Autumn Lake Healthcare At Norwalk
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, Connecticut.
- Location
- 34 Midrocks Drive, Norwalk, Connecticut 06851
- CMS Provider Number
- 075387
- Inspections on file
- 22
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Norwalk during CMS and state inspections, most recent first.
The deficiency centers on multiple residents for whom staff did not follow physician orders or facility protocols related to falls, acute changes in condition, and vascular access management. One resident with prior toe fractures and multiple psychoactive and pain medications reported slipping in an elevator, but staff did not classify it as a fall, did not notify the RN supervisor, and did not complete required assessments or accident/incident documentation. Another resident with dementia and cardiovascular issues was found pale and unresponsive, sent to the ER, yet there was no RN assessment or detailed documentation of the event, EMS involvement, or condition at transfer as required by policy. A third resident with sepsis was admitted with a midline catheter, but staff obtained and followed central line orders instead, failed to enter appropriate midline orders on the MAR/TAR, and did not document dressing changes, flushes, or routine site assessments per midline policy. Additionally, a cognitively intact resident with ESRD left the facility alone using a ride-share despite an active order requiring a responsible party for leave of absence, meaning the resident departed without adherence to the existing LOA order.
A resident with dementia and prior cerebral infarction experienced an acute change in condition, becoming pale and unresponsive in a wheelchair. Staff notified a physician, obtained an order to send the resident to the ER, called 911, and documented some vital signs and notifications, but there was no RN assessment documented before transfer. The DON later confirmed the record lacked key details such as the exact time of the incident, EMS arrival and departure times, the resident’s level of alertness at transfer, and evidence that a face sheet and report were provided to the hospital. An LPN reported checking blood sugar, performing a sternal rub, and moving the resident to bed as the resident began to recover, but none of this care was recorded, contrary to facility policy requiring documentation of changes in condition and related events.
A resident with severe cognitive impairment and multiple medical conditions had conflicting code status documentation in their records, with a DNR form signed by an unauthorized contact and a full code order in the electronic record. When the resident was found unresponsive, staff initiated CPR after confirming code status with the legal representative, but the inconsistency in documentation was confirmed by staff and administration.
A resident with severe cognitive impairment and a court-appointed conservator was found unresponsive and later pronounced deceased after CPR efforts. Although nursing staff notified the conservator of the resident's death by phone, they failed to document this notification in the medical record as required by facility policy.
A resident reported missing personal clothing items, which were not returned despite inquiries and reports to staff. The facility also failed to maintain a clean and homelike environment, with numerous issues such as soiled furniture and unclean bathrooms observed. The facility was undergoing renovations, but many issues remained unaddressed, and there was a lack of awareness among staff about the deficiencies.
A facility failed to maintain sanitary conditions during food preparation. A staff member was observed thawing chicken in a three-compartment sink filled with dirty pots and soap suds, without wearing gloves. The Dining Services Director and Dietitian were unaware of the issue, and the staff member used the sink due to the designated meat preparation sink being occupied. This practice violated the facility's policy and FDA guidelines.
A resident's request for a specific hospice provider was not honored due to miscommunication about contract availability. Despite the resident's representative requesting Hospice Agency #1, the facility admitted the resident to Hospice Agency #2, citing a lack of contract. Interviews revealed the facility could have arranged a one-time contract with the preferred provider, highlighting a failure to respect the resident's rights.
A resident experienced restricted access to personal funds managed by the facility, despite having intact cognition and being entitled to monthly disbursements. The Business Office Manager was on leave, and the administrator was temporarily covering fund access, but the process was unclear outside of designated hours. The resident also faced delays in receiving social security checks, and the facility failed to provide a policy on fund access during posted banking hours.
A resident's personal funds were mismanaged by the facility, with missing quarterly statements and discrepancies in financial records. The facility's Business Office Manager was on leave, and the Administrator was covering the position. An outside accounting firm was involved, but there were inconsistencies in the accounting documents, and the resident's name was missing from the Funds Balance Report. The facility failed to follow its policy on resident rights and personal needs allowance, leading to a lack of transparency in financial reporting.
The facility failed to document advance directives for two residents shortly after admission. One resident, with impaired cognition, had blank forms over two months post-admission, while another resident's form lacked specific treatment options despite a verbal request for full code status. The facility's policy requires these forms to be completed upon admission, but this was not adhered to, leading to the deficiency.
A resident returned from the hospital with a potential shoulder dislocation, but the facility failed to notify the physician as required. The resident had a history of falls and required assistance for transfers. Despite the facility's policy to notify physicians of significant changes, there was no documentation of such notification.
