Arden Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamden, Connecticut.
- Location
- 850 Mix Ave, Hamden, Connecticut 06514
- CMS Provider Number
- 075228
- Inspections on file
- 36
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Arden Care Center during CMS and state inspections, most recent first.
The facility failed to complete required Resident Care Conferences (RCCs), including 72-hour admission and quarterly care plan meetings, for three residents with conditions such as mild cognitive impairment, Alzheimer’s disease, major depressive disorder, chronic kidney disease, and functional dependence. One resident had a single documented RCC with a conservator, with no further RCCs held despite subsequent quarterly MDS assessments showing dependence in ADLs. Another resident had an RCC with a conservator but no documented RCCs after a later quarterly MDS that showed severely impaired cognition and dependence for mobility; no RCC signature sheet was available. A third resident had intact cognition and independence in mobility per quarterly MDS, yet there was no evidence of a 72-hour care plan meeting or any RCC, and no RCC signature sheet was obtained. The DON confirmed RCCs were expected within 72 hours of admission and at least quarterly, while the Director of Social Services cited staffing challenges and inconsistent completion of required RCCs, contrary to the facility’s person-centered care plan policy.
A resident with multiple comorbidities, including PVD, neuropathy, and onychomycosis, had severely thickened, debrided toenails with a planned podiatry follow-up that was repeatedly rescheduled without documented reasons and ultimately refused by the resident. Nursing staff did not document the refusal, did not assess or address the refusal per policy, and did not notify the provider or the resident’s healthcare decision maker about the toenail condition, need for follow-up, or refusal of podiatry care. The resident’s conservator later observed markedly overgrown, curling toenails at another facility and reported never having been informed of podiatry issues or refusals, while the DON and APRN confirmed they had not been notified and that required notification and documentation processes were not followed.
A resident with mild cognitive impairment, depression, left foot drop, and moderate protein-calorie malnutrition was admitted with a documented history of left foot drop, yet the facility did not include this condition or related interventions in the resident care plan over an extended period. PT reported multiple attempts to use an AFO brace and re-engage the resident in therapy, all of which were refused, but these refusals and the underlying condition were not care planned by nursing despite communication from therapy. Later podiatry documentation identified thick, yellow, brittle toenails with subungual debris and diagnoses of PVD, neuropathy, onychomycosis, and dermatophytosis, and described aseptic debridement of all toenails with planned follow-up; however, no podiatry-related problems or interventions were added to the care plan. The DON acknowledged that the IDT and licensed nursing staff should have developed comprehensive, individualized care plans for both the left foot drop and podiatry abnormalities in accordance with the facility’s person-centered care plan policy.
A resident with PVD, neuropathy, onychomycosis, dermatophytosis, left foot drop, and moderate protein calorie malnutrition received podiatry care with toenail debridement and a plan for follow-up in 6–8 weeks, but the care plan did not include foot or nail problems, and no subsequent podiatry treatment or refusals were documented over several months. Podiatry service lists repeatedly showed the resident was due for follow-up for tinea unguium, with visits rescheduled without documented reasons and one listed refusal not supported by nursing notes. The resident’s conservator later observed severely overgrown, curling toenails and reported not being informed of podiatry issues or refusals. The Administrator, DON, and APRN each reported they were not made aware of the podiatry findings or follow-up needs, and there was no designated nurse or process to ensure podiatry recommendations and visit outcomes were communicated to nursing staff or incorporated into ongoing care.
A resident with severe dementia, psychotic disturbances, and an adjustment disorder exhibited intrusive behaviors, including entering another resident’s room, following other residents, and briefly tugging another resident’s shirt collar. The existing care plan addressed mood, cognition, and communication issues but did not identify or include interventions for intrusive behaviors. Nursing notes and staff interviews described the resident frequently attempting to “help” by handing out cups and pushing other residents in wheelchairs, believing they were at work and enjoying staying busy. Although leadership and the IDT were aware of these behaviors, the care plan was not revised to include person-centered strategies to manage and redirect them, contrary to the facility’s person-centered care plan policy.
A resident with severe dementia, psychotic disturbances, and an adjustment disorder was moved to a new unit after being intrusive in another resident’s room and was placed on 15-minute safety checks. Social services initially met with the resident before and shortly after the room change, documenting confusion but no agitation and later noting that the resident was adjusting well, with a plan for two additional follow-up visits per protocol. However, no further social services follow-up was documented during the required 72-hour adjustment period after the move, and the Administrator confirmed that the mandated ongoing social services monitoring after a room change was missed when the responsible social worker was reassigned.
The facility failed to ensure accurate administration and documentation of controlled anxiolytic medications for three residents with dementia and psychiatric conditions. One resident repeatedly received double the ordered dose of Ativan due to nurses misreading the provider’s order and not comparing the eMAR with the blister pack label, and later received half the ordered dose after the prescription was changed. For two other residents, lorazepam and Xanax doses were signed as given on the MAR but were not recorded on the Controlled Substance Disposition Records, indicating omitted or undocumented doses. The APRN and DON stated that nurses are expected to follow the five rights of medication administration, fully read and verify orders, and ensure MAR entries match controlled substance records, consistent with facility policies defining medication errors as omissions and wrong doses.
A resident with epilepsy, multiple sclerosis, repeated falls, and impaired decision-making experienced a seizure and was transferred to the ED after receiving Ativan. Hospital records reflected that the family reported concerns that the facility had withheld the resident’s anti-seizure medications prior to the seizure. The former DON documented the family’s allegation in a nurse’s note but did not enter it into the grievance system, did not complete an Accident and Investigation report, and did not report the allegation to the State Agency as required by facility policy. The Administrator was only vaguely informed of a medication issue and was not made aware that it was an allegation of neglect or of the nurse’s note documenting the concern, resulting in the allegation not being reported or fully investigated.
A resident with epilepsy and multiple sclerosis experienced a seizure and was sent to the ED, where family members reported to hospital staff that the facility had withheld the resident’s anti-seizure medications. The former DON documented awareness of this allegation and reviewed the resident’s MARs but did not initiate a formal investigation, enter the allegation into the risk management system, or report it to the State Agency. No related grievance entry, A&I report, or state reportable event was found, and the Administrator stated she was only vaguely informed of a medication issue and was unaware it was an allegation of neglect. These omissions conflicted with the facility’s abuse prohibition policy requiring timely reporting and thorough investigation of suspected neglect.
A resident with epilepsy and multiple other conditions had standing orders for levetiracetam and oxcarbazepine twice daily for seizure control, but pharmacy order audits showed repeated delays in reordering these 14‑day supplies, with refills often requested days to weeks after the prior supply should have run out. MARs reflected that all doses were signed as given, yet the pharmacist confirmed no STAT orders were requested and Pyxis records showed no emergency pulls for this resident’s levetiracetam. An RN and several LPNs reported that when they could not locate the resident’s anti-seizure medications on multiple occasions, they did not notify a supervisor, use Pyxis, or contact the pharmacy; instead, they took doses from other residents’ anti-seizure medication supplies, contrary to facility policy and professional standards.
A resident with vascular dementia, anxiety, depression, and bipolar disorder was receiving Depakote and other psychotropic medications and had a care plan identifying risk for complications requiring monitoring. A physician ordered a CBC, CMP, and Depakote level to be drawn on the next lab day, but review of the clinical record showed no documentation that these labs were obtained. The DON reported that lab orders entered into the EHR should be transcribed into a lab book and verified by the night shift, yet there was no evidence the order was written in the lab book or that the bloodwork was drawn, and the facility could not provide related policies.
A resident with multiple chronic conditions and intact cognition was not informed of a new Clostridium Difficile diagnosis, was not offered antibiotic treatment, and did not receive education on the risks of refusing treatment. Facility staff and documentation confirmed that the required discussions and documentation did not occur, contrary to facility policy.
