Bloomfield Center For Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Bloomfield, Connecticut.
- Location
- 355 Park Avenue, Bloomfield, Connecticut 06002
- CMS Provider Number
- 075138
- Inspections on file
- 31
- Latest survey
- January 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Bloomfield Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with a neurogenic bladder, recurrent UTIs, and atrial fibrillation was scheduled for a suprapubic tube placement and had preoperative instructions from Interventional Radiology that included holding Eliquis for 48 hours before the procedure. An RN received these instructions verbally, verified them with the provider, and entered an order to hold the anticoagulant for two days, but did not confirm the electronic start and end dates or restart time. As a result, Eliquis doses were held only on the first day, while both doses on the second day and the morning dose before the procedure were administered, contrary to the intended 48-hour hold. The consultation report documented that the procedure was cancelled because Eliquis had not been held for the required time, and the DON later noted that the RN did not document the verbal pre-op orders in a nurse’s note, so a second licensed nurse did not perform a follow-up check of the transcription.
A resident with bladder dysfunction, recurrent UTIs, and atrial fibrillation was scheduled for a suprapubic catheter procedure while receiving Eliquis. Interventional Radiology provided detailed pre-op instructions, including required labs, NPO status, and specific directions to hold Eliquis starting two days before the procedure and to restart it afterward. Although the RN verified these instructions with the provider and entered related orders, she did not fully document the pre-op instructions in the clinical record. The record contained only a note about faxing lab results, and the MAR showed Eliquis was held on one day but still administered on subsequent doses contrary to the intended pre-op plan. The facility’s own documentation policy and the DON’s statements confirmed that all provider communications and pertinent care details should have been accurately and completely recorded, leading to the cited deficiency.
A resident who was totally dependent on staff for care was observed being wheeled down the hallway after a shower with their buttocks exposed, wearing only a hospital gown and no additional covering. Staff, other residents, and a surveyor were able to see the exposed area. The DON confirmed the resident should have been fully covered, and the responsible NA admitted she was aware of the policy but was in a hurry.
A resident with significant medical needs was placed on isolation precautions after a roommate tested positive for Covid, despite testing negative and showing no symptoms. The resident was not allowed to leave the room, was not evaluated for mask use, and was denied access to activities, resulting in missed religious services and social engagement. Facility staff were unclear on CDC guidelines and did not provide physician orders for isolation, leading to the resident's unnecessary confinement.
Two residents did not have comprehensive care plans reflecting their specific needs: one with quadriplegia and communication barriers lacked a documented 24-hour positioning plan and interpreter services, while another with dental pain did not have dental issues included in their care plan, despite clinical documentation and staff awareness.
The facility did not update care plans for two residents after significant changes in condition—one after a decline in mobility leading to pressure injuries, and another after multiple unwitnessed falls. Staff interviews confirmed that required care plan revisions and new interventions were not implemented as per facility policy.
A resident with COPD and other respiratory conditions was found with a portable oxygen cylinder stored sideways on a wheelchair in their room. An unqualified social worker reported administering oxygen to the resident, contrary to facility policy and without proper training, while the DON confirmed only nursing staff should perform this task.
A resident with quadriplegia and intact cognition was not provided with recreation activities suitable for their physical limitations. Although the care plan called for involvement in cognitive and social activities, the resident reported a lack of options due to hand paralysis, and the recreation director confirmed that no specialized programs were offered for residents with physical impairments, contrary to facility policy.
Two residents did not receive weekly skin checks, Braden Scale risk assessments, or timely nutritional evaluations after developing or being admitted with pressure ulcers. The dietician was not informed to assess nutritional needs, and care plans were not updated to reflect changes in condition, contrary to facility policy.
Surveyors found that a portable oxygen cylinder was improperly stored unsecured on a wheelchair, a dependent resident had a nasal foreign body removed by staff instead of being sent to the ED as ordered, and another resident sustained a hand injury from a bed side rail that was used without a required assessment or documentation. These deficiencies involved failure to follow safety protocols, physician orders, and facility policies.
A resident with CHF and other comorbidities was not weighed daily as ordered by the physician, with weights documented only sporadically over several months. Staff interviews confirmed the daily weight order was current and should have been followed, but no explanation was provided for the missed weights, and there was no documentation of refusals or reasons for not weighing the resident.
A resident with multiple medical conditions was administered the wrong IV solution after a provider order was changed, due to staff not verifying the updated order and using an available but incorrect fluid. The error was not detected during shift change or by supervisory staff, and facility protocols for IV verification and monitoring were not followed, resulting in the resident receiving inappropriate IV fluids until a change in condition was noted.
A resident receiving hemolytic treatment with a physician-ordered 1000 cc fluid restriction did not have daily fluid intake tracked or documented, as required. Staff interviews revealed confusion about responsibility for monitoring intake, and the fluid restriction order was not visible on the MAR. The resident was unaware of the restriction, and the facility could not show how total fluid intake was maintained, despite policy requiring such documentation.
A resident with multiple chronic conditions was found with several prescribed medications left unattended at the bedside by an LPN, who did not remain to ensure administration. The resident had not been assessed or approved for self-administration, and facility policy prohibits leaving medications at the bedside without observation.
A resident with COPD, heart failure, and quadriplegia was on isolation precautions for Covid, requiring staff to wear gloves, a gown, and an N-95 mask as posted on the room signage. During care, a nurse aide was observed wearing a surgical mask instead of the required N-95 mask, despite being aware of the correct PPE protocol. The facility's infection preventionist and policy confirmed that staff must follow posted PPE requirements.
