Autumn Lake Healthcare At Madison
Inspection history, citations, penalties and survey trends for this long-term care facility in Madison, Connecticut.
- Location
- 34 Wildwood Avenue, Madison, Connecticut 06443
- CMS Provider Number
- 075405
- Inspections on file
- 32
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Madison during CMS and state inspections, most recent first.
The facility failed to notify the responsible party timely when a resident developed a new deep tissue injury (DTI). Despite the resident's high risk for skin breakdown and the facility's policy requiring immediate notification, the charge nurse did not document or recall notifying the family. The Director of Nursing confirmed the necessity of such notifications but could not provide evidence that it was done.
A facility failed to maintain complete and accurate medical records for a resident receiving end-of-life care. The records lacked documentation of ADL care, hospice services, and the assessment at the time of death due to a change in ownership and missing records from the prior owner.
The facility failed to prevent and treat pressure ulcers for two residents. One resident developed an unstageable pressure ulcer due to inadequate repositioning and off-loading, while another resident's new pressure ulcer was not properly assessed or treated. Staff did not adhere to policies, and documentation was inconsistent.
The facility failed to adequately staff NAs, resulting in unmet care needs for residents. One resident with dementia was observed with poor hygiene due to insufficient staffing. Another resident with Alzheimer's had long, dirty nails, and a third resident with Down Syndrome was inadequately supervised, leading to unsafe behavior. Staff interviews and facility records confirmed frequent understaffing and restricted use of agency staff.
The facility failed to provide adequate snacks for residents during a 15-hour gap between dinner and breakfast. Snacks were only given upon request and were insufficient, with some units not receiving snack carts for weeks, contrary to facility policy.
The facility failed to follow infection control practices, leaving a resident's room in disarray and lacking required policies for undiagnosed respiratory illness and early detection of potentially infectious residents. This indicates significant gaps in the facility's infection control program.
The facility failed to adequately respond to resident grievances, including early supper meal times, lack of alternative meal choices, and staff discussing personal information loudly. Despite being aware of these issues, the facility did not take effective action to resolve them.
The facility failed to maintain a clean, comfortable, and homelike environment. Observations revealed trash on floors, deteriorated window seats, and broken wood molding in resident rooms. Interviews indicated that maintenance relied on staff notifications for repairs and did not perform routine audits. The facility also lacked an environmental condition and/or repair policy.
The facility failed to provide adequate personal hygiene care to several residents, resulting in long, soiled fingernails and unshaven facial hair. Staff cited staffing shortages and dull razors as reasons for the neglect, and nursing notes did not document any refusal of care by the residents.
The facility failed to label oxygen tubing for residents requiring oxygen therapy, despite physician orders. Multiple residents with conditions such as COPD, anoxic brain damage, and dementia were observed with unlabeled oxygen tubing. Staff confirmed the tubing was not labeled and did not routinely change it as required.
The facility failed to complete annual performance appraisals for two nurse aides. One aide's last appraisal was not dated, and another's was five years old. The Administrator cited inconsistent staffing and multiple changes in the DNS position as reasons for the lapse. Facility policy mandates annual appraisals and in-service education based on these reviews.
The facility failed to ensure behavior monitoring for two residents receiving psychotropic medications. One resident with dementia and agitation was prescribed Risperidone, and another with Down Syndrome and Alzheimer's was prescribed Olanzapine. In both cases, there was no documented behavior monitoring, contrary to facility policy.
The facility failed to provide dental services for a resident with significant medical conditions, despite multiple evaluations indicating the need for a dental consult. The resident had not seen a dentist since admission over a year and eight months ago, and the required permission forms were not completed by the admitting nurse.
The facility failed to ensure safe water temperatures in resident areas, with multiple instances of bathroom sink water temperatures exceeding the safe limit of 120 degrees Fahrenheit. The Director of Maintenance did not follow the facility's policy for monitoring and adjusting water temperatures and failed to notify the Administrator of the excessive temperatures.
The facility failed to ensure that two nurse aides completed the mandatory 12 hours of in-service education annually, including dementia care training. The training records were incomplete, and the facility could not provide an annual in-service training policy.
A resident with a suprapubic catheter was observed in the dining area with an exposed urinary collection bag. The OT assisting the resident was unaware of the need for a privacy cover, and the DNS confirmed the policy but could not provide a written document.
