Cherry Brook Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Connecticut.
- Location
- 102 Dyer Avenue, Canton, Connecticut 06019
- CMS Provider Number
- 075396
- Inspections on file
- 25
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cherry Brook Health Care Center during CMS and state inspections, most recent first.
Two residents experienced accidents due to failures in following orders and implementing fall and incontinence interventions. One resident with hemiplegia and a documented order and care plan for two-person assist with bed mobility was moved in bed by a single NA, who pulled on the resident’s shoulder while boosting in bed, after which the resident reported pain and an x-ray showed an anterior shoulder dislocation. Another resident with dementia, impaired balance, severe cognitive impairment, and progressive urinary and bowel incontinence had multiple unwitnessed falls related to toileting needs, while care plans lacked clear incontinence goals and a toileting schedule, and a required bowel and bladder assessment was not completed on readmission. Despite identified fall risk and orders for gripper socks in bed, staff did not consistently apply or verify gripper socks, and the resident fell from bed while attempting to use a urinal without gripper socks in place.
A resident with dementia, impaired balance, and progressive urinary and bowel incontinence required substantial assistance with toileting and ambulation and used a wheelchair. Despite repeated assessments showing severe cognitive impairment and frequent incontinence, the care plans did not include adequate goals or a specific toileting schedule, and the CNA care card lacked a toileting plan. The care plan required gripper socks while in bed and checks for their placement, but CNAs reported being unaware of this and applied regular socks instead. Over time, the resident sustained multiple unwitnessed falls in the room and bathroom, including a fall from bed while attempting to use a urinal without gripper socks, demonstrating that key fall-prevention and toileting interventions were not implemented as planned.
A resident with dementia, prior cerebral infarction, impaired cognition, wheelchair use, and frequent bowel and bladder incontinence did not receive a required bowel and bladder assessment upon readmission from a hospital stay. Earlier documentation showed bowel continence with the bladder section marked not applicable, while a later MDS indicated frequent incontinence and need for substantial assistance with toileting and personal hygiene. The resident’s care plan did not address continence status, and clinical record review confirmed no bowel and bladder assessment was completed after readmission, despite facility policy requiring a urinary assessment on admission, readmission, and with significant changes in continence, as acknowledged by the DNS.
A hospice resident with COPD, lung cancer, anxiety, and depression, who was drowsy, confused, and required maximal assistance for basic care, was not adequately assessed for ambulation and had a fall care plan with limited interventions despite being identified as at risk for falls. Over roughly a 24‑hour period, the resident sustained multiple unwitnessed falls from bed and a wheelchair, with post‑fall responses limited to measures such as gripper socks, frequent checks, call light placement, and low bed position. An APRN documented that the resident was actively transitioning and likely experiencing terminal agitation, and a hospice RN was informed that the resident was agitated, confused, banging the head on the floor, bleeding from an unidentified source, and expressing a desire to die, leading to administration and adjustment of morphine and Haldol. An RN’s request for 1:1 supervision due to repeated falls was denied because of staffing, and later an LPN found the resident on the floor repeatedly striking the head, with another RN documenting the resident face down in a pool of blood and striking all limbs before EMS transfer to the hospital.
A resident with severe cognitive impairment and multiple diagnoses was ordered Tramadol oral solution twice daily, while another resident was ordered Lacosamide oral solution twice daily. During a morning medication pass, an LPN poured and administered Lacosamide, prescribed for the other resident, instead of the ordered Tramadol. The DON reported that both medications were controlled substances stored together and had similar-appearing bottles, and that the LPN failed to read and verify the medication label against the Medication Administration Record as required by facility policy, resulting in the administration of the wrong medication.
A resident with severe cognitive impairment was involved in an incident where a nurse aide threatened to withhold feeding. The allegation was not reported immediately as required; instead, the witnessing NA informed an LPN, who did not escalate the report. The Director of Nursing was not notified until three days later, resulting in delayed investigation and state agency notification.
A resident with severe cognitive impairment was involved in an alleged mistreatment incident, but the facility failed to ensure complete and accurate documentation of social service and nursing support visits in the medical record. Required notes were missing from the EMR, and a paper note lacked essential identifiers such as date, resident name, and staff signature, contrary to facility policy.
The facility failed to securely store discontinued controlled drugs, leaving them in an unlocked cabinet in the DNS office with keys accessible in an unlocked desk drawer. This was against the facility's policy requiring controlled substances to be stored in a permanently affixed, double-locked compartment with restricted access.
