Aaron Manor Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Chester, Connecticut.
- Location
- 3 South Wig Hill Rd, Chester, Connecticut 06412
- CMS Provider Number
- 075410
- Inspections on file
- 24
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aaron Manor Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with intact cognition and multiple behavioral health diagnoses alleged that a nurse aide inserted a finger into their anus while applying hemorrhoidal ointment. The allegation was reported internally and the staff member was removed from the unit, but there was no documentation of the incident in the clinical record, and the event was not reported to the State Agency as required by facility policy. The Administrator was aware of the allegation but could not confirm if it had been reported, and no investigation documentation was found.
A resident with intact cognition and multiple diagnoses alleged that a nurse aide inserted a finger into their anus while applying hemorrhoidal ointment. The accused staff member was not immediately removed from duty as required by facility policy, and staff interviews revealed uncertainty about whether proper procedures were followed after the abuse allegation.
A resident with a history of adjustment disorder, anxiety, and chronic pain alleged that a nurse aide inappropriately applied hemorrhoidal ointment. Although staff reported that such allegations are typically investigated and documented, there was no record of an investigation or related documentation available for review, despite facility policy requiring prompt and thorough investigation of all abuse allegations.
A high-risk resident with a history of falls and dementia fell from a bed left in a high position, resulting in a head laceration and multiple fractures. The resident's care plan required two-person assistance and a low bed position, but these were not followed by the nursing assistant. The facility's policies on positioning and fall risk management were not adhered to, and the resident's fall risk was not adequately addressed.
A resident with severe cognitive impairment and multiple health conditions experienced a significant decline due to the facility's failure to monitor and document fluid intake and bowel movements accurately. Despite abnormal lab results indicating dehydration, the facility did not adjust care plans or make necessary referrals to speech therapy and dietician services. Inaccurate documentation and lack of communication led to severe health complications, including fecal impaction and acute kidney injury, resulting in prolonged hospitalization.
A facility failed to properly store medications for a resident and in the medication storage room. A resident's heparin and sodium chloride flush syringes were found in their room instead of a secure area. Additionally, expired influenza tests and insulin vials past their use date were discovered in the medication storage room. An RN confirmed the improper storage and expired items, acknowledging the facility's policy violations.
The facility failed to properly label and dispose of expired food items and did not maintain the ice machine scoop in a sanitary manner. Unsealed bags of bread and pastries were found without proper labeling, and the ice scoop was stored in unsanitary conditions. The Dietary Director and Administrator acknowledged these lapses, which contravened the facility's policies on food labeling and sanitation.
A facility failed to complete an advance directive form for a resident upon admission, despite the resident being a full code with specific treatment preferences documented. The resident, admitted with conditions like epilepsy and Parkinson's, was cognitively intact. Interviews revealed a lack of clarity in responsibility for completing the form, and the admission policy lacked a formal review process for documents, leading to the oversight.
The facility failed to update the care plans for two residents, one with CHF and another with dialysis access changes. A resident with CHF did not have the condition or necessary interventions included in their care plan, while another resident's care plan was not updated after hospitalization for sepsis and a change in dialysis catheter. The facility's policy requires care plans to be revised as conditions change, which was not adhered to in these cases.
The facility failed to provide adequate oral hygiene and grooming assistance for two residents. One resident, with chronic pain and impaired dentition, did not receive consistent oral care, resulting in swollen gums and plaque accumulation. Another resident, dependent on staff for grooming, was observed with unshaven facial hair. The facility's policy required assistance for residents unable to perform daily living activities independently, which was not followed, leading to deficiencies in care.
A facility failed to provide adequate pressure ulcer care for a resident with a history of pressure injuries. The resident was not repositioned in their wheelchair as per the 24-hour positioning plan, and the right heel was not offloaded as required by provider orders. Observations showed the resident's right foot resting directly on the wheelchair footrest without an offloading boot, contrary to care plan requirements. Staff interviews confirmed a lack of adherence to the care plan and provider orders, contributing to the deficiency.
A facility failed to provide necessary social services follow-up for a resident after a hospitalization and change in condition. The resident, with severe cognitive impairment, was eligible for hospice and had a change in code status to DNR. Despite these changes, the social worker did not follow up with the resident's representatives regarding goals of care after readmission. The social worker was not present at the care conference and last discussed goals of care in July, despite the resident's readmission in October.
