leaving a note in the APRN communication book, which was not an appropriate method of notification according to facility policy. The ADNS and DNS confirmed that the RN supervisor should have performed an assessment and contacted the physician directly. Another resident, admitted with dementia and nicotine dependence, was found smoking in their room, which was against the facility's smoking policy. Although the resident's representative was notified of one incident, subsequent incidents involving smoking materials found in the resident's room were not communicated to the representative. The facility's policy required that the resident representative be notified of significant clinical developments, which was not adhered to in this case. A third resident, with a history of traumatic brain injury and severe cognitive impairment, consistently refused scheduled showers. The facility failed to document these refusals adequately and did not notify the physician or the resident's representative of the ongoing issue. The care plan required assistance with bathing, but the lack of documentation and communication with the physician and representative indicated a failure to follow the established care plan and facility policy.
Failure to Provide Scheduled Showers and Incomplete Monitoring After Fall
Penalty
Summary
The facility failed to provide scheduled weekly showers for three residents, leading to deficiencies in their care. Resident #102, who was admitted with severe morbid obesity, paraplegia, and spinal cord compression, did not receive scheduled showers from July to October 2024. The facility's bariatric shower chair was deemed unsafe, and a new chair purchased in June 2024 was too wide to fit through the shower room door. Despite being aware of the issue, the facility continued to provide only bed baths, which did not meet the resident's preference for showers. Resident #76, admitted with congestive heart failure, peripheral vascular disease, and hypertension, also did not receive the preferred weekly showers. The resident expressed a strong preference for showers over bed baths, but the facility's nurse aides often cited time constraints and staffing shortages as reasons for not providing showers. Documentation was inconsistent, with some aides inaccurately recording that showers were given when only bed baths were provided. The resident's care plan did not reflect their preference for showers, and communication with the social worker and nursing staff did not result in any changes. Resident #116, admitted with a history of falls and a high risk for further falls, experienced an unwitnessed fall and reported hitting their head. The facility's policy required 72 hours of neurological monitoring following such incidents, but documentation showed that monitoring ceased after 50 hours. The lack of a care plan addressing the resident's fall risk and the incomplete neurological monitoring represent significant deficiencies in the resident's care. The medical director confirmed that the expected monitoring was not completed, which could have compromised the resident's safety.
Failure to Adhere to Physician Orders and Facility Policies
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice and physician's orders for several residents. For one resident, the facility did not document an RN assessment when the resident exhibited a change in condition, such as increased tremors and weakness, and failed to obtain weights according to facility policy and physician order. Interviews revealed that the RN supervisor was not aware of the resident's condition change, and no RN assessment was documented, including vital signs or a neurological assessment. Another resident, who was reviewed for nutrition, was not monitored for fluid intake and output and weights per the physician's orders. The facility's records showed incomplete documentation of fluid intake and output, and the resident's weights were not consistently recorded. Interviews with staff indicated that the intake and output records were not completed every shift, and the 24-hour totals were not calculated, which was against the facility's policy. Additionally, the facility failed to ensure neurological checks and post-fall assessments were completed for a resident who sustained an unwitnessed fall with a reported head strike. The facility's policy required 72 hours of neurological monitoring, but documentation showed that monitoring was not completed as required. Interviews with medical staff confirmed that the expected monitoring was not adhered to, and the facility's policy was not followed in this case.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to ensure the safety of Resident #20, who was a smoker with a history of behavioral symptoms and required a smoking apron as per the care plan. Despite the care plan's directive, the resident was observed smoking without a smoking apron on multiple occasions, leading to ashes being dropped on their clothing. Security Guard #1, who was responsible for supervising the smoking breaks, exercised personal discretion in deciding whether the resident needed a smoking apron, without consulting nursing staff or updating the care plan. This lack of adherence to the care plan and absence of proper training for security staff contributed to the deficiency. Resident #13 was found to have a pedestal fan in their room with the front cover missing, exposing the blades and creating a potential safety hazard. Despite multiple staff members, including nurse aides and housekeeping, being in the room, the missing cover went unnoticed for months. The facility lacked a policy related to the safety of fans in resident rooms, and there was no documentation of maintenance requests to address the issue, indicating a failure in ensuring a safe environment for the resident. Resident #111, who had severe cognitive impairment, was involved in multiple incidents of smoking inside the facility, contrary to the smoking policy. Despite these incidents, there was no documentation of reassessment or updates to the resident's care plan, nor were the incidents reported or investigated as required by the facility's policy. The facility also failed to notify the resident's conservator about these incidents, demonstrating a lack of communication and adherence to safety protocols.
Medication Transcription Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's medication orders were correctly transcribed and administered, resulting in a significant medication error. The resident, who had a history of hepatic encephalopathy, hepatic failure, and type 2 diabetes mellitus, was admitted to the facility with a care plan that identified a risk for falls due to comorbidities. The resident had been prescribed Lactulose to manage high ammonia levels associated with liver disease. However, a transcription error occurred when a telephone order was taken, leading to the resident receiving an incorrect dosage of Lactulose. The error was discovered after the resident experienced increased lethargy, weakness, and altered mental status, which led to a fall and subsequent hospitalization. The hospital discharge summary indicated that the resident was admitted with acute encephalopathy and high ammonia levels, which were attributed to the incorrect administration of Lactulose. The resident's condition improved after receiving the correct dosage of Lactulose and treatment for a urinary tract infection, and they were eventually discharged from the hospital. Interviews with facility staff revealed that there was confusion regarding the correct dosage of Lactulose, and the transcription error was not identified until after the resident's hospitalization. The facility's policies for telephone and verbal orders, as well as medication errors, were not adequately followed, contributing to the deficiency. The Director of Nursing Services and other staff members were unable to determine where the communication breakdown occurred, highlighting a gap in the facility's medication management processes.
Failure to Document Vaccine Education
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident #49, 78, and 94, or their representatives, were provided with education on the benefits and potential side effects of the influenza vaccine before its administration. During an infection control program review conducted as part of an annual recertification survey, it was found that the facility's documentation did not include evidence of education related to the influenza vaccine for these residents. The clinical records showed that Residents #78 and 94 received the influenza vaccination on October 15, 2024, and Resident #49 on October 18, 2024, without documented education on the vaccine's benefits, risks, or potential side effects. Interviews with LPN #2, who administered the vaccinations, and RN #8, the Regional Director of Infection Control, revealed that while the Vaccine Information Statement (VIS) from the CDC was provided to the residents upon administration, there was no documentation of this education in the residents' clinical records. RN #8 was under the impression that providing the VIS was sufficient and was unaware that the education provided should be documented. The facility's policy on Resident Influenza Immunizations required that residents or their legal representatives be educated about the risks and benefits of the influenza vaccine annually, be provided with a copy of the current VIS, and that this education be documented, which was not adhered to in these cases.
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What surveyors actually found near you
We read the 662 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Manchester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Touchpoints At Manchester | 0.1 mi | ★★★★★ | 0 | 0 |
| Manchester Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 17 | 0 |
| Glastonbury Center For Health & Rehabilitation | 3.1 mi | ★★★★★ | 0 | 0 |
| Civita Care Center At Salmon Brook | 4.3 mi | ★★★★★ | 4 | 0 |
| Riverside Health & Rehabilitation Center | 5.2 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.