The facility did not consistently document the removal and wasting of controlled substances on the CSDR for a resident, and failed to record the administration of controlled medications on the MAR for two residents. This included missing documentation for Fentanyl patches and Tramadol, despite facility policy requiring timely and accurate recording by nursing staff.
A resident with multiple chronic conditions did not receive controlled medications in accordance with provider orders. Documentation showed inconsistencies in the timing and dosage of Fentanyl patch administration, with one instance of a patch being given before a provider order was obtained and another where the correct dose and time could not be confirmed. The DON confirmed that medication administration did not follow established protocols.
A staff LPN removed and ingested a resident's prescribed oxycodone from the medication cart for personal use, bypassing required narcotic count procedures and altering documentation. Surveillance footage and staff interviews confirmed the LPN's suspicious behavior and the disappearance of both the medication and its disposition record, in violation of facility policy prohibiting misappropriation of resident property.
A resident with chronic pain and diabetic polyneuropathy did not have their scheduled dose of oxycodone properly administered and documented. The MAR showed the medication as given by an LPN, but the Controlled Substance Disposition Record did not confirm this, and the DON could not verify if the dose was actually provided. Facility policy required accurate documentation and adherence to physician orders, which was not followed in this case.
The facility did not ensure that two licensed nurses conducted the required shift count of controlled substances during the handoff of narcotic keys, resulting in missing oxycodone and incomplete, altered documentation on the Controlled Drug Inventory Sheets. An LPN received the narcotic keys without a count, and another LPN was rushed during the process, leading to discrepancies and missing records. Facility policy requiring two-nurse counts and accurate recordkeeping was not followed.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that residents, including those with cognitive capacity and those with conservators, were included in the development and updating of their person-centered care plans or provided with advance notification of changes. Documentation and interviews showed that care plan meetings were either not held as scheduled or residents were not invited to participate, contrary to facility policy.
Care plans were not consistently updated to reflect residents' changing needs, physician orders, or interventions, and documentation of care plan meetings and resident involvement was lacking. Several residents did not have timely care plan revisions for new treatments or discharge planning, and advance notice or records of care plan meetings were missing, contrary to facility policy.
The facility failed to maintain kitchen sanitation and proper equipment function, with water and food debris accumulating due to missing drain strainers and improper drainage. Broken thermometers and missing temperature logs were found in refrigeration units, and food items in a kitchenette refrigerator were not consistently labeled or dated as required. Staff interviews revealed confusion about responsibility for labeling food brought in from outside sources, contrary to facility policy.
A resident with an indwelling urinary catheter was observed in a hallway without a privacy bag covering the urinary collecting device, despite care plan instructions and physician orders requiring privacy measures. A nurse confirmed the privacy bag should have been in place but could not explain why it was missing.
Surveyors found that several residents were seated in wheelchairs without tables and were not served meals while others at tables were eating. Staff confirmed that meals are always served on trays, and some residents experienced delays in receiving food. The charge nurse was unaware of the reason for the delay, and no dining policy was provided upon request.
A resident with severe cognitive and physical impairments was observed using a pelvic positioning belt in a wheelchair without a physician's order or OT recommendation. The resident was unable to remove the belt independently, and facility policy defines such a device as a physical restraint. Despite recent assessment indicating the belt was not appropriate, it continued to be used without proper documentation.
A resident with a history of fracture, cognitive impairment, and substance abuse did not receive pain management according to provider orders. Staff failed to document non-pharmacological interventions before administering PRN pain medication, gave narcotic pain medication for a pain level of 0, and did not follow required medication administration intervals. The EHR lacked documentation codes, and staff did not use progress notes as directed by the DON.
The facility did not consistently implement or document required interventions to prevent pressure ulcers, including failure to apply pressure-relieving boots and perform regular turning and repositioning for a resident at high risk, and did not complete Braden Scale risk assessments as required for two other residents with skin breakdown risk. Staff were unaware of specific physician orders, and care plans lacked necessary preventative measures.
Oxygen, eye washing, and soiled linen rooms on a secured unit were found unlocked and accessible to residents, despite having coded locks that were not used. Staff entered these rooms without using codes, and residents were observed in the vicinity, with one using a door for support. Leadership confirmed these areas should have been secured.
A resident with diabetes and Adult Failure to Thrive experienced significant weight loss over several months, but staff did not reassess or document the resident's food preferences despite variable oral intake and ongoing nutritional risk. Only after three months did the dietician discuss food preferences with the resident, who then identified specific foods they would eat, highlighting a failure to follow facility policy for individualized nutrition care.
Expired stock medications, including Aspirin, ear drops, and Heparin Flush IV syringes, were found in medication rooms on two units. The process for checking expiration dates relied on Central Supply Office staff and nurses, but there was no set schedule or process for regular review, resulting in expired medications not being removed as required by facility policy.
A resident with multiple medical conditions lost their dentures, and the facility failed to identify the loss as an emergency dental issue or document it in the grievance log as required. Nursing staff did not communicate or follow up on the missing dentures, and the facility's policies did not adequately address denture care or ensure proper documentation and investigation of lost personal items.
Food items, including open and partially consumed products, were found stored in a room containing clean linen for the overnight shift. The clean linen was kept in open carts and on shelves alongside these food items. Both the Infection Control Nurse and the Director of Laundry/Housekeeping confirmed that food should not be stored with clean linen, and facility policies required food and drinks to be consumed only in designated areas.
Two residents did not receive required annual education on influenza vaccines or have proper documentation of informed consent. One resident with cognitive impairment lacked both vaccination and consent records for the current season, while another resident's record did not show that education on vaccine benefits and side effects was provided to the resident or their conservator.
A resident with moderate cognitive impairment and diabetes was found with their bed placed against the wall, lacking the required three-foot clearance on the side and foot of the bed. The facility did not have a current waiver for this arrangement, nor a policy on bed clearance, and could not provide documentation of a room audit to confirm compliance in other rooms.
The facility did not maintain sufficient surety bond coverage for resident trust accounts, with account balances frequently exceeding the bond amount. The Administrator was unaware of the discrepancy, and there was no regular monitoring to ensure the bond matched the highest account balances, resulting in a failure to secure all resident personal funds as required.
Six residents with Alzheimer's disease or dementia were admitted to a secured unit, but their care plans were not updated to reflect this placement. Despite clinical records and observations confirming their residence on the secured unit, care plans only addressed general cognitive and behavioral interventions. The DON stated that secured unit placement did not need to be included in care plans, which was inconsistent with facility policy requiring comprehensive, updated care plans.
Six residents with dementia or Alzheimer's disease were placed on a secured unit without documented clinical assessments or consent for their placement. Records showed no evidence that required criteria were evaluated or that residents or their representatives were involved in the decision-making process, despite facility policy requiring such steps.
A resident with a Stage III pressure ulcer and other chronic conditions was subjected to physical and verbal abuse by an LPN during a wound dressing change. The LPN was reported to have been aggressive, did not follow the physician's wound care orders, and dismissed the resident's input, resulting in the procedure being performed roughly and not as prescribed. Facility documentation and interviews confirmed the resident's account, and video review showed the LPN did not spend adequate time to complete the ordered care.
