Cheshire House Health Care Facility & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterbury, Connecticut.
- Location
- 3396 E Main Street, Waterbury, Connecticut 06705
- CMS Provider Number
- 075373
- Inspections on file
- 32
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Cheshire House Health Care Facility & Rehab Center during CMS and state inspections, most recent first.
A resident admitted after a right total hip replacement with diagnoses including type 2 DM, HTN, and hyperlipidemia was discharged from the hospital with a recommendation for Atorvastatin for hyperlipidemia, but the facility entered an order for Atogepant, a migraine medication, with the indication of hyperlipidemia. The admission evaluation documented that all active medication orders were accurate based on the referral form, and subsequent provider notes listed Atogepant and stated that medications had been reviewed in the EMR. During the initial drug regimen review, the pharmacist identified that Atogepant was ordered with an incorrect clinical indication, but there was no documentation that an APRN or physician reviewed or addressed this concern, contrary to facility policies requiring complete admission medication verification and documented follow‑up on identified irregularities.
A resident with dementia and behavioral disturbances was involved in an incident where a nurse aide witnessed another aide continue care after the resident refused, which was perceived as abusive. The witnessing aide did not report the allegation until the following day, exceeding the facility's required two-hour reporting timeframe, in violation of policy.
Surveyors found that several residents requiring oxygen and nebulizer therapy had unlabeled and undated tubing, and nebulizer masks were stored improperly. In addition, a resident with chronic respiratory conditions did not have oxygen saturation documented every shift as ordered. Nursing staff and the DNS were unable to explain the lapses or confirm when equipment was last changed, and there was a lack of clear documentation and staff education regarding respiratory care procedures.
The consultant pharmacist did not ensure that required behavior monitoring was implemented and documented for two residents receiving antipsychotic medications. Despite care plans and physician orders directing monitoring of specific target behaviors, the pharmacist failed to identify or address the lack of behavior monitoring during monthly drug regimen reviews.
Two residents prescribed antipsychotic medications did not have their target behaviors identified and monitored as required by facility policy. One resident with dementia and mood disorders had no documentation of behavior monitoring for yelling out, despite care plan interventions and physician orders. Another resident with psychiatric diagnoses continued to receive Quetiapine without the required behavior monitoring after re-admission, as the order was missed and not completed.
Multiple residents with dysphagia and cognitive impairment did not receive the required supervision during meals, as staff left them unsupervised or failed to provide necessary assistance such as cutting food or monitoring for aspiration. Communication lapses and incomplete documentation led to dietary and nursing staff being unaware of specific supervision and feeding guidelines, resulting in residents being served meals without appropriate precautions.
A resident with chronic venous and thrombotic conditions was not informed prior to a physician-ordered ultrasound or updated on the test results. The resident, who is cognitively intact, reported this lack of communication occurs frequently. An LPN failed to relay the resident's request for results to the APRN, resulting in a delay of seven days before the resident was updated, contrary to facility policy requiring residents to be informed and involved in their care.
The facility failed to notify the APRN of a significant weight gain in a resident with CHF and did not inform the family of another resident's substantial weight loss. In both cases, staff interviews and documentation review revealed confusion about responsibilities and a lack of communication, despite clear physician orders and facility policies requiring such notifications.
A resident with multiple chronic conditions reported missing money from their room. Although the facility conducted an internal investigation, reimbursed the resident, and implemented changes to secure resident funds, the incident was not reported to the State Agency as required by policy. Staff interviews revealed uncertainty about the nature of the loss, leading to the failure to report the suspected misappropriation.
A resident with multiple chronic conditions reported missing money from their room. The facility did not conduct or document a thorough investigation as required by policy, failing to record which staff were interviewed, the last time the resident saw the money, and which staff had access to the room. Key details were not documented or recalled by the Director of Social Services or the Administrator.
The facility did not ensure that care plans were accurately developed and implemented for two residents: one with a history of falls whose fall risk was not reflected in the care plan until after another incident, and another who required two staff for direct care but was often assisted by only one staff member. Staff were unaware of or unable to follow the care plan directives, resulting in deficiencies in care planning and delivery.
Two residents experienced deficiencies in care: one performed wound care without proper supervision, assessment, or infection control, and another was not weighed daily as ordered for nutritional monitoring. Staff were unaware or did not document these lapses, and facility policies for wound care and weight assessment were not followed.
A resident with a pressure ulcer did not receive recommended therapy and dietary consultations after a wound consultant's assessment, as staff were unaware of the recommendations and no follow-up occurred. The resident remained bedfast and was not evaluated for support surfaces or repositioning, despite facility policy requiring such actions after significant changes in condition.