A resident with pressure ulcers did not receive proper wound care due to an LPN's failure to follow infection control practices. The LPN did not maintain a clean field, failed to change gloves, and used unclean scissors during the dressing change, contrary to the facility's wound care policy.
The facility did not ensure residents were informed about the location of state inspection results, as revealed during a resident council meeting where several residents and the Ombudsman stated their unawareness. The survey binder was located in the lobby, but the administrator was unaware of the residents' lack of knowledge about its location.
The facility failed to document and address grievances for two residents, one with cognitive impairment and another cognitively intact, leading to a deficiency in honoring residents' rights. Concerns about personal belongings, cleanliness, and room intrusions were communicated to staff, but no grievance forms were completed, contrary to facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency for one resident. The resident, who had diagnoses including adjustment disorder, anxiety disorder, and chronic pain disorder, alleged that a nurse aide applied hemorrhoidal ointment and, during the process, inserted a finger into the resident's anus. The allegation was made to a registered nurse, who stated that he immediately informed the Administrator and Director of Nursing Services (DNS) and removed the accused staff member from the unit, but did not document the incident until directed by administration. Review of clinical records and nurse's notes did not reveal any documentation of the incident or the need for hemorrhoidal ointment during the relevant period. Further review of the State Agency Reportable Events website showed that the abuse allegation was not reported to the State Agency as required. The Administrator confirmed awareness of the allegation and acknowledged that it should have been reported, but was unsure if it had been. An investigation was initiated and statements were obtained, but the Administrator could not recall the reason for the unsubstantiated outcome. The DNS, who was not employed at the time, stated that such allegations should be reported immediately and the staff member removed pending investigation. No investigation documentation was found for the incident, and the facility's abuse prevention policy required immediate reporting of abuse allegations to the Department of Public Health within two hours.
Failure to Immediately Remove Accused Staff Following Abuse Allegation
Penalty
Summary
The facility failed to immediately remove a staff member accused of abuse following an allegation made by a resident. The resident, who had diagnoses including adjustment disorder, anxiety disorder, and chronic pain disorder, alleged that a nurse aide applied hemorrhoidal ointment and, during the process, inserted a finger into the resident's anus. The resident was cognitively intact and required moderate assistance with personal hygiene, transfers, and ambulation. Documentation review showed no incident or allegation recorded in the nurse's notes for the relevant period, and the accused staff member's timecard indicated they completed their full shift on the day of the alleged incident. Interviews with facility staff, including the RN, Administrator, and DNS, revealed uncertainty and lack of recall regarding whether the accused staff member was removed from duty immediately after the allegation was reported. The facility's abuse prevention policy requires immediate reporting and removal of accused staff during investigations, but there was no evidence that this protocol was followed in this case. Attempts to interview the accused staff member and the interim DNS were unsuccessful.
Failure to Document Abuse Investigation Following Resident Allegation
Penalty
Summary
The facility failed to maintain documentation that an investigation was completed following an allegation of abuse made by a resident. The resident, who had diagnoses including adjustment disorder, anxiety disorder, and chronic pain disorder, alleged that a nurse aide applied hemorrhoidal ointment and, during the process, inserted a finger into the resident's anus. The resident was cognitively intact and required moderate assistance with personal hygiene, transfers, and ambulation. The care plan and physician's orders included interventions for constipation and hemorrhoidal care, but there was no documentation in the nurse's notes regarding the incident or the need for ointment during the relevant period. Interviews with staff revealed uncertainty about the notification and documentation process for the abuse allegation. The RN interviewed could not recall being notified of the specific allegation but stated that all such allegations are reported to administration and the accused staff member is removed from duty. The administrator confirmed awareness of the allegation and stated that an investigation was initiated and unsubstantiated, but could not provide documentation of the investigation or recall the rationale for the outcome. Review of the facility's abuse prevention policy indicated that all reports of abuse should be promptly and thoroughly investigated, with documentation maintained, but the required investigation records could not be located.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to ensure the safety of a resident identified as a high fall risk, resulting in a fall with a major injury. The resident, who had a history of falls, dementia, and a recent hip fracture, was admitted to the facility with a care plan that required the bed to be kept in a low position and assistance from two staff members for bed mobility and transfers. However, on the day of the incident, the resident's bed was left in a high position after care was provided by a nursing assistant who did not follow the care plan's requirements for assistance and bed positioning. The resident fell from the bed, sustaining a head laceration and multiple fractures, including cervical and sacral fractures. The nursing assistant who provided care was unaware of the resident's need for two-person assistance and did not check the resident care card for guidance. Additionally, the facility's Director of Nursing Services was not aware of the resident's high fall risk status, and the facility did not evaluate the use of an air mattress from an interdisciplinary approach, which was initially thought to be a contributing factor to the fall. Interviews with staff and another resident in the room revealed that the resident was restless before the fall and that the bed was in a high position, which contributed to the incident. The facility's policies on positioning and fall risk management were not adhered to, as the bed was not lowered after care, and the resident's fall risk was not adequately addressed in practice, despite being documented in the care plan.