The facility failed to date and label open food items in the Dietary Department, as observed in the walk-in refrigerator, freezer, and dry storage room. The Kitchen Manager admitted to not conducting required weekly spot checks and was unaware of any policy on labeling. The Administrator confirmed the absence of a facility or corporate policy on this matter.
The facility failed to conduct quarterly QAPI meetings since June 2024 and did not ensure the required attendance of the Infection Preventionist and two other staff members. The administrator, new to the role, cited staff turnover as a reason for the oversight and was unaware of the attendance requirements.
The facility failed to properly store a urinary containment bag for a resident with specific care instructions, did not implement Enhanced Barrier Precautions for residents with MDRO histories, and failed to ensure proper use of PPE and TBP. Additionally, the facility did not maintain a clean and sanitary environment, with observations of unlabeled personal care items on the floor and soiled wipes in common areas.
A resident reported that an LPN was on her cell phone arguing and using inappropriate language while providing care. The LPN's actions violated the facility's policy on cell phone usage, which prohibits personal conversations during work hours.
A facility failed to develop a comprehensive care plan for a resident with PTSD, despite the resident's history of childhood trauma and triggers. The care plan lacked specific interventions for PTSD, although it noted the resident's discomfort with male caregivers and preference to avoid apple juice. A social worker acknowledged the oversight, stating the care plan should have included a focus on PTSD, as required by facility policy.
A resident with dementia and diabetes experienced significant weight loss, but the facility failed to implement the dietician's recommendation for weekly weight monitoring. The dietician communicated the need for weekly weights to the Nursing Supervisor, but the order was not updated in the EMR, and monthly weight checks continued. The APRN was unaware of the weight loss, and the physician managing the care was unavailable for comment.
A facility failed to follow the toileting plan for a resident with severe cognitive impairment and multiple diagnoses, including traumatic brain injury and quadriplegia. The resident required total assistance with daily activities, including toileting. Observations showed the resident was not checked for incontinence or toileted as per the care plan, resulting in a saturated brief. Interviews revealed staff were unaware of the resident's needs due to poor communication and failure to reference care instructions.
A facility failed to maintain aspiration precautions for a resident with a high risk of aspiration during pleasure eating. The resident, with multiple diagnoses including TBI and Dysphagia, was fed yogurt while reclined at 30 degrees instead of the required 10-15 degrees. An LPN corrected the position and educated the nursing assistant on proper precautions.
A facility failed to provide trauma-informed care for a resident with PTSD, leading to exposure to known trauma triggers such as apple juice and spicy foods. Despite the resident's care plan specifying these triggers, staff, including agency staff, were not consistently informed or compliant. The lack of a trauma-informed care policy and inadequate communication among staff contributed to the deficiency.
The facility failed to maintain completed shift change reconciliation records for controlled drugs and did not periodically reconcile the inventory. Count Sheets for Narcotics and Sedatives were missing signatures on multiple dates, and no one monitored the completeness of these forms. The DNS attempted follow-up but was unsuccessful, and audits were not documented.
A facility failed to maintain a medication error rate below 5%, resulting in an 8.57% error rate due to omitted supplements for a resident. The resident, admitted with multiple diagnoses, required specific supplements that were not administered because the family did not provide them. An LPN notified the supervisor but failed to inform the provider, and an RN later confirmed the omission. The facility's medication ordering policy was not adhered to, contributing to the error.
The facility failed to adequately address resident grievances documented in Resident Council meetings, including concerns about agency staff, staff distractions, and lack of follow-up. Despite the Administrator and DNS acknowledging these issues, there was no documentation of follow-up actions, and the grievance policy was not adhered to, highlighting procedural lapses.
The facility failed to notify two residents and their representatives of the bed hold policy during hospital transfers. One resident with COPD, diabetes, and COVID-19 was transferred without notification, and another with leukemia and coronary artery disease was also transferred without the required notice. The facility's policy requires informing residents and families about bed reservation conditions, but this was not followed, leading to a deficiency.
A resident with dementia was subjected to verbal abuse by a nursing assistant who used derogatory language during care. The incident was reported by the resident's roommate, and the NA admitted to using inappropriate language out of frustration. The facility's policy emphasizes treating residents with dignity and prohibits such language.