Failure to Complete Required Resident Care Conferences and 72-Hour Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to complete Resident Care Conferences (RCCs) within required timeframes, including 72-hour admission conferences and at least quarterly reviews, as required by facility policy and regulatory expectations. For a resident with mild cognitive impairment, dysthymic disorder, left foot drop, and moderate protein calorie malnutrition, the record showed a care plan meeting held in early May 2025 with the resident and conservator, but no subsequent RCCs were scheduled or held from early May 2025 through mid-January 2026. Following a quarterly MDS dated in mid-January 2026, which documented intact cognition (BIMS 15) and dependence on staff for personal hygiene, bed mobility, and transfers, there was no evidence of an RCC being scheduled or held through the resident’s discharge in early February 2026. Another resident with Alzheimer’s disease (late onset), age-related macular degeneration, and major depressive disorder had an RCC documented in late September 2025 with the conservator present, but the record contained no evidence of any subsequent RCC being scheduled or held after a quarterly MDS completed in early December 2025, despite the MDS showing severely impaired cognition (BIMS 4) and dependence on staff for bed mobility and transfers; an RCC signature sheet for this resident was not available. A third resident with major depressive disorder, chronic kidney disease, and generalized abdominal pain had a quarterly MDS indicating intact cognition (BIMS 15) and independence with bed mobility, transfers, and ambulation, yet the clinical record from admission in mid-May 2025 through early March 2026 showed no 72-hour care plan meeting or any RCC scheduled or held, and no RCC signature sheet was obtained. The DON stated that RCCs should occur within 72 hours of admission and at least quarterly, and the Director of Social Services reported that staffing challenges contributed to inconsistent completion of 72-hour, change-in-condition, and quarterly RCCs, contrary to the facility’s Person-Centered Care Plan policy requiring invitations and documentation of care plan meetings via a Care Plan Meeting note.
Failure to Notify Provider and Representative of Change in Condition and Refusal of Podiatry Care
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a change in condition and refusal of care for one resident reviewed for allegations of neglect. The resident had diagnoses including mild cognitive impairment, dysthymic disorder, left foot drop, moderate protein calorie malnutrition, PVD, neuropathy, onychomycosis, and dermatophytosis. A quarterly MDS showed intact cognition with dependence on staff for personal hygiene, bed mobility, and transfers. A podiatry note documented that all ten toenails were thick, yellow, brittle, with subungual debris, and that aseptic debridement was performed with a plan for follow-up in 6–8 weeks. However, from the date of that podiatry visit through early the following year, the clinical record did not show that the provider or the resident’s conservator had been notified of the toenail condition or the need for follow-up. Subsequent podiatry service lists over several months identified that the resident was due for follow-up for tinea unguium, but visits were repeatedly rescheduled without documented reasons, and the resident was not seen. A later podiatry service list showed that the resident refused a scheduled podiatry visit. Nursing notes for the days following this refusal did not contain documentation of the refusal, any assessment of the refusal, or notification to the provider or the resident’s conservator. A facility reportable event later documented receipt of a complaint alleging neglect due to the appearance of the resident’s legs and stated that the resident had been seen by podiatry and wound personnel but refused treatments and had since been discharged. The resident’s conservator reported being present at the admission assessment at the receiving facility and observed that the resident’s toenails were so thick and long they were curling, and stated shock at their condition. The conservator stated that the facility had never notified them of podiatry issues or refusals of treatment and that they would have advocated for care if informed. The DON and APRN both stated they had not been notified of the condition of the toenails or the refusal of podiatry care and indicated that nursing staff should have documented the podiatry visit, ongoing toenail condition, and refusal, and notified the provider and conservator. Facility policies on notification of change in condition, refusal of treatment, and foot care required timely notification of the physician and healthcare decision maker, assessment and documentation of refusals, and appropriate referral and follow-up for residents with complicating disease processes requiring foot care, which were not followed in this case.
Failure to Care Plan Left Foot Drop and Podiatry Conditions
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan to address a resident’s left foot drop, which was documented in hospital records as a past medical history diagnosis at the time of admission in 2022. Review of the resident care plan from admission through early February 2026 showed no identification of left foot drop and no interventions to treat or manage this condition. A physical therapist reported that the resident was admitted with significant left foot drop and that therapy attempted to use an AFO brace, but the resident refused, leading to discontinuation. The therapist stated that therapy reattempted AFO use and therapy services several times, but the resident refused to participate or get out of bed. The therapist also indicated that therapy communicated functional and ADL status updates to nursing, and that nursing was responsible for developing the resident care plan with appropriate interventions, including care planning for left foot drop and documenting refusals since admission. The facility also failed to care plan podiatry abnormalities identified during the resident’s stay. A podiatry note documented that the resident had thick, yellow, brittle toenails with subungual debris and diagnoses of PVD, neuropathy, onychomycosis, and dermatophytosis, and that aseptic debridement of all ten elongated, thick toenails was performed with a plan for follow-up. However, review of the resident care plan from the date of this podiatry visit through early February 2026 showed no care plan addressing nail disorders, infections, or foot and nail diagnoses to ensure proper treatment and prevent complications. The DON stated that the IDT should have care planned the left foot drop present on admission, initiated interventions, documented treatment refusals, and that licensed nursing staff or the IDT reviewing podiatry notes should have developed a podiatry care plan with interventions. The facility’s Person-Centered Care Plan policy required comprehensive, individualized care plans with measurable objectives and timetables, including services not provided due to the resident’s right to refuse treatment, to be developed and reviewed based on comprehensive assessments.
Failure to Ensure Ongoing Podiatry Care and Follow-Up for Foot and Nail Abnormalities
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing podiatry care and timely follow-up for a resident with documented foot and nail abnormalities. The resident had diagnoses including mild cognitive impairment, dysthymic disorder, left foot drop, moderate protein calorie malnutrition, PVD, neuropathy, onychomycosis, and dermatophytosis. A podiatry note documented on 9/22/25 described thick, yellow, brittle toenails with subungual debris and indicated that aseptic debridement of all ten toenails was performed, with a plan for follow-up in six to eight weeks. However, the resident’s care plan from 9/22/25 through 2/9/26 did not include podiatry abnormalities, nail disorders, infections, or foot and nail diagnoses to guide ongoing treatment and monitoring. From 9/22/25 to 2/9/26, the clinical record contained no further podiatry treatment notes or documentation of refusals of podiatry care for this resident. Nurse’s notes during this period did not address the condition of the resident’s feet or toenails or any refusals of podiatry services, and the TARs for September 2025 through February 2026 did not show any treatments or monitoring related to the resident’s feet or toenails. Podiatry Service Lists dated 11/10/25, 12/22/25, and 1/6/26 showed the resident was due for follow-up for tinea unguium, but each visit was rescheduled without a documented reason, and the resident was not seen. A Podiatry Service List dated 2/3/25 indicated the resident was due for follow-up and refused the visit, but there was no corresponding nursing documentation of this refusal in the nurse’s notes from 2/3/26 through 2/9/26. The resident’s conservator later reported being shocked by the condition of the resident’s toenails, describing them as so thick and long that they were curling, and stated that the facility had not notified them of podiatry issues or refusals of care. The Administrator acknowledged being unaware of the 9/22/25 podiatry note and was unsure how nursing staff became aware of podiatry recommendations, noting that podiatry notes were sent to Medical Records and communication with the podiatry group occurred by email. The DON stated that nursing staff should have followed up on the 9/22/25 podiatry visit for orders and recommendations, assessed and documented the toenail condition, and notified leadership to facilitate timely follow-up, but there was no designated nurse responsible for coordinating podiatry visits and no process to ensure specialty providers’ findings were communicated to nursing before leaving the facility. The DON also reported misinterpreting several Podiatry Service Lists as refusals and could not determine why the resident was not seen on those dates. The APRN reported she was never notified of the podiatry findings or the reported refusal and stated that nursing should have documented and notified her of the podiatry visit and ongoing issues so that monitoring and timely follow-up could have occurred.
Failure to Care Plan for Intrusive Behaviors in Resident With Dementia
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan to address a resident’s intrusive behaviors toward other residents. The resident had diagnoses of severe dementia with psychotic disturbances and an adjustment disorder with mixed anxiety and depressed mood, and the admission MDS showed severely impaired cognition with a BIMS score of 4 and a need for supervision with transfers and ambulation. The existing Resident Care Plan addressed distressed or fluctuating mood, impaired cognitive function related to dementia, and impaired communication due to hearing impairment, with interventions such as providing consistent caregivers, structured routines, simplified communication, reassurance, and referral to a behavioral health specialist as needed. However, the care plan did not identify or address intrusive behaviors toward other residents. Nursing notes documented specific incidents of intrusive behavior, including the resident entering another resident’s room and following that resident down the hallway, and a separate incident in which the resident was observed tugging the front collar area of another resident’s shirt in a brief, non-aggressive, non-threatening manner. Staff interviews indicated the resident frequently attempted to “help” others by obtaining plastic cups from nurse carts and passing out drinks, pushing other residents in wheelchairs, and at times following other residents, reflecting a belief that the resident was at work and enjoyed staying busy. The Director of Nursing acknowledged awareness of these behaviors and that the interdisciplinary team had discussed the need for a behavioral care plan after an incident, but the care plan was not updated to include intrusive behaviors or person-centered interventions, contrary to the facility’s Person-Centered Care Plan policy requiring individualized care plans that are reviewed and revised to reflect changing needs and goals.
