Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodlake At Tolland during CMS and state inspections, most recent first.
A resident with CHF, protein-calorie malnutrition, and colon cancer, who was cognitively intact and normally ate independently, developed an abnormal bradycardic pulse and later a significant change in eating ability and mental status. An LPN documented a manual pulse of 47 BPM but there was no documentation that a provider was notified, despite policy requiring notification for vital signs significantly deviating from baseline. Later that day, staff observed the resident not eating, requiring assistance, and becoming lethargic and confused, while a family member reported the resident was breathing heavily and dribbling liquid as a NA continued spoon-feeding. An RN then documented low BP and lethargy, an APRN assessed the resident with hypotension, bradycardia, pallor, and concern for possible sepsis, and EMS found severe hypoxia before hospital transfer, where imaging showed bilateral pleural effusions and lower lobe consolidation/atelectasis and the resident subsequently expired.
A resident with CHF, malnutrition, and colon cancer, who was cognitively intact and normally ate independently, experienced a decline in condition over the course of a day. An LPN recorded bradycardia but did not document notifying a provider, despite facility policy requiring notification for abnormal vitals. Later, staff noted lethargy, hypotension, and altered mental status, and an APRN ordered transfer to the ED. Around this time, a visitor observed a CNA spoon-feeding liquid to the resident, who was breathing heavily and dribbling liquid from the mouth, even though the resident had eaten independently the prior day and was on aspiration precautions. EMS arrived to find the resident alone behind a closed door, in respiratory distress with severe hypoxia and no staff present or interventions initiated; staff interviews confirmed that after calling 911, nursing staff left the resident’s room and no one remained with the resident until EMS assumed care.
Care plans were not updated to reflect a resident's repeated skin tears and use of Geri-sleeves, and another resident's wandering, exit seeking, and elopement-related behaviors were not included in the care plan or supported by an elopement risk assessment. Documentation showed repeated combative episodes, additional skin tears, wandering into other residents' rooms, attempts to open a stair door, and a fire alarm being pulled, while the care plans remained incomplete for these identified needs.
Medication Left at Bedside Without Authorization: A resident with glaucoma had opened Latanoprost eye drops kept in plain sight on an overbed table, even though there was no order, care plan, or self-administration assessment allowing bedside storage. Staff observed the medication in the room, removed it to the med cart, and later reported that the resident’s home supply had been used while a facility supply was available in the med storage area. An RN supervisor was also observed asleep on shift in an office visible from the resident unit.
A resident with intact cognition and extensive ADL assistance needs, including toileting, bathing, dressing, transfers, and incontinent care, remained in bed in a hospital gown after calling for help early in the morning. Staff reported an aide was late, the charge nurse did not answer the call light, and the resident’s morning care was not completed until after 11:00 AM, despite the resident’s request before breakfast. The DNS stated call lights should be answered within a few minutes and that the delay was unacceptable.
A resident with dementia, severe cognitive impairment, and contractures had physician-ordered palm guards, elbow splints, and knee splints, but observations showed the devices repeatedly not in place or left on furniture instead of being worn as ordered. During care, an NA applied the hand splints incorrectly, did not reapply the elbow splints, and stated she had never been trained to place splints. Therapy staff also could not identify which caregivers had received education on proper donning, doffing, and wearing schedules.
A resident with dementia and repeated exit-seeking behavior was not given an elopement risk assessment per policy despite wandering, door-opening, and fire alarm activation. Another resident with severe cognitive impairment wore an expired wander guard that did not alarm at the unit exit as expected. A third resident who required 2-person bed-level care rolled out of bed while an NA provided incontinent care alone, contrary to the care plan and physician orders.
Missed Quarterly Nutrition Assessment and Re-weight: A resident with DM2, GERD with esophagitis, Barrett’s esophagus, and other chronic conditions had monthly weights showing a >5 lb loss, but the dietician did not identify the loss for re-weighing and missed the required quarterly nutrition assessment tied to the resident’s MDS. Facility policy required re-weighing for a 5 lb variance and quarterly nutrition documentation to monitor dietary changes and whether interventions were working.
Controlled substance receipt and disposition records were not accurately reconciled. The receiving nurse and a second nurse signed CSDRs, but the ADNS kept copies in binders and piles around her office, did not review delivery slips, and stated she had not been trained on an audit and reconciliation process. Surveyors found 253 unreconciled CSDR copies, including 66 flagged for reconciliation, and the DNS and ADM were unaware the ADNS lacked a reconciliation process.
Improper medication storage was observed when an LPN left a resident’s nasal spray and insulin pen unattended on top of a med cart during med pass, with no nurse at the cart for several minutes. In a separate med room, surveyors found expired IV dressing change trays and IV start kits. Staff acknowledged the medications should not have been left out and that expired supplies should not be used.
A facility failed to ensure ordered adaptive eating equipment was used for two residents. One resident with dementia, MS, and OA had an order and care plan for a 2 handled mug with straw, but observations and meal tickets showed only standard cups and no handled mug. Another resident with cancer, arthritis, and weakness had OT and physician orders for a 2 handled mug for all liquids, yet repeated observations found only plastic cups in the room, with staff giving inconsistent reports about the device and whether it was needed.
Failure to document MDRO history in resident diagnoses. Three residents had MRSA or ESBL histories listed on the MDRO tracking form, but their clinical records did not include those MDROs in the medical diagnoses. The infection control nurse said MDRO history should be included so other providers would be aware, but could not recall whether she communicated the information to the MDS coordinator, who was responsible for adding diagnoses and also could not recall being aware of the MDRO history.
Failure to complete required nurse aide annual in-service training: review of 2 nurse aides’ files showed missing documentation for mandatory topics such as abuse/neglect/exploitation, resident rights, dementia care, infection control, behavioral health, and communication. Interviews with the Staff Development Nurse and Administrator confirmed that mandatory education was to be tracked through scheduled monthly trainings and an annual skill fair, but the requested training materials could not be located.
A resident with severe cognitive impairment and a history of falls was witnessed by staff to fall and strike their head, resulting in altered mental status and inability to obtain vital signs. Despite these symptoms, the supervising RN directed staff to move the resident from the floor to a wheelchair and then to bed, rather than waiting for EMS as required by protocol. The resident was later transferred to the hospital and expired a few hours after the incident. Staff interviews and documentation confirmed that the resident should not have been moved following the fall.
During a kitchen tour, it was observed that opened refrigerator items lacked date labels, spoiled food was not discarded, and frozen food items were uncovered. Specifically, opened Lactaid cartons and tomato juice were not labeled with open dates, spoiled iceberg lettuce and undated bread were found, and unsealed bags of rice were observed. Additionally, unwrapped food items were stored in the walk-in freezer, and a refreshment cart for breakfast service contained soiled items. The Dietary Director acknowledged these issues, indicating that staff were expected to label opened containers, inspect perishable items upon delivery, date undated bread, wrap all food items after opening, and maintain cleanliness on service carts. The facility's policies on date marking, food storage, and sanitation were not consistently followed, leading to these deficiencies.