Surveyors found dirty trays, fruit flies in a resident's room, and stained carpets in multiple areas. The Housekeeping Supervisor confirmed ongoing pest issues and persistent carpet stains despite recent cleaning efforts, with no documentation available to verify cleaning or carpet replacement plans.
A resident with severe cognitive impairment and multiple health issues experienced a decline in functional abilities, requiring increased assistance with bed mobility, transfers, and ambulation. Although the care plan was updated to reflect these changes, staff failed to complete a significant change MDS assessment within the required timeframe. The decline was not promptly communicated to the DON or identified by the MDS Coordinator until after the resident developed a new pressure ulcer.
Surveyors identified that the facility failed to accurately code MDS assessments for two residents. One resident with a Level II PASRR was incorrectly coded as not having one on the annual MDS, and another resident with significant eating deficits was coded as independent despite documentation and observations showing total dependence on staff for eating. These deficiencies were confirmed through record review, staff interviews, and direct observation.
Two residents with multiple mental health diagnoses did not have accurate or complete Level 1 PASRR screenings, and the facility failed to submit required Level 2 PASRR evaluations after changes in diagnosis. Care plans lacked PASRR information, and staff interviews revealed gaps in PASRR documentation and oversight.
Three residents, including individuals with cognitive impairments, experienced unauthorized withdrawals from their personal funds accounts. In each case, funds were withdrawn in amounts or under circumstances not consistent with the residents' usual patterns, and required documentation such as vendor receipts or proper signatures was missing. Investigation identified a former receptionist as responsible for these unauthorized transactions, which were not in accordance with facility policy or procedures.
A resident with a history of bipolar disorder and dementia, who was alert and independent, was involved in an altercation with a nurse aide over a spilled lunch tray. During the incident, the nurse aide threatened to retaliate if the resident hit her, a statement witnessed by another staff member. This threat caused the resident distress and violated facility policies prohibiting abuse and intimidation.
A witnessed verbal abuse allegation involving a resident with bipolar disorder and dementia was not reported within the required timeframe. The incident, in which a nurse aide threatened to retaliate if struck, was observed by an Administrative Assistant who did not immediately notify the DON as required by policy, resulting in a delayed report.
A resident with a brain tumor, seizure disorder, and behavioral care plan requiring two caregivers was left alone with an LPN who became frustrated, handled the resident roughly, and engaged in a loud verbal altercation. The incident was not properly reported or investigated, and facility documentation was incomplete, failing to ensure the resident was free from abuse as required by policy.
Two residents experienced incidents involving delayed care and alleged mistreatment, which were reported to the DON but not to the State Agency as required. In both cases, the facility did not complete formal investigations or document findings, and failed to follow its policy for immediate reporting and investigation of abuse or neglect allegations.
The facility did not thoroughly investigate or document allegations of abuse and neglect involving two residents. In one case, a resident was reportedly left in soiled incontinence products for extended periods, and in another, a resident alleged emotional abuse by an LPN. The DON was notified but failed to ensure investigations or proper documentation were completed, as required by facility policy.
A resident with a brain tumor, seizure disorder, and behavioral concerns had a care plan requiring two caregivers at all times. An LPN, unaware of this requirement, entered the room alone to provide pain medication and assistance, leading to a distressing interaction where the resident felt emotionally mistreated. The incident was reported to the nursing supervisor and DNS, but the care plan directive was not followed, resulting in a deficiency.
A resident with multiple medical conditions and documented urinary incontinence was not provided with a bladder evaluation upon admission, despite facility policy requiring such an assessment within three days for incontinent individuals. Staff documentation and care plans noted the incontinence, but the necessary evaluation to guide interventions was not completed.
Two residents did not receive timely social services support after reporting incidents of neglect and emotional abuse. In both cases, required follow-up and documentation by social services did not occur, as the responsible social workers were either not notified or did not document any intervention, despite facility policy requiring such actions.
A resident with dementia and a history of aggression physically assaulted three other residents with cognitive and psychiatric conditions on separate occasions, resulting in injuries such as bruising and a bloody nose. Despite care plans and interventions like one-to-one supervision and medication management, the facility did not prevent repeated incidents of physical abuse between residents.
Incorrect Transcription of Preoperative Anticoagulant Hold Order Leading to Procedure Cancellation
Penalty
Summary
The deficiency involves the facility’s failure to correctly transcribe and implement preoperative orders to hold an anticoagulant, resulting in the medication being administered too close to a scheduled procedure and the procedure being cancelled. The resident involved had diagnoses including neuromuscular dysfunction of the bladder, recurrent UTIs, and atrial fibrillation, and was alert and oriented with a BIMS score of 15. The resident’s care plan documented an indwelling catheter for neurogenic bladder with monitoring for UTI symptoms. Interventional Radiology staff called the facility with preoperative instructions for a suprapubic tube placement, including required lab work, NPO status after midnight except medications with sips of water, and directions to hold Eliquis starting on a specified morning and to restart it after the procedure. The nurse receiving the call verified the instructions with the provider and entered the orders the same day. A physician’s order was created directing Eliquis to be held for two days as preparation for the suprapubic tube procedure. However, review of the MAR showed that while the morning and evening doses of Eliquis were held on the first designated day, both doses on the second day and the morning dose prior to the procedure were administered. A consultation report documented that the suprapubic catheter replacement was cancelled because Eliquis had not been held for the required 48 hours, and the nurse reported that the medication was held only on the first day. The 3–11 PM RN supervisor later stated she had selected a start date and duration for the hold order but did not confirm the end date or restart time were correct. The DON stated that, although there was no specific policy for licensed nurses to verify order transcription accuracy after entering verbal orders, nursing standards required the RN to ensure the orders were complete and accurate, and that because the preoperative orders were received verbally and not documented in a nurse’s note, a second licensed nurse check on the next shift did not occur. The facility’s Transcription of Orders policy described who may accept and transcribe orders but no separate physician orders policy was provided.