A nurse failed to follow infection control protocols during a dressing change for a resident on Enhanced Barrier Precautions, including not wearing required PPE, not performing hand hygiene at key steps, and using unsanitized scissors to cut dressing material. These actions were not in accordance with facility policy and standard infection control practices.
Surveyors found that wheelchairs, both standard and electric, were being stored in the dining room and a resident lounge during meal times and while residents were present. Staff confirmed this was due to lack of space in resident rooms, and the DNS acknowledged the practice was inappropriate. The facility did not have a policy for wheelchair storage, resulting in a failure to provide a homelike environment.
A resident with severe cognitive impairment and multiple chronic conditions developed pneumonia and was started on antibiotics after assessment and diagnostic testing. The facility did not document in the clinical record that the family was notified of the change in condition, diagnostic results, or new treatment, despite facility policy requiring such documentation.
The facility did not complete required annual performance evaluations for two nurse aides, as shown by the absence of evaluations in their personnel files despite ongoing employment and work activity. The DON confirmed the evaluations were not done and no written policy was provided when requested.
A resident with diabetes and other serious conditions experienced a change in mental status and became unresponsive. Although the care plan and facility policy required blood glucose monitoring when symptoms of hypo- or hyperglycemia were present, staff did not perform a fingerstick blood glucose check at the time of the incident. The omission was confirmed by both the DON and an LPN, and the resident was later found to have a critically low blood glucose level in the emergency department.
A resident with severe cognitive impairment and agitation, whose family held power of attorney, requested a room change due to a disruptive roommate causing anxiety and sleep issues. Despite the request being communicated to staff, there was no evidence that the facility addressed or acted on the request before the resident was discharged, and key staff were unaware of the request until much later.
Residents voiced ongoing concerns about delayed call bell responses during multiple council meetings, particularly on the second shift. The DNS was aware of these grievances but could not provide documentation that the facility addressed or acted upon them, nor evidence of staff education or completed audits prior to surveyor inquiry. The facility also could not provide a resident council policy when requested.
A resident with multiple health conditions experienced symptoms including malaise, body aches, chills, loss of appetite, and a raspy voice, along with signs of oral thrush. An LPN observed these changes but did not notify the physician or APRN as required, instead leaving a note in the APRN book. The resident was not assessed by the APRN until three days later, after the family requested it, at which point oral thrush was diagnosed and treated. Facility policy required immediate notification of such changes, which did not occur.
Two residents with dementia and cognitive impairment, who had a family-approved friendly relationship with specific boundaries, were involved in an incident where one was found touching the other's genital area in their room. Despite care plan interventions and staff monitoring, the supervision provided was inadequate to prevent this sexual contact, which exceeded the consent given by the family and violated facility policy.
Controlled medications and their disposition records for multiple residents, all of whom were alert, oriented, and receiving pain management for various conditions, were wrongfully removed from the facility by an LPN. The issue was discovered during a routine narcotic count, leading to an audit that confirmed the loss of several residents' medications and records. The DON was unable to locate the missing items, and the incident was reported to regulatory authorities for investigation.
A resident admitted with a left knee replacement, pain, and osteoarthritis did not receive a prescribed cryocuff (cold compress) treatment as ordered in the hospital discharge summary. The order was not transcribed into the facility's admission orders, and the resident reported never receiving ice to the affected knee. Nursing staff indicated there was no order for ice, and the DON could not explain the omission.
Surveyors found that many residents did not have identification bracelets or any visible form of identification, with most residents lacking name bands according to a facility audit. The DON confirmed that all residents were expected to have identification for medication administration, but this was not consistently implemented, and no policy for resident identification was available.