A resident with intact cognition and independence in eating was not asked for consent before a nursing assistant applied a clothing protector during a meal. The resident expressed a preference to be asked first, and the facility's policy on resident rights was not followed.
The facility failed to notify the APRN or physician when daily weights were not obtained for a resident with edema, congestive heart failure, and dementia. Multiple missed weights were not documented or explained, and the APRN or physician was not informed, contrary to the facility's policies.
A facility failed to protect a resident from perceived abuse by a nursing assistant, who was later terminated after an altercation with the resident's spouse. The incident revealed significant gaps in the facility's hiring and screening processes, including missing documentation and background checks.
The facility failed to develop a comprehensive care plan for a resident with chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The use of a CPAP was not included in the care plans until after surveyor inquiry, despite physician orders being in place 120 days post-admission. Interviews revealed that the MDS coordinator missed including the CPAP in the initial care plans.
The facility failed to conduct required neurological assessments for a resident after an unwitnessed fall and did not provide continuous 1:1 monitoring for another resident with suicidal ideations, leading to significant lapses in care and safety.
The facility failed to follow its bowel management protocol for a resident with Parkinson's disease, resulting in the resident having no bowel movement for five days without the necessary interventions being initiated as required by the facility's policy.
A resident with chronic kidney disease and high potassium levels repeatedly received high potassium foods despite a prescribed renal diet. This led to elevated potassium levels and required additional medical interventions. Interviews confirmed the dietary errors, and the facility's nutritional management policy was not followed.
The facility failed to ensure respiratory equipment was cleaned, changed, and stored per policy and manufacturer's recommendations for two residents. One resident's oxygen therapy equipment was not dated or properly stored, and another resident's CPAP machine was not properly maintained, with missing labels, dates, and necessary physician orders for cleaning and maintenance.
The facility failed to ensure nursing staff were competent in caring for a JP drain for a resident with dementia and other medical conditions. Observations and interviews revealed improper handling and lack of education on JP drain care, with staff admitting to not receiving relevant training in the past two years.
A pharmacy failed to identify a non-crushable medication for a resident with Parkinson's disease and other conditions, leading to the medication being improperly administered crushed 720 times. Facility staff, including an LPN, APRN, and pharmacists, were unaware of the medication's status, despite policies requiring reference checks for drug administration.
A resident with diabetes type 2 had a critical glucose level of 41 mg/dl, but the facility failed to monitor blood sugars further or issue new orders, contrary to its diabetes protocol.
A resident admitted with dementia, PTSD, and anxiety was prescribed multiple psychotropic medications, but the facility failed to ensure targeted behavior monitoring was in place upon admission. Despite the care plan indicating the need for monitoring, it was not ordered until nine days later, following incidents of suicidal ideation. Interviews confirmed this oversight, which was against the facility's policy.
The facility failed to maintain sanitary conditions for a resident with a JP drain, did not consistently follow transmission-based precautions for a COVID-19 positive resident, and did not sanitize shared medical equipment between uses, leading to potential infection control issues.
A resident admitted with hypertension and diabetes mellitus did not receive the pneumococcal vaccine as required. The resident's immunization record showed they had not received the vaccine since 2013, and the quarterly MDS assessment failed to provide a reason for the missing vaccination. The new Infection Control Nurse was unaware of the resident's vaccine status, and the resident was missed by the previous nurse. The DNS expected all vaccines to be offered upon admission and eligibility, which was not done in this case.
The facility failed to notify the State LTC Ombudsman when two residents were transferred to the hospital. The social worker responsible for sending the reports was unaware that incorrect reports were being sent, and the issue was discovered during a review of the reports.
The facility failed to provide bed hold notices to residents or their representatives upon hospital transfer for three residents with various medical conditions. Interviews with staff revealed that the facility does not issue these notices, and no documentation or policy was provided upon request.
Failure to Notify Provider of Abnormal Vital Signs and Change in Eating Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provider notification of a significant change in condition for one resident, resulting in delayed medical intervention and subsequent hospital transfer. The resident was admitted with acute on chronic CHF, protein-calorie malnutrition, and malignant colon cancer, and was care planned for nutritional problems with interventions to monitor and report signs of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, multiple swallowing attempts, and refusal to eat. On admission, the resident was documented as cognitively intact, independent with supervision for feeding, and without chewing or swallowing problems, with a regular diet and thin liquids ordered. Progress notes shortly before the event documented ongoing nausea, aspiration precautions, and use of Zofran with good effect, with instructions to continue monitoring for nausea and vomiting. On the morning of the incident date, a nursing note documented the resident as alert, able to make needs known, with stable vital signs and no distress. Later that morning, an LPN obtained a manual pulse of 47 BPM, which was outside the normal range of 60–100 BPM, but the clinical record contained no evidence that a provider was notified of this abnormal vital sign, despite facility policy requiring provider notification and documentation when vital signs significantly deviate from baseline. A subsequent nursing note by the same LPN that afternoon described the resident as alert with some forgetfulness, stable vital signs, no respiratory or cardiac distress, no cough or congestion, denial of nausea, and fair appetite, again without documentation of provider notification regarding the earlier abnormal pulse. Later that day, staff identified more pronounced changes in the resident’s condition. According to interviews, a nursing assistant reported to an LPN that the resident, who normally ate independently, was not eating and required assistance, and the LPN instructed the assistant to help feed the resident and reported altered mental status and poor intake to an RN. A family member reported arriving and finding the resident lying on the side with the head of bed flat, breathing heavily, dribbling liquid from the mouth while a nursing assistant continued spooning liquid into the resident’s mouth, prompting the family member to seek the nursing supervisor and state the resident was gasping for air and needed hospital care. An RN assessment documented the resident as lethargic, confused, not responding, with low BP and a pulse of 52 BPM, and an APRN note identified low BP, bradycardia, pallor, cool skin, and concern for possible sepsis in the setting of chronic wounds, leading to transfer to the ED. EMS records documented severe hypoxia on arrival, and hospital records showed bilateral pleural effusions and lower lobe consolidation/atelectasis; the resident expired the same day. Interviews with the APRN and DNS confirmed expectations that abnormal vital signs and significant changes in eating status or mentation should trigger timely provider notification and assessment, which were not documented in this case.