Incomplete Documentation of Preoperative Instructions and Anticoagulant Management
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident undergoing coordination with a community provider for a suprapubic catheter procedure. The resident had diagnoses including neuromuscular dysfunction of the bladder, recurrent urinary tract infections, and atrial fibrillation, and was receiving Eliquis 5 mg twice daily per monthly physician orders. A quarterly MDS showed the resident was alert and oriented with a BIMS score of 15/15. On 12/4/25, the 3–11 PM nursing supervisor received a call from the hospital’s Interventional Radiology department with preoperative instructions for a suprapubic tube placement scheduled for 12/11/25. These instructions included required blood work to be obtained and faxed, NPO status after midnight except medications with sips of water, and specific directions to hold Eliquis starting on the morning of 12/9/25 and to restart it after the resident’s return from the procedure. Although the nurse verified these instructions with the provider and entered related orders, she did not document the full preoperative instructions in a narrative note in the clinical record. Subsequent review of the clinical record from 12/4/25 through 12/11/25 showed no documentation of the complete preoperative instructions received on 12/4/25, aside from a 12/5/25 nurse’s note indicating that INR, CBC, and CMP results were faxed to the hospital. A physician’s order dated 12/4/25 directed that Eliquis be held on 12/9/25 and 12/10/25 for procedure preparation. However, the December MAR showed that while both doses of Eliquis were held on 12/9/25, the morning and evening doses on 12/10/25 and the morning dose on 12/11/25 were administered. A consultation report on 12/11/25 documented that the suprapubic catheter replacement was cancelled because Eliquis had been held on 12/9/25 but not on 12/10/25, and that Eliquis needed to be held for 48 hours. The DON stated that licensed nurses are responsible for documenting all communication with community providers, and the facility’s Charting and Documentation policy requires accurate, relevant, and complete documentation of assessments, observations, and services, including communication used to develop the plan of care and measure quality of care. The lack of complete documentation of the preoperative instructions and related communication led to the cited deficiency.
Resident Dignity Compromised During Post-Shower Transfer
Penalty
Summary
A resident with quadriplegia, diabetes, and feeding difficulties, who was totally dependent on staff for mobility, transfers, eating, and bathing, was observed being wheeled down the hallway in a shower chair after a shower with their buttocks exposed. The resident was wearing only a hospital gown with no additional covering, and staff, other residents, and the surveyor were able to view the exposed area. The resident's care plan indicated total dependence on staff for bathing and transfers, and the facility's policy required residents to be treated with dignity and to have privacy during personal care. The Director of Nursing (DNS) witnessed the incident and confirmed that the resident should have been fully covered during the transfer. The nursing assistant responsible for the transfer acknowledged awareness of the policy but stated she was in a hurry at the time. The facility's resident rights policy emphasized the right to dignity, respect, and privacy during care, which was not upheld in this instance.
Failure to Prevent Involuntary Seclusion During Covid Exposure Precautions
Penalty
Summary
A resident with quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease was placed on isolation precautions after their roommate tested positive for Covid. Despite testing negative and showing no symptoms, the resident was not allowed to leave their room, even when wearing appropriate PPE, and was not evaluated for mask use or compliance. The facility's infection preventionist and nursing staff were unable to correctly identify CDC recommendations for cohorting or the appropriate use of source control, and there were no physician orders directing isolation or specific precautions for the resident. The resident was observed alone in their room, behind a privacy curtain, without a mask or access to engaging activities, and expressed distress over missing religious services. Staff interviews revealed a lack of clarity regarding when the resident could leave the room, and the infection preventionist stated that no activities could be offered during the isolation period. The director of recreation confirmed the resident had not participated in or been offered any activities since the exposure. The director of nursing services stated it was unsafe for the resident to leave the room, despite staff being able to enter and exit with masks, and acknowledged the resident had not been trialed for mask use. The administrator was not aware of the resident's request to leave the room and recognized that restricting the resident could be considered involuntary seclusion. The facility's operational guide indicated exposed residents should be monitored, tested, and wear masks, but did not support the level of restriction imposed.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents with specific needs. For one resident with quadriplegia, diabetes, and feeding difficulties, the care plan did not include a 24-hour positioning plan as ordered by the physician, nor did it address the resident's communication barriers, despite the resident being Spanish-speaking and requiring an interpreter. Documentation such as the nurse aide care card and the resident care plan lacked information about the positioning plan and the need for specialized communication services, even though occupational therapy notes and physician orders specified these requirements. Interviews confirmed that staff were unaware of these omissions in the care plan. For another resident with a history of malignant neoplasm, malnutrition, and dysphagia, the care plan did not reflect ongoing dental issues, despite dental and hygienist notes documenting tooth pain and the need for further evaluation. The resident's dental discomfort was known to nursing staff, and previous assessments had recommended referral for treatment, but the care plan was not updated to include these dental concerns. Review of facility policy indicated that care plans should be revised to reflect current status and new problems, but this was not done for the resident's dental issues.
