Autumn Lake Healthcare At Cromwell
Inspection history, citations, penalties and survey trends for this long-term care facility in Cromwell, Connecticut.
- Location
- 385 Main Street, Cromwell, Connecticut 06416
- CMS Provider Number
- 075263
- Inspections on file
- 21
- Latest survey
- July 25, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Cromwell during CMS and state inspections, most recent first.
The facility was found to have multiple deficiencies in food storage and sanitation practices. Observations included undated and improperly stored food items, unsanitary conditions in the kitchen and storage areas, and a lack of adherence to facility policies on cleanliness and food safety. The Dietary Manager was unaware of some issues, such as dirt and debris from recent air conditioner installation.
The facility did not submit PBJ data for the third quarter of 2023 as required by CMS. The Administrator was aware of this issue and noted that the corporate office was responsible for the submission but failed to do so.
The facility failed to maintain a safe and clean environment across multiple units, with issues such as exposed plumbing, discolored ceiling tiles, broken window blinds, and missing cover plates. The DOM was unaware of how long these problems persisted, indicating a lack of oversight and prompt action.
The facility failed to report resident-to-resident altercations to appropriate agencies. In one case, a resident with dementia was involved in altercations with another resident, resulting in physical contact. The DNS did not notify Adult Protective Services due to a lack of awareness of reporting requirements. In another incident, a cognitively impaired resident touched another resident inappropriately, but the facility did not report it to the state agency, believing there was no malintent. Additionally, a physical altercation over a cellphone occurred between two residents, but Adult Protective Services were not informed.
The facility failed to provide food at a palatable and safe temperature, as reported by several residents who received cold and unappealing meals. A test tray confirmed that the meatloaf and cheesecake were not within acceptable temperature ranges, with issues attributed to a non-functioning pellet plating system and improper storage of desserts.
A resident with hemiplegia and chronic incontinence did not receive timely incontinent care, as required by their care plan. Observations showed a 4-hour gap in care, with dried fecal material found on the resident. Interviews with staff revealed inconsistencies in care timing, and no specific incontinence care policy was provided.
The facility failed to monitor fluid intake for two residents with kidney failure on fluid restrictions, leading to deficiencies in care. One resident with chronic kidney disease had a fluid restriction of 1200 ml per day, but records did not indicate total intake for each 24-hour period. Another resident with end-stage renal disease had intake records not exceeding 480 ml per day without a 24-hour total documented. Staff interviews revealed a lack of process to monitor fluid goals, contributing to the deficiency.
A LTC facility failed to follow physician orders for two residents, leading to deficiencies in medication administration. One resident did not have blood pressure monitored as required before Atenolol administration, resulting in over 340 missed readings. Another resident received incorrect Vitamin D3 dosage and Procrit was administered despite hemoglobin levels exceeding prescribed limits. The facility's medication administration policies were not adequately followed.
A facility failed to maintain proper infection control during wound care for a resident with a stage 4 pressure ulcer, as an LPN did not wear a gown despite EBP requirements. Additionally, the facility's laundry services were found to be unclean, with debris on equipment and improper storage of clean laundry. The facility's policies lacked detailed procedures for maintaining cleanliness in the laundry area.
The facility did not act on concerns raised by the Food Committee, as residents reported that their feedback was not addressed. Specific requests for meal preferences were documented but not implemented, and the Dietary Department lacked a policy for responding to these concerns.
A resident with a new diagnosis of schizoaffective disorder was not referred for a Level II PASRR evaluation as required. Despite the resident's significant change in mental health status, the facility did not submit the necessary referral to the state-designated authority. The social worker, new to the facility, was unaware of the oversight, which was contrary to the facility's policy on coordinating assessments with the PASRR program.