A facility failed to complete a timely PASARR rescreen for a resident with mental health diagnoses, including schizoaffective disorder and schizophrenia. The resident was admitted with a 30-day hospital discharge exemption, requiring a rescreen if the stay extended beyond this period. The rescreen was conducted 10 days after the exemption expired, contrary to the facility's policy and federal regulations.
The facility failed to notify the state mental health authority of significant changes in the mental health diagnoses of two residents. One resident, initially diagnosed with anxiety and bipolar disorder, later received a dementia diagnosis, which was not updated in the PASARR. Another resident's diagnosis changed from major depression to situational depression episodes, but the state was not informed. The social worker was unaware of the requirement to update the PASARR, leading to a deficiency.
A facility failed to develop a comprehensive care plan for a resident with dementia, despite the resident receiving anti-psychotic medication and having a documented diagnosis of non-Alzheimer's dementia. Interviews with the DNS and social services indicated an expectation for a dementia care plan, but it was not included in the comprehensive care plan. The MDS coordinator, who typically initiates such plans, was unavailable for interview.
A resident with intact cognition and multiple diagnoses was not invited to care conferences, and no conferences were documented for over six months. Interviews with staff revealed issues with scheduling and executing these conferences, despite facility policies mandating resident participation.
The facility failed to ensure RN assessments were conducted after falls for two residents, leading to improper handling and documentation of injuries. Resident #6, with multiple fractures, was moved without an RN assessment, and a bruise was not properly evaluated. Resident #112 experienced falls without RN assessments, contrary to facility policy.
The facility failed to maintain correct air mattress settings for a resident with dementia and COPD, and did not ensure a helmet was consistently worn by another resident with a history of stroke. The air mattress was set incorrectly multiple times, and the helmet was not documented as worn when the resident was out of bed, with no physician's order obtained for its use.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in deficiencies. One resident was admitted with a history of pressure ulcers and did not receive consistent skin assessments or Braden Scale evaluations, leading to the development of a new ulcer. Another resident, admitted with an unstageable pressure ulcer, also did not receive required assessments, resulting in new pressure ulcers on the heels. Staff interviews revealed a lack of adherence to facility policies and documentation requirements.
The facility failed to provide adequate supervision and intervention for residents, leading to deficiencies in fall prevention, smoking policy enforcement, and elopement risk management. A nurse aide was found asleep while supervising residents in a fall prevention program, a resident repeatedly violated the non-smoking policy, and another resident at risk of elopement was able to leave the facility unattended. These incidents highlight lapses in adherence to facility policies and procedures.
A resident with multiple diagnoses, including phantom limb syndrome, did not receive a PRN dose of Hydromorphone for severe pain as requested. Despite multiple requests during a shift, the LPN failed to administer the medication, citing being busy. The resident suffered from pain throughout the night, and staff interviews revealed a lack of adherence to physician's orders for PRN medication administration.
The facility failed to ensure consistent completion of shift-to-shift controlled drugs counts for two medication carts. On the first floor, the 1B unit's controlled drugs count record for July 2024 was missing 11 signatures across all shifts. Similarly, on the third floor, the 3 AB unit's record was missing 8 signatures. The DNS and ADNS were unaware of these issues until they were highlighted during observations. The facility's policy requires nurses to count controlled drugs at each shift change and sign the record, which was not adhered to.
The facility failed to store PPE in a sanitary manner for a resident on transmission-based precautions. An LPN identified an isolation cart with PPE stored on the floor in a missing drawer slot. The LPN could not explain the missing drawer or the floor storage. Facility policy requires PPE to be stored according to guidelines and instructions.