Failure to Provide Required Social Services Follow-Up After Room Change
Penalty
Summary
The facility failed to provide ongoing medically-related social services monitoring during the 72-hour adjustment period following a room change for a resident with severe cognitive impairment and psychiatric diagnoses. The resident had severe dementia with psychotic disturbances and an adjustment disorder with mixed anxiety and depressed mood, with an admission MDS showing severely impaired cognition (BIMS score of 4) and a need for supervision with transfers and ambulation. The resident’s care plan identified that the resident was adjusting to a new memory care environment, with interventions including reminiscence, discussion of meaningful family relationships, and opportunities for quiet, one-to-one visits. On the day of the incident, an LPN documented that the resident was intrusive in another resident’s room and followed that resident down the hallway, after which the resident was redirected, separated, placed on 15-minute safety checks, and moved to a new unit. Social services were notified, and a social worker met with the resident to show the new room and documented that the resident was confused by the change but not agitated or behavioral. The following day, another social worker documented an assessment of the resident’s adjustment to the room change, noting that the resident was adjusting well with no signs of anxiety or distress and stating that she would follow up two more times per protocol. However, review of the clinical record from 1/17/26 through 1/21/26 revealed no further social services follow-up notes for the resident during the required 72-hour adjustment period. The Administrator confirmed that facility policy and practice required social services staff to follow up with a resident for 72 hours after a room change to ensure a smooth transition and that social services did not complete the required follow-up after the initial post-move visit. The Administrator also identified that the responsible social worker was reassigned after the 1/16/26 visit and that the follow-up was missed during the transition to a new social worker, contrary to the facility’s Room Change policy, which directed that social services assess and document how the resident is adjusting and address any issues after relocation.
Failure to Accurately Administer and Document Controlled Anxiolytic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors related to anxiolytic medications, including incorrect dosing and omitted doses. For one resident with vascular dementia, anxiety disorder, and depressive episodes, a physician’s order directed administration of Ativan 0.25 mg (½ of a 0.5 mg tablet) three times daily for anxiety. However, documentation on the Medication Administration Record (MAR) and the Controlled Substance Disposition Record showed that from 12/10/25 through 12/23/25, nurses repeatedly administered 0.5 mg per dose instead of 0.25 mg, resulting in double the prescribed dose on at least seventeen occasions. The Controlled Substance Disposition Record also showed that after a later order change to 0.5 mg three times daily, the resident received only 0.25 mg at several subsequent administrations, which was half of the ordered dose. Charge nurses, including LPNs and an RN, later stated they had misread the physician’s orders and failed to compare the electronic MAR with the medication blister pack label before administration. For a second resident with dementia, schizophrenia, anxiety, major depressive disorder, and epilepsy, a physician’s order directed lorazepam 0.5 mg by mouth every eight hours for anxiety and agitation. The January MAR indicated that lorazepam 0.5 mg was administered at scheduled times each day. However, review of the Controlled Substance Disposition Record did not show that the 5:00 AM dose on 1/3/26 was documented as administered, despite the MAR indicating it had been given. This discrepancy between the MAR and the controlled substance record demonstrated a failure to accurately document and verify administration of a controlled anxiolytic medication as ordered. For a third resident with dementia with behavioral disturbances, paranoid personality disorder, generalized anxiety disorder, and major depressive disorder, a physician’s order directed Xanax 0.5 mg by mouth three times daily for anxiety and agitation. The January MAR showed that Xanax 0.5 mg was signed out as administered at the scheduled times. In contrast, the Controlled Substance Disposition Record did not reflect administration of the medication for six specific scheduled doses, even though all six were signed off on the MAR as given. The psychiatric APRN stated that licensed nurses are expected to fully read orders, follow the five rights of medication administration, and clarify any uncertainties, and the DON stated that nurses are expected to compare the physician’s order with the blister pack label and to document medications at the time of administration so that the MAR and Controlled Substance Disposition Record match. The facility’s own Medication Administration and Medication Errors policies defined medication errors to include omissions and wrong doses and required staff to follow written provider instructions and verify doses, which did not occur in these cases. The psychiatric APRN also reported that no one contacted him to clarify or question the Ativan orders for the first resident until 12/24/25 and that he was not informed that any of the three residents had omitted doses of anxiolytic medications during the period in question. The APRN identified that all three residents had dementia and were at risk for increased anxiety, agitation, and impaired comfort when scheduled anxiolytic medications were omitted. The DON confirmed that licensed nurses did not follow expectations to fully read and verify orders and to ensure the five rights of medication administration, resulting in the wrong dose being given to one resident and undocumented or omitted doses for the other residents, and that the MARs should have matched the corresponding Controlled Substance Disposition Records but did not. Overall, the survey findings show that for three residents receiving controlled anxiolytic medications, the facility failed to administer medications in accordance with provider orders and failed to maintain accurate, consistent documentation between the MAR and the Controlled Substance Disposition Records. These failures included administering double the ordered dose, administering half the ordered dose, and omitting or failing to document scheduled doses, contrary to facility policy and provider expectations.
Failure to Report Allegation of Neglect Involving Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of neglect to the State Agency when it was identified. A resident with epilepsy, multiple sclerosis, repeated falls, and an adjustment disorder had a BIMS score of 7/15, indicating they rarely or never made decisions regarding tasks of daily living. An SBAR note documented that the resident experienced a seizure and was transferred to the ED after receiving Ativan per provider orders. A subsequent nurse’s note, written by the former DON, recorded that the resident’s family reported to hospital staff their concern that the facility had withheld the resident’s anti-seizure medications prior to the seizure event. This allegation of neglect was not entered into the facility’s grievance book, and there was no Accident and Investigation (A&I) documentation related to the allegation. Review of the State Agency Reportable Events website showed no evidence that the allegation of neglect was reported to the State Agency around the time it was identified. The former DON acknowledged in interview that, despite documenting the family’s allegation in the nurse’s note and reviewing the Medication Administration Records, she did not report the allegation to the State Agency or fully investigate it. The Administrator stated that the former DON had only casually mentioned a medication issue and did not communicate that it was an allegation of neglect, and the Administrator was unaware of the nurse’s note. The facility’s Abuse Prohibition policy required immediate entry of allegations into the risk management portal, reporting to state and local authorities within specified time frames, and initiation of a documented investigation within 24 hours, but these steps were not carried out for this allegation.
Failure to Investigate and Report Allegation of Withheld Anti-Seizure Medication
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and report an allegation of neglect related to a resident’s anti-seizure medication. The resident had diagnoses including epilepsy, multiple sclerosis, repeated falls, and adjustment disorder, and a BIMS score of 7/15 indicating significantly impaired decision-making for daily tasks. An SBAR note documented that the resident experienced a seizure and was transferred to the ED with new orders for IM Ativan. A subsequent nurse’s note by the former DON, based on the hospital record, stated that the resident’s family reported to hospital staff concerns that the facility had withheld the resident’s anti-seizure medications. The DON documented that she reviewed the resident’s October and November MARs. However, there was no corresponding grievance or documentation in the facility’s Grievance Book related to the family’s allegation that seizure medications were withheld, and no Accident and Investigation (A&I) report was available despite being requested. Review of the State Agency Reportable Events website showed no evidence that the allegation of neglect was reported to the State Agency. In an interview, the former DON acknowledged she did not report the allegation to the State Agency or fully investigate it beyond reviewing the MARs, explaining that the family had only reported the concern to hospital staff and not directly to the facility. The Administrator reported that the DON had only casually mentioned a medication issue and had not communicated that it was an allegation of neglect, and the Administrator was unaware of the DON’s nurse’s note. These actions and omissions were inconsistent with the facility’s Abuse Prohibition policy, which required prompt reporting to authorities and initiation of a documented investigation upon receiving information about suspected or alleged abuse or neglect.