Failure to Reconcile Admission Medications and Address Pharmacy-Identified Irregularity
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate medication reconciliation and appropriate follow‑up to a pharmacist’s drug regimen review for a newly admitted resident. The resident had diagnoses including aftercare following joint replacement, type 2 diabetes, hypertension, and hyperlipidemia, and was discharged from the hospital after a right total hip replacement with a recommendation for Atorvastatin 10 mg nightly for hyperlipidemia. The hospital discharge summary did not list migraine headaches as a diagnosis. Upon admission, a physician’s order was entered for Atogepant 10 mg by mouth once daily for hyperlipidemia, even though Atogepant is a medication used to treat migraine headaches. The admission evaluation signed the day after admission stated that all active medication orders had been reviewed and were accurate based on the Inter‑Agency Referral Form/W‑10. During the initial pharmacy medication regimen review conducted shortly after admission, the pharmacist identified a concern that Atogepant had been ordered with an incorrect clinical indication of elevated lipids. However, review of interim physician orders and provider progress notes over the following days showed no documentation that this pharmacy concern was reviewed or addressed by an APRN or physician. Provider progress notes during this period documented a full medication list including Atogepant and indicated that medications had been reviewed in the EMR, but did not address the pharmacist’s identified irregularity. Interviews with the DON, the attending physician, and the pharmacist confirmed that nursing staff were responsible for entering and reconciling admission orders, that the physician relied on pharmacy to notify the facility of inappropriate medications, and that the pharmacist recognized Atogepant’s indication as migraine headaches and not hyperlipidemia. The facility’s own Medication Verification and Medication Regimen Review policies required complete review of admission medications and documentation by the attending physician of any identified irregularities and actions taken, which was not done in this case.
Failure to Timely Report Alleged Abuse
Penalty
Summary
A deficiency occurred when an allegation of abuse involving a resident with dementia, anxiety, and repeated falls was not reported to the facility Administrator or designee within the required two-hour timeframe. The resident, who had impaired cognition and required assistance with daily activities, was the subject of an incident witnessed by a nurse aide (NA #1). NA #1 observed another nurse aide (NA #2) continue to attempt care after the resident refused, which NA #1 perceived as abusive. NA #1 intervened by directing NA #2 to leave the room and redirected the resident. Despite facility policy requiring immediate reporting of abuse allegations, NA #1 did not report the incident until the following day. The Director of Nursing confirmed that the policy mandates reporting within two hours of the incident, and that NA #1 failed to comply with this requirement. Facility documentation and interviews corroborated that the delay in reporting constituted a failure to follow established abuse reporting protocols.
Failure to Maintain and Document Safe Respiratory Care Practices
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for several residents requiring oxygen therapy and nebulizer treatments. For four residents, oxygen and nebulizer tubing were found to be unlabeled and undated, contrary to facility policy which requires weekly changing, labeling, and dating of such equipment. In addition, nebulizer masks were observed to be stored improperly, either uncovered in bedside drawers or on top of bedside tables, rather than in a manner that would maintain cleanliness and prevent contamination. These deficiencies were observed during direct inspection and confirmed through interviews with nursing staff, who were unable to provide reasons for the lapses or confirm when the equipment was last changed. For one resident with chronic obstructive pulmonary disease, asthma, and congestive heart failure, the facility failed to document oxygen saturation levels every shift as required by physician order. Review of the electronic medical record revealed that oxygen saturation was not consistently recorded for every shift, and the documentation system lacked a prompt to ensure compliance with the order. The Director of Nursing Services (DNS) acknowledged that the absence of documentation made it impossible to verify that the resident's oxygen saturation remained above the physician-ordered threshold on every shift. Interviews with nursing staff and the DNS revealed a lack of clarity regarding responsibility for changing, labeling, and dating respiratory equipment, as well as uncertainty about whether staff had received adequate education on these procedures. Facility documentation and physician orders were also found to be lacking in directives for the maintenance of respiratory equipment. The facility's own policy requires oxygen tubing to be dated and changed weekly, but this was not consistently implemented or documented for the residents reviewed.
Pharmacist Failed to Ensure Required Behavior Monitoring for Residents on Antipsychotics
Penalty
Summary
A deficiency was identified in the facility's process for monthly drug regimen reviews by the consultant pharmacist, specifically regarding residents prescribed antipsychotic medications. For two residents with significant psychiatric and cognitive diagnoses, the pharmacist failed to ensure that behavior monitoring was implemented and documented as required by facility policy and physician orders. In both cases, the residents were prescribed antipsychotic medications, and orders or care plans directed that specific target behaviors be identified and monitored every shift. For one resident with vascular dementia, major depressive disorder, and anxiety, the care plan and physician orders required monitoring of target behaviors related to antipsychotic use. Although the pharmacist initially recommended the inclusion of specific, objectively documented target behaviors, subsequent monthly reviews did not follow up on whether these recommendations were implemented. There was no documentation that behavior monitoring was being completed as required, and the pharmacist did not identify or address this ongoing lack of compliance in later reviews. For another resident with bipolar disorder and other psychiatric diagnoses, physician orders and the care plan required behavior monitoring for antipsychotic use. After a change in orders, behavior monitoring was not completed or documented, and the pharmacist's monthly review did not identify or recommend correction of this omission. Interviews with facility staff and the pharmacist confirmed that the required monitoring was not in place, and the pharmacist did not detect or address the deficiency during the medication regimen review.