The facility failed to properly date and discard multi-dose vials and expired medications, as observed in several medication storage rooms. Opened vials of Tuberculin PPD and Lidocaine lacked proper dating, and expired medications like Biotin and Omeprazole were not discarded timely. Staff interviews revealed a lack of awareness of the facility's policy on medication dating and disposal, and the facility could not provide a specific policy for multi-use vials.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and sanitation standards in the Dietary Department, as observed during a tour with the Dietary Manager. Several deficiencies were noted, including an accumulation of dust and debris on the threshold of the walk-in refrigerator, and multiple open food items such as hotdogs, Ricotta cheese, pancakes, omelets, French toast, and pork crumble that were not dated with open or expiration dates. Additionally, the Ricotta cheese was found with a black and orange-like substance, and the container for Spanish onions was visibly dirty and uncovered. The ice machine had a heavy accumulation of white and dark substances inside, and dust on the side vents, indicating a lack of regular cleaning. In the Dry Storage room, a bag of dried cranberries was found open to air, and heavy dirt and debris were observed behind the can shelving near the air conditioner. The Dietary Manager was unaware of the dirt and debris, attributing it to recent air conditioner installation. Furthermore, a stained ceiling tile was noted in the third-floor Nourishment Room. The facility's policies on maintaining clean and sanitary food preparation and storage areas were not adhered to, as evidenced by the unsanitary conditions and improper food storage practices observed during the survey.
Failure to Submit PBJ Data for Third Quarter 2023
Penalty
Summary
The facility failed to submit Payroll Based Journal (PBJ) data for the third quarter of 2023, which includes the months of April, May, and June, as required by the Centers for Medicare and Medicaid Services (CMS). During an interview and review of facility documentation on July 25, 2024, the Administrator acknowledged awareness of the failure to submit the PBJ data. The Administrator indicated that the responsibility for submitting the PBJ data to CMS lay with the facility's corporate office, which did not fulfill this obligation.
Environmental Deficiencies Across Multiple Units
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents across multiple units, as observed during surveys conducted on two separate days. On the Elm Unit, several issues were identified, including exposed plumbing and wall studs due to missing drywall and tile, discolored ceiling tiles with a black substance, and peeling paint with holes in the drywall. The Director of Maintenance (DOM) was unable to specify how long these issues had persisted, indicating a lack of awareness and oversight. On the Maple Unit, similar deficiencies were noted, such as a fallen radiator faceplate, broken window blinds, a permanently locked bathroom door handle, and discolored ceiling tiles. The DOM again expressed uncertainty regarding the duration of these problems, suggesting that they were not promptly identified or addressed during environmental rounds. Additionally, the Oak Unit exhibited issues like stained toilet bowls, exposed sheetrock, missing cover plates with exposed wires, and dusty bathroom vents. The DOM acknowledged that some of these issues were missed during previous inspections. The Hickory Unit also had notable deficiencies, including holes stuffed with paper towels and a missing faceplate cover above a resident's bed. The DOM confirmed that environmental rounds are conducted quarterly, and maintenance logs are reviewed routinely. However, the persistence of these issues across multiple units indicates a systemic failure to ensure a safe and sanitary environment for residents, as the DOM admitted that the identified concerns were unacceptable.
Failure to Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report allegations of mistreatment involving resident-to-resident altercations to the appropriate agencies, including Adult Protective Services and the state survey agency. In one instance, a resident with dementia and hallucinations, identified as Resident #20, was involved in two separate altercations with another resident, Resident #153, who also had dementia and hallucinations. During these incidents, Resident #20 slapped Resident #153, and in another instance, hit Resident #153 in the face. Although the police and responsible parties were notified, Adult Protective Services were not informed, as the Director of Nursing Services (DNS) was unaware of the requirement to report such incidents. In another case, Resident #140, who was severely cognitively impaired, was observed touching another resident, Resident #80, on the chest over clothing. Despite the incident being reported to the DNS and an internal investigation being conducted, the facility did not report the incident to the state survey agency. The DNS and other staff believed that due to the cognitive impairments of both residents, there was no malintent, and thus, the incident was not reportable. Additionally, an altercation occurred between Resident #20 and Resident #668, where Resident #668 attempted to take Resident #20's cellphone, leading to a physical confrontation. Both residents sustained minor injuries, and while the police and responsible parties were notified, Adult Protective Services were not informed. The DNS admitted to being unaware of the state guidelines requiring notification of Adult Protective Services in such cases.