Failure to Respond to Change in Condition and Remain With Resident During Medical Emergency
Penalty
Summary
The deficiency involves the facility’s failure to recognize and appropriately respond to an acute change in condition for a resident with significant medical issues, including acute on chronic CHF, protein-calorie malnutrition, and malignant colon cancer. On admission, the resident was cognitively intact, independent with eating (with supervision), and had no documented chewing or swallowing problems. The care plan and nutrition assessment called for monitoring and reporting signs of dysphagia and aspiration risk, and the resident was on a regular diet with thin liquids. An APRN note identified ongoing nausea and that the resident was on aspiration precautions, and another APRN note documented recent nausea treated with Zofran and the need to continue monitoring for nausea and vomiting. On the morning of the incident date, nursing documentation indicated the resident was alert, able to make needs known, and without distress. Later that morning, an LPN obtained a manual pulse of 47 BPM, which was outside the normal range, but there was no documentation that the provider was notified, contrary to facility policy requiring notification and documentation when vital signs significantly deviate from baseline. In the early afternoon, another nursing note described the resident as alert with some forgetfulness, stable vital signs, and no respiratory or cardiac distress. By late afternoon, an RN documented via SBAR that the resident was lethargic, confused, not responding, and had low blood pressure, with vital signs showing hypotension and bradycardia. The APRN note from that time described low blood pressure, a heart rate of 52 BPM, pale cool skin, and concern for possible sepsis in the context of chronic wounds, leading to the decision to send the resident to the ED. Around this same time, a visitor reported entering the resident’s room and finding the resident lying on their side with the head of the bed flat while a nursing assistant spoon-fed liquid into the resident’s mouth, despite the resident having eaten independently the day before. The visitor observed heavy breathing and liquid dribbling from the resident’s mouth while the nursing assistant continued to insert more liquid, prompting the visitor to tell the assistant to stop and to seek the nursing supervisor, reporting that the resident was gasping for air and needed hospital care. An LPN later stated that this was the first time she had cared for the resident and that, after being told the resident was not eating, she evaluated the resident, learned the resident normally ate independently, and directed the nursing assistant to assist with feeding. She reported that she informed an RN that the resident was not eating, required assistance, and had altered mental status, and that after low blood pressure was identified, the RN notified the APRN and the APRN ordered transfer to the ED. EMS records and interviews revealed that EMS was dispatched and arrived within minutes, but the EMT found the resident’s room door closed and the resident alone, with no nurse or provider in or near the room and no staff meeting EMS on entry to the building. The EMT observed the resident lying on their side, drooling, with liquid on clothing, labored breathing, slightly purple lips, and severe hypoxia with an oxygen saturation of 55% on room air; oxygen was initiated at 4 L via nasal cannula. The EMT did not leave the resident to locate staff because it was unsafe to leave the resident unattended. The EMT’s partner arrived about 16 minutes later and then located the resident’s nurse, who reported that a nursing assistant had spoon-fed liquid food at about 5:00 p.m., that the resident was later found hypotensive with severely altered mental status, and that no interventions were provided before EMS arrival. Facility staff interviews confirmed that after the RN assessed the resident and called 911, she left the room to complete transfer paperwork and acknowledged that someone should have remained with the resident until EMS arrived. The DNS and APRN both stated that abnormal vital signs and significant changes in eating or mentation should be reported and that a staff member should remain with a resident during a medical emergency until EMS assumes care. Facility policies on change of condition, vital signs, and aspiration precautions required provider notification and documentation when vital signs significantly deviated from baseline, RN assessment and documentation of changes in condition, and specific positioning and speech therapy involvement for residents on aspiration precautions. The record showed no provider notification of the abnormal pulse earlier in the day, no documented interventions prior to EMS arrival despite the resident’s acute deterioration, and that the resident was left alone in the room during a medical emergency until EMS arrived and assumed care.
Care plans did not reflect skin tear prevention and wandering behaviors
Penalty
Summary
The facility failed to complete and revise care plans to address identified resident needs for two sampled residents. One resident had diagnoses including dementia and anemia, with severe cognitive impairment and total assistance needed for personal hygiene and dressing. After a skin tear to the left hand was documented, the accident and incident report noted that the resident was combative at times, had fragile and thin skin, and that Geri-sleeves were added to the plan of care to protect the resident's skin. However, the resident care plan only included interventions for pain, treatment, infection monitoring, and re-approaching the resident when combative; it did not reflect the use of Geri-sleeves at that time. The same resident later sustained additional skin tears after becoming combative during care and striking the side rail with the hands and forearm. The care plan for skin tears was not updated to include Geri-sleeves until after the third skin tear. During observations, the resident was found lying in bed wearing a hospital gown without the Geri-sleeves in place, and one sleeve was later found in the bedside drawer. An NA stated the resident was supposed to have Geri-sleeves applied to the upper extremities at all times and removed only for care. The DNS stated the resident should have been wearing the Geri-sleeves at all times and could not explain why the care plan was not implemented when the intervention was first identified. A second resident, admitted with diagnoses including anemia, chronic kidney disease, and dementia, had moderately impaired cognition and required assistance with toileting hygiene, personal hygiene, transfers, and bed mobility. Psychiatry notes and nursing documentation described increased confusion, yelling, exit seeking, wandering into other residents' rooms, refusing care, being difficult to redirect, and pulling a fire alarm after attempting to open a door to the stairs. Despite these documented behaviors, the clinical record from November 2025 through February 2, 2026 did not show an elopement risk assessment or interventions for wandering and exit seeking. The resident's care plan addressed refusal of care and non-compliance with transfer status, but it did not include elopement risk, wandering, exit seeking, or individualized interventions such as an elopement assessment or wander guard device. The care plan coordinator and DNS both acknowledged that the resident's wandering and exit seeking behaviors should have been reflected in the care plan.
Medication Left at Bedside Without Authorization
Penalty
Summary
The facility failed to ensure medications were not left at a resident’s bedside when there was no physician order, self-administration assessment, or care plan authorizing bedside storage or self-administration. Resident #116 had diagnoses including acute kidney failure, bacteremia, and nontraumatic subdural hemorrhage, and the admission MDS identified intact cognition with extensive assistance needed for toileting hygiene, lower body dressing, transfers, and ambulation. On 2/5/26, the resident was observed in bed with an overbed table beside the bed holding a clear plastic bag containing an opened bottle of Latanoprost ophthalmic solution 0.005% from an outside pharmacy, with about a quarter of the medication remaining. The resident stated the eye drops were brought from home, were used nightly for glaucoma, and were kept in plain sight on the overbed table. The monthly physician order directed Latanoprost one drop in both eyes at bedtime, but the order did not include self-administration or bedside storage. The Charge Nurse and Unit Manager observed the medication in the room and the Charge Nurse removed it and placed it in the medication cart. A facility supply of unopened Latanoprost was found in the medication storage room refrigerator, while the medication cart did not contain a facility supply at the time it was checked. Interviews showed staff were aware the resident had eye drops in the room, but the medication remained at the bedside without the required authorization. The resident had signed a self-administration consent form indicating he/she did not wish to self-administer medication and did not want an interdisciplinary assessment, and the RN identified the medication should not be kept in the room unless there was a physician order directing storage in a lock box. The Charge Nurse later stated he had been using the resident’s supply from home, had not reported finding the eye drops in the room, and had not brought them to the supervisor. The DNS stated medications cannot be left at the bedside unless there is a care plan, self-administration assessment, and physician order in place.