Failure to Update Care Plans After Resident Decline and Falls
Penalty
Summary
The facility failed to update the Resident Care Plan (RCP) with appropriate interventions following significant changes in residents' conditions. For one resident with severe protein calorie malnutrition, vascular dementia, and difficulty walking, a decline in bed mobility, transfers, and ambulation was documented in a physical therapy discharge summary. Despite this decline, the RCP was not updated to include new preventative measures for pressure ulcer development. The resident subsequently developed a deep tissue injury and a stage 2 pressure ulcer, with the RCP only being updated after these injuries were identified. Another resident, admitted with hypertension, generalized body weakness, and dementia, experienced two unwitnessed falls within a short period. The RCP for this resident identified a risk for falls and included some interventions, but after the falls occurred, no new interventions were added to the care plan to prevent further incidents. The responsible nurse acknowledged that the RCP should have been updated post-fall but could not explain the omission. Interviews with facility staff, including the Director of Nursing Services (DNS) and the MDS Coordinator, confirmed that the care plans were not reviewed or revised in response to significant changes in the residents' conditions or after adverse events. Facility policies required ongoing updates to care plans when new problems arose, but these were not followed in the cases reviewed.
Improper Storage and Administration of Portable Oxygen Cylinder
Penalty
Summary
A deficiency was identified when a portable oxygen cylinder was observed stored improperly, lying sideways on the seat of a manual wheelchair at the base of a resident's bed. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, and congestive heart failure, had been provided with an extra oxygen tank to facilitate movement and socialization within the facility. The resident was cognitively intact and required varying levels of assistance with mobility and dressing. The care plan included monitoring for respiratory symptoms and administering oxygen as ordered. During interviews, a social worker reported that she had provided oxygen to the resident in the past and knew how to operate the oxygen tank, despite not being professionally trained or qualified to do so. The Director of Nursing confirmed that only nursing staff should administer oxygen and that the social worker did not have the necessary competency or qualifications. Facility policy required staff to identify hazards related to oxygen therapy, particularly for residents with COPD, but this was not followed in this instance.
Failure to Provide Activities for Resident with Physical Impairment
Penalty
Summary
The facility failed to provide activities that met the needs of a resident with significant physical impairments. The resident, who had diagnoses including quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease, was cognitively intact but dependent on others for personal hygiene and mobility, using a motorized wheelchair. The resident's care plan specified involvement in cognitive and social activities, with interventions such as invitations to scheduled activities and provision of an activity calendar. However, interviews revealed that the resident was not offered recreation activities suitable for someone with paralyzed hands, and the Director of Recreation confirmed that no specialized recreation programs were provided for residents with physical limitations, despite the facility's policy requiring resident-centered activities based on physical and cognitive limitations.
Failure to Perform Required Pressure Ulcer Assessments and Care Planning
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for two of three sampled residents. For one resident with multiple comorbidities including diabetes, chronic kidney disease, dementia, and congestive heart failure, the facility did not perform weekly skin checks as ordered, nor did they complete weekly Braden Scale risk assessments after the initial admission assessment. The resident developed a reddened heel, a sacral pressure injury, and a deep tissue injury to the left big toe during their stay. Additionally, the dietician did not conduct a nutritional assessment after the development of pressure ulcers, despite facility policy and physician orders requiring such evaluations. For another resident with diabetes, chronic kidney disease, and intellectual disability, the facility also failed to perform weekly skin assessments as required, with missed documentation for two weeks. The Braden Scale risk assessment was not repeated after the initial assessment, and the dietician did not evaluate the resident's nutritional status following the identification of a pressure ulcer present on readmission. Furthermore, the resident's care plan and nurse aide care card were not updated to reflect necessary interventions for pressure ulcer prevention and care after the resident was readmitted with an unstageable pressure ulcer. Interviews with facility staff confirmed that weekly skin and wound assessments, Braden Scale evaluations, and timely nutritional assessments by the dietician were expected per facility policy but were not completed. The Director of Nursing and the dietician both acknowledged lapses in communication and adherence to protocols, resulting in the deficiencies identified. Review of facility policies confirmed the requirements for regular assessments and care plan updates, which were not followed for the affected residents.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
A deficiency was identified when a portable oxygen cylinder was observed unsecured and lying sideways on the seat of a wheelchair in a resident's room. The resident, who had diagnoses including chronic obstructive pulmonary disease, respiratory failure, and congestive heart failure, required oxygen therapy. Facility policy and OSHA regulations require that oxygen cylinders be stored upright and secured, but the cylinder was not in a holder or chained area as required. Another deficiency occurred when a resident with quadriplegia, congestive heart failure, and chronic obstructive pulmonary disease had a Q-tip lodged in their nostril. The resident was dependent on staff for care and unable to independently grasp objects. Despite a provider order to send the resident to the Emergency Department for Q-tip removal, facility staff removed the Q-tip themselves with tweezers and did not immediately send the resident to the hospital as ordered. Additionally, the facility did not complete an accident or reportable incident form for this occurrence. A further deficiency was found when a resident with dementia and generalized weakness sustained a skin tear after their hand became caught in a bed side rail. The resident was alert but confused and required maximum assistance for mobility and hygiene. The care plan did not indicate side rail use, and interviews and record review confirmed that a side rail assessment was not completed prior to the use of side rails, contrary to facility policy. The facility also failed to obtain informed consent or document side rail use in the resident's plan of care.