Food Temperature and Palatability Deficiency
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the food, citing issues such as receiving cold meals, unappealing presentation, and a lack of awareness about meal options. Specific complaints included cold food, mushy vegetables, and a general lack of appeal in the meals provided. These observations were corroborated by interviews with several residents who expressed their dissatisfaction with the quality and temperature of the food served. A test tray conducted with the Dietary Manager revealed that the food temperatures were not within the acceptable range. The meatloaf's internal temperature was significantly below the palatable temperature of 135 degrees Fahrenheit, and the cheesecake was served at a temperature much higher than the recommended 38 to 40 degrees Fahrenheit. The Dietary Manager identified that the cheesecake was stored on an open metal cart for an extended period, contributing to its high temperature, while the low temperature of the meatloaf was attributed to a non-functioning pellet plating system.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to Resident #103, who was diagnosed with hemiplegia and hemiparesis following a stroke and was always incontinent of bowel and bladder. The resident was totally dependent on staff for bed mobility and toileting hygiene. The care plan required that the resident receive incontinent care every 2 hours and as needed. However, observations on 7/24/24 revealed that the resident had not received care for approximately 4 hours, as dried fecal material was found on the resident's buttocks, indicating a lack of timely care. Interviews with nursing assistants and the LPN revealed inconsistencies in the timing of care provided to the resident. NA #2 claimed to have provided care at 7:45 AM and checked the resident at 11:00 AM, but the surveyor did not observe NA #2 entering the room at that time. The LPN expected care to be provided every 2 hours, but the resident was not checked until 11:39 AM. The Director of Nursing Services stated that care is given 4 times a shift and as needed, but no specific policy for incontinence care was provided upon request.
Failure to Monitor Fluid Intake for Residents on Fluid Restrictions
Penalty
Summary
The facility failed to implement a systematic approach to assess daily fluid intake for residents with kidney failure on fluid restrictions, leading to deficiencies in care for two residents. Resident #94, diagnosed with chronic kidney disease Stage 4 and diabetes, had a physician's order for a fluid restriction of 1200 ml per day. However, the Medication Administration Record (MAR) did not indicate a total fluid intake for each 24-hour period, and the clinical record lacked calculations of total fluid intake from 7/14/24 through 7/20/24. Interviews revealed that the facility did not have a mechanism to total fluid intake every 24 hours, and there was no designated staff to monitor if the fluid goal was met or exceeded. Resident #152, with diagnoses including end-stage renal disease and congestive heart failure, was also on a fluid restriction of 1200 ml per day. Observations noted dry mucous membranes, and intake and output records showed documentation that did not exceed 480 ml per day without a 24-hour total documented. The Director of Nursing Services (DNS) acknowledged that the intake and output record flowsheets were not part of the official clinical record and that a total intake for 24 hours was not documented. Interviews with staff indicated a lack of process to identify when a resident did not meet their fluid goal for consecutive days. The facility's policy directed staff to record fluid intake and total amounts at the end of each shift, but this was not consistently followed. The clinical record for Resident #152 failed to reflect documentation of total fluid intake meeting the fluid restriction, with 14 days of documented amounts not totaling over 800 ml for 24 hours. There was no corresponding nursing staff documentation or assessments to indicate the resident's hydration status when fluid intake did not meet 800 ml. The facility lacked a process to tally 24-hour totals and identify deviations from fluid goals or restrictions, contributing to the deficiency.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in medication administration. For Resident #25, who had diagnoses including hypertension and atrial fibrillation, the physician ordered Atenolol to be administered with specific parameters: holding the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60 beats per minute. However, the facility did not consistently take the resident's blood pressure before administering the medication, resulting in over 340 missed blood pressure readings. Interviews with LPNs revealed that the electronic system did not prompt for a blood pressure reading, contributing to the oversight. For Resident #107, who had conditions such as anemia and chronic myeloid leukemia, there were multiple issues with medication orders. A pharmacy consultant recommended a change in Vitamin D dosage, which was misinterpreted by the APRN, leading to the resident receiving Vitamin D3 50,000 units twice a month instead of once. Additionally, the resident was to receive Procrit with specific parameters to hold the medication if hemoglobin levels were above 10. Despite this, Procrit was administered when the hemoglobin was 11.1 and 10.1 on separate occasions, contrary to the physician's orders. The APRN and LPNs involved were unaware of the errors in medication administration. The facility's policies on administering medications and following physician orders were not adequately followed, as evidenced by the lack of pre-administration assessments and incorrect medication orders. The absence of a facility policy for physician orders further compounded the issue, leading to the administration of unnecessary medications and failure to adhere to prescribed parameters.
