Bel-air Manor Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newington, Connecticut.
- Location
- 256 New Britain Avenue, Newington, Connecticut 06111
- CMS Provider Number
- 075393
- Inspections on file
- 26
- Latest survey
- June 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bel-air Manor Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Three residents with diabetes did not have their blood glucose levels checked or insulin administered according to physician orders, with insulin often given at times not aligned with scheduled meals. Facility staff and policy required blood glucose monitoring and insulin administration before or with meals, but medication records and interviews showed these standards were not consistently met.
Surveyors found that various dry stock and frozen food items were not labeled with expiration dates, and the Dietary Director could not provide a policy or method for identifying expired items after original packaging was removed, despite facility policies requiring all food to be labeled and dated.
Two residents experienced significant, unplanned weight loss, but the facility failed to notify the APRN and family as required by policy. In both cases, weight loss was documented and confirmed, yet there was no evidence of timely communication to the provider or responsible party, and staff interviews confirmed the notifications did not occur.
A resident reported that a call bell was left unanswered for hours overnight, and observed an LPN sleeping at the nurse's station. Another resident was later found with a saturated brief and reported not receiving care overnight. Despite these incidents and facility policy requiring external reporting of suspected neglect, the DON did not notify authorities, addressing the matter only through the internal grievance process.
Surveyors identified that two residents did not have comprehensive care plans: one resident's use of side rail padding was not documented in the care plan or on aide care cards, and another resident's ongoing refusals of repositioning and offloading—contributing to a worsening pressure ulcer—were not reflected in the care plan until after surveyor inquiry. Staff interviews confirmed a lack of awareness and documentation regarding these care needs and behaviors.
A nurse administered Morphine ER tablets to a resident with chronic pain without checking the expiration date, as required by facility policy. The medication blister pack displayed an expired date, and doses were given after this date. The nurse later acknowledged not verifying the expiration before administration, resulting in a deficiency related to medication administration standards.
A resident with multiple medical conditions and a high risk for weight loss did not have weekly weights or a reweight obtained as ordered by the physician, despite significant weight loss. Staff interviews and record reviews confirmed that required weights were missed and not documented according to facility policy.
Surveyors found expired, unlabeled, and undated medications, as well as non-medication items and food, stored in medication rooms and carts. Staff acknowledged that these items should not be present, but could not explain their presence. Facility policy requires proper labeling, separation, and removal of expired medications, but these procedures were not followed.
A resident with severe malnutrition, dementia, and ongoing weight loss did not have meal intake percentages consistently documented by nurse aides, despite care plans and clinical notes indicating the need for close monitoring. Multiple days of missing documentation were identified, and staff interviews confirmed that accurate and complete charting was expected but not performed.
Two residents with documented MDROs were transferred to a hospital without their MDRO status, special instructions, or necessary precautions being communicated or documented in the transfer paperwork. Facility staff relied on verbal communication without retaining documentation, and the required information was not included in face sheets or electronic records. Facility policies did not clearly require notification of MDRO status upon transfer.
A resident with significant cognitive impairment and multiple medical conditions was not included in the development or implementation of their person-centered care plan. The facility could not provide documentation that a care conference was held or that the resident or their representative was invited, despite policy requiring such involvement.
A resident with major depressive disorder, anxiety disorder, and PTSD was admitted without a new PASRR Level 1 screening, as the facility relied on an outdated screen from a previous LTC stay. Staff interviews confirmed that a new screening should have been completed due to the resident's mental health diagnoses, but this was not done in accordance with policy and state procedures.
A resident with multiple chronic conditions was transferred to the hospital for acute symptoms, but the POA was not notified of the change in condition or transfer. The POA only learned of the hospitalization after being contacted by the hospital, and was later updated by staff. Additionally, medication changes were communicated to someone other than the POA, contrary to facility policy requiring immediate notification of the legal representative for significant changes.
A resident with severe cognitive impairment and a history of falls experienced a fall during a transfer, resulting in pain and an order for a left lower extremity x-ray. When the radiology provider reported a delay in obtaining the x-ray, nursing staff did not document that the physician or APRN was notified of the delay. Interviews confirmed that the APRN was not informed, and the nurse involved could not verify or document any notification to the on-call provider team. The DON stated that documentation of such notifications was expected, but it was not completed.