Failure to Obtain and Document Daily Weights for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document daily weights for a resident with Congestive Heart Failure (CHF) as ordered by the physician. The resident, who had a history of hypertension, CHF, and diabetes, was admitted in July 2024 and had a care plan that included daily weight monitoring due to the risk of fluid overload associated with CHF. Despite a physician's order to weigh the resident every day and notify the physician of significant weight changes, the clinical record showed that weights were only recorded sporadically over several months, with significant gaps in documentation. There was no evidence in the record of the resident refusing to be weighed, nor were refusals or reasons for missed weights documented. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the daily weight order was current and should have been followed, and that any refusals should have been documented. However, staff were unable to explain why the resident was not weighed as directed. Additionally, the facility's weight policy required documentation of refusals or circumstances preventing weighing, but this was not done. The facility was unable to provide a specific CHF policy when requested.
Failure to Administer Correct IV Solution per Physician Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, acute kidney failure, and malnutrition was administered the incorrect intravenous (IV) solution, contrary to the physician's order. The resident was at risk for dehydration and had an order for Sodium Chloride 0.45% IV at 75 ml/hr, which was later changed to Dextrose 5% (D5W) at 65 ml/hr due to hypernatremia and tachycardia. Despite this change, the resident was given D5 ½ NS (Dextrose 5% in 0.45% Sodium Chloride) instead of the ordered D5W, as the correct solution was not available in stock. The LPN who administered the IV solution believed it was correct after confirming with an RN, but did not verify the updated order or contact the provider for clarification when the correct solution was unavailable. The error was not identified during the shift change, as the incoming LPN did not verify the IV solution due to arriving late and only received a verbal report. The oncoming nurse checked the IV site but not the fluid, and did not take vital signs upon assuming care. The incorrect IV solution continued to be administered until the resident was found to be lethargic and tachycardic, prompting further assessment and eventual transfer to the emergency department. Multiple staff interviews revealed that the facility's protocol for verifying IV solutions during shift change and monitoring IV sites every two hours was not followed. Facility documentation and staff interviews confirmed that the wrong IV fluid was administered and that there was a failure to verify the correct solution at multiple points, including by the supervising RN and the Director of Nursing. The policies required staff to follow physician orders for IV fluids and to monitor IV sites regularly, but these procedures were not adhered to, resulting in the administration of an incorrect IV solution to a resident with significant medical needs.
Failure to Monitor and Document Fluid Restriction for Resident on Hemolytic Treatment
Penalty
Summary
A resident with end stage renal disease, congestive heart failure, and anemia was admitted to the facility and required hemolytic treatment. The resident had a physician's order for hemolytic treatment three times per week and a fluid restriction of 1000 cc per 24 hours, as recommended by a nephrologist due to episodes of hypotension during treatment. The care plan and dietary instructions reflected this restriction, with specific fluid amounts allocated for meals and medication administration. Despite these orders, a review of the clinical records, including nursing notes, MAR, and TAR, revealed that there was no documentation or tally of the resident's daily fluid intake from the time the fluid restriction order was implemented. Interviews with nursing staff showed confusion regarding responsibility for tracking fluid intake, with some staff believing it was the responsibility of licensed nurses and others indicating it was a shared responsibility. The fluid restriction order was not visible on the MAR, and staff acknowledged that the order had not been properly activated to prompt documentation. The resident was not aware of the fluid restriction until two days prior to the survey, and reported consuming both facility-provided and outside food and fluids without tracking intake. The dietician confirmed that nursing staff were expected to maintain intake records for residents on fluid restriction, but the order may not have been activated in the system. The facility's policy required nursing personnel to document fluid intake, but this was not done for the resident in question. The facility was unable to demonstrate how the total fluid intake was tracked or maintained for the resident as required by the physician's order.
Medications Left Unattended at Bedside Without Self-Administration Assessment
Penalty
Summary
A deficiency occurred when a resident, admitted with diagnoses including hypertension, congestive heart failure, and diabetes, was found with five pills in a medication cup left on the bedside table. The resident, who was cognitively intact and required varying levels of assistance for activities of daily living, reported that an LPN had left the medications at the bedside for self-administration. Observation and interview confirmed that the LPN left the room before ensuring the resident had taken the medications, despite the resident not being assessed or approved for self-administration. Further review of the clinical record and facility policy revealed that there was no completed self-administration assessment or evaluation for the resident. The facility's medication pass policy requires staff to observe residents until all medications are swallowed and prohibits leaving medications at the bedside. The LPN identified the medications left as trazodone, carvedilol, Ativan, and torsemide, and acknowledged that leaving them at the bedside was not in accordance with facility policy.
Failure to Use Required PPE for Resident on Covid Isolation Precautions
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control program by not wearing the required Personal Protective Equipment (PPE) when providing care to a resident on isolation precautions for Covid. Specifically, a nurse aide was observed wearing a gown, gloves, and a surgical mask instead of the required N-95 mask, as indicated by the signage posted outside the resident's room. The signage clearly stated that gloves, a gown, and an N-95 mask were required for entry due to airborne precautions. The resident involved had a history of chronic obstructive pulmonary disease (COPD), heart failure, and quadriplegia, and was dependent on staff for personal hygiene and mobility. The resident was on isolation precautions for Covid, as documented in the care plan and nurse progress notes. During the observation, the nurse aide acknowledged awareness of the requirement to wear an N-95 mask but stated she had forgotten to use the correct mask. The facility's policy and the infection preventionist both confirmed that staff are expected to follow the posted PPE requirements for residents on precautions.