The facility failed to ensure accurate documentation and updating of advance directives for three residents. Discrepancies were found in the code status of one resident, while two others lacked documented advance directives upon admission. Staff interviews revealed confusion and lack of clarity regarding responsibilities for updating records.
A resident with dementia and other health issues experienced significant weight loss over three months. The facility failed to notify the resident's representative, and the dietician confirmed the lack of a specific policy for such notifications, highlighting a systemic communication issue.
A resident with Down Syndrome and Alzheimer's was found restrained to their wheelchair with a bed sheet due to insufficient staffing and inadequate supervision. The restraint was discovered by an SLP, who reported the incident, revealing ongoing staffing issues and inadequate behavioral interventions in the care plan.
A resident with multiple diagnoses, including Down Syndrome and Alzheimer's, was found restrained to a wheelchair by a bed sheet. The incident, admitted by a nursing assistant, was not reported to managerial staff until three days later, and the Administrator delayed reporting to the state agency, citing a lack of information from a witness. This delay violated the facility's abuse reporting policy.
The facility failed to update and implement new interventions in the care plans for several residents following significant events, including falls and the development of pressure ulcers. Care plans were not revised to reflect increased needs or to prevent further incidents, leading to inadequate care and safety measures.
The facility failed to provide appropriate foot care for a resident with chronic kidney disease, total hip arthroplasty, and gout. Despite a physician's order to consult podiatry as needed and multiple requests for foot care, no referral was made. Observations revealed the resident's toenails were long and curling forward, and the facility's Foot Care policy was not followed.
The facility failed to implement care plan interventions, provide adequate supervision, and conduct risk assessments following falls for three residents. Despite being identified as fall risks, the residents experienced unwitnessed falls due to inadequate monitoring and non-compliance with fall protocols.
The facility failed to notify the Ombudsman regarding multiple hospital transfers of a resident with heart failure, anemia, and dementia. Despite several medical emergencies requiring hospital transfers, the facility did not follow its policy for timely notification, as confirmed by interviews with the Social Worker and the Ombudsman.
The facility failed to notify a resident's representative in writing about the bed hold policy during multiple hospital transfers, despite the resident's moderate cognitive impairment and need for assistance. The Business Office Manager acknowledged the oversight, noting a recent shift in responsibility for completing the notifications.
Failure to Notify Responsible Party of Change in Skin Integrity
Penalty
Summary
The facility failed to ensure the responsible party was notified timely when a change in skin integrity was identified for Resident #1. Resident #1, who was admitted with diagnoses including schizoaffective disorder, generalized muscle weakness, and senile degeneration of the brain, was at risk for skin breakdown due to inadequate oral intake, fragile skin, incontinence, and limited mobility. Despite interventions such as floating heels while in bed and using a low-loss mattress, a deep tissue injury (DTI) was identified on Resident #1's right foot by a wound Nurse Practitioner (NP) on 10/23/2023. However, the clinical record review failed to show that the responsible party was notified of this new DTI. Interviews with the infection control/wound nurse and the charge nurse revealed that the charge nurse was responsible for notifying the family and documenting the notification in the clinical record. The charge nurse on duty at the time of the DTI identification could not recall if the family was notified and acknowledged that if it was not documented, it was not done. The Director of Nursing (DON) confirmed that notification to the physician and family was necessary for new pressure areas but was unable to provide documentation that the family was notified. The facility's policy on Change in Condition: Notification of, dated 6/1/2021, directed that the facility must immediately inform the resident's health care authority or Health Care Decision Maker of significant changes in the resident's physical status or the need to commence new treatment.