Delayed Assistance With ADLs After Resident Request
Penalty
Summary
The facility failed to ensure a resident who requested assistance with ADL care received timely help. Resident #116 was admitted with diagnoses including acute kidney failure, bacteremia, and nontraumatic subdural hemorrhage. The admission MDS identified intact cognition and the need for maximal assistance with toileting hygiene, bathing, lower body dressing, transfers, and ambulation, with frequent bladder incontinence and always incontinent of bowel. The care plan and care card identified the resident needed assistance with dressing, personal hygiene, toileting, transfers, incontinent care every two hours, and getting out of bed daily as tolerated. On the morning of the event, Resident #116 was observed still lying in bed wearing a hospital gown. The resident stated he/she had called for help early in the morning to get washed and dressed, but no one had come. During the observation, the resident again stated that he/she had requested assistance to get washed up and out of bed and had not received it. The resident was later interviewed and stated the last incontinent care had been provided sometime after 5:00 AM, and that the call light had been rung before breakfast, but the resident remained in bed until after surveyor intervention. Staff interviews showed the delay occurred while the unit was short an aide because one aide arrived late. The charge nurse stated she did not answer the resident’s call light and that they were down one aide. The LPN stated she answered the call light before breakfast, was told the aide was with another resident, and then told an aide the resident needed morning care. The assigned aides stated they did not hear or answer the call light and that morning care for the resident was not completed until minutes after 11:00 AM. The DNS stated call lights should be answered within a few minutes and that waiting until 10:45 AM after an early morning request was unacceptable.
Splints Not Applied Per Ordered Wearing Schedule
Penalty
Summary
The facility failed to ensure splints were applied according to the physician-ordered wearing schedule for a resident with unspecified dementia, severe cognitive impairment, bilateral upper extremity impairment, hydrocephalus, poly-osteoarthritis, and documented contractures. The resident’s orders directed bilateral upper extremity palm guards for skin integrity and contracture management, bilateral elbow extension splints during AM care and off during PM care, and bilateral knee splints on in the evening and off in the AM. The care plan also directed staff to remove elbow splints prior to Hoyer lift transfers and reapply them after transfers were completed, with staff responsible for checking skin integrity, splint cleanliness, and documenting concerns. Observations showed the resident repeatedly without the ordered upper extremity splints and palm guards in place, with the devices instead found on the dresser, chair, or otherwise not applied. On one observation, the resident was in bed without elbow splints or palm guards, with the upper extremities very bent at the elbows and the hands contracted with fingers bent inward. On another observation, the resident was in bed without the elbow splints or palm guards in place, and the splints were present on the dresser. At another time, the resident was observed asleep in bed without the upper extremity splints in place, and the knee splint was only visible under the blanket. The resident was also observed without the elbow or palm guard splints in place while asleep in bed, with one elbow splint on the dresser and one on a chair. During morning care, NA#5 applied the knee brace and palm guards, but placed the hand splints incorrectly, with the thumb hole on the pinky side, and did not reapply the bilateral elbow splints. NA#5 stated she did not put the elbow splints on until the resident was moved to the wheelchair and said she had never been trained to place splints. The Rehab Director confirmed the hand splints were placed on the wrong hands. The Therapy Director stated the resident should have bilateral knee splints, bilateral elbow splints, and bilateral hand splints, but could not identify which staff had received education on donning and doffing the splints. The Therapy Director also stated that even if the resident remained in bed, the elbow splints should be put in place with AM care, and that staff education would be completed because the facility did not know whether splinting had been consistently completed appropriately.
Failure to complete elopement assessments, maintain wander guard function, and follow fall care plan
Penalty
Summary
Resident #54, who was admitted with anemia, chronic kidney disease, and dementia, had a quarterly MDS showing moderately impaired cognition, behaviors, and need for assistance with toileting, hygiene, transfers, bed mobility, and wheelchair mobility. The resident’s care plan addressed non-compliance and refusal of care, and a physician order directed seating near the nurse’s station with stimulating activity during the late-night shift. Clinical records and staff notes documented repeated wandering and exit-seeking behavior, including going into other residents’ rooms, wandering on the unit, attempting to open the stairs door, and pulling the fire alarm. Despite these behaviors, the clinical record from the relevant period did not reflect that an elopement risk assessment was completed or that interventions were implemented for the wandering and exit-seeking behavior described in the notes and psychiatry progress notes. Resident #54’s psychiatry notes documented increased confusion, yelling, exit seeking, refusal of care, and periods when the resident was not always redirectable. Staff reported the resident was up during the night with increased behaviors, and trazodone was used and later increased at bedtime. After the fire alarm incident and continued wandering behavior, the DNS acknowledged that an elopement risk assessment should have been completed at the time of the quarterly MDS and again after the incident to determine whether the resident was at risk for elopement and wandering. The facility’s own policy required wandering/elopement risk assessments on admission, quarterly, and after elopement incidents. Resident #110, who had type 1 diabetes mellitus, anxiety, and metabolic encephalopathy, had severely impaired cognition on the admission MDS and required maximal assistance with personal care, bed mobility, wheelchair mobility, and was dependent for transfers. The care plan identified the resident as at risk for elopement related to confusion, and a physician order directed a wander guard bracelet on the right ankle with checks each shift and nightly function checks. During observation, the resident wore a wander guard bracelet, but the alarm did not sound when the resident was taken to the second-floor exit door; the alarm sounded only later at the first-floor entry doorway. The device was also found to be expired, and the binder used by the facility did not identify expiration dates or serial numbers for the wander guards in use. Staff and maintenance interviews confirmed the device had not been checked or documented as functioning at the exit door as intended. Resident #11, who had schizoaffective disorder, a lumbar compression fracture, right knee osteoarthritis, and morbid obesity, had a quarterly MDS showing intact cognition but total dependence for personal hygiene, dressing, bed mobility, transfers, and non-ambulatory status. The physician ordered bed-level toileting, dressing, and hygiene with assistance of two people and use of a mechanical lift with two people, and the care plan repeated the need for two-person assistance at bed level. During incontinent care, the resident was turned by one NA while alone in the room and rolled out of bed onto the floor. The incident record and nursing note documented the fall, knee redness and bruising, pain, physician notification, and x-ray evaluation. Interviews confirmed the NA was new, was not aware the resident required two-person assistance for bed mobility, and did not check the care plan before providing care.
Missed Quarterly Nutrition Assessment and Re-weight
Penalty
Summary
The facility failed to ensure quarterly nutrition assessments were completed for one sampled resident with Type II diabetes, GERD with esophagitis, Barrett’s esophagus without dysplasia, intestinal malabsorption, prostate cancer, hypertension, and coronary artery disease. The resident’s care plan identified risk for nutrition problems and included interventions such as diet consults as needed, honoring food preferences, monthly weight monitoring, and dietician evaluation and recommendations as needed. The quarterly MDS assessment identified the resident as moderately cognitively impaired and independent with bed mobility, transfers, dressing, eating, and personal hygiene. A physician order directed monthly weights, and the resident’s weights showed 136.8 lbs on 6/5/25 and 130.4 lbs on 7/4/25. Review of the nutrition assessments showed the dietician completed a quarterly assessment on 3/28/25, but the next quarterly assessment was not completed until 11/26/25. The dietician stated that a weight loss greater than 5 lbs should trigger a re-weight, and that the 7/4/25 weight loss should have prompted one. She also stated she missed completing the resident’s quarterly nutrition assessment that should have been completed for the August 2025 MDS. The DNS stated he expected quarterly nutrition assessments to be completed by the dietician and weights to be identified by the nurse or dietician when a re-weight is needed. The facility’s Weight Measurement Policy directed that residents with a weight variance of 5 lbs more or less than the previous month be re-weighed, and the Nutrition Documentation Policy directed quarterly assessments or progress notes to identify dietary changes and monitor whether interventions were working and goals were being met.