Failure to Follow Physician Orders and Assessment Protocols for Falls, Acute Changes, and Vascular Access
Penalty
Summary
The deficiency involves multiple failures to provide treatment and care according to physician orders, resident preferences, and facility policies for documentation, assessment, and vascular access management. One resident with multiple orthopedic, neurologic, cardiac, respiratory, and psychiatric diagnoses, who was cognitively intact and on psychoactive medications, opioids, and an antipsychotic, experienced a slip while exiting an elevator after having previously sustained toe fractures from a fall. Staff did not classify the elevator event as a fall, did not report it to the nursing supervisor on the day it occurred, and did not complete a nursing assessment or documentation at that time. The Assistant Director of Nursing Services later learned of the event directly from the resident the following morning and documented the resident’s report of slipping and having pain in the same previously injured foot. Staff reported that they did not complete an Accident and Incident report because the resident described the event as a slip rather than a fall, and the then-Director of Nursing Services had advised that no report was necessary. This was inconsistent with the MDS definition of a fall and with facility policies requiring documentation of changes in condition, evaluation of falls, and reporting of accidents and incidents. Another resident with dementia and a history of cerebral infarction had a documented care plan for altered cardiovascular status, including assessment of chest pain, shortness of breath, and cyanosis and reporting changes to the physician. On one occasion, this resident was found pale and unresponsive in a wheelchair, and the physician was notified with an order to send the resident to the emergency room. An LPN documented vital signs and notification of the physician and responsible party, and another LPN recalled checking the resident’s blood sugar and obtaining a minimal response to a sternal rub before transferring the resident to bed. The resident became more alert and was transferred to the hospital. However, there was no documented RN assessment in the clinical record prior to the transfer, no documentation of the exact time of the incident, no times for EMS arrival and departure, no description of the resident’s state of alertness at transfer, and no documentation of sending a face sheet or calling the hospital emergency room with report. This lack of RN assessment and incomplete documentation did not meet the facility’s Acute Condition Changes/RN Assessment Protocol, which required RN involvement and documentation when residents experienced acute changes in condition. A third resident with sepsis had been discharged from the hospital with a midline catheter placed in the upper arm for IV antibiotic therapy. The hospital discharge summary and intra-agency report identified the device as a midline catheter, and an outside IV company’s documentation described placement of a 12 cm midline catheter in a vein in the inner left arm, with instructions for midline care per protocol. However, the admitting nurse obtained physician orders for a central line catheter rather than a midline, including orders for central line observation, dressing changes, and flushing with normal saline followed by heparin. The facility did not use heparin in IVs, and the prepopulated heparin orders should have been removed. There were no appropriate midline-specific orders entered on the MAR/TAR for dressing changes, flushing, or routine site assessments, and there was no documentation that dressing changes or flushes had been completed since admission. The midline site was observed with a clear dressing and a manufacturer label stating "MIDLINE," but the clinical record lacked consistent documentation of care per the facility’s midline catheter policies, which required specific physician orders and detailed documentation of flushing, dressing changes, and site assessments. A fourth resident with type 2 diabetes, chronic kidney disease, ESRD on hemodialysis, psychiatric diagnoses, and mild cognitive impairment had a physician’s order allowing leave of absence only with a responsible party and medications. This resident was cognitively intact and psychiatrically stable at the time. On one occasion, the resident told staff they were going to the lobby but instead left the facility alone via a ride-share without notifying staff or signing out on LOA, contrary to the active physician order requiring accompaniment by a responsible party. Staff discovered the resident was no longer in the lobby and then determined the resident had gone to a local hospital to see a nephrologist. At the time of this event, the physician’s order had not yet been updated to allow independent LOA, and the resident’s departure without a responsible party was inconsistent with the existing order. This failure to follow the physician’s LOA order contributed to the overall deficiency in ensuring care and services were provided in accordance with physician directives and facility policies.
Incomplete and Inaccurate Documentation During Resident Change in Condition and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident with dementia and a history of cerebral infarction who experienced an acute change in condition. The resident’s quarterly MDS showed moderate cognitive decline, and the care plan directed staff to assess for chest pain, shortness of breath, cyanosis, and to report changes to the physician. On the date of the incident, a progress note labeled as a change in condition documented that the resident was observed sitting in a wheelchair, pale and unresponsive, that the physician was notified, an order was obtained to send the resident to the emergency room, and that 911 was called. The note further stated that while awaiting EMS, the resident became alert and returned to baseline but was still sent to the emergency room. A concurrent review assessment by an LPN recorded vital signs and notification of the physician and responsible party regarding the transfer. During interviews and record review, the DNS confirmed there was no RN assessment documented prior to the transfer, despite an expectation that an RN assessment would be written in the progress notes and, if an LPN documented the assessment, the RN would sign it. The DNS also reported that the record lacked documentation of the exact time of the incident, EMS arrival and departure times, the resident’s state of alertness at the time of transfer, and any indication that a face sheet with diagnoses, medications, and pertinent data was sent with the resident or that the hospital emergency room was called with report. An LPN working the 3–11 shift stated that upon being notified the resident was unresponsive in a wheelchair, blood sugar was checked (within normal range), a sternal rub was performed with minimal response, and the resident was moved to bed and began to “come around,” while the RN supervisor remained at the nurses’ station making calls and preparing transfer paperwork. None of this LPN’s described evaluation and care was documented in the clinical record. Another RN recalled seeing the resident in the wheelchair starting to come to but could not remember details. These omissions occurred despite a facility policy requiring documentation of changes in condition, events, incidents, or accidents involving the resident.