Failure to Timely Refill and Properly Administer Anti-Seizure Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure anti-seizure medications were refilled in a timely manner and administered from the correct resident-specific supply, in accordance with professional standards and facility policy. Resident #1 had diagnoses including epilepsy, multiple sclerosis, repeated falls, and adjustment disorder, and had physician orders for levetiracetam 1000 mg twice daily and oxcarbazepine 300 mg twice daily for seizure control. The resident’s care plan identified seizure risk and included interventions to medicate as ordered and monitor for effectiveness and side effects. An SBAR note documented that on 11/10/25 the resident experienced a seizure, the provider was notified, Ativan 1 mg IM was ordered as a rescue medication, and the resident was transferred to the ED for further evaluation. Review of the October and November Medication Administration Records showed all scheduled doses of levetiracetam and oxcarbazepine at 9:00 AM and 9:00 PM were signed as administered, and a nurse’s note by the former DON stated there were no missed doses. However, pharmacy records and order audit reports showed repeated delays in reordering both medications, with multiple refills requested several days to two weeks after the prior 14‑day supply should have been exhausted. The pharmacist confirmed that both medications were dispensed in 14‑day supplies, that no STAT deliveries were requested for these drugs during the review period, and that levetiracetam was available in the Pyxis emergency supply while oxcarbazepine was not. A Pyxis report showed that levetiracetam had not been pulled from emergency stock for this resident during the relevant timeframe. Multiple nursing staff interviews revealed that when the resident’s levetiracetam and oxcarbazepine could not be located, nurses did not follow facility procedures for medication unavailability. A 3–11 PM RN reported that when she returned after days off, she frequently had to refill the resident’s anti-seizure medications and, if they were not available, she would obtain doses from other residents who were on the same medications rather than notify the supervisor, pull from Pyxis, or call the pharmacy for a STAT refill. Several LPNs similarly reported that when they could not find the medications on several occasions, they took doses from other residents’ anti-seizure medication supplies instead of contacting the supervisor, using Pyxis, or arranging refills through the pharmacy or eMAR. The DON confirmed that the medications had not been pulled from emergency stock for this resident, that charge nurses were responsible for reordering when two to three days of supply remained, and that nurses should not use other residents’ medications at any time. Facility policies on reordering medications and medication administration required timely communication with the pharmacy and adherence to the seven rights of medication administration, which were not followed in these instances.
Failure to Obtain Ordered Lab Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to obtain ordered laboratory tests for a resident receiving medication that required lab monitoring. The resident had diagnoses including vascular dementia with mood disturbances, anxiety disorder, and depressive episodes, and had a BIMS score of 15/15, indicating the resident was alert and oriented. A physician ordered Depakote sprinkles 125 mg, six capsules by mouth at bedtime for bipolar disorder, and the resident’s care plan identified risk for complications related to psychotropic medications, with interventions including monitoring for side effects and consulting the physician or pharmacist as needed. A subsequent physician’s order directed that a CBC, CMP, and Depakote level be obtained on the next laboratory draw day. Review of the clinical record from the date of the lab order through the survey date showed no documentation that the ordered bloodwork was obtained. The DON stated that routine lab days were Monday, Wednesday, and Friday, and that the resident’s bloodwork should have been drawn on the next scheduled lab day, but she was unable to find documentation that the lab draw occurred. The DON explained that when lab orders are entered into the EHR, the same shift is responsible for confirming the order and writing it in the lab book, and the 11 PM–7 AM shift is responsible for ensuring the order matches what is written in the lab book. The DON was unable to provide documentation that the lab orders were entered into the lab book or explain why the labs were not obtained, and facility policies for physician orders, transcription of orders, and obtaining bloodwork were not provided.
Failure to Inform Resident of New Diagnosis and Treatment Options
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident with multiple complex diagnoses, including type 2 diabetes mellitus, chronic heart failure, and end stage renal disease, of a new diagnosis of Clostridium Difficile. The resident, who was cognitively intact and dependent on staff for activities of daily living, was not notified of the diagnosis, was not offered available treatment options, and did not receive education regarding the risks of refusing treatment. Documentation showed that the resident had a history of refusing medications and was on hospice care, but there was no evidence that the resident was informed about the new diagnosis or the rationale for antibiotic therapy at the time the positive lab result was received. Interviews with facility staff confirmed that the standard practice would be to inform the resident of a new diagnosis, discuss treatment options, and provide education on the consequences of refusal. However, both the clinical record and staff interviews indicated that this process did not occur for the resident on the date of the positive Clostridium Difficile result. The facility's own policy required staff to explain the negative effects of refusing medications and to document refusals, but this was not followed in this instance.
Failure to Document Controlled Substance Administration and Removal
Penalty
Summary
The facility failed to properly document the removal and wasting of controlled substances on the Controlled Substance Distribution Record (CSDR) for one resident, and failed to record the administration of controlled medications on the Medication Administration Record (MAR) for two residents. Specifically, for one resident with diagnoses including Type 2 Diabetes Mellitus, chronic heart failure, and End Stage Renal Disease, the CSDR did not indicate that Fentanyl patches administered on two occasions were removed or wasted according to facility policy. Additionally, a 100 microgram/hour Fentanyl patch administered to the same resident was not documented as removed or wasted, despite policy requiring two licensed professionals to destroy and document the destruction of controlled substances. For the same resident, the MAR did not reflect the administration of a 100 microgram/hour Fentanyl patch, even though the CSDR showed it was given. Another resident, with a history of diabetes, chronic heart failure, and chronic pain syndrome, was administered Tramadol as documented on the CSDR, but this administration was not recorded on the MAR. Facility policy requires that nurses document the administration of medications on both the MAR and CSDR at the time the medication is given. Interviews with the Interim Director of Nurses confirmed that the facility's policy mandates documentation of both the administration and removal/wasting of controlled substances, with two nurses required to sign off on the removal/wasting. The review of facility policies and records demonstrated that these procedures were not consistently followed for the residents in question.
Failure to Administer Controlled Medications per Provider Orders
Penalty
Summary
A deficiency was identified in the administration of controlled medications for one of three residents reviewed for medication administration. The resident, who had diagnoses including type 2 diabetes mellitus, chronic diastolic heart failure, and end stage renal disease, required total assistance with activities of daily living and was noted to have refused medications at times. On one occasion, a physician's order directed the application of two 50 microgram/hour Fentanyl patches every three days for chronic pain. Documentation inconsistencies were found: the Medication Administration Record (MAR) indicated two patches were administered at 8:00 AM, while the Controlled Substance Distribution Record (CSRD) only documented one patch given at 12:00 PM. The assigned LPN could not confirm whether the correct dose was administered at the correct time. The Director of Nursing (DON) confirmed that the patches should have been administered as ordered and that the five medication rights were not followed. In a separate incident, a physician's order for a 100 microgram/hour Fentanyl patch was received at 7:45 PM, but the CSRD showed the patch was administered at 3:00 PM, several hours before the order was obtained. The DON acknowledged that the medication was given prior to receiving the provider's order and reiterated the importance of following the five medication rights, including administering medications at the correct time. Facility policy required staff to follow written provider instructions and document medication administration at the time it occurred, which was not adhered to in these cases.