Controlled Substance Reconciliation Not Maintained
Penalty
Summary
The facility failed to ensure there was a system of receipt and disposition to accurately reconcile controlled substances received into the facility. The nursing supervisor stated that when controlled substances arrived, the receiving nurse inventoried them, a second nurse verified and signed the controlled substance disposition record (CSDR), and a copy was sent to the ADNS while the original went with the medication on the cart. The ADNS stated that copies of CSDRs were placed in a binder, and when a medication was zeroed out the original sign-off CSDR was brought to her office and the copy was discarded. She also stated that she kept delivery slips but did not review them, and that she had not been trained on a process for audit and reconciliation. Observation of the ADNS office found two large binders with completed CSDR signature sheets, one binder with CSDR copies, and several piles of CSDRs around the office. The ADNS produced a file of complete CSDRs for medications that had been destroyed and stated that outstanding CSDR copies were in the binder and around her office. Review of the outstanding CSDR copies identified 253 CSDR copies that were not reconciled, meaning the medication was not in use in the facility and it was unknown if it had been destroyed, returned, completed, discontinued, or sent home with a discharged resident; 66 of these CSDRs were flagged for reconciliation. The DNS and ADM stated they were not aware the ADNS did not have a reconciliation process, and the facility policy identified the DNS as responsible for complete accounting of all control drugs in the facility.
Improper Medication Storage and Expired IV Supplies
Penalty
Summary
Drugs and biologicals were not stored appropriately in the facility. During observation on [DATE] at 9:18 AM, a bottle of Fluticasone 50 mcg nasal spray for Resident #39 and a Tresiba Flex Touch insulin degludec injection for Resident #31, with 12 units dialed into the pen and approximately 100 units remaining, were left on top of a medication cart in the Rehab unit. No nurse was attending the cart at the time, and the medications were observed unattended for approximately 4 minutes before the nurse returned. LPN #5 identified that she was assigned to the cart and had left the two medications out because they were the last medications to be given during her medication pass, and she stated they should not have been left on top of the cart because a resident could have picked them up and it would be dangerous. Observation of the second-floor medication room on [DATE] at 2:29 PM identified 5 expired IV dressing change trays and 12 expired IV start kits. RN #7 stated the facility does not start IVs and that the kits would only be used by an outside company that starts IVs, but she acknowledged the expired items should not be used and should be thrown out. Stock Person #1 stated she did not order or receive IV supplies and that expired supplies should be thrown out. Review of the medication storage policy stated medications and biologicals are to be stored safely, securely, and properly, with access limited to authorized personnel, and that drugs in original containers are to be labeled with the manufacturer's expiration date.
Failure to Implement Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure that ordered adaptive eating equipment was implemented in accordance with physician orders for two residents reviewed for nutrition. For one resident with dementia, multiple sclerosis, and primary generalized osteoarthritis, occupational therapy evaluated the resident for difficulty using a regular cup due to fine motor deficits and identified a goal for the resident to use a two handled mug for all liquids to improve self-feeding independence and fluid intake. The physician ordered use of a two handled mug with a straw during all meals, and the care plan also directed staff to use the mug, but observations on two separate occasions showed only a scoop dish and standard plastic cups in the room, with the two handled mug not listed on the meal ticket. The Food Service Director and rehab staff both stated they were not aware why the mug was not reflected on the resident meal ticket. For the second resident, who had diagnoses including adult failure to thrive, cancer, arthritis, cataracts, muscle weakness, and lack of coordination, occupational therapy assessed the resident after spilling hot liquids and identified a goal for the resident to safely self-feed using a 2 handled mug for proper positioning and improved independence. The resident’s care plan identified that OT adaptive equipment provided a 2 handled mug for liquids with all meals, and physician orders directed OT adaptive equipment for a 2 handled mug for all liquids. However, multiple observations showed only plastic cups with straws or other drinks on the overbed tray table, and no handled cup was present in the room. Staff interviews reflected inconsistent awareness of the ordered equipment, with some staff stating the resident did not need a handled cup and others stating they had never seen one in use. The record also showed that the second resident had poor oral intake, dehydration concerns, IV fluid administration, and significant weight loss, while staff from nursing, dietary, therapy, and the APRN gave differing accounts of the resident’s need for the adaptive cup and whether it was being used. The dietician acknowledged the resident had a fluid goal but said fluid intake was not reviewed consistently unless there was a fluid restriction, and the APRN stated that if therapy had ordered the device, she would expect it to be implemented. The facility policy required adaptive self-help devices to be provided as indicated and for food and fluid intake to be observed and recorded, but the ordered adaptive equipment was not consistently present or reflected in the meal ticket or room observations.
Failure to Document MDRO History in Resident Diagnoses
Penalty
Summary
The facility failed to maintain a system to track a Multi-Drug Resistant Organism (MDRO) infection to other healthcare providers upon transfer for three sampled residents reviewed for infection surveillance. Review of the facility’s MDRO line listing tracking form showed that one resident had a history of MRSA to a wound, another had a history of ESBL in the urine, and a third had a history of ESBL in the urine. For each of these residents, the medical diagnoses in the clinical record did not identify the MDRO history. The residents’ diagnoses included multiple sclerosis, dementia, anxiety, COPD, osteoarthritis, depression, and anemia, and the quarterly MDS assessments identified one resident with severe cognitive impairment and extensive assistance needs, another with intact cognition and extensive assistance needs, and another with severe cognitive impairment and extensive assistance needs. During interview, the infection control nurse stated that residents with a history of MDRO should be included in the medical diagnoses so other providers would be aware of the history, and that the MDS coordinator was responsible for adding the MDRO diagnosis in the clinical record. She also stated that she could not recall whether she communicated the MDRO history for the three residents to the MDS coordinator. The MDS coordinator stated that she was responsible for adding medical diagnoses in the clinical record and would add the MDRO when made aware, but she could not recall whether she was aware of the MDRO history for the three residents. The facility’s MDRO policy stated that appropriate precautions would be taken for residents with known or suspected MDRO, and addressed cohorting residents with the same MDRO when single rooms were not available.
Failure to Complete Required Nurse Aide Annual In-Service Training
Penalty
Summary
The facility failed to complete required annual in-service training for 2 of 3 nurse aides reviewed. Review of NA #12’s personnel file showed she was hired on 2/9/09 and did not have documentation for Abuse Neglect and Exploitation, Resident Rights, Dementia Care, or Infection Control training for 2024. The only 2024 trainings available for review were Communication and Behavioral Health. Review of NA #13’s personnel file showed she was hired on 11/7/24 and did not have documentation that Dementia Care, Behavioral Health, or Communication training was completed for 2025. The training completed for 2025 was Abuse Neglect and Exploitation, Resident Rights, and Infection Control. Review of the facility’s training schedule showed monthly scheduled trainings, and interviews with the Staff Development Nurse and Administrator confirmed that mandatory education was supposed to be tracked and completed through scheduled trainings and an annual skill fair. The Administrator also stated there had been significant turnover in the staff development nurse role and that the requested training materials could not be located.