Failure to Follow Transfer Orders and Implement Fall/Incontinence Interventions Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents. For one resident with hemiplegia and hemiparesis affecting the left, non-dominant side, the physician’s admission assessment documented that the resident was chair bound with no ability to move the left upper or lower extremity, and physician orders, the care plan, and the nurse aide care card all directed an assist of two staff for bed mobility and transfers. Despite these orders, a nurse aide moved the resident in bed alone. The aide reported that he was in a rush, stood at the head of the bed, grasped the transfer sheet with one hand and the resident’s left shoulder with the other, and pulled the resident up in bed, even though he was aware that two-person assistance was required for bed mobility. Following this event, the resident complained of shoulder pain and reported hearing a pop while being moved in bed by the aide. Nursing documentation identified complaints of left shoulder, arm, and hand pain, with intact sensation but no active movement in the left upper extremity at baseline, and noted greenish-yellow ecchymosis on the left hand. An x-ray of the left shoulder showed a normal left humerus with an anterior dislocation of the left shoulder. The facility was unable to provide a transfer policy when requested, and the director of nursing confirmed that the aide had moved the resident in bed without assistance, contrary to the provider’s orders for two-person assistance with bed mobility. The deficiency also involves a second resident with dementia, cerebral infarction, difficulty in walking, severely impaired cognition, impaired balance, and progressive urinary and bowel incontinence who was at high risk for falls. The resident’s care plans over time identified fall risk and directed interventions such as applying gripper socks while in bed, instructing the resident to ask for assistance before ambulating, placing the call bell within reach, and orienting to surroundings. However, the care plans repeatedly lacked clear goals and adequate interventions for incontinence care and did not include a toileting plan or schedule, despite MDS assessments documenting occasional and later frequent incontinence and the resident’s severe cognitive impairment. The bowel and bladder assessment was not completed on readmission after a hospitalization, contrary to facility policy. This resident experienced multiple unwitnessed falls, several associated with toileting needs. Incident reports documented falls in the bathroom and in the room, including one with the wheelchair tipped over and another due to ambulating without assistance. Later documentation showed the resident was frequently incontinent of bowel and bladder, yet the care plan still did not include a toileting schedule. The resident sustained an unwitnessed fall under the bathroom sink with skin tears and rib pain, and after readmission with rib fractures, the care card continued to list the resident as continent and did not provide a toileting plan, instead listing only transfer status. In a subsequent fall from bed while attempting to use a urinal, the resident was not wearing gripper socks, and the assigned nurse aides reported they were unaware that gripper socks were required in bed and did not identify this need from the care card. The director of nursing services acknowledged that the resident should have had a toileting plan/schedule based on severe cognitive impairment and incontinence patterns and that a bowel and bladder assessment should have been performed on readmission, but these were not implemented, and gripper sock interventions were not consistently carried out at the time of the fall.
Failure to Implement Fall-Prevention and Toileting Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, measurable care plan addressing fall prevention and incontinence/toileting needs for a cognitively impaired resident at high risk for falls. The resident, admitted in February 2025 with dementia, cerebral infarction, difficulty walking, and severely impaired cognition (BIMS score of 3), required substantial assistance with toileting, hygiene, and ambulation, used a wheelchair, and progressed from occasional to frequent incontinence of bowel and bladder. Despite these documented needs and changes in continence status on multiple MDS assessments, the Resident Care Plans dated 6/12/25, 9/24/25, and 12/9/25 did not include adequate goals and interventions for incontinence care or a specific toileting plan/schedule, even though facility policy required urinary assessments and toileting plans based on continence status. The facility also failed to consistently implement an established fall-prevention intervention requiring gripper (non-skid) socks while the resident was in bed. The care plan identified the resident as at risk for falls due to impaired balance and unsteady gait and directed that gripper socks be applied while in bed, with the 12/9/25 plan further directing staff to check placement of gripper socks at the beginning of the 11 PM–7 AM shift. However, the Certified Nurse’s Aide care card dated 11/20/25 only indicated the resident was continent and included transfer assistance and ensuring non-skid socks were in place, without a toileting schedule. Nursing assistants interviewed reported they were unaware the resident required gripper socks while in bed and described applying regular socks instead. Over the review period, the resident experienced multiple unwitnessed falls, including being found on the bathroom floor with a skin tear to the left elbow, on the room floor with a tipped wheelchair and complaints of pain, next to the bed after ambulating without assistance, and under the bathroom sink with skin tears and reported rib and back pain. A later fall investigation documented that the resident fell out of bed while attempting to use a urinal and was not wearing gripper socks at the time. Interviews with nursing assistants and the DNS confirmed that the resident should have had a toileting plan/schedule due to severe cognitive impairment and incontinence patterns, and that NAs were expected to review care cards for updated care needs, but the care card and care plans did not reflect a specific toileting schedule or fully implemented fall-prevention interventions.