Failure to Maintain Clean, Sanitary, and Pest-Free Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary environment, as well as an environment free of pests. During a tour, dirty trays were found on a counter and fruit flies were present in a resident's room on the A Wing. Additionally, on the C Wing, carpets in front of the nurse's station were noted to be stained brown, yellow, and red. These observations were made over a period of approximately 30 minutes. The Housekeeping Supervisor confirmed that although pest control had recently treated another resident's room for fruit flies, fruit flies remained in the affected resident's room. The supervisor also stated that spot and steam cleaning of the carpet had been performed the previous week, but stains persisted, and no documentation could be provided to verify the cleaning. The facility had received a quote for carpet replacement, but this was not provided to the surveyor as requested. Facility policies required daily spot checks and semiannual wet extraction of carpets, but the observed conditions indicated these procedures were not effectively implemented.
Failure to Complete Significant Change MDS Assessment After Resident Decline
Penalty
Summary
A deficiency occurred when the facility failed to identify and complete a significant change Minimum Data Set (MDS) assessment for a resident who experienced a decline in condition. The resident, who had diagnoses including severe protein calorie malnutrition, vascular dementia, and difficulty walking, was initially assessed as requiring only supervision for bed mobility, transfers, and ambulation, and was at risk for skin breakdown but had no current pressure ulcers. However, subsequent documentation from physical therapy indicated a decline in the resident's functional abilities, with increased assistance needed for bed mobility, transfers, and ambulation. The resident care plan was updated to reflect these changes, but a significant change MDS assessment was not completed as required. Further review revealed that the Advanced Practice Nurse Practitioner documented a recent decline in the resident's function, including increased time spent in bed, decreased interaction, and the development of a new pressure ulcer. The DON was not made aware of the resident's decline until after the pressure ulcer developed, and the MDS Coordinator did not recognize the need for a significant change assessment until after meeting with rehabilitation staff. The MDS Coordinator acknowledged that the assessment should have been completed within 14 days of the decline, but this was not done due to oversight.
Inaccurate MDS Coding for Resident Assessment and ADL Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to resident assessment accuracy. For one resident with diagnoses including schizophrenia, encephalopathy, and morbid obesity, the clinical record showed a Level II PASRR outcome document was on file. The admission MDS assessment correctly indicated a positive Level II PASRR, but the subsequent annual MDS assessment was incorrectly coded as negative for Level II PASRR, despite no change in the resident's status. The Director of Social Work confirmed the inconsistency and was unable to explain the miscoding. For another resident with a history of malignant neoplasm of the left breast, moderate protein calorie malnutrition, and dysphagia, the annual MDS assessment indicated the resident was independent with eating. However, the care plan, nurse aide documentation, and direct observations showed the resident required extensive or total assistance with eating, including the use of adaptive equipment and staff feeding. The Director of Nursing Services acknowledged the conflicting documentation and could not explain the incorrect MDS coding. These findings were based on observations, record reviews, and staff interviews.
Failure to Ensure Accurate PASRR Screening and Timely Level 2 Referrals
Penalty
Summary
The facility failed to ensure the accuracy and completeness of Level 1 PASRR screenings and did not submit required Level 2 PASRR evaluations for two residents with mental health diagnoses. For one resident admitted with anxiety disorder, major depressive disorder, and PTSD, the Level 1 PASRR did not accurately reflect the resident's history of suicidal ideation or prior psychiatric hospitalizations, and did not trigger a Level 2 PASRR evaluation. Additionally, after a new diagnosis of anxiety was made, the facility did not submit a new PASRR as required for a change in condition. For another resident admitted with multiple mental health diagnoses, including anxiety, dependent personality disorder, major depressive disorder, and bipolar disorder, the Level 1 PASRR failed to include all relevant diagnoses and did not prompt a Level 2 PASRR evaluation. The facility also did not submit a status change to the PASRR vendor after the resident was later diagnosed with unspecified dementia, as required by PASRR protocols. Interviews with facility staff revealed that the Level 1 PASRR forms were not coded correctly and that there was a lack of understanding or oversight regarding the need to update PASRR documentation following changes in residents' mental health diagnoses. The facility did not have a policy in place for PASRR, and the care plans for both residents did not include information related to PASRR requirements.
Failure to Protect Residents from Misappropriation of Personal Funds
Penalty
Summary
The facility failed to protect residents from the wrongful use and misappropriation of their personal funds, as evidenced by incidents involving three residents. One resident, diagnosed with schizophrenia and major depressive disorder and noted to be alert and oriented, discovered a significant discrepancy in their account balance after attempting to withdraw funds. Upon review, it was found that several withdrawals had been made in amounts inconsistent with the resident's usual withdrawal pattern, and the resident denied authorizing these transactions or signing the receipts. Investigation revealed that a former receptionist, whose signature appeared on the questionable receipts, was present at the facility during at least one of the unauthorized transactions, despite having called out sick that day. For another resident with schizophrenia, metabolic encephalopathy, and dementia, an audit of personal funds uncovered several handwritten receipts for food purchases without corresponding receipts from the restaurant, raising concerns about the legitimacy of these transactions. Similarly, a third resident with depression, anxiety, and dementia was found to have a withdrawal noted for food, but again, no vendor receipt was available to verify the transaction. Both residents had memory recall deficits, making them particularly vulnerable to financial misappropriation. Interviews with facility staff confirmed the standard process for resident fund withdrawals, which requires a receipt signed by the resident and the distributing staff member, with additional management signatures if the resident is unable to sign. However, the investigation determined that the former receptionist did not follow these procedures and was responsible for the misappropriation of funds from the residents' accounts. Facility policy explicitly prohibits misappropriation and exploitation of resident property, but these incidents demonstrated a failure to adhere to established protocols, resulting in unauthorized withdrawals from resident accounts.