Failure to Ensure Accurate and Legally Authorized Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately obtained from the legal representative and that the medical record reflected the correct advance directives. The resident, who had diagnoses including dementia, hypertension, and cirrhosis of the liver, had a court-appointed Conservator of Person (COP) listed as the emergency contact. However, the advanced directive form in the record was signed by a different emergency contact who was not the legal representative, and the required signature from the COP and the physician was missing. Additionally, there was a discrepancy between the paper medical record, which indicated Do Not Resuscitate (DNR), and the electronic medical record, which indicated full code status (administer CPR). Physician orders and care plans also reflected conflicting code statuses. When the resident was found unresponsive, staff reviewed the chart and found both a DNR directive and a full code physician order. The COP was contacted and confirmed the resident was a full code, leading staff to initiate CPR. Emergency Medical Services (EMS) continued resuscitation efforts upon arrival, but the resident was ultimately pronounced deceased. Interviews with staff and facility leadership confirmed the inconsistency between the paper and electronic records and acknowledged that the advanced directive should have been signed by the COP. The facility's policy required that advance directives be signed by the appropriate legal representative and physician, which was not followed in this case.
Failure to Document Notification of Responsible Party After Resident Death
Penalty
Summary
The facility failed to ensure that the medical record for a resident with dementia, hypertension, and cirrhosis of the liver was complete and accurate regarding notification of the responsible party after a change in condition. The resident, who had a court-appointed Conservator of Person (COP) and was identified as having severely impaired cognition, was found unresponsive and subsequently pronounced deceased after CPR was administered by staff and EMS. Although the COP was listed as the emergency contact and was contacted to confirm advance directives when the resident was found unresponsive, there was no documentation in the medical record that the COP was notified after the resident was pronounced deceased. Interviews with two RNs revealed that both believed they had notified the COP of the resident's death via telephone, but neither documented this notification in the medical record, each assuming the other would do so or forgetting to write the note. The Director of Nursing Services (DNS) and Administrator confirmed that the COP was notified, but acknowledged that the nurse failed to document the notification as required. Review of the facility's Charting and Documentation policy indicated that such notifications should be documented, but this was not done in this instance.
Deficiencies in Resident Property Security and Facility Maintenance
Penalty
Summary
The facility failed to ensure the safety and security of a resident's personal property, as evidenced by the case of a resident who reported missing clothing items. The resident, who was cognitively intact and required assistance with dressing, had sent several personal clothing items to the laundry, which were not returned. Despite making inquiries and reporting the missing items to various staff members, the resident only received replacement items from donations, which did not include all the missing items, some of which held sentimental value. Interviews with the Director of Laundry and a Laundry Aide revealed a lack of awareness about the missing items, and the facility's social worker and Director of Nursing Services were also unaware of the resident's reports. Additionally, the facility was found to have failed in maintaining a safe, clean, comfortable, and homelike environment. Observations during a tour of the facility revealed numerous issues, including soiled and damaged furniture, unclean bathrooms, and disrepair in various rooms and common areas. The facility was undergoing renovations, but the maintenance director, who was newly hired, was not aware of many of the issues identified. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the unclean and poorly maintained conditions observed. The facility's failure to address these issues was further compounded by the lack of a personal property policy and the absence of a signed agreement for the intended repairs. The facility's staff, including the nursing staff, were expected to report maintenance concerns, but the issues persisted, indicating a breakdown in communication and follow-through. The facility's corporate management was reportedly addressing the concerns, but the deficiencies remained uncorrected at the time of the survey.
Unsanitary Food Preparation Practices
Penalty
Summary
The facility failed to ensure food was prepared under sanitary conditions in accordance with professional standards. During an observation, a staff member was seen thawing frozen chicken in a deep pot under running cold water in the third compartment of a three-compartment sink. The first sink was filled with dirty pots and bowls soaking in soapy water, while the second sink contained soap suds and food debris. The staff member was preparing the chicken without gloves, which is against the facility's food preparation policy. Interviews with the Dining Services Director, Dietitian, and the staff member involved revealed that the staff member was not supposed to use the three-compartment sinks for thawing chicken, especially when they were dirty. The Dining Services Director and Dietitian were unaware of the issue, and the staff member explained that the designated meat preparation sink was occupied, and the other preparation sink was reserved for fruits and vegetables. The facility's policy requires that all foods be prepared in accordance with the FDA food code, and the FDA guidelines for three-compartment sinks state that each sink must be emptied, washed, and sanitized before and after each use if food products are to be washed or thawed in them.