Failure to Complete Bowel and Bladder Assessment on Readmission
Penalty
Summary
The deficiency involves the facility’s failure to complete a required bowel and bladder assessment upon a resident’s readmission, as required by facility policy and professional standards. One resident, admitted in February 2025 with dementia, cerebral infarction, difficulty in walking, and severely impaired cognition (BIMS score of 3), had an earlier Bowel and Bowel assessment that documented bowel continence but listed the bladder section as not applicable. A subsequent quarterly MDS identified that this resident required substantial assistance with toileting hygiene, personal hygiene, and ambulation, used a wheelchair, and was frequently incontinent of both bowel and bladder. The resident’s care plan dated 9/24/25 did not identify the resident’s continence status. After a hospitalization from late November 2025 through 11/27/25, the resident returned to the facility, but review of the clinical record showed no evidence that a Bowel and Bladder Assessment was completed upon readmission. In an interview, the DNS confirmed that, according to the facility’s Urinary Incontinence policy, a urinary assessment should have been completed on admission, readmission, and with any significant change in continence, and acknowledged that such an assessment should have been done following this resident’s readmission. This failure to perform the required assessment upon readmission, despite the resident’s documented incontinence and functional limitations, constituted noncompliance with the facility’s own urinary incontinence policy and professional standards of quality for assessment and care planning.
Failure to Adequately Supervise Hospice Resident With Terminal Agitation and Repeated Falls
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and individualized care for a hospice resident experiencing terminal agitation who sustained multiple unwitnessed falls within a 24‑hour period. The resident was admitted with COPD, lung cancer, anxiety, depression, and was on hospice care. On admission, the nursing assessment documented that the resident was oriented to person, drowsy, confused, and required maximal assistance with toileting, personal hygiene, and rolling, but did not assess ambulation. The resident’s care plan identified fall risk related to new admission and cognitive impairment, with limited interventions such as leaving a urinal at bedside, while the CNA care card later documented that the resident required one‑person assist for transfers and could ambulate without an assistive device. Over the course of one night and the following day, the resident experienced a series of unwitnessed falls. An A&I report documented a fall at midnight where the resident was found scooting on the floor near the bed, with gripper socks in bed added as a post‑fall intervention. A second unwitnessed fall occurred at 3:00 a.m. from a wheelchair at the nurse’s station, after a loud thump was heard, and “frequent checks” were added as an intervention. Later that morning, an APRN documented that the resident was experiencing increased agitation, had fallen twice during the night, appeared to be actively transitioning, and that the agitation was likely terminal agitation, but the record did not show new interventions or treatment related to terminal agitation. Additional unwitnessed falls occurred at 5:00 p.m., with the resident found on the floor by the window side of the bed and sustaining skin tears, and at 9:00 p.m., with the resident again found on the floor; post‑fall interventions at these times were limited to placing the call light within reach and keeping the bed in low position. During this period, the hospice RN was notified of the falls and escalating agitation, including reports that the resident was banging his or her head on the floor, had blood on the floor with an unidentified source, and verbalized a desire to die. Multiple doses of morphine and Haldol were administered, and the hospice RN obtained a modified Haldol order, but no documentation showed implementation of enhanced supervision such as 1:1 monitoring. A facility RN reported requesting 1:1 supervision due to the repeated falls, but this was denied by the ADNS due to staffing, and staff instead informally tried to monitor the resident more closely. Later that night, an LPN found the resident on the floor repeatedly striking his or her head; another RN documented the resident lying face down in a pool of blood, repeatedly hitting the head and striking all four limbs on the floor before EMS transported the resident to the hospital. Interviews with facility and hospice staff confirmed that the resident exhibited abnormal and unpredictable behaviors consistent with terminal agitation, that 1:1 supervision was not implemented, and that the DNS was not informed of the earlier fall and self‑harm incident.
Medication Error Due to Failure to Verify Medication Label Against Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders, resulting in a significant medication error for one resident reviewed in a sample of three. Resident #2, who had diagnoses including Parkinson’s disease, dementia, anxiety, and a history of alcohol and polysubstance abuse, was severely cognitively impaired and dependent on staff for all care. A physician’s order directed that Resident #2 receive Tramadol oral solution 50 mg by mouth twice daily. Another physician’s order directed that Resident #3 receive Lacosamide oral solution 200 mg twice daily. On the morning medication pass, the LPN responsible for administering medications poured and administered Lacosamide, which was prescribed for Resident #3, to Resident #2 instead of the ordered Tramadol. According to facility documentation and interviews, the DON reported that both Tramadol and Lacosamide were controlled substances stored in a locked area and that the medication bottles appeared similar. The DON identified that the LPN did not read the medication label prior to pouring the medication, despite the facility’s Medication Administration policy directing staff to compare the medication label to the resident’s Medication Administration Record. A nurse’s note documented that the incorrect medication was given to Resident #2 at 8:00 AM and that this was recognized and recorded later that day. The incident was also documented on a Facility Reported Incident form, which identified that Resident #2 had been given the incorrect medication.