Incomplete Medical Records and Documentation for End-of-Life Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was receiving end-of-life care. The resident, who had diagnoses including schizoaffective disorder, generalized muscle weakness, and senile degeneration of the brain, was at risk for skin breakdown and had a Stage III pressure ulcer. However, the facility did not have documentation of Activities of Daily Living (ADL) care for a specific period due to a change in ownership, and the requested documentation from the prior owners was not available for review. This lack of documentation was against the facility's ADL policy, which required real-time recording of ADL care in the medical record. Additionally, the resident was on hospice services, but the medical record lacked the hospice election form and documentation of hospice services provided during a specific month. The facility's hospice policy required obtaining the hospice election form and documenting all hospice care provided. The Director of Nursing (DON) acknowledged the missing documentation and indicated that a request had been made to the prior owner's corporate office and the hospice service provider to obtain the necessary records. Furthermore, the facility failed to document the assessment of the resident at the time of death. Although a registered nurse (RN) pronounced the resident's death and notified the family, the RN did not document the assessment criteria used to determine death, as required by the facility's Pronouncement of Death policy. The policy mandated detailed documentation of the clinical criteria for pronouncing death, including vital signs, pupil reaction, and other physical assessments. The DON confirmed that the facility did not have access to the prior owner's electronic medical records and had requested the missing documentation.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and provide necessary treatment for two residents. For Resident #9, the facility did not ensure timely turning, repositioning, and off-loading of heels, failed to conduct pressure ulcer risk assessments per policy, and did not perform weekly skin assessments. Despite Resident #9's decline in condition due to pneumonia and urinary tract infection, the care plan was not updated to reflect the increased need for assistance. This led to the development of an unstageable pressure ulcer on the left heel, which worsened over time due to inadequate off-loading and repositioning by staff. For Resident #62, the facility failed to conduct an initial pressure ulcer assessment, obtain initial measurements, inform the wound nurse of the new pressure ulcer, and ensure off-loading of the pressure area. Despite a physician's order for heel boots at all times, Resident #62 was observed without heel boots on multiple occasions. The facility's documentation did not reflect the presence of a new pressure ulcer, and the wound nurse was not informed, leading to a lack of appropriate treatment and monitoring. Interviews with staff revealed a lack of adherence to the facility's policies and procedures for pressure ulcer prevention and care. Staff failed to implement new interventions when residents' conditions changed, did not conduct required assessments, and did not ensure proper off-loading of pressure areas. The facility's documentation was inconsistent and did not accurately reflect the residents' needs or the care provided, contributing to the development and worsening of pressure ulcers in both residents.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to adequately staff Nurse Aides (NAs) throughout the facility, resulting in unmet resident care needs. Resident #21, diagnosed with dementia and heart disease, was observed with long, dirty fingernails and unshaven facial hair, indicating a lack of personal hygiene care. Despite requiring extensive assistance, the resident's hygiene needs were not met due to insufficient staffing, as confirmed by NA #2, who stated that hygiene tasks were often neglected when the facility was understaffed. The facility's documentation and interviews revealed that the required number of staff was rarely met, leading to compromised care for residents like Resident #21. Resident #53, diagnosed with Alzheimer's disease and major depressive disorder, was also observed with long, jagged nails and dried blood on their hands. Despite the care plan indicating the need for extensive assistance with personal hygiene, the resident's nails remained untrimmed and dirty. Interviews with NAs revealed that nail care and other hygiene tasks were only completed when the facility was fully staffed, which was not often the case. The NAs reported having assignments of up to 12 residents when short-staffed, making it difficult to provide adequate care. Resident #527, diagnosed with Down Syndrome and Alzheimer's Disease, exhibited behaviors such as disrobing and attempting to self-transfer, requiring close supervision. However, due to staffing shortages, the resident was not adequately monitored, leading to incidents of self-harm and unsafe behavior. On one occasion, an NA resorted to restraining the resident with a bed sheet due to the inability to provide proper supervision. Interviews with staff and review of facility records confirmed that the unit was frequently understaffed, with managerial staff acknowledging the lack of sufficient personnel to meet the residents' needs. The facility's corporate policies further restricted the use of agency staff, exacerbating the staffing issues and compromising resident care.
Inadequate Snack Provision for Residents
Penalty
Summary
The facility failed to provide adequate snacks for residents when mealtimes exceeded 14 hours. Observations and interviews with residents revealed that snacks were only provided upon request and consisted of small items such as cookies, cookie bars, applesauce, or juice, which residents did not consider adequate or substantive. The meal schedule showed a 15-hour gap between dinner at 4:30 PM and breakfast at 7:30 AM, during which residents were not provided with sufficient nourishment. Interviews with dietary staff and nursing aides indicated inconsistencies in the delivery of snack carts to the units, with some units not receiving snack carts for weeks at a time. The facility's policy stated that evening snacks should be planned as part of the menu and that stock foods should be stored for use on nursing units. However, observations and staff interviews confirmed that this policy was not being followed, leading to residents not receiving the necessary nourishment during long gaps between meals.