A resident with cognitive impairment and unable to consent was subjected to inappropriate touching and kissing by another resident, as observed on video and reported by a family member. The incident occurred despite facility policies prohibiting abuse and requiring consent for sexual expression.
Failure to Administer Insulin and Monitor Blood Glucose as Ordered
Penalty
Summary
The facility failed to ensure that blood glucose levels were obtained before meals and that insulin was administered prior to meals as ordered for three residents with diabetes. Physician orders for each resident specified that blood glucose monitoring and insulin administration should occur before meals, with specific sliding scale instructions or set doses. However, review of medication administration records revealed that insulin was frequently given at times not aligned with scheduled meal times, including after meals or significantly delayed from the prescribed schedule. For example, one resident with severe cognitive impairment and diabetes had insulin administered at times such as 10:00 AM and 12:05 PM, which did not correspond with the scheduled breakfast or lunch times. Another resident, who was dependent on staff for activities of daily living, received insulin doses at times such as 10:36 AM and 7:11 PM, rather than with meals as ordered. A third resident with severe cognitive impairment and diabetes also received insulin at times inconsistent with meal schedules, such as 5:56 PM and 1:10 PM, rather than before or with meals as directed by the physician. Interviews with nursing staff and the Director of Nursing Services confirmed that the facility's standard practice was to check blood glucose prior to meals and administer insulin either thirty minutes before or with meals. Despite these policies, documentation and staff interviews indicated that these practices were not consistently followed, resulting in the failure to meet professional standards of quality for medication administration as required by facility policy and physician orders.
Failure to Label and Date Food Items in Dietary Department
Penalty
Summary
During a tour of the Dietary Department, surveyors observed that multiple food items in both the basement dry stock and walk-in freezer were not labeled with expiration dates. Specifically, 16 bags of sliced white bread, two 1-gallon jars of coleslaw dressing, and four 1-pound cans of chicken base in the dry stock, as well as 12 packages each of hot dog and hamburger buns, two 5-pound beef chucks, a 5-pound bag of chicken tenders, and a 10-pound bag of chicken breast in the freezer, all lacked expiration dates. The Dietary Director was unable to provide a policy for expiration dating and stated that items were removed from their original boxes due to space constraints, making it unclear how expired items would be identified. Facility policies reviewed required all food to be labeled and dated for proper rotation and storage, but these procedures were not followed.
Failure to Notify Provider and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the Advanced Practice Registered Nurse (APRN) and family or responsible party of significant, unplanned weight loss in two residents. In the first case, a resident with diagnoses including dysphagia, dementia, and a history of pressure wounds experienced a weight loss of over 10% in less than one month. The resident's care plan included monitoring for nutritional problems and regular weight checks. Despite documentation of the weight loss and a subsequent reweight confirming the loss, there was no evidence that the APRN or family were notified at the time the loss was identified. Interviews with nursing staff, the APRN, and the Director of Nursing confirmed that the expected notifications did not occur, and the APRN was unaware of the weight loss until much later. In the second case, another resident with dysphagia, aphasia, and diabetes mellitus was to be weighed weekly per physician's orders. The resident experienced a significant weight loss of over 14% in two weeks, but the only weights recorded were at the start and end of this period. The APRN and physician were not notified of the severe weight loss, and the dietician initiated a reweight order without provider notification. Interviews with nursing staff and APRNs confirmed that neither was aware of the weight loss, and the facility's own policies requiring provider and family notification were not followed. Facility policies directed that significant weight changes should be confirmed with a reweight and communicated to the dietician, provider, and family. In both cases, documentation and interviews revealed that these steps were not taken as required. The failures were identified through review of clinical records, facility documentation, and staff interviews, which consistently showed a lack of timely notification to the appropriate parties regarding significant changes in residents' conditions.
Failure to Report Allegation of Neglect to Authorities
Penalty
Summary
The facility failed to notify state and local authorities of an allegation of neglect involving a resident who reported that a call bell in another resident's room was not answered for several hours during the night. The reporting resident observed an LPN sleeping at the nurse's station and later noted that the call light remained unanswered until another nurse completed medication administration. The resident expressed concern that the unattended call light could have resulted in harm to the other resident. Additionally, the same resident overheard staff discussing that two residents had not been changed overnight due to unanswered call bells. A nurse aide found another resident with a saturated brief and pad, who reported not receiving care overnight. The nurse aide immediately reported this to the supervising RN, who also observed the resident's condition and reported it to the DON as a possible neglect incident. Despite these reports and the facility's policy requiring prompt reporting of suspected neglect to authorities, the DON did not notify state or local agencies, instead handling the matter solely through the facility's grievance process. The facility's own policies defined neglect as the failure to provide necessary care and required reporting such allegations to external authorities.