Failure to Timely Report Alleged Resident Mistreatment
Penalty
Summary
Staff failed to report an allegation of mistreatment involving a resident with severe cognitive impairment and a history of traumatic brain injury, dysphagia, and aphasia. The incident occurred when a nurse aide (NA) overheard another NA threaten not to feed the resident if certain behaviors continued. The NA who witnessed the event informed an LPN, who did not escalate the report as required, instead instructing the NA to report it to the Director of Nursing Services (DNS) or Administrator. The DNS was not notified until three days after the incident, delaying the initiation of the facility's investigation. Facility documentation and staff interviews confirmed that the resident was unable to communicate about the incident due to cognitive impairment. The facility's policy required immediate reporting of any suspicion of abuse or neglect, but both the NA and LPN failed to follow this protocol. The delay in reporting resulted in a late notification to the state agency, which should have occurred within two hours of the allegation according to facility policy.
Incomplete Documentation of Support Visits After Alleged Mistreatment
Penalty
Summary
The facility failed to ensure that the medical record for a resident with severe cognitive impairment and a history of traumatic brain injury was complete and accurate following an allegation of mistreatment. After a nurse aide reported hearing another aide threaten to withhold feeding from the resident, an investigation was initiated. However, documentation of support visits by social services and nursing staff was either missing or incomplete in the resident's medical record. Specifically, there were no records of social service or nursing support visits prior to a psychiatric provider note made seven days after the incident. Further review revealed that the social worker did not document a support visit in the electronic medical record (EMR), instead placing an undated, unsigned, and unnamed note in the paper chart. The Director of Nursing (DNS) also assessed the resident after the allegation but did not document this assessment in the EMR. Facility policy required licensed nursing personnel to document care and assessments in the resident's medical record, and any paper documentation was to include the resident's name, date, and staff signature. These documentation failures resulted in an incomplete and inaccurate medical record for the resident following the abuse allegation.
Failure to Securely Store Discontinued Controlled Drugs
Penalty
Summary
The facility failed to store discontinued controlled drugs in a securely locked and permanently affixed compartment, as required by regulations. During an observation, it was noted that the Director of Nursing Services (DNS) office door was left open without any staff present, and the discontinued controlled drugs were stored in a cabinet drawer within this office. The DNS confirmed that the keys to the cabinet drawer were kept in an unlocked desk drawer, which was also left unlocked, allowing potential unauthorized access to the controlled substances. Further observations revealed that the cabinet drawer contained a significant quantity of various controlled drugs, including Oxycodone, Hydromorphone, Tramadol, Lorazepam, and others. These drugs were not stored in accordance with the facility's policy, which mandates that controlled substances be kept in a permanently affixed, double-locked compartment separate from other medications. The facility's policy also requires that only authorized personnel have access to these substances, and that a controlled substance accountability record be maintained. The facility's failure to adhere to its own policy and regulatory requirements was evident in the unsecured storage of controlled drugs and the lack of a system to limit access to these substances. The DNS and RN #1 reconciled the quantities of the controlled drugs, which matched the controlled drug disposition records, indicating that the drugs were accounted for despite the storage deficiencies. However, the lack of secure storage and restricted access posed a significant risk of diversion or misuse of these controlled substances.
Failure to Date and Label Open Food Items
Penalty
Summary
The facility failed to ensure that open food items were properly dated and labeled, as observed during a tour of the Dietary Department. In the walk-in refrigerator, there were several opened food items, including a bag of cheddar cheese, a container of mayonnaise, and a bag of croissants, none of which had an open date or expiration date. Similarly, the walk-in freezer contained opened bags of French fries, fish filets, and potato tots without any date markings. The dry storage room also had opened bags of elbow noodles, tri-color macaroni noodles, taco seasoning, and pearled barley, all lacking proper labeling. During an interview, the Kitchen Manager acknowledged that it was the responsibility of the staff member who opened the food items to label them with the date they were opened and when they should be discarded. The Kitchen Manager also admitted that he was responsible for conducting weekly spot checks to ensure compliance, but this was not done. Furthermore, the Kitchen Manager was unaware of any policy regarding the labeling and dating of open food items. The Administrator confirmed that there was no facility or corporate policy on date marking or labeling open food items.