Failure to Monitor and Document Resident's Nutrition and Hydration
Penalty
Summary
The facility failed to adequately monitor and document the fluid intake and bowel movements of Resident #3, leading to a severe health decline and prolonged hospitalization. Resident #3, who was admitted with conditions including spinal stenosis, dementia, and protein-calorie malnutrition, was identified as severely cognitively impaired and dependent on assistance for daily activities. Despite being at risk for weight loss and dehydration, the facility did not accurately track the resident's intake and output, nor did they adjust the care plan to address the risk of constipation, which was exacerbated by the resident's pain management regimen and lack of mobility. Laboratory reports indicated elevated levels of blood urea nitrogen, creatinine, and sodium, suggesting dehydration and impaired kidney function. Orders to encourage additional fluid intake and adjust diuretic medication were not effectively implemented, as evidenced by continued abnormal lab results and the resident's deteriorating condition. The facility's documentation of fluid intake was inaccurate, with nursing assistant #8 admitting to not properly recording the resident's actual intake. Additionally, bowel movement records were misleading, as loose stools were not reported accurately, leading to a lack of appropriate medical intervention. The facility also failed to make timely referrals to speech therapy and dietician services despite Resident #3's documented weight loss and poor meal intake. Observations revealed that the resident was not consuming adequate food and often coughed while drinking fluids, yet no adjustments were made to the diet or feeding approach. The speech and language pathologist was not informed of the resident's declining intake, and the diet was not downgraded until after surveyor inquiry. This lack of communication and failure to reassess the resident's needs contributed to the resident's severe fecal impaction, acute kidney injury, and other complications that necessitated hospitalization.
Improper Medication Storage and Expired Medications Found
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for a resident and within the medication storage room. A resident admitted with osteomyelitis and other conditions had heparin and sodium chloride flush syringes improperly stored in their room on top of a refrigerator, contrary to facility policy which requires such medications to be stored in a medication room or on medication carts. This was confirmed by an RN who was unable to explain why the medications were stored in the resident's room. Additionally, during an inspection of the medication storage room, expired influenza tests and insulin vials past their beyond use date were found. The insulin vials were dated beyond the 28-day usage period recommended by the manufacturer. An RN acknowledged the presence of these expired items and indicated that expired medications should be placed in a designated bin for pharmacy pick-up, as per facility policy. The facility's failure to adhere to its medication storage policies resulted in these deficiencies.
Deficiencies in Food Storage and Ice Machine Sanitation
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a tour of the dietary department. Unsealed bags containing cake and cornbread were found with expired dates, and other bags containing hotdog and hamburger rolls lacked any expiration or open dates. Additionally, the ice machine scoop was improperly stored in a holder with water and covered in white residue, indicating a lack of cleanliness. The facility's policy requires all food items to be labeled and dated, and for potentially hazardous foods to be discarded within three days of preparation. Further inspection revealed a box of Danishes and a container of thickened cranberry cocktail in the nursing unit nourishment room refrigerator, both of which were not properly labeled with open dates. The Dietary Director acknowledged that expired foods should have been discarded and that open bags should have been labeled. The Administrator confirmed the need to dispose of the improperly stored items. The facility's policy mandates that ice machines and storage containers be maintained in a clean and sanitary manner, which was not observed in this instance.