Infection Control Deficiencies
Penalty
Summary
The facility failed to follow infection control practices on one of its units, specifically in the case of Resident #53. Resident #53, who has Alzheimer's disease, cognitive communication deficit, and inflammatory polyarthropathy, was observed in a room with a full trash can on the bedside chair and soiled linens and incontinent pads on the floor. The resident's care plan indicated they required extensive assistance with activities of daily living, including bed mobility, dressing, personal hygiene, and bathing. A housekeeper confirmed that the room should not have been left in such a state and suggested that staff often leave rooms messy, making it difficult for her to maintain cleanliness given her workload of 40 rooms per shift. This indicates a lapse in maintaining a clean environment for the resident, which is crucial for infection control. Additionally, the facility's infection control program was found lacking required policies for undiagnosed respiratory illness and a plan for early detection and management of potentially infectious residents. During an interview, a registered nurse was unable to locate these policies or provide guidance on them, and neither she nor the Director of Nursing Services could find the missing policies. The facility's Infection Control Outcome and Process Surveillance and Reporting policy, last revised on 2/1/23, mandates regular surveillance and compliance monitoring, but the absence of these critical policies indicates a significant gap in the facility's infection control program.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately respond to resident grievances as identified in the Resident Council meeting minutes. Residents expressed concerns about the early arrival of supper meals and the lack of alternative meal choices. Despite these concerns being documented and communicated to the dietary staff, the issue persisted. Additionally, residents reported that they were left in bed until lunch due to staffing shortages, and their beds were not made or changed after they got up. Staff were also heard discussing personal information loudly in the hallways and using inappropriate language. These issues were raised multiple times in Resident Council meetings, but the facility did not take effective action to resolve them. Interviews with the Director of Dietary and the Director of Nursing Services (DNS) revealed awareness of the issues but highlighted systemic problems such as the lack of a Human Resources staff member and restrictions on using agency staff due to cost. The DNS admitted that the facility was aware of the staffing issues but had not been informed about the specific concern regarding the early arrival of dinner. The Director of Dietary acknowledged the problem but indicated that it persisted when a manager was not present. The facility's grievance policy mandates prompt investigation and resolution of concerns, which was not adequately followed in this case.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure equipment and furniture were maintained in a clean, comfortable, and homelike manner. During an initial facility tour, trash was observed on the floors in the hallways and in several resident rooms. In one room, a medicine cup with white powder was found on the floor, and used medical gloves were seen in flower boxes. Additionally, a piece of wood molding under a window seat was broken, exposing a sharp edge. Multiple rooms had window seats that were significantly deteriorated, with cracked, peeling, and discolored padding, and worn wood cabinets with no protective finish. Interviews with the Director of Maintenance and the Maintenance Assistant revealed that maintenance was responsible for maintaining the furnishings but relied on staff to notify them of needed repairs. The Director of Maintenance was unaware of the disrepair in certain rooms and indicated that routine audits or rounds to observe room conditions were not performed. The facility also failed to provide an environmental condition and/or repair policy when requested.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure personal hygiene care and services were provided to dependent residents, as evidenced by observations and interviews. Resident #21, diagnosed with dementia and heart disease, was observed with dark debris under fingernails and long facial hair on multiple occasions. Despite being identified as requiring assistance with personal hygiene, staff interviews revealed that hygiene tasks were often neglected due to staffing issues. Nursing notes did not indicate any refusal of care by the resident during the observed period. Resident #27, with severe cognitive impairment and cancer, was also found with dark debris under fingernails and long facial hair. Observations and staff interviews indicated that the resident's hygiene needs were not met, and staff cited dull razors and staffing shortages as reasons for the neglect. Nursing notes did not document any refusal of care by the resident. Similar issues were observed with Resident #46, who had long, soiled fingernails and substantial facial hair growth, and Resident #53, who had long, jagged nails with dark debris and dried blood. Resident #69, diagnosed with Alzheimer's disease and dementia, was observed with long fingernails and caked-on dark orange material in facial hair. Despite being totally dependent on staff for personal hygiene, the resident's needs were not met. Staff interviews confirmed that hygiene care was often delayed or neglected due to staffing shortages. Nursing notes did not indicate any refusal of care by the resident. The facility's policies on fingernail care and shaving were not adhered to, contributing to the deficiencies observed.