Infection Control and Laundry Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain proper infection control techniques for Enhanced Barrier Precautions (EBP) during wound care for a resident with subacute osteomyelitis and a stage 4 pressure ulcer. The resident was cognitively intact and dependent on staff for various activities. Despite the presence of EBP signage and a physician's order requiring EBP, an LPN performed wound care without wearing a gown, as required. The LPN was unaware of the EBP requirement for the resident and only realized the oversight after reviewing the Medication Administration Record and Treatment Administration Record. The Infection Preventionist confirmed that the nurse should have worn a gown and gloves during wound care, and noted that the facility was still working on staff education regarding EBP. In the facility's laundry services, the environment was not maintained in a clean state, as observed in the laundry room. There was a moderate buildup of debris on washers, dryers, and other surfaces, and a dark gray substance on the ceiling fan and filters. The Regional Environmental Services Manager, who visits the facility weekly, acknowledged the need for thorough cleaning, as similar conditions had been observed previously. The Environmental Services Director also noted issues with open windows allowing substances to re-enter the dryer room, where clean laundry was stored uncovered. Despite the cleaning schedule being signed off as completed, the observed conditions indicated otherwise. The facility's laundry policy did not include specific procedures for clean laundry operations, such as drying, folding, storage, or cleaning of the laundry areas. This lack of detailed policy contributed to the deficiencies observed in maintaining a clean environment for laundry processing. The facility's failure to ensure proper infection control and environmental cleanliness in the laundry area highlights significant lapses in adherence to established protocols and procedures.
Failure to Address Food Committee Concerns
Penalty
Summary
The facility failed to address concerns raised by the Food Committee, as evidenced by interviews with residents and staff, and a review of committee minutes. During a Resident Council meeting, two residents reported that despite providing feedback during monthly Food Committee meetings, no corrective actions were taken. Specific requests from residents, such as smaller portions, no bread, dislike of pork, and preferences for egg servings, were documented in the committee minutes but were not acted upon by the Dietary Department. The Regional Dietary Manager's review of food tickets from January to July 2024 confirmed that no notes were added to reflect these requests. Additionally, the Dietary Manager acknowledged the absence of a policy for responding to Food Committee concerns.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation and determination after a new psychiatric diagnosis was identified. The resident, who was initially screened with a PASRR Level I on March 4, 2020, was diagnosed with schizoaffective disorder in September 2020. Despite this significant change in the resident's mental health status, the facility did not submit a referral for a Level II PASRR evaluation to the appropriate state-designated authority. The resident's medical history included dementia, congestive heart failure, and a new diagnosis of schizoaffective disorder. Psychological service notes from September 2020 and May 2022 confirmed the presence of a psychotic disorder and schizoaffective disorder, respectively. The resident's care plan, updated in January 2024, acknowledged the psychosocial wellbeing problem related to the schizoaffective disorder. However, the social worker, who began working at the facility in 2023, was unaware of why the Level II PASRR had not been completed and admitted that it might have been overlooked. The facility's policy mandates coordination with the PASRR program to ensure appropriate care for residents with mental diseases, but this was not adhered to in this case.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to adhere to its medication storage policies, resulting in several deficiencies related to the handling of multi-dose vials and expired medications. During a review of the medication storage rooms, it was observed that a vial of Tuberculin PPD on the Maple Unit was opened and dated 2/28/24, well beyond the 30-day usage period. Additionally, a vial of Lidocaine on the same unit was opened but lacked an opening date. On the Oak Unit, a bottle of Biotin with an expiration date of 1/2024 was found, and two bottles of Omeprazole suspension were noted to be expired, with one opened and dated 5/20/24 and the other sealed but expired on 7/18/24. Similarly, on the Elm Unit, a vial of Tuberculin PPD was opened and dated 3/13/24, exceeding the recommended usage period. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding the dating and disposal of multi-dose vials. The ADNS and Infection Control Nurse confirmed that the policy required dating upon opening and discarding after 30 days, but an LPN was unaware of this policy. Pharmacists highlighted the importance of adhering to expiration dates to prevent infection risks. Despite requests, the facility could not provide a specific policy for multi-use medication vials, indicating a gap in documentation and staff training.
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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