Failure to Conduct Required QAPI Meetings and Ensure Attendance
Penalty
Summary
The facility failed to conduct quarterly Quality Assurance and Performance Improvement (QAPI) meetings as required, with the last meeting documented in June 2024. The administrator, who began working at the facility in September 2024, acknowledged that no QAPI meeting had been held since June 2024 and was unable to provide meeting minutes for that session, only a sign-in sheet. The administrator cited staff turnover as a reason for not holding the meetings and admitted to not having a future QAPI meeting scheduled. Additionally, the facility did not ensure that the required members, including the Infection Preventionist and two other staff members, attended the QAPI meetings. The review of attendance sheets from March 2023 to June 2024 revealed their absence. The administrator, during an interview, admitted to being unaware of the requirement for these members to attend. The facility's policy, dated April 2015, emphasizes the importance of leadership involvement and adequate resources for QAPI efforts, which were not adhered to, leading to the deficiency.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to properly store a urinary containment bag for a resident with paraplegia, multiple sclerosis, and neuromuscular dysfunction of the bladder. Observations on multiple occasions identified the urinary containment bag on the floor under the resident's bed without a basin, contrary to the Resident Care Plan which directed the bag to be placed in a basin. Interviews with nursing staff revealed a lack of awareness and specific instructions regarding the proper storage of the urinary containment bag, and the NA Care Card did not include necessary care instructions. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with a history of Multidrug-Resistant Organisms (MDROs). Several residents with histories of ESBL, VRE, MRSA, and C. Diff were not placed on EBP as required by CDC guidelines. An interview with an LPN confirmed that residents with a history of MDROs should be on EBP, but the facility's lists did not reflect this requirement. Additionally, the facility did not maintain proper use of Personal Protective Equipment (PPE) and Transmission-Based Precautions (TBP). A nursing assistant provided care to a resident requiring EBP without using PPE, despite signage indicating the need for such precautions. Another nursing assistant entered a room of a resident on contact and droplet precautions for COVID-19 wearing a surgical mask instead of the required N95 mask. Furthermore, the facility failed to maintain a clean and sanitary environment, with observations of unlabeled personal care items on the floor, soiled wipes, and a strong odor of urine in common areas.
Inappropriate Cell Phone Use by LPN During Resident Care
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner while services were provided. The resident, who was cognitively intact and had diagnoses including spinal stenosis, anxiety, and depression, reported an incident involving an LPN who was on her cell phone arguing with someone and using inappropriate language while in the resident's room. This behavior was deemed inappropriate by the resident, who felt that such conduct should not occur while care was being provided. The investigation revealed that the LPN was indeed on her phone with earbuds in, using foul language, and this was witnessed by other staff members on the unit. The facility's policy on cell phone usage clearly states that personal conversations should not occur during work hours and that devices should only be used in designated areas during non-working times. The LPN's actions were in direct violation of this policy, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, admitted in November 2017, had diagnoses including cerebral palsy, PTSD, and major depressive disorder. The annual Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and had PTSD as an active diagnosis. Despite this, the Resident Care Plan (RCP) did not include a focus on the resident's PTSD diagnosis or interventions for triggers causing flashbacks or emotional responses related to past trauma. The RCP did identify the resident's discomfort with male caregivers and a preference to avoid apple juice due to past trauma, but it lacked specific interventions for PTSD. During an interview, Social Worker #2 acknowledged awareness of the resident's childhood trauma and triggers but was unaware of the PTSD diagnosis until prompted by the surveyor. The social worker admitted that the RCP should have included a focus on PTSD and that it was the responsibility of the Social Work department to enter these focuses. The facility's policy requires comprehensive care plans to be developed by the interdisciplinary team and revised as needed, but at least quarterly, which was not adhered to in this case.