Failure to Honor Resident's Hospice Provider Choice
Penalty
Summary
The facility failed to honor the request of a resident's representative for a specific hospice provider, leading to a deficiency in resident rights and care planning. Resident #23, who had diagnoses including dementia and chronic obstructive pulmonary disease, was admitted to the facility and required hospice care. The resident's representative, Person #1, requested Hospice Agency #1, which had previously provided satisfactory services to the resident at home. Despite this request, the facility did not accommodate the choice, citing a lack of contract with Hospice Agency #1. The facility's social worker, SW #2, informed Person #1 that the facility did not have a contract with Hospice Agency #1 and offered alternatives from the facility's contracted providers. SW #2 did not explore the possibility of a one-time contract with Hospice Agency #1, nor did she consult with the Director of Social Services or the Administrator about the request. Consequently, Resident #23 was admitted to Hospice Agency #2, contrary to the expressed wishes of Person #1. Interviews with the Director of Social Services and the Administrator revealed that the facility could have arranged a one-time contract with Hospice Agency #1 to honor the resident's choice. The Administrator confirmed that the facility indeed had a contract with Hospice Agency #1, contradicting the information given to Person #1. This oversight resulted in a failure to respect the resident's right to participate in their care planning and choose their hospice provider, as outlined in the facility's policies on hospice services and resident rights.
Resident's Access to Personal Funds Restricted
Penalty
Summary
The facility failed to ensure that a resident had ready and reasonable access to their personal funds, which were managed by the facility. The resident, who was admitted for short-term rehabilitation and had intact cognition, reported difficulties in accessing their funds since admission. The resident was supposed to receive $75 monthly but experienced restricted access to their money. The resident also did not receive any quarterly statements and mentioned that the previous social worker, who attempted to assist with fund access, was no longer employed at the facility. The resident expressed frustration over the situation, noting that the facility administrator had given them $20 from his wallet due to the resident's distress, despite the resident having their own funds. The administrator acknowledged that the Business Office Manager, responsible for disbursing residents' funds, was on leave, and he was temporarily covering the position. He stated that he was available during specific hours for residents to access their funds and that residents could contact a nursing supervisor outside of these hours. However, the administrator could not explain how funds would be accessed if he or the Director of Nursing Services (DNS) were unavailable by phone. Additionally, the administrator mentioned delays in the resident's social security checks, which were being mailed instead of direct deposit, but could not recall specific discussions with the resident about this issue. An observation noted a sign indicating banking hours, but the facility failed to provide a policy on accessing personal funds during these hours.
Failure to Manage Resident's Personal Funds
Penalty
Summary
The facility failed to properly manage the personal funds of a resident, identified as Resident #44, who was admitted for short-term rehabilitation with diagnoses including cardiomyopathy, insulin-dependent diabetes, and anxiety disorder. The resident, who had intact cognition, did not receive quarterly statements or an accounting of their funds managed by the facility. The facility's policy required that residents receive quarterly banking statements and that funds be kept in an interest-bearing account, but these requirements were not met. The facility's Business Office Manager, responsible for dispersing residents' funds, was on leave, and the Administrator was temporarily covering the position. An outside accounting firm was used for managing the residents' funds, but discrepancies were found in the accounting documents for Resident #44. The resident's name was missing from the Funds Balance Report, and there were inconsistencies in the statements provided, including missing vouchers and unexplained debits. The facility and the accounting firm failed to provide a clear and accurate accounting of the resident's funds. Interviews with the Administrator and a representative from the accounting firm revealed confusion and lack of clarity regarding the responsibility for disbursing quarterly statements to residents. The facility's policy on resident rights and personal needs allowance was not followed, as the resident was not given access to their financial records, and the funds were not managed according to generally accepted accounting principles. The facility's failure to ensure proper management of the resident's funds led to multiple discrepancies and a lack of transparency in financial reporting.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to obtain and document the code status for two residents, Resident #45 and Resident #93, shortly after their admission, as required by their policy. Resident #45, who was admitted with acute kidney failure and dementia, had severely impaired cognition, making it necessary for the facility to discuss code status with the resident's representative. However, over two months after admission, the Advance Directives Level of Treatment Options forms remained blank. The Nurse Manager acknowledged that the code status should have been determined and documented within 72 hours of admission. Resident #93, who was cognitively intact and admitted with conditions including hypertension and chronic kidney disease, had a physician's order indicating full code status. However, the Advance Directives Level of Treatment Options form in the resident's clinical record was incomplete, lacking specific treatment options. The Nurse Supervisor confirmed that the form was not filled out with the resident's choices, despite the resident verbally requesting full code status upon admission. The facility's policy mandates that the Advance Directives Level of Treatment Options form be reviewed and completed upon admission. The Director of Nursing (DNS) stated that it is the responsibility of the charge nurse and admitting supervisor to ensure the form is completed. The policy also requires that if a resident is incapacitated, the information should be provided to the legal representative. The failure to adhere to these procedures resulted in the deficiency noted by the surveyors.