Misappropriation of Narcotic Medication by Staff Member
Penalty
Summary
A deficiency occurred when a staff member, specifically an agency LPN, removed a narcotic medication, oxycodone 5 mg, from the medication cart for personal use, violating facility policy and procedures. The incident involved a resident with diagnoses including generalized abdominal pain, interstitial pulmonary disease, chest pain on breathing, and anxiety, who was alert and oriented. The resident had a physician's order for oxycodone 5 mg to be administered as needed for pain, and the medication was documented as received and partially administered prior to the incident. On the day of the incident, the LPN arrived late for her shift and did not participate in the required narcotic count with the outgoing nurse, instead taking the keys without following protocol. Throughout her shift, surveillance footage captured the LPN engaging in suspicious behavior around the medication cart, including handling the narcotic log binder out of camera view, shuffling papers, and being observed placing medication cups to her mouth on multiple occasions. The narcotic count logs were found to have been altered, and a significant quantity of oxycodone tablets, along with the disposition record, went missing from the cart and could not be located despite a thorough search. Interviews with staff confirmed that the required two-nurse narcotic count was not performed at shift change, and that the LPN in question appeared anxious and fidgety during her shift. The DON and other staff members identified discrepancies in the narcotic count and documentation, and the LPN was observed ingesting medication at the cart. The facility's abuse prohibition policy, which defines misappropriation of resident property as the wrongful use of a resident's belongings without consent, was not followed in this instance, resulting in the misappropriation of the resident's narcotic medication.
Failure to Accurately Administer and Document Narcotic Pain Medication
Penalty
Summary
A deficiency occurred when a resident with chronic pain and diabetic polyneuropathy, who was alert and oriented, did not receive narcotic pain medication as ordered by the physician. The resident was prescribed oxycodone 5 mg to be administered three times daily for pain management. On a specific date, the Medication Administration Record (MAR) indicated that the 2:00 PM dose was signed off as administered by an LPN, but the Controlled Substance Disposition Record did not show that the medication was dispensed at that time. The disposition record only reflected administration at 6:00 AM and 10:00 PM. During interviews, the LPN could not recall the specific resident or event but stated that if the medication was not signed out on the disposition record, it was not administered, and she was unsure why it was marked as given on the MAR. The Director of Nursing confirmed that an audit of the records could not verify whether the 2:00 PM dose was actually given. Facility policy required staff to follow provider instructions and document medication administration accurately, which was not done in this instance.
Failure to Perform Two-Nurse Narcotic Shift Count and Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to ensure that the required shift count of controlled substances was conducted by two licensed nurses during the handoff of narcotic keys, and did not maintain complete, accurate, and unaltered documentation on the Controlled Drug Inventory Sheets. On the date in question, a charge nurse discovered that both a blister pack of oxycodone 5 mg and its corresponding disposition record sheet were missing from the medication cart and narcotic count book. Despite searching the medication cart and room, the missing medication and documentation could not be located. The incident was reported, and statements were obtained from all staff with access to the medication cart. Interviews revealed that an agency LPN, who was scheduled for the day shift, arrived late and did not perform the required narcotic count with the outgoing nurse. Instead, the narcotic keys were handed over without a count, contrary to facility policy. Later, another LPN reported being rushed during the shift change and did not count the total number of disposition sheets or physical blister cards as required. The Controlled Medication Shift Change Log showed alterations, with numbers crossed off and changed, and missing disposition sheets for the relevant period. Staff interviews confirmed that the required two-nurse count was not performed at multiple shift changes, and documentation was altered or incomplete. Facility policy requires a complete count of all controlled substances at each shift change, performed by two licensed nurses, and mandates accurate recordkeeping. The investigation found that these procedures were not followed, resulting in missing medication, altered documentation, and a lack of reconciliation between narcotic cards and disposition sheets. The failure to adhere to these protocols led to the deficiency cited in the report.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's well-being.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Include Residents in Person-Centered Care Planning
Penalty
Summary
The facility failed to ensure that residents were included in the development and updating of their person-centered care plans and were not provided with advanced notification of changes to their care plans. For three residents reviewed, documentation and interviews revealed that care plan meetings were either not held as scheduled or residents were not invited to participate, despite being cognitively intact and able to contribute to their care planning. In several instances, care plan meetings were documented as attended only by staff or conservators, with no evidence that the residents themselves were notified or included. One resident with end stage renal disease, supplemental oxygen dependence, and a right leg amputation was found to have been informed about care plans only after decisions were made, and had not been invited to participate in care plan meetings for several years. Another resident with peripheral vascular disease, hemiplegia, and chronic pain syndrome, who had a court-appointed conservator, was also not notified or included in care plan meetings, despite facility policy requiring both the conservator and the resident to be involved. A third resident with a femur fracture, history of falls, and benign prostatic hyperplasia, also with a conservator, had no documentation of care plan meetings or invitations to participate, even though the resident was cognitively intact. Interviews with facility staff, including the Director of Social Services and the Director of Nursing Services, confirmed that both MDS Coordinators and Social Services were responsible for scheduling care plan meetings and inviting residents. However, they were unable to provide reasons for the lack of documentation or resident involvement. Review of facility policy confirmed that residents have the right to participate in care planning and to be informed in advance of changes, but these requirements were not met for the residents reviewed.
Failure to Update and Document Resident Care Plans and Involvement
Penalty
Summary
The facility failed to ensure that care plans were consistently developed, updated, and revised to reflect the changing needs and preferences of residents, as well as to document resident involvement and provide advance notice of care plan meetings. For several residents, care plans did not include necessary interventions or reflect current physician orders. For example, one resident with a history of malnutrition, vascular disease, and amputation developed a deep tissue injury, but the care plan lacked interventions for turning and repositioning, and there was no consistent documentation of offloading or repositioning prior to the injury. Another resident utilizing a pelvic positioning belt did not have a care plan or physician order reflecting the use or rationale for the belt, and the care plan was only updated after inquiry, not in real time with the resident's needs. Additionally, a resident receiving intravenous hydration therapy did not have this intervention reflected in the care plan, despite physician orders and staff acknowledgment that it should have been included. Another resident undergoing discharge planning did not have a discharge care plan initiated, even though social service notes indicated active efforts to arrange a transfer to another facility. These omissions demonstrate a lack of timely and accurate care plan updates in response to significant changes in residents' conditions or care needs. The facility also failed to provide advance notice of care plan meetings, document that meetings were held, or ensure that care plan revisions reflected resident involvement for multiple residents. Documentation was missing for several scheduled care plan meetings, and interviews with residents and staff confirmed that residents were not consistently invited or involved in the care planning process. Facility policy required resident participation and advance notification, but these requirements were not met, as evidenced by missing sign-in sheets, lack of meeting notes, and resident reports of not being informed or involved.
Deficient Kitchen Sanitation, Equipment Maintenance, and Food Labeling
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not ensure that kitchen equipment was operating properly. Observations revealed water and food debris accumulating on the floor under the prep sink area due to missing drain strainers, causing dirty water to drain directly onto the kitchen floor. Tiles were missing in the prep sink area as a result of repeated water buildup, and the kitchen floor would require excavation and plumbing to correct the drainage. Additionally, a coffee maker's overflow grate drained fluid directly onto the floor, which then flowed several feet to a floor drain in a high-traffic area. The Dietary Manager acknowledged these issues and indicated that efforts were made to avoid fluid overflow, but the problems persisted. Temperature monitoring and food labeling practices were also found to be inconsistent. Broken thermometers were observed in both the walk-in refrigerator and a stand-alone refrigerator/freezer, with missing temperature logs for the freezer over a 17-day period. The Dietary Manager confirmed that the wrong temperature log was posted and that no freezer temperatures had been recorded during that time. Furthermore, food items in a kitchenette refrigerator were found to be unlabeled or labeled only with resident names and room numbers, lacking required dates. Staff interviews revealed uncertainty about responsibility for labeling and dating food items brought in from outside sources, despite facility policy assigning this responsibility to the dietary department.