Failure to Implement Dietician's Recommendation for Weight Monitoring
Penalty
Summary
The facility failed to follow a dietician's recommendation for a resident with known weight loss. The resident, who was admitted with diagnoses including dementia, diabetes, and abnormal weight loss, experienced a significant weight loss over several months. Despite the dietician's recommendation for weekly weight monitoring, the facility continued with monthly weight checks. The dietician had communicated the need for weekly weights to the Nursing Supervisor, but this was not reflected in the electronic medical record (EMR), and the order for weekly weights was not implemented. Interviews revealed that the dietician sometimes entered orders directly into the EMR and other times used a Dietary Recommendation form, which was supposed to be handed to the Nursing Supervisor. However, the Registered Nurse responsible for entering these recommendations into the EMR did not recall receiving the recommendation for weekly weights, and the order was not updated. Additionally, the Advanced Practice Registered Nurse (APRN) was not aware of the resident's weight loss, and the care was primarily managed by a physician who was unavailable for comment. Facility policies for dietician assessments and recommendations were not provided upon request.
Failure to Follow Toileting Plan for Resident
Penalty
Summary
The facility failed to follow the toileting plan and provide incontinence care for Resident #75, who was admitted with multiple diagnoses including Diffuse Traumatic Brain Injury and Quadriplegia. The resident was severely cognitively impaired and required total assistance with daily activities, including toileting. The Resident Care Plan (RCP) specified a maintenance toileting plan, which included checking for incontinence every two hours and providing toileting assistance before and after meals, at bedtime, and as needed. However, the Resident Care Card (RCC) did not reflect these instructions, leading to a lack of proper care. Observations on two separate days revealed that Resident #75 was not checked for incontinence or toileted as per the care plan. On one occasion, the resident's brief was found saturated with urine, indicating a failure to provide timely incontinence care. Interviews with nursing staff, including a temporary agency nurse aide and LPN, revealed a lack of awareness of the resident's toileting needs due to inadequate communication and failure to reference the RCP and RCC. The Director of Nursing acknowledged that agency staff should follow the RCP and RCC but was unaware of why the staff did not adhere to the care instructions.
Failure to Maintain Aspiration Precautions During Feeding
Penalty
Summary
The facility failed to maintain aspiration precautions for Resident #75 during pleasure eating. Resident #75, who was admitted with diagnoses including Diffuse Traumatic Brain Injury, Aphasia, Dysphagia, Gastrostomy Tube status, Seizures, and Quadriplegia, was identified as being at elevated risk for aspiration. The resident's care plan specified that they should be fed pureed food and honey thick liquids by teaspoon only, with strict aspiration precautions, and that their wheelchair should be reclined to 10-15 degrees during feeding. However, during an observation, a nursing assistant was seen feeding the resident yogurt while the resident's chair was reclined to 30 degrees, contrary to the specified precautions. The incident was observed by an LPN who then repositioned the resident's wheelchair to the correct recline of 10-15 degrees and educated the nursing assistant on the proper aspiration precautions. The LPN acknowledged the resident's risk for aspiration and the associated interventions but was unaware of why the nursing assistant was feeding the resident in a reclined position. The facility's Aspiration Precautions policy requires individualized precautions for residents at significant risk of aspiration, and any signs of aspiration should be assessed with the physician notified. This deficiency highlights a failure to adhere to the specified care plan and facility policy for aspiration precautions.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with PTSD, leading to repeated exposure to known trauma triggers. The resident, who was moderately cognitively impaired and had a history of PTSD, expressed discomfort with male caregivers and specific food items like apple juice and spicy foods, which were linked to past traumas. Despite these preferences being documented in the Resident Care Plan (RCP), the facility did not consistently adhere to these guidelines. The resident reported being served apple juice and spicy foods, which triggered memories of childhood trauma. Additionally, the resident expressed difficulty with agency and per diem staff who were unfamiliar with their specific needs and triggers. The facility's lack of a trauma-informed care policy and inadequate communication among staff contributed to the deficiency. The Clinical Social Worker and APRN were aware of some of the resident's triggers but failed to ensure that all staff, including agency staff, were informed and compliant with the resident's care plan. The dietary slips did not initially reflect the resident's dietary preferences, leading to further exposure to trauma triggers. The facility's generalized in-services on PTSD were not resident-centered, and there was no clear strategy to educate staff on the specific needs of the resident, resulting in a failure to prevent re-traumatization.