Failure to Notify Physician of Resident's Shoulder Displacement
Penalty
Summary
The facility failed to notify the physician when a resident returned from the hospital with a new mild anterior displacement of the right humerus, which could represent an anterior glenohumeral dislocation. The resident, who had a history of congestive heart failure, pulmonary embolism, rheumatoid arthritis, and repeated falls, was admitted to the facility and required extensive assistance for transfers. Upon returning from the hospital, the resident's discharge summary indicated a potential shoulder dislocation, but there was no documentation that the physician or APRN was notified of this condition. Interviews revealed that the facility's DNS stated that the receiving supervisor, unit manager, and ADNS were responsible for reviewing hospital paperwork and notifying the physician of any significant findings. However, the physician was not informed of the shoulder displacement, and there was no documentation of such notification in the progress notes. The facility's Change in Condition Policy mandates prompt notification of the physician for significant changes in a resident's condition, which was not adhered to in this case.
Failure to Timely Complete PASARR Rescreen
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) rescreen for a resident with mental health diagnoses, including schizoaffective disorder, schizophrenia, bipolar disorder, and depressive episodes. The resident was admitted with a 30-day hospital discharge exemption, which required a rescreen if the stay extended beyond this period. The initial PASARR Level I Screen Outcome indicated that a rescreen was necessary by the 30th day if the resident remained in the facility. However, the facility did not conduct the required rescreen until 10 days after the exemption expired. The resident's admission Minimum Data Set (MDS) noted intact cognition and a lack of Level II PASARR evaluation, despite the presence of serious mental illness. The care plan included the use of psychotropic medications and monitoring for side effects. The Director of Social Services acknowledged the oversight, stating that the rescreen should have been completed before or on the expiration date. The facility's policy mandates compliance with state and federal regulations for PASARR, which was not adhered to in this instance.
Failure to Notify State Mental Health Authority of Diagnosis Changes
Penalty
Summary
The facility failed to notify the state mental health authority of significant changes in the mental health diagnoses of two residents, leading to a deficiency. Resident #2, who was initially diagnosed with anxiety and bipolar disorder, was admitted with these diagnoses and later received a new diagnosis of dementia on 10/1/22. Despite this significant change, the PASARR was not updated, and the state mental health authority was not informed, as required. The social worker (SW #1) was unaware of the need to update the PASARR with the new diagnosis, resulting in a lack of reevaluation by the state mental health authority. Similarly, Resident #39 was admitted with major depressive disorder, bipolar disorder, and PTSD. The PASARR identified these diagnoses but did not include dementia. Over time, the resident's diagnosis changed from major depression to situational depression episodes, as noted in psychiatric evaluations on 9/22/22 and 7/9/24. However, the state mental health authority was not notified of this change in diagnosis, as SW #1 was unsure of the requirement to update them. This oversight resulted in the failure to conduct a necessary PASARR reevaluation for Resident #39.
Failure to Develop Comprehensive Dementia Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of dementia, which was identified during a review of the clinical record, facility policy, and interviews. The resident, who was admitted with diagnoses including moderate dementia with behavioral disturbances and delirium, was receiving anti-psychotic medication routinely. However, the care plan dated 6/19/24 did not include goals and interventions for the resident's dementia diagnosis, despite the quarterly MDS indicating moderately impaired cognition and non-Alzheimer's dementia. Interviews with the Director of Nursing Services (DNS) and the Director of Social Services (SW #1) revealed an expectation for a dementia care plan to be in place. The DNS noted that the resident's dementia diagnosis was documented in the baseline care plan, and expressed uncertainty as to why it was not included in the comprehensive care plan. SW #1 indicated that typically the MDS coordinator initiates the dementia care plan, although the social worker could also do so. The MDS coordinator was unavailable for interview. The facility's policy mandates the development of an individualized comprehensive care plan based on thorough assessments, including MDS assessments, and requires revisions as the resident's condition changes.