Failure to Label Oxygen Tubing
Penalty
Summary
The facility failed to appropriately label oxygen tubing for residents requiring oxygen therapy. Resident #4, diagnosed with anoxic brain damage and other conditions, was observed with unlabeled oxygen tubing despite a physician's order specifying oxygen administration at 2 liters per minute. Similarly, Resident #51, who has COPD and obstructive sleep apnea, was found with unlabeled oxygen tubing, contrary to the physician's order to change and label the tubing weekly. LPN #1 confirmed the tubing was not labeled and subsequently changed it after surveyor inquiry. Resident #57, with non-rheumatic aortic valve insufficiency and dementia, was also observed with unlabeled oxygen tubing, despite a physician's order for oxygen administration as needed. Additionally, Resident #279, diagnosed with COPD and heart failure, reported that staff did not routinely change the oxygen tubing, which was confirmed by RN #1. The facility did not provide a policy for oxygen equipment when requested, indicating a systemic issue in adhering to proper oxygen therapy protocols.
Failure to Complete Annual Performance Appraisals
Penalty
Summary
The facility failed to complete annual performance appraisals for two nurse aides, NA #10 and NA #11. NA #10's last performance appraisal was not dated by either the nurse aide or the next level manager, while NA #11's last performance appraisal was dated five years ago. The Administrator acknowledged the lapse, attributing it to inconsistent staffing and multiple changes in the Director of Nursing (DNS) position. The current DNS was attempting to catch up on tasks left incomplete by previous staff. According to the facility's policy, managers are required to conduct performance appraisals or performance-based conversations with employees at least annually, and in-service education should be provided based on these reviews.
Failure to Monitor Behaviors for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that behavior monitoring was completed for a resident receiving psychotropic medications. Resident #62, diagnosed with dementia with agitation, anxiety, and paranoid personality disorder, was prescribed Risperidone for agitation. Despite the care plan's directive to monitor for changes in mental status and functional level, no behavioral monitoring order was in place from 6/21/23 to 11/6/23. Nurse's notes and psychiatric notes lacked documentation of target behaviors or behavior monitoring, and interviews with staff confirmed the absence of such monitoring in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The Director of Nursing Services (DNS) acknowledged the lack of behavior monitoring and confirmed it was against facility policy, which mandates monitoring for residents on antipsychotic medications every shift. Similarly, Resident #527, admitted with Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was prescribed Olanzapine for behavioral disturbance. The physician's order did not include behavioral monitoring, and a review of the MAR, TAR, and nurse's notes from 10/13/23 to 11/13/23 showed no evidence of behavior monitoring. The DNS confirmed that behavioral monitoring should be conducted for residents with dementia on antipsychotic medications without a psychiatric diagnosis, but was unable to locate any such documentation in the clinical record. The facility's policy on managing behavioral symptoms, which requires staff to monitor and document exhibited behavioral symptoms, was not followed. The lack of behavior monitoring for both residents receiving psychotropic medications indicates a failure to adhere to the facility's policies and procedures. This deficiency was identified through clinical record reviews, facility documentation, and staff interviews, highlighting a significant oversight in the care and monitoring of residents with behavioral and psychiatric needs.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for Resident #61, who was admitted with diagnoses including end-stage renal disease, right above knee amputation, and coronary artery disease. The Resident Care Plan dated 2/25/22 identified the resident as being at risk for oral health or dental care problems due to tooth decay, with interventions including obtaining a dental consultation. Despite oral health evaluations on 2/25/22 and 2/26/23 indicating a dental consult was ordered, the resident had not been seen by a dentist since admission over one year and eight months ago. The resident expressed a desire to see a dentist, and observations confirmed the presence of scattered broken and discolored teeth. Interviews with the Director of Nurses (DNS) and RN #4 revealed that the admitting nurse was responsible for ensuring permission forms for dental services were completed, which had not been done. The DNS confirmed that the resident had not received a dental consultation, and RN #4 indicated that if permission was not obtained on admission, the facility had 24 hours to complete the paperwork. The facility's dental service policy mandates routine dental services, including annual inspections of the oral cavity, which were not provided to Resident #61.