Failure to Maintain Comprehensive Care Plans for Side Rail Padding and Repositioning Refusals
Penalty
Summary
The facility failed to ensure that the Resident Care Plan (RCP) was comprehensive for two residents, specifically regarding the use of side rail padding and documentation of refusals for repositioning. For one resident with vascular dementia, muscle weakness, and cachexia, physician orders directed the use of quarter side-rails for mobility and transfer. However, side rail evaluations were either incomplete or lacked specific details about the number and length of side-rails. Observations showed the resident in bed with double-sided Velcro pads on both side-rails, but neither the active physician's orders nor the RCP documented the use of side-rail padding. Additionally, the Nurse Aide Care Card did not mention the use of side-rails or padding, and the Director of Nursing Services (DNS) was unaware of the reason for the padding or its absence from care documentation. For another resident with type 2 diabetes, chronic pain, and edema, the RCP identified a risk for skin breakdown and included interventions such as turning and repositioning every two hours and use of pressure redistribution devices. Despite these interventions, wound care notes and staff interviews revealed that the resident frequently refused repositioning, offloading, and an out-of-bed schedule, which contributed to the worsening of a coccyx wound to a Stage 3 pressure ulcer. Staff interviews confirmed that refusals had been ongoing for months, but the RCP did not reflect these refusals until after surveyor inquiry. The wound nurse and nurse aide both acknowledged the resident's non-compliance with repositioning and the lack of documentation in the care plan. Facility policy required that ongoing changes in residents' status be updated by nursing or the interdisciplinary team as needed, and that care plans be revised accordingly. However, the care plans for both residents were not updated to reflect the actual care being provided or the residents' behaviors, resulting in incomplete and non-comprehensive care plans that did not meet regulatory requirements.
Failure to Check Expiration Date Before Administering Narcotic Medication
Penalty
Summary
A deficiency occurred when a nurse failed to check the expiration date on a narcotic medication prior to administration for a resident with diagnoses including Parkinson's disease, chronic pain, and type 2 diabetes mellitus with polyneuropathy. The resident was receiving Morphine Sulfate Extended Release 15 mg tablets as part of a prescribed pain management regimen. During a review and observation of the medication cart, it was found that the blister pack of Morphine had an expiration date that had already passed, and the medication had been administered multiple times after this date. The nurse involved acknowledged not checking the expiration date before administering the medication and stated that this step should have been performed. Facility documentation showed that the medication was received from the pharmacy after the expiration date printed on the packaging, and the controlled substance disposition record confirmed that doses were administered from this pack after the listed expiration date. The facility's policy required nurses to check expiration dates before administering any medication and prohibited the administration of expired medications. The failure to verify the expiration date prior to administration led to the deficiency.
Failure to Obtain and Document Weekly Weights and Reweight for Resident with Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for obtaining weekly weights and a reweight for a resident with significant weight loss. The resident, who had diagnoses including dysphagia, aphasia, and type 2 diabetes mellitus, was admitted with a care plan that identified risks for weight loss and required weekly weights on shower days. Despite these orders, documentation showed that weights were only recorded on two occasions over a period of several weeks, revealing a severe weight loss of 20.8 pounds (14.4%) in two weeks. Additionally, a physician's order for a reweight to verify this loss was not carried out as directed. Interviews with staff confirmed that nurse aides were responsible for obtaining weights and nurses were to check and transcribe them into the electronic health record. However, review of records and staff interviews indicated that the required weekly weights and the ordered reweight were not completed as per protocol. The facility's policy also required retaking weights after significant changes and notifying the dietician, but these steps were not documented as completed at the time of the survey.