Failure to Conduct Timely Resident Care Conferences
Penalty
Summary
The facility failed to invite a resident and their representative to care conferences and did not hold these conferences in a timely manner. The resident, who was admitted for short-term rehabilitation with diagnoses including cardiomyopathy, insulin-dependent diabetes, and anxiety disorder, had intact cognition as per the quarterly MDS. Despite this, the resident could not recall participating in a care conference, and the clinical record showed no documentation of care conferences for over six months in 2024, with the last noted conference occurring in January 2024. Interviews with facility staff, including the Social Services Director and the DNS, revealed awareness of issues related to the scheduling and execution of resident care conferences. The Social Services Director, who assumed the role in April 2024, was unable to explain the lapse in care conferences for the resident. The DNS acknowledged problems with the social services staff, including the previous Social Services Director, in ensuring timely care conferences. Facility policy mandates resident participation in care planning, with the Social Services Director responsible for scheduling these conferences, highlighting a failure to adhere to these guidelines.
Failure to Conduct RN Assessments After Falls
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) completed an assessment after falls and prior to moving residents off the floor, as well as conducting neurological assessments after falls or when new bruising was found. For Resident #6, who had diagnoses including drug-induced parkinsonism and osteoporosis, the facility did not perform an RN assessment after an unwitnessed fall on 5/12/23. The resident was found on the floor with pain, and despite the presence of multiple fractures diagnosed later at the hospital, the assessment was conducted by an LPN instead of an RN. The resident was moved off the floor without an RN assessment, contrary to facility policy. Additionally, on 9/26/23, Resident #6 was observed with a bruise on the forehead, and the resident claimed to have fallen. However, there was no RN assessment or neurological assessment conducted, and no measurements of the bruise were taken. The facility's policy requires an RN to perform a head-to-toe assessment and document any findings, which was not done in this case. The lack of proper documentation and assessment highlights a failure to adhere to the facility's protocols for handling falls and potential injuries. For Resident #112, who had a history of end-stage renal disease and stroke, the facility also failed to conduct RN assessments after falls on 2/14/24 and 3/13/24. Both incidents were assessed by LPNs, and the residents were moved without an RN evaluation. The facility's policy mandates that an RN must assess residents after a fall before they are moved, which was not followed. This repeated failure to ensure RN assessments after falls indicates a systemic issue in adhering to the facility's protocols for managing resident safety and care.
Failure to Ensure Proper Equipment Settings and Usage
Penalty
Summary
The facility failed to ensure proper settings for an air mattress for Resident #23, who was admitted with diagnoses including dementia and chronic obstructive pulmonary disease. The physician's order specified that the air mattress should be set between 160lbs. and 200lbs., with checks every shift. However, observations revealed that the air mattress was incorrectly set at 260lbs. and later at 120lbs., despite the resident's weight being 158.8lbs. Interviews with staff indicated confusion and inconsistency in adhering to the physician's order, with the air mattress settings being adjusted incorrectly multiple times. For Resident #94, who had a history of stroke and required a helmet when out of bed due to a decompressive hemicraniectomy, the facility failed to ensure the helmet was consistently worn. The discharge summary and care plan indicated the necessity of the helmet, but the clinical records over several months did not reflect its use when the resident was out of bed. Additionally, there was no physician's order obtained for the helmet upon admission, and the DNS was unaware of this oversight. The deficiencies highlight lapses in following physician orders and ensuring proper care for residents with specific medical needs. The facility's staff, including charge nurses and unit managers, were responsible for checking and maintaining the correct settings and equipment usage, but failed to do so consistently, leading to potential risks for the residents involved.
Failure to Ensure Proper Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for two residents, leading to deficiencies in their care. Resident #94 was admitted with a history of pressure ulcers and other medical conditions that increased the risk of skin breakdown. Despite a physician's order for regular skin assessments and the use of the Braden Scale to assess pressure ulcer risk, these assessments were not consistently documented. Weekly skin evaluations were missing for several weeks, and a new pressure ulcer was identified without proper documentation of the assessment, including measurements and descriptions. Resident #111 was admitted with an unstageable pressure ulcer and required regular skin assessments and Braden Scale evaluations as per physician orders. However, the facility failed to document the Braden Scale assessment upon admission and did not consistently perform weekly skin assessments. After the resolution of the initial pressure ulcer, new pressure ulcers developed on the resident's heels, which were not identified until a later date. The facility's failure to adhere to physician orders and document assessments contributed to the development of these new pressure ulcers. Interviews with facility staff revealed a lack of adherence to policies and procedures regarding pressure ulcer care and documentation. The Director of Nursing Services (DNS) and other nursing staff acknowledged the deficiencies in completing and documenting skin assessments and Braden Scale evaluations. The facility's policies required these assessments to be completed and documented, but the staff failed to follow through, leading to the deficiencies identified in the report.