Failure to Ensure Safe Water Temperatures
Penalty
Summary
The facility failed to ensure safe water temperatures in resident areas, as observed on multiple occasions. On 10/31/23, the bathroom sink water temperatures for several residents were found to be significantly above the safe limit of 120 degrees Fahrenheit, with temperatures ranging from 122.6 to 127.0 degrees Fahrenheit. The Director of Maintenance confirmed these findings but believed that temperatures up to 124 degrees Fahrenheit were acceptable. However, the facility policy stated that water temperatures should be between 105 and 120 degrees Fahrenheit. The Director of Maintenance also failed to notify the Administrator of these excessive temperatures and did not follow the proper procedure for adjusting the water temperatures, instead opting to adjust the cold water to bring the hot water down. The Administrator was unaware of the excessive water temperatures until the surveyor's inquiry and confirmed that the water temperature logs from 10/14/23 showed nine resident rooms with temperatures above 120 degrees Fahrenheit. The Director of Maintenance was unable to provide a full month of water temperature logs, only producing logs for 10/14/23. The Administrator acknowledged that the Director of Maintenance had not adhered to the facility's policy for taking water temperatures and stated that she would address this issue with him. The facility's Hot Water Temperatures: Inspection policy, last revised on 6/1/23, directed that hot water temperatures should be tested weekly and documented, but this procedure was not followed correctly.
Failure to Complete Mandatory In-Service Training
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA) #1 and NA #10 completed the mandatory 12 hours of in-service education annually. NA #1 completed only 5.78 hours of online training and attended in-person training sessions on Personal Protective Equipment (PPE) and hand washing, as well as on Abuse, Neglect, and Exploitation, but the duration of these sessions was not specified. Additionally, NA #1 did not receive any dementia care training. NA #10 did not complete any online training but attended the same in-person training sessions as NA #1, also without specified durations, and similarly did not receive dementia care training. An interview with RN #5 revealed that she was responsible for providing the education and in-service training through an online portal and in-person sessions, but she could not explain why the mandatory training was not completed. The facility also failed to provide an annual in-service training policy when requested.
Failure to Use Urinary Privacy Bag
Penalty
Summary
The facility failed to ensure a urinary privacy bag was utilized for Resident #477, who had a suprapubic catheter. Resident #477, diagnosed with a fracture of the left femur, benign prostatic hyperplasia with lower urinary tract symptoms, and dementia, was observed in the dining area with a urinary collection bag attached to the wheelchair without a privacy cover. The Nursing Admission Assessment indicated that Resident #477 required extensive assistance for personal hygiene, bathing, toileting, dressing, and transfers, and had a suprapubic catheter in place. An interview with the Occupational Therapist (OT) who assisted Resident #477 out of bed revealed that she was unaware of the need for a privacy cover for the urinary collection bag. The Director of Nursing (DNS) confirmed that the facility's policy required all urinary collection bags to have a privacy covering and that staff, including the therapy department, were educated on this policy. However, the facility was unable to provide a written policy regarding the use of privacy covers for urinary collection bags.
Failure to Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that Resident #21's current preference for code status was accurately documented in both the paper and electronic health records. Despite having a Resident Healthcare Instruction form indicating a full code status, a transfer document from a recent hospitalization indicated a Do Not Resuscitate (DNR) status. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for updating the code status in the Electronic Health Record (EHR), leading to discrepancies in the resident's documented preferences. The Director of Nursing Services (DNS) and the Administrator acknowledged the failure to update the advance directive upon the resident's return from the hospital, resulting in conflicting information in the resident's records. Resident #428's medical records also lacked documentation of an advance directive upon admission. Although a State of Connecticut transfer order indicated a DNR status, there was no evidence in the paper chart or EHR that the resident or their representative had been given the opportunity to choose an advance directive. An interview with an LPN confirmed the absence of documentation and the failure to complete the advance directive process upon admission. It was only after surveyor inquiry that a signed advance directive consent and a physician's order were obtained, confirming the resident's DNR status. Similarly, Resident #527's records did not include a physician order or identification of code status in either the paper chart or EHR. The paper chart contained a blank and unsigned Resident Healthcare Instruction form. Interviews with nursing staff revealed that the responsibility for completing an advance directive upon admission was unclear, and no advance directive was obtained for the resident during their stay. Subsequent to surveyor inquiry, efforts were made to contact the resident's representative to obtain the necessary documentation. The facility's policy requires that code status be easily accessible and documented as part of the admission order set, which was not adhered to in these cases.