Staff Member Threatens Retaliation Against Resident
Penalty
Summary
A deficiency occurred when a staff member failed to protect a resident from intimidation and the threat of retaliation. The incident involved a resident with bipolar disorder and vascular dementia, who was alert and oriented with a BIMS score of 15, and generally independent in activities of daily living. The resident reported an altercation with a nurse aide following a spilled lunch tray, during which the nurse aide stated that if the resident hit her, she would hit the resident back. This statement was made in the presence of another staff member and was confirmed during the facility's investigation. The facility's abuse policy prohibits any form of abuse, including intimidation or threats that result in mental anguish. The nurse aide's comment was witnessed by the Administrative Assistant, who intervened to calm the resident and advised the nurse aide against making such statements. The incident was reported to the Director of Nursing, who confirmed that the statement upset the resident. The facility's policies and the resident's rights were not upheld in this instance, as the resident was subjected to a threat of retaliation by a staff member.
Failure to Timely Report Witnessed Verbal Abuse Allegation
Penalty
Summary
A witnessed allegation of verbal abuse involving a resident with bipolar disorder and vascular dementia was not reported to the Administrator or designee within the required two-hour timeframe. The resident, who was alert, oriented, and independent with most activities of daily living, reported that a nurse aide stated, during an altercation over a spilled lunch tray, that if the resident hit her, she would hit the resident back. This statement was witnessed by the Administrative Assistant, who intervened to calm the resident but did not report the incident to the Director of Nursing (DON) as required by facility policy. The incident was only brought to the attention of the DON when the resident reported it to social services approximately two weeks later. The Administrative Assistant acknowledged being aware of the policy to immediately report allegations of abuse but failed to do so, focusing instead on de-escalating the situation. Facility documentation and interviews confirmed that the delay in reporting was not in accordance with the facility's abuse policy, which mandates immediate notification of the administrator or nursing supervisor upon witnessing or learning of abuse.
Failure to Protect Resident from Verbal and Emotional Abuse and Inadequate Reporting
Penalty
Summary
A deficiency occurred when a resident with a history of malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD was not protected from verbal and emotional abuse. The resident, who was cognitively intact and required moderate assistance with mobility and transfers, had a care plan specifying that two caregivers should be present at all times due to behavioral concerns. Despite this, an LPN entered the resident's room alone to administer pain medication and became visibly annoyed when the resident requested additional assistance. The LPN handled the resident's bedding roughly, caused medication to spill, and engaged in a loud verbal exchange with the resident, which was overheard by a supervising RN. The resident reported feeling demeaned and emotionally abused by the LPN's actions and words. The incident was not properly reported or investigated according to facility policy. The supervising RN, who heard the altercation, did not collect a statement from the LPN at the time, did not report the incident to the Director of Nursing Services (DNS), the Administrator, or the oncoming nurse supervisor, and did not ensure the grievance form was collected from the resident. The DNS later confirmed that no formal investigation was conducted, and the incident was handled as a customer service issue rather than an abuse allegation, despite the resident's report of mental and emotional abuse. Facility documentation revealed further lapses, including an incomplete grievance form with no documented actions taken or follow-up provided to the resident. The abuse policy required immediate reporting and investigation of all abuse allegations, but these procedures were not followed. The LPN was unaware of the care plan requirement for two caregivers, and staff failed to ensure the resident's safety and dignity as outlined in facility policy.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure timely reporting of suspected abuse, neglect, or mistreatment to the State Agency for two residents. In the first case, a resident with a history of right fibula fracture, congestive heart failure, and muscle weakness required maximal assistance with bed mobility and was dependent on staff for toileting hygiene. There were two incidents where incontinent care was not provided for over three hours, despite requests. The responsible party reported these incidents to the Director of Nursing Services (DNS), but did not receive follow-up. The facility did not report these allegations to the State Agency, and there was no documentation of completed investigations or Accident & Investigations (A&Is) for either incident. In the second case, a resident with diagnoses including malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, who required moderate assistance with bed mobility and was dependent on staff for transfers, reported an incident involving an LPN. The resident described being treated roughly and spoken to in a loud, unprofessional manner, which caused emotional distress. The incident was reported to the DNS, but no formal investigation was conducted, and the event was not reported to the State Agency. The DNS handled the matter as a customer service issue and did not document a formal investigation or reporting. Facility policy requires that all allegations of abuse, neglect, or mistreatment be reported immediately to the Administrator and DNS, with a two-hour requirement to notify the Department of Public Health and local law enforcement. In both cases, the facility did not follow its own policy or regulatory requirements for reporting and investigating allegations of abuse or neglect, as evidenced by the lack of timely notification to authorities and incomplete documentation of investigations.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that allegations of abuse and/or neglect were thoroughly investigated in accordance with facility policy for two residents. For one resident with a history of right fibula fracture, congestive heart failure, and muscle weakness, there were multiple reports from a family member that the resident was left in a soiled diaper for extended periods despite requests for care. The Director of Nursing Services (DNS) was notified of these incidents via phone and email, but did not provide follow-up to the family member and was unable to produce documentation of any completed investigations or staff re-education, as required by facility policy. For another resident with diagnoses including a malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, an incident occurred in which the resident alleged emotional abuse by an LPN who entered the room alone, acted in an unprofessional and rough manner, and yelled at the resident. The resident reported the incident to the DNS and believed a grievance was filed, but there was no evidence of a formal investigation, grievance documentation, or follow-up in the clinical record. The DNS acknowledged that no formal investigation was conducted and that required documentation was missing. Interviews with staff confirmed that allegations were either not reported to the appropriate personnel or not investigated according to policy. The facility's abuse policy requires thorough investigation and reporting of all allegations of abuse, mistreatment, or neglect, but the facility was unable to provide documentation that these procedures were followed for the incidents involving both residents.