Failure to Maintain Proper Medication Storage and Labeling
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage practices, including the presence of expired and unlabeled medications in both the medication room and medication carts. Specifically, expired Diphenhydramine capsules and Beneprotein packets were found in the South Wing medication room, along with opened, unlabeled, and undated containers of Miconazole Nitrate cream and Lactulose solution. Food items such as coffee creamers, sugar packets, and a foam takeout container with utensils were also stored alongside medications. Additionally, drawers contained non-medication items like curling irons, razors, charging cords, headphones, air pumps, glasses, and hearing aids. The Director of Nursing Services (DNS) confirmed that these items should not be present in the medication room and that expired or discontinued medications should be placed in designated bins for pharmacy return, not stored in cabinets or on countertops. Further observations revealed improper storage of medications in the nursing supervisor's office, where a box of Juven packets and multiple bottles of Kayexalate were found on a shelf. The nursing supervisor was unsure why the Juven packets were there and acknowledged that the Kayexalate bottles, intended for the Pyxis system, did not fit in the drawers and should not have been stored in the office. Medication carts were also found to contain expired medications, opened and unlabeled containers, loose pills, and non-medication items such as hairbrushes, glasses, lancets, and wound care products. Staff interviewed, including LPNs and the Infection Preventionist, recognized that expired medications and non-medication items should not be stored in the carts but could not explain why these items were present. The facility's policy requires that all medications be stored in properly labeled containers, separated by route of administration, and that medication storage areas remain clean and free of clutter. The policy also mandates that opened medication containers be dated and that expired medications be removed and destroyed. Despite these policies, the facility failed to maintain proper medication storage practices, as evidenced by the presence of expired, unlabeled, and non-medication items in medication storage areas and carts. No policy on medication cart cleaning was provided upon request.
Failure to Consistently Document Meal Intake for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure consistent documentation of meal intake percentages for a resident with significant weight loss and multiple complex medical conditions, including dementia, dysphagia, severe protein-calorie malnutrition, and type 2 diabetes mellitus. The resident's care plan required monitoring of dietary intake, and clinical notes indicated ongoing weight loss and poor oral intake, averaging around 50%. However, review of nurse aide documentation revealed multiple instances where meal intake percentages were not recorded for breakfast, lunch, and dinner over several days in April and May. This lack of documentation occurred despite the resident's ongoing nutritional decline and the need for accurate intake records to inform care decisions. Interviews with facility staff, including the dietician and Director of Nursing Services (DNS), confirmed that nurse aides were expected to document meal intake accurately and consistently for all residents, especially those with significant weight loss. The dietician relied on this documentation to calculate intake trends and guide treatment, while the DNS was unaware of the omissions until the review. The facility was unable to provide a specific policy regarding nurse aide documentation, though staff reported that training on electronic documentation was provided. The deficiency was identified due to the failure to maintain complete and accurate medical records in accordance with professional standards.
Failure to Communicate MDRO Status During Resident Transfers
Penalty
Summary
The facility failed to ensure that the MDRO (Multi-Drug Resistant Organism) colonization status, special instructions, or precautions for ongoing care were communicated to the receiving hospital at the time of transfer for two residents. In both cases, the residents had documented MDROs, including ESBL Klebsiella and MRSA, as confirmed by laboratory results and the facility's MDRO log. Despite this, nursing notes and transfer documentation did not indicate that this information was shared with the hospital during the transfer process. The facility's process relied on verbal communication, but there was no documentation to confirm that the MDRO status or necessary precautions were conveyed to the hospital. For both residents, the face sheets provided at transfer did not include MDRO diagnoses, and the electronic transfer/discharge documentation was not utilized. Interviews with facility staff, including the Infection Preventionist, DNS, and Regional Nurse, confirmed that the required information was not documented or retained. Additionally, the facility's policy on MDRO control did not specify the requirement to notify the hospital upon transfer, and the policy on MRSA only partially addressed inter-agency notification. These actions and omissions led to the deficiency in communicating critical infection control information during resident transfers.
Failure to Include Resident in Person-Centered Care Planning
Penalty
Summary
A deficiency occurred when the facility failed to include a resident in the development and implementation of their person-centered plan of care. The resident, admitted with diagnoses including dysphagia, aphasia, and Type 2 diabetes mellitus, was identified as having a decline in intellectual functioning and was noted as the guarantor and care conference contact. Despite being severely cognitively impaired and requiring substantial assistance with daily activities, the resident was documented as an active participant in assessment and goal setting, with a goal to return to the community. The facility was unable to provide evidence that a resident care conference (RCC) was held or that the resident or their alternate was invited to participate. There was no RCC attendance sheet, nor documentation from social services or the MDS coordinator indicating that the meeting took place or that the resident was invited. Facility policy required a care plan conference with the resident or responsible party within 48-72 hours of admission and quarterly thereafter, but interviews with staff confirmed that this did not occur for the resident in question.