Failure to Complete Advance Directive Form Upon Admission
Penalty
Summary
The facility failed to complete an advance directive form for Resident #28 upon admission. Resident #28, who was admitted with diagnoses including epilepsy, Parkinson's disease, and dysphagia, was identified as cognitively intact with a BIMS score of 14. Despite being a full code, as documented in the Resident Care Plan and physician's orders, the advance directive form in the resident's paper chart remained blank and unsigned. Interviews with the Advanced Practice Registered Nurse (APRN) and Medical Director (MD) revealed a lack of clarity and responsibility regarding the completion of the advance directive form, with MD #2 acknowledging that he would have filled out the form if it was missing during his review. The Registered Nurse Supervisor (RN) was unaware of the blank advance directive form and had not completed the admission process for Resident #28. The facility's process for completing advance directives involves the resident or their representative filling out and signing the form, followed by verification and signatures from two staff members, and notification to the provider for an order in the EMR. However, the admission policy lacked a formal process for reviewing all admission documents, contributing to the oversight. The advance directive form was eventually completed after surveyor inquiry, but the initial failure to document the resident's treatment preferences upon admission constituted a deficiency.
Failure to Update Resident Care Plans for CHF and Dialysis Access
Penalty
Summary
The facility failed to revise the comprehensive Resident Care Plan (RCP) for two residents, leading to deficiencies in care planning. Resident #20, admitted with diagnoses including diabetes, chronic kidney disease, and hypertension, was identified by a medical doctor as having congestive heart failure (CHF) and was prescribed Furosemide to manage fluid overload. However, the RCP did not include CHF as an active diagnosis or interventions to monitor for fluid overload, such as monitoring neck vein distention or abnormal lung sounds. The oversight was discovered during an interview and clinical record review with a registered nurse, who was unaware of the CHF diagnosis and stated that the RCP would have been updated if she had known. Resident #33, admitted with end-stage renal disease and other conditions, was hospitalized for sepsis related to an infected hemodialysis catheter. Upon readmission, the resident had a new catheter placed, and the previous catheter was removed due to a positive MRSA culture. The RCP failed to document these changes, including the discontinuation of monitoring for an AV fistula that was no longer in use. The registered nurse acknowledged that the RCP should have been updated to reflect the resident's current status and hospitalization details, but believed the existing interventions were still relevant. The facility's policy on Comprehensive Person-Centered Care Plans requires that care plans be revised as residents' conditions change, particularly after hospital readmissions. The failure to update the RCPs for both residents indicates a lapse in adhering to this policy, resulting in care plans that did not accurately reflect the residents' current medical conditions and necessary interventions.
Deficiencies in Oral Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide adequate oral hygiene and grooming assistance for two residents, leading to deficiencies in their care. Resident #10, who was admitted with chronic pain, fibromyalgia, rheumatoid arthritis, depression, and anxiety disorder, required moderate assistance with oral care due to mouth pain and impaired dentition. Despite having a care plan that included daily mouth care and oral brushing, observations revealed that Resident #10 had swollen and inflamed gums with thick plaque accumulation, indicating a lack of proper oral hygiene. Interviews with staff and the resident confirmed that oral care was not consistently provided, especially on days when the resident complained of pain. Resident #49, admitted with hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for grooming and other activities of daily living. Observations showed that Resident #49 had unshaven facial hair, which was not addressed by the facility staff. The facility's policy stated that residents who are unable to perform activities of daily living independently should receive necessary services to maintain grooming and personal hygiene, which was not adhered to in this case. Interviews with the Director of Nursing Services (DNS) confirmed that the facility should have been providing the necessary assistance for oral care and grooming based on the residents' needs as identified in their assessments. The failure to provide these services resulted in deficiencies in the care provided to both residents, as they did not receive the necessary support to maintain their personal hygiene and comfort.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a history of pressure injuries and an active pressure injury on the right heel. The resident, who was severely cognitively impaired and dependent on staff for mobility and care, was not repositioned in their wheelchair according to the 24-hour positioning plan. Despite a provider order for offloading the right heel with a pillow and applying offloading boots, the resident was observed without an offloading boot on the right foot, which was resting directly on the wheelchair footrest. This oversight was confirmed by staff interviews and observations, indicating a lack of adherence to the care plan and provider orders. Additionally, the resident's care plan did not include interventions for offloading the heels, and the resident was not included in the facility's wound report for November due to an oversight. The facility's policy on positioning and repositioning emphasizes the importance of avoiding pressure on existing pressure injuries, yet the resident's right heel was not adequately offloaded, potentially impeding healing. Staff interviews revealed a lack of awareness and implementation of the necessary interventions, contributing to the deficiency in care for the resident's pressure injury.