Failure to Notify Resident Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure that the representative of a resident with dementia, myocardial infarction, and hypertension was notified of a significant weight loss. The resident, who was severely cognitively impaired and required assistance with eating, experienced a weight loss from 139.1 lbs to 133.7 lbs between July 1, 2023, and August 1, 2023, which was a 7.6% weight loss. Despite a physician's order to weigh the resident monthly and a care plan that included monitoring for unplanned weight loss, the resident's representative was not informed of this significant change. Further review showed that the resident's weight continued to decline, reaching 127.1 lbs by October 2, 2023, marking an 8.6% weight loss over three months. The dietician confirmed the significant weight loss trend but admitted that the facility lacked a specific policy for notifying family or representatives of such changes. The dietician also noted that no single person was responsible for making these notifications, indicating a systemic issue in communication and responsibility within the facility's team.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure Resident #527's right to be free from physical restraints. Resident #527, who had diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was admitted with psychiatric and behavioral issues. The resident exhibited behaviors such as agitation, restlessness, and attempts to self-transfer, which placed them at risk for falls. Despite these behaviors, the facility's care plan and interventions did not adequately address the resident's needs, leading to an incident where the resident was found restrained to their wheelchair with a bed sheet tied around their waist by a nursing assistant (NA) due to insufficient staffing and inability to provide one-to-one supervision. On the day of the incident, the facility was short-staffed, with only one NA present initially, and additional NAs arriving later in the shift. The NA who restrained Resident #527 reported feeling overwhelmed by the resident's behaviors and the demands of other residents, leading her to use the restraint as a temporary measure to prevent the resident from falling or causing harm. The restraint was discovered by a Speech Language Pathologist (SLP), who removed it and reported the incident to the charge nurse and her supervisor. However, there was a delay in reporting the incident to higher management, and conflicting accounts from staff about who was informed and when. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, revealed ongoing issues with staffing shortages and inadequate supervision for residents with high behavioral needs. The DNS and Administrator acknowledged the challenges in providing appropriate care for Resident #527 and the lack of specific interventions in the care plan to manage the resident's behaviors. The facility's policy prohibited the use of physical restraints not required to treat medical symptoms, highlighting a significant deficiency in ensuring resident safety and compliance with regulatory standards.
Failure to Timely Report Allegation of Mistreatment
Penalty
Summary
The facility failed to report an allegation of mistreatment involving Resident #527 to the state agency in a timely manner. Resident #527, who had diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, was admitted with psychiatric and behavioral issues. The resident required extensive assistance for mobility and toileting and had a care plan addressing behavioral problems and fall risks. On a specific date, the resident was found restrained to a wheelchair with a bed sheet tied around the waist, an act admitted by NA #12. However, the incident was not reported to the RN Supervisor or managerial staff until three days later, and the Administrator delayed reporting to the state agency until the following day, citing a lack of information from a witness as the reason for the delay. The facility's policy on Abuse, Neglect, and Exploitation mandates immediate reporting of suspected abuse to a supervisor and subsequent reporting to the Administrator or designee within two hours. Despite this policy, the Administrator acknowledged awareness of the two-hour reporting window but failed to comply. The delay in reporting the incident to the state agency constitutes a deficiency in adhering to the facility's abuse reporting protocols.
Failure to Update Care Plans and Implement Interventions
Penalty
Summary
The facility failed to update and implement new interventions in the care plans for several residents following significant events. Resident #6, who had diagnoses including muscle weakness, Alzheimer's disease, and seizures, experienced two falls on 10/14/23 and 10/31/23. Despite these incidents, the care plan was not updated with new interventions to prevent future falls, and the existing intervention of using a floor mat was not consistently implemented. Additionally, the facility's policy of closely monitoring residents after a fall was not followed, as evidenced by the unwitnessed fall in the dining room on 10/31/23. Resident #9, with diagnoses including pneumonia, urinary tract infection, dementia, and bipolar disorder, developed an unstageable pressure ulcer on the left heel. The care plan, which initially did not include a turning or repositioning schedule, was not updated to reflect the resident's increased need for assistance following a decline in condition. Despite the worsening of the pressure ulcer, no new interventions were added to the care plan to prevent further deterioration. Resident #68, admitted with Alzheimer's dementia and an infection of the right hip prosthesis, experienced an unwitnessed fall on 10/27/23. The care plan was not revised to include additional interventions to prevent future falls, even though a physical therapy evaluation identified multiple fall risk factors. Similarly, Resident #527, with diagnoses including Down Syndrome, Alzheimer's Disease, and diabetes mellitus, exhibited behaviors that increased the risk of falls and injury. The care plan did not provide specific interventions for staff to implement when the resident exhibited these behaviors, leading to an incident where the resident was improperly restrained with a bed sheet for safety reasons.