Failure to Follow Protocol After Resident Fall with Head Injury
Penalty
Summary
Staff failed to follow professional standards of care after a resident with dementia, heart failure, and severe cognitive impairment experienced a witnessed fall with a head injury. The resident, who was known to be at risk for falls and had a history of recent illness, was observed by a nurse aide to become dizzy, spin, and fall, striking their head on the floor. Following the fall, the resident exhibited altered mental status, was unable to follow commands, and staff were unable to obtain vital signs. Despite these significant changes in condition and the presence of a head injury, the supervising RN directed staff to move the resident from the floor into a wheelchair and then into bed, rather than leaving the resident in place and awaiting EMS as per standard protocols for suspected head or spinal injury. Multiple staff, including an LPN and the APRN, later acknowledged that the resident should not have been moved given the circumstances. Facility policy and medical references reviewed also indicated that residents with head injuries and neurological compromise should not be moved and should be referred immediately for emergency care. The resident was eventually transferred to the hospital by EMS after oxygen was applied, but expired a few hours later. Documentation and interviews confirmed that the decision to move the resident was made by the RN, and that other staff present did not question this directive, despite recognizing it was not consistent with best practice or facility policy for post-fall care involving head injury and altered mental status.
Observations of Inconsistent Food Storage and Labeling Practices
Penalty
Summary
During a facility kitchen tour, it was observed that opened refrigerator items were not dated, spoiled food products were not discarded, frozen food items were uncovered, and beverage items were not stored in a sanitary manner. Specifically, opened Lactaid cartons and tomato juice were not labeled with open dates, spoiled iceberg lettuce and undated bread were found, unsealed bags of rice were observed, and unwrapped food items were stored in the walk-in freezer. Additionally, a refreshment cart set for breakfast service contained soiled items, contrary to the facility's policies on food storage, labeling, and sanitation. The Dietary Director acknowledged the deficiencies during interviews, indicating expectations for staff to label opened containers, inspect perishable items upon delivery, date undated bread, wrap all food items after opening, and maintain cleanliness on service carts. The facility's policies on date marking, food storage, and sanitation were not consistently followed, leading to the identified deficiencies in food handling and storage practices.
Failure to Honor Resident's Rights During Meal
Penalty
Summary
The facility failed to honor Resident #68's rights during a meal. Resident #68, who was admitted with diagnoses including metabolic encephalopathy, hypothermia, and congestive heart failure, was identified as having intact cognition and being independent with eating. During an observation, NA #2 applied a large clothing protector to Resident #68 without asking for consent or providing the option to refuse. Resident #68 expressed that this was the first time a clothing protector had been applied and would have preferred to be asked first. NA #2 admitted during an interview that she should have asked Resident #68 if they wanted the clothing protector. The Director of Nursing Services (DNS) confirmed that Resident #68 should have been asked and had the right to decide whether to use a clothing protector. The facility's policy on resident rights emphasizes treating residents with respect and allowing them to make choices about their lives, which was not followed in this instance.
Failure to Notify Physician of Missed Daily Weights
Penalty
Summary
The facility failed to ensure that the APRN or physician was notified when daily weights were not obtained for a resident with diagnoses including edema, congestive heart failure, and dementia. The resident had a physician's order to complete daily weights and notify the provider for significant weight gains. However, there were multiple missed opportunities for obtaining daily weights over several months, and the clinical record did not reflect any refusals or explanations for the missed weights. Additionally, the APRN or physician was not notified of the missing weights or refusals, as required by the facility's policy. The resident's care plan and physician's orders emphasized the importance of daily weights due to the resident's medical conditions. Despite this, the treatment administration records showed numerous missed weights, and the progress notes did not document any refusals or reasons for the missed weights. An interview with the DNS confirmed that the charge nurse was responsible for ensuring daily weights were obtained and that the APRN or physician should be notified if weights were missed or refused. The facility's policies on weight management and change of condition were not followed, leading to the deficiency.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement policies to protect residents from abuse, as evidenced by an incident involving a resident with dementia, emphysema/COPD, and depression. The resident believed a nursing assistant (NA) was making a joke about their move by singing a song, which upset the resident and their spouse. The NA was sent home pending investigation, but the interim Director of Nursing Services (DNS) could not substantiate the abuse allegation as no other staff or residents heard the exchange. Despite this, the NA was placed on final warning and later terminated after another altercation with the resident's spouse in the parking lot. Further review revealed significant gaps in the facility's hiring and screening processes. The NA's personnel file lacked documentation of the incident, a final warning, or a background check. The Human Resources (HR) Director could not locate any preliminary screening associated with the NA's employment application. The DNS confirmed that it is expected for employees to be screened and background checks completed before hiring, but these procedures were not followed in this case. The facility also failed to provide a policy for hiring and screening when requested.
Failure to Develop Comprehensive Care Plan for Respiratory Equipment
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for Resident #75, who was admitted with diagnoses including chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The admission MDS assessment did not indicate the use of a CPAP, and the baseline care plan did not identify the use of a CPAP. The comprehensive care plan also failed to include the diagnosis of sleep apnea or the use of the CPAP. It was only after 120 days from admission that the physician's orders directed the use of the CPAP, specifying its usage and maintenance. However, the care plan still did not reflect this until after the surveyor's inquiry. Interviews with the DNS and the MDS coordinator revealed that the MDS coordinator, who works remotely, was responsible for including the use of the CPAP in the care plans based on physician orders. The MDS coordinator admitted that the CPAP was not included in the initial admission orders, leading to its omission in the care plans. The facility's Care Plan Policy mandates an interdisciplinary care plan to address all resident needs, but this was not adhered to in the case of Resident #75, resulting in a deficiency in the care provided.