Failure to Maintain Resident Dignity During Catheter Use
Penalty
Summary
A resident with diagnoses including obstructive and reflux uropathy, moderate dementia, mood disturbance, anxiety, and a urinary tract infection was observed in the hallway near the nursing station with an indwelling urinary catheter that was not covered by a privacy bag. The resident's care plan specified the use of privacy bags and leg bags as appropriate to maintain privacy and comfort, and a physician's order directed catheter care as needed. Despite these directives, the resident was seen without a privacy bag in a public area, and a registered nurse confirmed that the resident should have had a privacy bag in place but could not explain the omission.
Failure to Provide Homelike Dining Experience
Penalty
Summary
Surveyors observed that the facility failed to provide a homelike dining experience for residents in one of its dining rooms. During a meal service, several residents were seated in wheelchairs without access to dining tables, facing other residents who were eating at tables. Some residents at tables had not been served food while others at the same tables were eating. All residents in the dining room were served their meals on trays. Staff interviews confirmed that meals are always served on trays, and there was no explanation provided for why some residents had not received their meals while others had begun eating. Further, the charge nurse present in the dining room was unaware of the reason for the delay in meal service to certain residents. The facility was unable to provide a policy or procedure for resident dining on the nursing units when requested. The observations and staff interviews indicated a lack of coordination and inconsistency in meal service, resulting in some residents not receiving their meals in a timely or homelike manner.
Failure to Ensure Resident Is Free from Physical Restraints
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Alzheimer's disease, paranoid schizophrenia, and hypertension was observed using a pelvic positioning belt in a wheelchair, which was not supported by a physician's order or occupational therapy (OT) recommendation. The resident's Minimum Data Set (MDS) assessment indicated severe impairment and a need for maximal assistance with mobility and hygiene, but did not document the use of restraints. The care plan referenced the use of a custom wheelchair but did not specify the use of a pelvic positioning belt, and the physician's orders did not include this device. Observations on multiple occasions confirmed the resident was using the pelvic positioning belt, and interviews with nursing and OT staff revealed that the resident was unable to remove the belt independently. The facility's policy defines a physical restraint as a device that the resident cannot remove easily and that restricts movement. Despite recent OT assessment determining the belt was not appropriate for this resident, the device continued to be used without proper documentation or orders, resulting in the resident not being free from physical restraints as required.
Failure to Follow Pain Management Orders and Documentation Requirements
Penalty
Summary
The facility failed to follow physician's orders for pain management for one resident with a history of left femur fracture, liver disease, hypertension, moderate cognitive impairment, and a history of substance abuse. The resident's care plan required monitoring for pain, use of non-pharmacological interventions before administering PRN pain medication, and documentation of these interventions and their effectiveness every shift. Despite multiple reports of pain over several days, there was no documentation of non-pharmacological interventions in the electronic health record or on paper. Additionally, the facility's electronic health record system was missing codes for documenting these interventions, and staff did not document them in progress notes as expected by the Director of Nursing Services. Further review revealed that pain medications were not administered according to physician orders. Oxycodone, a narcotic pain medication, was given for a pain level of 0 and for mild pain when acetaminophen should have been used first, as per orders. There were also instances where Oxycodone was administered at intervals shorter than the prescribed four hours. Interviews with nursing staff and the APRN confirmed that pain medication should not be given for a pain level of 0 and that non-pharmacological interventions should be attempted first. The facility's pain management policy required documentation of non-pharmacological interventions and their effectiveness, which was not done for this resident.
Failure to Prevent Pressure Ulcers and Inconsistent Risk Assessments
Penalty
Summary
The facility failed to prevent the re-occurrence of a pressure injury and did not consistently implement or document required interventions for residents at risk for pressure ulcers. For one resident with multiple risk factors, including protein calorie malnutrition, peripheral vascular disease, amputation, and dementia, staff did not consistently apply a pressure-relieving boot as ordered, nor did they consistently turn and reposition the resident, despite the resident being dependent on staff for mobility. Documentation showed that turning and repositioning was not performed or recorded for several weeks prior to the development of a deep tissue injury (DTI), and the care plan lacked specific interventions for these preventative measures. Additionally, the pressure-relieving boot was not applied while the resident was out of bed, contrary to physician orders, and staff were unaware of the full requirements of the order. For two other residents at risk for pressure ulcer development, the facility did not consistently conduct or document Braden Scale risk assessments according to facility policy. One resident had only two Braden assessments completed upon admission, with no further assessments documented, despite ongoing risk factors and actual skin breakdown. The other resident had Braden assessments completed at irregular intervals, not aligning with the policy requirement for weekly assessments during the first month after admission. Both residents had care plans indicating risk for skin breakdown, but the required risk assessments and documentation were not consistently performed. Interviews with facility staff, including the DNS and regional director, confirmed that the process for scheduling and completing Braden Scale assessments was not consistently followed. The facility's policy required risk evaluations on admission/readmission, weekly for the first month, quarterly thereafter, and with any change in condition. However, these assessments were not completed as required, and preventative interventions such as turning, repositioning, and use of pressure-relieving devices were not consistently implemented or documented for residents at risk.
Unsecured Storage Areas Accessible to Residents
Penalty
Summary
The facility failed to ensure that the oxygen room, eye washing room containing medical supplies, and soiled linen room on a secured unit were properly locked, allowing residents access to these areas. Observations revealed that the oxygen room, which contained four oxygen tanks, as well as the eye washing and soiled linen rooms, were not locked despite having coded locks that were not utilized. Staff were observed entering these rooms without using the codes, and residents were seen wandering the hall and using the eye washing room door for support. Interviews with the DNS and Regional Clinical Director confirmed that these storage areas should not be accessible to residents and that the Maintenance Department is responsible for ensuring the locks are functional.
Failure to Assess and Honor Food Preferences for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a nutritional assessment included a resident's food preferences for a resident at risk for malnutrition and experiencing significant weight loss. The resident, who had diagnoses including diabetes mellitus and Adult Failure to Thrive, was admitted with a nutritional assessment that did not specify any particular food preferences. Although the resident was cognitively intact and able to communicate, the facility did not document or update the resident's food preferences after a significant weight loss was identified. Over several months, the resident experienced a notable weight loss, with weights dropping from 138.7 lbs to 123.8 lbs within one month, representing a 10.7% loss. Despite this, interventions such as dietary supplements and medication adjustments were implemented without reevaluating or discussing the resident's food preferences. The care plan included honoring food preferences and offering alternatives if less than 50% of a meal was consumed, but there was no evidence that the resident's preferences were reassessed during this period of weight loss and variable oral intake. It was not until three months after the initial significant weight loss that the dietician met with the resident to discuss food preferences, at which point the resident expressed a strong preference for peanut butter and jelly sandwiches and pasta. Observations confirmed the resident consistently consumed these preferred foods. Staff interviews and documentation review revealed that food preferences were not obtained or updated as required by facility policy, and the only documented preferences were entered months after the weight loss began.
Expired Medications Found in Stock Rooms Due to Lack of Review Process
Penalty
Summary
Surveyors observed expired stock medications in medication rooms on two separate units, including bottles of Aspirin 325 mg, Carbamide Peroxide ear drops, and Heparin Flush IV syringes, with expiration dates ranging from August to December of the previous year. The process for ensuring medications are not expired involved Central Supply Office staff checking expiration dates when stocking and rotating stock, as well as nurses checking dates before placing medications on carts. However, there was no established process or set frequency for reviewing stock medications, which led to expired medications remaining in storage areas. Facility policy required expired, discontinued, or contaminated medications to be removed and disposed of, but this was not consistently followed.