Inadequate Supervision and Intervention in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and intervention for several residents, leading to multiple deficiencies. For residents participating in the fall prevention program, a nurse aide was observed with her eyes closed while supervising residents, which was against the facility's expectations. This lapse in supervision was acknowledged by the Assistant Director of Nursing Services (ADNS) and resulted in the nurse aide being removed from her duties. The facility's policy emphasized the importance of active supervision to prevent falls, yet this was not adhered to, compromising resident safety. Another deficiency involved a resident with a history of smoking who repeatedly violated the facility's non-smoking policy. Despite being educated on the policy and having smoking materials confiscated on multiple occasions, the resident continued to possess contraband. The facility's documentation lacked detailed records of room searches and the disposition of contraband, indicating a failure to implement effective measures to prevent smoking and ensure safety. The facility's contraband policy required immediate action upon detection of contraband, which was not consistently followed. Additionally, the facility failed to revise interventions for residents at risk of falls and elopement. One resident experienced multiple falls without any new interventions being implemented, and another resident, identified as an elopement risk, was able to leave the facility unattended despite wearing a wander guard. The facility's policies on fall prevention and elopement required systematic monitoring and intervention, which were not adequately executed, leading to these deficiencies.
Failure to Administer PRN Pain Medication
Penalty
Summary
The facility failed to administer a PRN pain medication to Resident #42, who was admitted with multiple diagnoses including an infection following a procedure, deep incisional surgical site, infective bursitis, cellulitis, and phantom limb syndrome with pain. The physician's order included a PRN dose of 4mg Hydromorphone for severe pain, which was not administered when requested by the resident. The resident reported experiencing breakthrough pain and indicated that some nurses did not take his reports of pain seriously, leading to delays in receiving pain medication. On the evening of 7/14/24, Resident #42 requested the PRN dose of Hydromorphone from LPN #7 multiple times between 8:00 PM and 10:00 PM, but it was not administered. LPN #7 admitted to forgetting to administer the PRN dose due to being busy, despite having administered the scheduled medications. The resident later approached another nurse during the 11:00 PM - 7:00 AM shift, but the request was ignored, resulting in the resident suffering from pain throughout the night. Interviews with staff revealed a lack of awareness and adherence to the physician's orders for PRN medication administration. LPN #7 acknowledged the oversight, and RN #2 expressed the expectation that PRN medications should be given when requested within the appropriate timeframe. The facility's Pain-Clinical Protocol emphasizes the importance of evaluating and reporting the frequency of PRN medication requests, which was not followed in this case.
Failure to Complete Controlled Drugs Count
Penalty
Summary
The facility failed to ensure that shift-to-shift controlled drugs counts were consistently completed for two of the seven medication carts. On the first floor, the controlled drugs count record for July 2024 was missing signatures on multiple dates across all shifts on the 1B unit, totaling 11 missing signatures. The Director of Nursing Services (DNS) was unaware of these missing signatures until they were pointed out during an observation. It was noted that it is the responsibility of all nurses to sign the controlled drugs count record at the beginning and end of each shift. Similarly, on the third floor, the controlled drugs count record for July 2024 was also missing signatures on multiple dates across all shifts on the 3 AB unit, with 8 signatures missing. Interviews with the DNS and the Assistant Director of Nursing Services (ADNS) revealed that they became aware of the issue on the previous day. Both the DNS and ADNS confirmed that the facility's expectation is for the on-coming and off-going nurses to count the controlled drugs together during each shift change and sign the record afterward. The facility's controlled substances policy mandates compliance with all laws and regulations related to the handling and documentation of controlled substances, requiring nurses to count controlled drugs at the end of each shift and report any discrepancies.
Improper Storage of PPE for Resident on Precautions
Penalty
Summary
The facility failed to store personal protective equipment (PPE) in a sanitary manner for a resident on transmission-based precautions. During an observation, an LPN identified an isolation cart containing PPE, where the PPE was improperly stored on the floor in a slot meant for a third drawer, which was missing. The LPN was unable to explain the absence of the drawer or why the PPE was stored on the floor. The facility's policy for PPE storage requires that infection prevention and control equipment and supplies be obtained, stored, and used according to current guidelines and manufacturer instructions.
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.
Trusted data from CMS and state health departments
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