Failure to Maintain Controlled Drug Reconciliation Records
Penalty
Summary
The facility failed to maintain completed shift change reconciliation records for controlled drugs and did not periodically reconcile the facility inventory of controlled drugs. During an observation of the Apple Gate South medication cart, it was identified that the Count Sheets for Narcotics and Sedatives were missing signatures on multiple dates. These forms are intended to be completed by on-coming and off-going nurses to ensure controlled drugs are counted accurately. Interviews with staff, including an LPN and the RN supervisor, revealed that there were blanks on the Count Sheets, and no one was monitoring whether the forms were complete. The completed forms were placed in the Director of Nursing's (DNS) document bin, but there was no follow-up to ensure they were filled out correctly. The DNS attempted to follow up with nurses to complete the missing signatures but was unsuccessful. Although the DNS stated that she conducted twice-monthly audits of random medication carts, she failed to provide documentation of these audits. When questioned about how diversion of narcotics would be identified, the DNS did not provide a comment. The facility's policy on the storage of controlled substances requires that a physical inventory of all controlled substances be conducted by two licensed personnel at each shift change and documented. However, this policy was not adhered to, leading to the deficiency.
Medication Error Rate Exceeds 5% Due to Omitted Supplements
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an error rate of 8.57% due to the omission of three medications out of 35 opportunities. This deficiency involved a resident who was admitted with diagnoses including a fracture of thoracic vertebrae, thrombocytopenia, and severe protein calorie malnutrition. The resident was cognitively intact and required assistance with various activities of daily living. The resident's care plan included monitoring nutritional status and administering specific supplements as ordered by the physician. The deficiency occurred when the resident's prescribed supplements, Prevagen, Quercetin, and [NAME] cartilage, were not administered as directed. The LPN responsible for medication administration noted that the resident's family was providing these supplements from home and had failed to bring them in. Despite notifying the supervisor of the omission, the LPN did not inform the provider. The RN later confirmed the omission and indicated that the provider would be notified to place the medications on hold until they were supplied by the family. The facility's policy for ordering medications from the pharmacy was not followed, contributing to the medication error.
Inadequate Response to Resident Grievances
Penalty
Summary
The facility failed to adequately respond to resident grievances as documented in the Resident Council meeting minutes from September to November 2024. Concerns were raised about the high number of agency staff, their lack of introduction, and insufficient knowledge of individual resident needs. Additional issues included staff using cell phones and earbuds while on duty, and a general lack of staff. Despite these concerns being documented, the facility's response was inadequate, as evidenced by the absence of follow-up documentation and continued resident dissatisfaction. Interviews with the Recreation Director and the Administrator revealed that grievances were forwarded to respective departments and the Administrator, but the process was ineffective. The Administrator acknowledged addressing some concerns but lacked documentation to support this. The Director of Nursing Services (DNS) admitted that no follow-up was conducted due to a COVID-19 outbreak, and the facility was in the process of changing its grievance follow-up procedures. The facility's grievance policy mandates resolution within seven days, but the policy was only provided seven days after the surveyor's request, indicating further procedural lapses.
Failure to Notify Residents of Bed Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide the required notification of a bed hold policy to two residents and their representatives during hospital transfers. Resident #14, who was admitted in September 2024, had multiple diagnoses including COPD, diabetes, and COVID-19. Despite a decline in condition and a transfer to the hospital on November 26, 2024, there was no record of a bed hold policy being communicated to the resident or their family. The facility's documentation and interviews revealed that the social work office and reception did not have a record of the bed hold policy being provided, and the resident's name was not listed in the binder of discharged residents. Similarly, Resident #36, who had diagnoses including leukemia and coronary artery disease, was transferred to the hospital on October 21, 2024, due to chest pain. The facility failed to provide a Notice of Emergency Transfer to a Hospital that included the bed hold policy to the resident or their family. The Social Service Director acknowledged the oversight and the absence of a certified mail notification. The facility's Bed Reservation policy mandates informing residents and their families about the conditions under which a nursing home bed will be reserved at the time of admission and upon hospital transfer. However, in both cases, the facility did not adhere to this policy, resulting in a deficiency in notifying the residents and their representatives about the bed hold policy during hospital transfers.
Verbal Abuse Incident Involving Nursing Assistant
Penalty
Summary
The facility failed to protect a resident from verbal abuse, as evidenced by an incident involving a nursing assistant (NA) and a resident with dementia and moderately impaired cognition. The resident, who required assistance for activities of daily living and was frequently incontinent, was subjected to derogatory language by NA #2 during care. The incident was reported by the resident's alert and oriented roommate, who overheard the NA using inappropriate language while addressing the resident after a bowel movement incident. The NA admitted to using the derogatory term "s***" in frustration due to the mess in the room, acknowledging that the language was inappropriate and could be considered abusive. The Director of Nursing (DON) confirmed the NA's admission and recognized the language as disrespectful, although not willfully intended to harm. The facility's policy on abuse and residents' rights emphasizes treating residents with dignity and respect, prohibiting the use of disparaging and derogatory terms.
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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