Failure to Conduct Neurological Assessments and Provide 1:1 Monitoring
Penalty
Summary
The facility failed to ensure that neurological assessments were completed per policy for Resident #47 after an unwitnessed fall with injury. Resident #47, who had a history of dementia, diabetes, and difficulty in walking, experienced an unwitnessed fall resulting in a nasal fracture. Despite the facility's Fall Prevention Program Policy requiring neurological assessments at specific intervals following an unwitnessed fall, there was no evidence in the clinical record that these assessments were conducted after the resident returned from the emergency room. The Director of Nursing Services (DNS) confirmed that the neurological assessments should have been restarted upon the resident's return to the facility but were not completed as required by policy. The facility also failed to provide appropriate behavior observation and monitoring for Resident #84, who required 1:1 constant supervision due to suicidal ideations. Resident #84, diagnosed with dementia with agitation, PTSD, and anxiety, expressed a desire to harm themselves and was placed on 1:1 monitoring per physician's orders. However, the clinical record lacked documentation of continuous 1:1 monitoring on 3/18/24 and 3/19/24. Interviews with nursing staff revealed that the monitoring was not consistently provided by facility staff, and the responsibility was inappropriately placed on the resident's significant other during their visit. The DNS acknowledged that 1:1 monitoring should have been maintained by trained facility staff until the resident was cleared by psychiatric providers. The deficiencies in both cases highlight a failure to adhere to established policies and procedures for resident safety and monitoring. The lack of proper neurological assessments for Resident #47 and the inadequate 1:1 supervision for Resident #84 demonstrate significant lapses in care that could have serious implications for resident well-being. These findings were corroborated by interviews with facility staff and a review of the clinical records, underscoring the need for strict adherence to care protocols to ensure resident safety and proper documentation of care provided.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its policy to assist a resident in maintaining bowel function. Resident #12, who was admitted with diagnoses including Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions, was identified as having moderately impaired cognition and being incontinent of both bowel and bladder. The care plan for Resident #12 included a focus on constipation with specific interventions outlined in the facility's bowel management protocol. However, the facility did not adhere to these protocols as required. A physician's order directed the administration of various laxatives if the resident had no bowel movement in three shifts. Despite this, documentation revealed that Resident #12 had no bowel movement for five days, and the necessary interventions were not initiated on the fourth day as per the facility's policy. The DNS confirmed that the interventions should have begun on the fourth day without a bowel movement, but there was no documentation to support that the resident's bowels were monitored according to the policy and care plan. This lapse in following the bowel management protocol led to the deficiency identified in the report.
Failure to Follow Prescribed Renal Diet
Penalty
Summary
The facility failed to ensure that a resident's prescribed renal diet was followed according to the physician's order. Resident #19, who was admitted with diagnoses including acute metabolic acidosis, chronic kidney disease, and ileostomy, had a physician's order for a renal diet and medication to manage high potassium levels. Despite this, the resident repeatedly received high potassium food items such as tomatoes, tomato sauce, and potatoes. This was confirmed through observations, interviews, and clinical record reviews. The resident's potassium levels were elevated, necessitating additional medical interventions, including IV fluids and medication to lower potassium levels. Interviews with the Dietary Director, Dietician, Regional Dietician, and APRN confirmed that the resident should not have received high potassium foods. The Dietary Director acknowledged the error and indicated plans to re-educate staff. The Dietician and Regional Dietician were aware of the renal diet order but were not fully informed about the resident's elevated potassium levels and additional medical treatments. The facility's policy on nutritional management and renal diet guidelines was not followed, leading to the deficiency in providing appropriate dietary care for Resident #19.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to ensure respiratory equipment was cleaned, changed, and stored per policy and manufacturer's recommendations for two residents. Resident #5, who was admitted with COPD, centrilobular emphysema, and diabetes type 2, had oxygen therapy equipment that was not dated or properly stored. Observations revealed that the oxygen nasal cannula tubing was on the floor, and the nebulizer mask was on the bedside table without proper dating. LPN #1 confirmed that the dating of the tubing was supposed to be done on the Sunday 11-7 shift but could not explain why it was not completed. The Director of Nursing Services (DNS) confirmed that the oxygen tubing should be changed and dated on the 11 PM-7 AM shift on Sunday night but was not aware of the specific reasons for the lapse in procedure. Resident #75, admitted with chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea, had a CPAP machine that was not properly maintained. The CPAP mask and tubing were not labeled or dated, and the mask was not stored in a bag when not in use. LPN #2 indicated that the CPAP tubing and mask should be labeled and dated each week after cleaning and that the mask should be bagged when not in use. The DNS was unsure of the specific cleaning and changing schedule for the CPAP equipment and had to refer to the facility policy and manufacturer's recommendations. It was found that the CPAP equipment had not been cleaned or changed since admission, and the necessary physician orders for cleaning and maintenance were missing. The facility's policy and the manufacturer's recommendations for CPAP equipment maintenance were not followed, leading to the failure to clean and change the equipment as required. The DNS confirmed that the CPAP mask and tubing were not dated when last changed and that the filter had a layer of dust on it. The facility's policy required daily cleaning of the CPAP mask and tubing, weekly disinfection, and monthly changes of the white disposable filter. The DNS acknowledged the oversight and indicated that the necessary physician orders for the care and cleaning of the CPAP equipment would be added.
Lack of Competency in JP Drain Care
Penalty
Summary
The facility failed to ensure that the nursing staff were competent in caring for specialized medical equipment, specifically a Jackson Pratt (JP) drain, for Resident #88. Resident #88, who was admitted with diagnoses including dementia, chronic cholecystitis, and hydronephrosis with renal and ureteral calculus obstruction, had a JP drain following gall bladder removal. Observations revealed that the JP drain bulb was found touching the floor, and LPN #4 placed it back on the bed without disinfecting it. Additionally, the dressing at the insertion site was not labeled or dated, and LPN #5 admitted to not receiving education on JP drains for at least two years. Interviews with nursing assistants (NAs) and licensed practical nurses (LPNs) indicated a lack of proper training and understanding of JP drain care. NA #5 and NA #4 were unaware of the correct procedures for handling the JP drain, with NA #5 relying on common sense and NA #4 recalling education from certified nursing school but not from the facility. NA #7 also demonstrated a lack of proper technique and admitted to not using alcohol pads when handling the drain. RN #7 confirmed that nursing assistants do not typically empty the JP drain, and the dressing should be labeled with the date and nurse's initials. The Director of Nursing Services (DNS) and the Staff Development and Wound Nurse (RN #2) acknowledged the lack of ongoing education and competencies related to JP drains. RN #2 admitted that there had been no education or competencies provided in the past two years and that JP drains were not included in the general orientation checklist. The DNS and RN #2 both indicated that education should be provided if a need is identified, but this had not been done for JP drains, leading to the observed deficiencies in care for Resident #88.
Failure to Identify Non-Crushable Medication
Penalty
Summary
The pharmacy failed to identify a non-crushable medication for Resident #12, who was admitted with diagnoses including Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions. The resident's care plan included long-term use of antipsychotics for schizoaffective disorder and drug-induced tremors. A physician's order directed the administration of several medications, including Austedo 6 mg, which should not be crushed. However, the medication was administered crushed 720 times from April 2022 through April 2024, despite guidelines indicating it must be swallowed whole. Interviews with the LPN, APRN, and pharmacists revealed a lack of awareness and failure to identify the medication as non-crushable, leading to its improper administration. The facility's policy for medication administration required personnel to refer to reference materials when unfamiliar with a drug's pharmacology, contraindications, and specific indications. Despite this policy, the medication Austedo was not flagged as a do-not-crush medication by the pharmacy, nor was it acknowledged by the facility staff. The pharmacist and pharmacist supervisor confirmed the medication should not be crushed and failed to provide information on the efficacy or toxicity of administering it in crushed form. The APRN admitted responsibility for identifying whether a medication can be crushed but was unaware of the medication's status at the time of the decision. An interview with the medical director was not obtained.