Failure to Provide Emergency Dental Services After Loss of Dentures
Penalty
Summary
A deficiency occurred when the facility failed to identify and provide emergency dental services for a resident who lost their dentures. The resident, who had diagnoses including vascular dementia, left-sided hemiplegia and hemiparesis, and chronic pain syndrome, was care planned for oral health risks and required assistance with oral hygiene and eating. Despite documentation in the dental note that the dentures were missing and staff were instructed to search for them, there was no evidence that the loss was entered into the grievance log or that appropriate follow-up actions were initiated. The resident reported the loss to staff, but the dentures remained missing, and the incident was not documented as required by facility policy. Interviews with nursing staff revealed a lack of communication and follow-through regarding the missing dentures, with responsibilities for reviewing dental notes and logging lost items not being fulfilled. The Director of Nursing Services confirmed that, in the absence of an Assistant Director of Nursing Services, nurse managers were responsible for reviewing specialty provider notes, but this process was not completed. Additionally, the facility's oral health policy did not address denture care and maintenance, and the personal property policy required documentation and investigation of lost items, which did not occur in this case.
Improper Storage of Food Items in Clean Linen Room
Penalty
Summary
During a tour of the facility's laundry area with the Infection Control Nurse, food items such as an empty can of orange soda, an empty bag of crackers, aluminum foil with yellow residue, a can of cashews with crumbs, an open mayonnaise packet, a piece of candy cane, plastic forks with residue, unopened tea bags, a cough drop, and a sugar packet were found stored in a room containing clean linen for the overnight shift. The clean linen, including incontinence pads, towels, curtains, and a fitted sheet, was stored in open, partially filled carts and on shelves in the same room as these food items. The Infection Control Nurse and the Director of Laundry/Housekeeping both confirmed that food items should not have been stored with clean linen, and the Director was unaware of who placed the items there. The facility's linen handling policy did not address the storage of food in linen rooms, but the employee handbook specified that food and drinks may only be consumed in designated areas and not in work areas.
Failure to Provide Annual Influenza Vaccine Education and Obtain Informed Consent
Penalty
Summary
The facility failed to ensure that residents received annual education on influenza vaccines and that annual informed consent was obtained, as identified through clinical record reviews and staff interviews for two residents. One resident with severe cognitive impairment did not have documentation of receiving the influenza vaccine for the current season, nor was there evidence of written consent or refusal for the vaccine. The Infection Control Nurse was unable to provide a reason for the absence of vaccination or consent documentation for this resident. Another resident, who had a Conservator of Person as the responsible party and was moderately cognitively impaired, received influenza vaccinations over multiple years. While there was documentation of consent and provision of a Vaccination Information Sheet (VIS) in previous years, for the most recent vaccination, there was no indication that the resident or their conservator received education on the benefits and potential side effects of the vaccine. Nursing notes confirmed the administration of the vaccine but did not document the provision of required education.
Failure to Maintain Required Bed Clearance in Resident Room
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Type 2 diabetes mellitus, who was moderately cognitively impaired and independent with bed mobility and transfers, was observed with the left side and foot of their bed positioned directly against the wall. This arrangement did not maintain the required three-foot clearance around the bed. The issue was confirmed during multiple observations, including one with the facility Administrator present, who acknowledged the bed's placement and discussed the lack of current waivers for the room size. Further review revealed that the facility did not have a policy regarding bed clearance and could not provide documentation of a room audit that was reportedly conducted to ensure compliance in other rooms. The Administrator referenced previous waiver requests from 2019 and explained that the room's size necessitated the bed's placement to accommodate wheelchair access to the bathroom. However, no current waivers were in place, and the facility failed to ensure the required clearance for the resident's bed.
Inadequate Surety Bond Coverage for Resident Trust Accounts
Penalty
Summary
The facility failed to ensure adequate coverage of resident personal funds deposited with the facility, as required for the security of resident trust accounts. Review of the Resident Trust Account (RTA) balances over several months revealed that the account balances frequently exceeded the $100,000 surety bond coverage in place from June 3, 2024, through June 3, 2025. Specifically, during the period from July 1, 2024, through July 31, 2024, the RTA balance reached as high as $304,637.38, far surpassing the bond coverage. Other months also showed balances well above the $100,000 limit, with amounts ranging from over $100,000 to nearly $190,000 at various times. Interviews and documentation review indicated that the facility did not regularly monitor the adequacy of the surety bond coverage in relation to the fluctuating RTA balances. The Administrator acknowledged being unaware that the resident trust account regularly exceeded the bond coverage limit and confirmed that there was no routine process in place to ensure the bond amount matched or exceeded the highest RTA balances. The facility's policy required all resident funds entrusted to the facility to be covered by the surety bond, but this was not consistently achieved during the review period.
Failure to Update Care Plans for Residents on Secured Unit
Penalty
Summary
The facility failed to ensure that the care plans for six residents were reviewed and revised in a timely manner to include their placement on a secured unit. Each of these residents had diagnoses such as Alzheimer's disease or dementia, with varying levels of cognitive impairment as documented in their Minimum Data Set (MDS) assessments. Despite being admitted to a secured unit, their Resident Care Plans (RCPs) did not reflect this placement, nor did they include interventions or documentation specific to residing on a secured or locked unit. Clinical record reviews confirmed that all six residents were admitted to the secured unit on specific dates, yet their care plans lacked any mention of this significant aspect of their care environment. Observations during the survey verified that these residents resided on the secured unit, which required a code for entry and exit, accessible only to staff. The care plans instead focused on general interventions related to cognitive loss, behavioral health, and support, without addressing the unique needs or considerations associated with living on a secured unit. An interview with the Director of Nursing (DON) revealed that, although individualized care plans were developed for each resident, the DON did not believe that residing on a secured unit needed to be included in the care plans. Review of the facility's care plan policy indicated that care plans should be comprehensive, person-centered, and updated to reflect changes in the resident's needs and environment, including after each assessment. However, the care plans for these residents were not updated to include their placement on the secured unit, contrary to facility policy and regulatory expectations.
Failure to Assess and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to ensure that six residents placed on a secured unit were properly assessed for clinical criteria requiring such placement and did not obtain consent for their placement. Clinical record reviews for all six residents revealed that there was no documentation of an assessment being completed or consent being obtained prior to their admission to the secured unit. The residents involved had diagnoses including Alzheimer's disease and dementia, with varying levels of cognitive impairment as indicated by their BIMS scores and care plans. Some residents were noted to be severely cognitively impaired, while others were cognitively intact, yet all were admitted to the secured unit without the required documentation. Observations during the survey confirmed that these residents resided on a secured unit where access and egress were controlled by a keypad code known only to staff. Additional record reviews failed to identify documentation of the clinical criteria used for placement on the secured unit by the physician or the interdisciplinary team prior to a specified date. There was also no evidence that residents or their representatives were involved in the decision-making process for placement in the secured unit prior to that date. Interviews with facility staff confirmed that, although there was a policy outlining criteria for admission to the secured dementia unit, the facility was unable to provide documentation of assessments or consents for residents placed on the unit before a change in facility ownership. The facility's policy required a medical diagnosis, evidence of functional decline, behavioral changes, and a medical assessment confirming the need for specialized care in a secure environment, but there was no documentation that these criteria were met or that consent was obtained for the residents in question.
Failure to Protect Resident from Physical and Verbal Abuse During Wound Care
Penalty
Summary
A deficiency occurred when a resident with a Stage III pressure ulcer, type 2 diabetes, and chronic pain syndrome was not protected from physical and verbal abuse by a staff member. The resident, who was cognitively intact and required moderate assistance with activities of daily living, reported that a charge nurse was aggressive during a dressing change, did not follow the physician's wound care orders, and made dismissive comments when the resident attempted to provide input on their care. Documentation and interviews confirmed that the nurse told the resident not to instruct her on how to do her job and performed the dressing change in a manner the resident described as rough and uncomfortable. The nurse did not apply the soaked gauze as ordered and completed the dressing change in a time frame inconsistent with the prescribed procedure. Facility records, including nurse and social service notes, corroborated the resident's account of the incident, noting the resident's preference for how care was provided and the staff member's failure to listen and adhere to the care plan. The Director of Nursing's review of video footage further indicated that the nurse was not in the room long enough to perform the wound care as ordered. The facility's policies require prevention of abuse and respect for resident rights, but these were not upheld in this instance, resulting in the resident experiencing both physical and verbal mistreatment during a necessary medical procedure.
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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