Failure to Provide Social Services Follow-Up After Resident's Hospitalization
Penalty
Summary
The facility failed to provide adequate social services follow-up for a resident after a change in condition that resulted in hospitalization. The resident, who was admitted in August 2022, had diagnoses including spinal stenosis, dementia, and protein-calorie malnutrition, and was identified as severely cognitively impaired. After a hospitalization, the resident was deemed eligible for hospice care, and a change in code status to Do Not Resuscitate (DNR) was made following discussions with the family. Despite these significant changes, the social worker did not follow up with the resident's representatives regarding goals of care after the resident's readmission to the facility. The social worker acknowledged not being present for the care conference on October 16, 2024, and admitted that the last discussion with the resident's representatives about goals of care was during a care conference in July 2024. The facility's Director of Nursing Services (DNS) confirmed that either a registered nurse supervisor or the social worker should have followed up with the resident's representatives regarding goals of care after the resident's readmission. The social worker recognized the importance of being present at care conferences to support the resident's representatives, especially given the resident's severe cognitive impairment and the differing goals of care among the representatives.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with significant pressure ulcers. The resident, admitted in October 2024, had a history of complete paraplegia, osteomyelitis, and stage 3 and 4 pressure ulcers on the buttocks. The care plan included specific interventions for skin integrity and wound management. However, during an observed dressing change, the LPN did not follow the facility's wound care policy. The LPN performed hand hygiene and donned gloves initially but failed to maintain a clean field and did not change gloves or perform hand hygiene after removing the dirty dressing. Additionally, the LPN did not wear gloves while preparing and applying the new dressing, and used unclean scissors to cut the dressing. The LPN admitted to not knowing the dressing change policy and acknowledged the mistakes made during the procedure. The facility's wound care policy requires establishing a clean field, using gloves appropriately, and ensuring all items used are clean. The LPN's actions were inconsistent with these guidelines, leading to a deficiency in infection control practices. The surveyor intervened during the procedure to remind the LPN of the correct protocol, highlighting the lapse in adherence to established infection control measures.
Residents Unaware of Survey Results Location
Penalty
Summary
The facility failed to ensure that residents were aware of the location of the state inspection results, which is a deficiency in providing residents with their right to access this information. During a resident council meeting, multiple residents and the Ombudsman expressed that they were unaware of the availability and location of the state inspection results. A review of the resident council minutes from the past three months showed no mention of the residents' right to access inspection results. Additionally, postings on bulletin boards and recreation calendars did not indicate where the inspection results were located. An observation confirmed that the survey binder was placed in the lobby entrance, but the administrator was unaware that residents did not know its location.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to properly document and address grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #3, who was severely cognitively impaired, had multiple concerns raised by their representative regarding personal belongings and cleanliness issues. Despite these concerns being communicated to various staff members, including the administrator, no grievance forms were filled out, and the representative was not familiar with the grievance process. Observations confirmed the presence of labels on dresser drawers and items stored in the bathroom shower stall, indicating ongoing issues. Resident #39, who was cognitively intact, expressed frustration over another resident wandering into their room. Although the issue was discussed in Resident Council meetings and with the administrator, no grievance was filed on behalf of Resident #39. The Director of Nursing Services (DNS) offered a room change and emotional support through a behavioral health provider, but again, no formal grievance documentation was completed. The facility's policy required that any concerns or complaints brought to the attention of the charge nurse or nursing supervisor be documented on a grievance form and submitted to the social worker. However, interviews with staff revealed that emails were sent to administration instead of completing the required grievance forms. The administrator did not consider the complaints as grievances, resulting in a failure to adhere to the facility's grievance policy.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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