Failure to Monitor Blood Sugars According to Professional Standards
Penalty
Summary
The facility failed to monitor blood sugars according to professional standards of care for a resident with diabetes type 2. The resident, who had moderately impaired cognition and was wheelchair dependent, had a critical glucose level of 41 mg/dl on 1/23/24, which was significantly below the normal range of 74-100 mg/dl. Despite this critical lab result, no new orders were issued, and the resident's blood sugar was not monitored further. The facility's diabetes protocol requires follow-up on significant changes in blood sugars, but this was not adhered to in this case. The APRN reviewed the critical lab results but did not take any action to address the low glucose level. The DNS confirmed that the critical glucose level warranted additional monitoring, which was not done. The facility's policy mandates that the physician follow up on acute episodes and adjust treatments based on lab results, but this protocol was not followed, leading to a deficiency in the resident's care.
Failure to Monitor Targeted Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to ensure targeted behaviors were identified and monitored for a resident receiving psychotropic medications. Resident #84, who was admitted with diagnoses including dementia with agitation, PTSD, and anxiety, was prescribed multiple psychotropic medications. However, the clinical record did not include any orders or documentation related to targeted behavior monitoring following the resident's admission. Despite the care plan identifying the resident's risk for depression and the need for monitoring, the necessary behavior monitoring was not ordered until nine days after admission, following incidents of the resident verbalizing suicidal ideations. Interviews with the psychiatric APRN and the Director of Nursing Services (DNS) confirmed that behavior monitoring should have been ordered upon admission but was overlooked. The facility's policy on psychoactive medication use mandates that residents receiving such medications be monitored for effectiveness, adverse reactions, and specific behaviors. This oversight resulted in a failure to comply with the facility's policy and ensure the resident's targeted behaviors were appropriately monitored from the time of admission.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain medical equipment in a sanitary manner for Resident #88, who had a JP drain following a laparoscopic cholecystectomy. Observations revealed that the JP drain collection bulb was touching the floor, and an LPN placed it back on the resident's bed without disinfecting it. Additionally, the LPN did not check the placement of the tubing at the insertion site. Interviews with the DNS and RN #2 confirmed that the JP drain should not touch the floor and should be disinfected if it does. The facility's policy on JP drains was not followed, leading to potential infection control issues. The facility also failed to maintain transmission-based precautions for Resident #91, who tested positive for COVID-19. Despite being on contact/droplet precautions, there was confusion among staff regarding the resident's status. Observations showed that the precaution signage and PPE cart were inconsistently placed and removed. Interviews with the DNS, RN #3, and LPN #9 revealed a lack of clarity and communication about the resident's COVID-19 status, leading to lapses in infection control measures. Furthermore, the facility did not ensure that shared medical equipment was sanitized between use on residents. NA #3 was observed using the same vital sign monitoring equipment on two residents without sanitizing it in between. Interviews with NA #3, RN #3, and LPN #9 confirmed that the equipment should be sanitized between uses, but this practice was not consistently followed. The facility's policy on cleaning durable medical equipment was not adhered to, increasing the risk of cross-contamination and infection among residents.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide the pneumococcal immunization to Resident #74, who was admitted with diagnoses including hypertension and diabetes mellitus. The resident's immunization record showed they received PCV13 in 2013, but the quarterly MDS assessment indicated they were not up to date with the pneumococcal vaccination. The assessment did not provide a reason for the missing vaccination. An interview with the Infection Control Nurse revealed that she was unaware of the resident's vaccine status and eligibility, as she had only started in her role in November 2023. Further investigation confirmed that the resident had not received the pneumococcal vaccine since 2013, and the resident was missed by the previous Infection Control Nurse. A physician's order was issued to administer the pneumococcal vaccine, and the resident's responsible party consented to the vaccination, which was then administered. The Director of Nursing Services (DNS) stated that it was expected for all applicable vaccines to be offered to residents upon admission and whenever they are eligible. The DNS also expected the Infection Control Nurse to audit residents' clinical records for vaccine eligibility. The facility's policy aligns with CDC recommendations for pneumococcal vaccinations, which were not followed in this case, leading to the deficiency.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure the State Long-Term Care Ombudsman was notified when two residents were transferred to the hospital. Resident #28, who had diagnoses including chronic obstructive pulmonary disease, morbid severe obesity, congestive heart failure, and asthma, was transferred to the hospital and readmitted to the facility without the Ombudsman being notified. Similarly, Resident #46, with diagnoses including diabetes, asthma, and atrial fibrillation, was also transferred to the hospital and readmitted without the required notification to the Ombudsman. The facility's Admit/Discharge Report did not reflect these notifications, indicating a failure in the process of informing the Ombudsman about hospital transfers. Interviews with facility staff revealed that the social worker responsible for sending the reports was unaware that incorrect reports were being sent. The Administrator and Director of Nursing Services confirmed that the social worker was responsible for ensuring the reports were sent to the Ombudsman. The issue was discovered when the facility reviewed the reports and found that the wrong ones had been sent from January to March 2024. The Administrator acknowledged the problem and indicated that the issue would be discussed with the Regional Admission Director, and in-service training would be provided to the social worker.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives upon transfer to the hospital for three residents. Resident #24, admitted with diagnoses including anxiety disorder, pneumonia, and acute respiratory failure, was transferred to the hospital due to altered mental status and readmitted with metabolic encephalopathy and pneumonia. The clinical record did not reflect that a bed hold notice was provided upon transfer. Similarly, Resident #28, with chronic obstructive pulmonary disease, morbid severe obesity, congestive heart failure, and asthma, was transferred to the hospital and readmitted, but no bed hold notice was documented. Resident #46, admitted with diabetes, asthma, and atrial fibrillation, was also transferred to the hospital and readmitted without a bed hold notice being provided or documented in the clinical record. Interviews with facility staff, including the Social Worker, DNS, and Admission Director, revealed that the facility does not issue bed hold notices upon hospital transfers. The DNS indicated that the Admission Director is responsible for ensuring that bed hold notices are provided, and that a packet for transfer should include the notice. However, no documentation or policy regarding bed hold notices was provided upon request. The facility's policy states that beds will be reserved for private-pay residents as long as payment is available and for Medicaid-assisted residents for up to seven days, with a possible extension of an additional eight days, provided the resident is expected to return at the same level of care.
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Illustrative
What surveyors actually found near you
We read the 625 citations issued within 25 miles in the last 12 months — including the 8 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 Tolland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Fox Hill | 1.3 mi | ★★★★★ | 12 | 0 |
| Vernon Rehabilitation And Healthcare Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Evergreen Center For Health & Rehabilitation | 7.4 mi | ★★★★★ | 0 | 0 |
| Manchester Rehabilitation And Healthcare Center | 10 mi | ★★★★★ | 17 | 0 |
| Mansfield Center For Nursing And Rehabilitation | 10 mi | ★★★★★ | 5 | 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 July 2026) and official state health department websites.