Failure to Provide Appropriate Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for Resident #23, who was admitted with diagnoses including chronic kidney disease, total hip arthroplasty, and gout. The resident was cognitively intact and required extensive assistance with bed mobility, toilet use, and personal hygiene. Despite a physician's order dated 8/25/23 to consult podiatry as needed, no referral to podiatry was noted in the medical record. On 9/7/23, a physician's progress note identified that Resident #23's right great toe was swollen, yet no podiatry consult was made. Observations on 11/7/23 revealed that Resident #23's toenails were long and curling forward, and Person #2 confirmed having requested foot care for the resident multiple times without any action taken. Interviews and clinical record reviews indicated that any staff member could have brought concerns about the resident's toenails to the nurse, who would then request a podiatry consult. However, RN #1 was unable to locate any record of concerns being raised by the family or staff regarding the resident's toenails. The facility's Foot Care policy, dated 8/7/23, directed that residents with complicating disease processes requiring foot care must be referred to qualified professionals such as podiatrists. This policy was not followed, resulting in the deficiency noted in the report.
Failure to Implement Fall Prevention Measures and Conduct Risk Assessments
Penalty
Summary
The facility failed to ensure care plan interventions were implemented, provide adequate supervision to prevent falls, and conduct risk assessments following falls for three residents. Resident #6, diagnosed with muscle weakness, Alzheimer's disease, and seizures, was identified as a fall risk. Despite care plan interventions such as the use of floor mats and encouraging the use of a call bell, Resident #6 experienced two falls. Observations revealed that the resident's bed was in a high position without floor mats, contrary to the care plan. Interviews with staff indicated inadequate monitoring and insufficient staffing during the incidents, leading to unwitnessed falls and non-compliance with the fall protocol. Resident #68, admitted with Alzheimer's dementia and an infection of the right hip prosthesis, was initially assessed as a low fall risk. However, after an unwitnessed fall, it was found that quarterly fall risk assessments had not been completed since admission, and no fall risk assessment was conducted post-fall. The Director of Nursing confirmed the lapse in protocol, and the Physical Therapist classified the resident as a high fall risk based on a subsequent evaluation. Resident #527, with diagnoses including Alzheimer's disease, bacterial pneumonia, and Type 2 Diabetes, was identified as a high fall risk upon admission. Despite this, after a witnessed fall, the facility failed to complete a fall risk assessment post-fall. Instead, the facility's process involved a Nursing Change of Condition Evaluation and a verbal referral to Physical Therapy, which did not align with the facility's fall management policy. The Director of Nursing acknowledged the failure to follow the policy, which required reassessments after falls to minimize recurrence and risk.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide timely notification to the Ombudsman regarding multiple transfers of a resident to the hospital. Resident #21, who had diagnoses including heart failure, anemia, and dementia, experienced several medical emergencies that required hospital transfers. These incidents included elevated temperature, falls with head injuries, dislodged cholecystectomy drain, abnormal vital signs, and other acute conditions. Despite these transfers, the facility did not notify the Ombudsman as required by their policy and federal regulations. Interviews with the Social Worker and the Ombudsman revealed that the facility's process for notifying the Ombudsman was inadequate. The Social Worker indicated that notifications were made using an online reporting system every 30 days, but documentation of these reports was not provided. The Ombudsman confirmed that Resident #21's transfers were not reported, and only three months of reporting appeared in the system from 2021 to the present. The facility's Discharge and Transfer Policy required verbal and written notifications to the resident and their representative, as well as copies of notices to the Ombudsman, which were not adhered to in this case.
Failure to Notify Resident Representative of Bed Hold Policy
Penalty
Summary
The facility failed to provide the required notification of the bed hold policy for a resident with diagnoses including heart failure, anemia, and dementia. The resident was moderately cognitively impaired and required supervision and assistance for daily activities. Despite multiple hospital transfers and returns, the facility did not consistently notify the resident's representative in writing about the bed hold policy as required. Specifically, notifications were missing for hospital admissions on several dates, including 9/25/22, 12/1/22, 12/24/22, 1/29/23, 2/12/23, 7/29/23, and 8/14/23. The Business Office Manager (BOM) acknowledged the oversight and indicated that the responsibility for completing the Bed Hold Notice of Policy & Authorization form had recently shifted from the Admissions department to the Business Office. The facility's policy mandates that the resident or their representative be notified in writing about the bed hold policy upon each transfer, with the notice delivered via email, fax, or mail within 24 hours if the representative is not present. However, this procedure was not followed for the specified hospital admissions, resulting in a failure to comply with the notification requirements.
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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