Failure to Complete PASRR Level 1 Screening for New Admission with Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a Level 1 Pre-admission Screening and Resident Review (PASRR) was completed for a new admission with diagnoses of major depressive disorder, anxiety disorder, and post-traumatic stress disorder. The resident was admitted with a PASRR Level 1 screen dated several years prior from a previous LTC stay, which was negative at that time. The facility relied on this outdated PASRR Level 1 screen and did not conduct a new screening upon admission, despite the resident's current mental health diagnoses. Interviews with facility staff, including the Administrator and Social Worker, confirmed that the process involved reviewing PASRR outcomes received from the discharging facility. The Social Worker acknowledged that a new PASRR Level 1 screen should have been conducted for a resident admitted with mental disorders, but could not provide a reason for the omission. Facility policy and state procedures require that individuals with known or suspected serious mental illness be evaluated through the PASRR process prior to admission, which was not followed in this case.
Failure to Notify POA of Hospital Transfer and Medication Changes
Penalty
Summary
The facility failed to ensure timely notification of a resident's Power of Attorney (POA) regarding significant changes in the resident's condition, hospital transfer, and medication changes. Specifically, a resident with diagnoses including congestive heart failure, chronic kidney disease, tremors, and anxiety was transferred to the hospital for lethargy, altered mental status, low oxygen saturation, and bradycardia. Documentation did not show that the POA was notified of the change in condition or the hospital transfer. The POA only learned of the hospital admission after being contacted by the hospital and was later informed by facility staff upon the resident's return. The Director of Nursing confirmed that the supervising nurse was responsible for the notification, but the reason for the failure to notify was not identified. Additionally, the facility did not notify the correct legal representative regarding medication changes. Nursing notes indicated that another individual, not the POA, was informed about changes in the resident's medication regimen, including the initiation and discontinuation of Clonazepam and a neurology referral. Facility policy required immediate notification of the resident's legal representative for significant changes in treatment or condition, but this was not followed in these instances.
Failure to Document Provider Notification of Delayed X-ray After Resident Fall
Penalty
Summary
The facility failed to ensure that the clinical record for a resident was complete and accurate regarding physician or APRN notification when an ordered x-ray was delayed following a fall. The resident, who had diagnoses including Alzheimer's disease, dementia, and anxiety, was identified as a fall risk and required maximum assistance for transfers. After a fall during a transfer, the resident complained of left lower extremity pain, and an x-ray was ordered. However, when the radiology provider informed nursing staff that the x-ray would be delayed due to staffing issues, there was no documentation in the clinical record that the physician or APRN was notified of this delay. Interviews revealed that the APRN was not informed of the delay while present in the facility, nor was the on-call service notified, as confirmed by the APRN. Although a nurse stated she notified the on-call physician team, she could not verify whom she spoke to and did not document the notification in the clinical record. The Director of Nursing confirmed that the expectation was for nursing staff to document provider notifications, which was not done in this case. The facility also did not have a policy related to documentation.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment and lacking the capacity to consent was subjected to inappropriate physical contact by another resident. The incident was captured on a video camera installed in the cognitively impaired resident's room for virtual visitation purposes. The video showed an alert and oriented resident entering the room, kissing the cognitively impaired resident on the mouth, and touching the resident's breast. The incident was witnessed by the spouse of the cognitively impaired resident, who then informed facility staff. Documentation and interviews confirmed that the cognitively impaired resident was only alert to self, had baseline confusion, and required supervision or assistance with most activities of daily living. Facility records and staff interviews indicated that the resident who initiated the contact was aware of their actions and admitted to initiating the physical contact. The facility's abuse prevention policies explicitly prohibit any form of abuse, including sexual abuse, and only permit sexual expression between consenting adults. Despite these policies, the facility failed to prevent the incident, resulting in a substantiated case of sexual abuse due to the lack of consent capacity in the affected resident.
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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