Failure to Follow Care Plan Requiring Two Caregivers for Resident with Behavioral Needs
Penalty
Summary
The facility failed to follow the established care plan for a resident with a malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, who required the presence of two caregivers at all times due to behavioral concerns. The resident's care plan, dated 10/23/24, specifically directed that two caregivers be present at all times, along with other interventions to address accusatory behaviors and ensure the resident's safety and well-being. Despite this directive, an LPN entered the resident's room alone to administer pain medication and assist with repositioning and other requests. During the interaction, the LPN appeared rushed and agitated, resulting in a rough handling of the resident's bedding and an incident where the medication was dropped. The resident reported feeling emotionally mistreated, describing the LPN as yelling, slamming doors, and acting unprofessionally. The incident was witnessed in part by the nursing supervisor, who acknowledged hearing the LPN yelling and provided the resident with a grievance form. The resident reported the incident to the Director of Nursing Services (DNS) the following day, expressing feelings of mental and emotional abuse, but did not receive follow-up regarding the grievance. Interviews with the LPN revealed she was unaware of the requirement for two caregivers to be present with the resident at all times, indicating a lack of communication or training regarding the resident's care plan. The DNS confirmed that staff are expected to review and be aware of care plans prior to providing care and was unable to explain why the LPN was unaware of the two-caregiver requirement. Facility policy requires the interdisciplinary team to develop and implement person-centered care plans, but in this case, the plan was not followed, resulting in a deficiency.
Failure to Complete Bladder Evaluation on Admission for Incontinent Resident
Penalty
Summary
A resident admitted with diagnoses including a right fibula fracture, congestive heart failure, and muscle weakness was identified as frequently incontinent of bowel and bladder upon admission. The admission MDS assessment indicated the resident had intact cognition, required maximal assistance with bed mobility, and was dependent on staff for toileting hygiene. The resident care plan and nurse aide documentation reflected ongoing urinary incontinence, with interventions directing staff to check and clean the resident every two to three hours. Despite these findings, a review of the clinical record revealed that a bladder evaluation was not completed for the resident upon admission, as required by facility policy. The policy mandates that all residents with incontinence be evaluated within three days of admission to guide care interventions. The DNS confirmed awareness of the resident's incontinence but was unable to explain why the evaluation was missed, acknowledging that it should have been completed according to policy.
Failure to Provide Timely Social Services Support After Allegations of Abuse/Neglect
Penalty
Summary
The facility failed to provide timely social services support to two residents following allegations of abuse or neglect. For the first resident, who had diagnoses including a right fibula fracture, congestive heart failure, and muscle weakness, there were two incidents where incontinent care was not provided for over three hours. Despite these incidents being reported to the Director of Nursing Services (DNS), there was no documented follow-up or social services intervention, and the social worker responsible for follow-up was not made aware of the allegations. Review of social service notes for the relevant period showed no documentation regarding these incidents. For the second resident, who had a malignant neoplasm of the frontal lobe, epilepsy, anxiety disorder, and PTSD, an incident occurred involving an LPN who was reportedly rough and verbally aggressive while providing care. The resident reported feeling emotionally abused and reported the incident to the DNS, expecting social services support. However, there was no documentation in the social service notes indicating that support or follow-up was provided by social services after the incident. Interviews with facility staff confirmed that the social workers were either not notified of the allegations or did not document any follow-up or support provided to the residents. Facility policy required social services to meet with residents following allegations of abuse or neglect and to document these interactions, but this did not occur in either case.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by another resident with a known history of aggression and cognitive impairment. One resident, diagnosed with Alzheimer's disease, anxiety, and psychotic disorder, had a care plan identifying a risk for physical aggression due to dementia and a history of aggressive behavior. Despite interventions such as one-to-one support during agitation and medication management, this resident was able to physically strike three other residents on separate occasions. In each incident, the resident entered another resident's room and engaged in physical altercations, resulting in injuries such as bruising, a black eye, and a bloody nose. The affected residents had varying degrees of cognitive impairment and psychiatric diagnoses, including dementia, schizoaffective disorder, schizophrenia, and depression. Their care plans included interventions for behavioral monitoring, medication administration, and psychiatric services. However, these interventions did not prevent the resident with a history of aggression from accessing other residents' rooms and causing harm. Documentation shows that the resident was able to strike another resident in the face after an argument, hit a roommate with slippers, and punch a resident multiple times, causing visible injuries. Interviews and facility documentation revealed that after each incident, the aggressive resident was placed on one-to-one supervision, but this was discontinued following psychiatric evaluation without implementing more frequent checks or additional safeguards. The facility's abuse policy states that residents have the right to be free from abuse and neglect, but the actions taken were insufficient to prevent repeated physical contact and harm between residents.
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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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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