Failure to Monitor Target Behaviors for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to identify and monitor target behaviors for two residents who were prescribed antipsychotic medications. For one resident with vascular dementia, major depressive disorder, and anxiety, the care plan included monitoring target behaviors and gradual dose reduction as ordered. Despite multiple physician orders for antipsychotic medications and care plan interventions, there was no documentation that the specific target behavior of yelling out was monitored every shift as required by facility policy. The Director of Nursing Services (DNS) confirmed that behavior monitoring should have been documented electronically but was unable to provide evidence that this was done. For another resident with bipolar disorder, anxiety disorder, and mood disorder, physician orders required behavior monitoring every shift for specific target behaviors while receiving Quetiapine. Although behavior monitoring was completed prior to a certain date, after the resident was re-admitted and continued on Quetiapine, the order for behavior monitoring was missed and not completed as required. The DNS acknowledged that the responsibility for ensuring behavior monitoring fell to the admitting nurse and that the monitoring had not been done. Facility policies directed that residents on antipsychotic medications must have specific target behaviors identified and monitored every shift, but this was not followed for these residents.
Failure to Provide Adequate Mealtime Supervision for Residents at Aspiration Risk
Penalty
Summary
Surveyors identified that the facility failed to provide adequate supervision during mealtimes for multiple residents with a history of aspiration and dysphagia. For one resident with diagnoses including dysphagia, blindness, and Alzheimer's dementia, physician orders and care plans required direct supervision during meals, including verbal cues and alternating solids with liquids. However, the resident was observed eating alone in their room without staff present, and the assigned nurse aide left the resident unsupervised. Interviews revealed inconsistencies in staff understanding and communication regarding the required level of supervision, and the dietary report did not include the necessary supervision and feeding guidelines as required. Another resident with severe cognitive impairment and dysphagia was observed eating alone in their room without assistance or supervision, despite orders for intermittent distant supervision and assistance with cutting food into bite-sized pieces. The dietary aide delivered the meal without knowledge of the resident's specific needs, and the tray ticket failed to indicate the required precautions and assistance. Nursing and dietary staff were unclear about their responsibilities, and the resident's care needs were not communicated effectively through the facility's documentation systems. A third resident, admitted with dementia and malnutrition, was also not provided the required supervision during meals. The resident was observed with a meal tray in front of them and no staff in eyesight, despite orders for distant supervision and aspiration precautions. Staff interviews confirmed a lack of awareness of the resident's supervision requirements, and the tray ticket did not reflect the necessary precautions. Facility documentation and communication breakdowns contributed to the failure to ensure appropriate supervision and adherence to aspiration precautions for residents at risk.
Failure to Inform Resident of Diagnostic Testing and Results
Penalty
Summary
Resident #34, who has diagnoses including chronic venous hypertension, chronic embolism, thrombosis of the lower extremities, and anxiety, was not fully informed about physician-ordered testing or the results of those tests. The resident, who is cognitively intact and dependent on staff for most activities of daily living, was not notified prior to a venous and arterial ultrasound being performed on their lower extremities, nor was the resident informed of the reason for the test. The resident reported that this lack of communication regarding tests and results occurs frequently, including with blood work and other diagnostic procedures. After the ultrasound was completed, the resident requested to speak with the APRN about the results, informing an LPN of this request. The LPN did not communicate the resident's request to the APRN or document it, stating she forgot. The APRN was unaware of the resident's request and only provided the results seven days after the report was available. Facility policy states that residents have the right to be informed of changes in their medical condition and to participate in care planning, but these procedures were not followed in this instance.
Failure to Notify APRN and Family of Significant Weight Changes
Penalty
Summary
The facility failed to notify the Advanced Practice Registered Nurse (APRN) of a significant weight gain in a resident with congestive heart failure (CHF). The resident, who had diagnoses including COPD, chronic kidney disease, and CHF, was to be weighed weekly with instructions to notify the physician or APRN if there was a weight gain of 2 pounds or more in a day or 5 pounds or more in a week. Despite a documented weight gain of 7.7 pounds in one week, there was no evidence in the nursing notes or clinical record that the APRN was informed of this change. The APRN confirmed she was not notified and would have investigated the cause if she had been made aware. Nursing staff described inconsistent practices regarding weight monitoring and communication, with some confusion about shift responsibilities and documentation in the APRN communication book. Additionally, the facility failed to notify the family or responsible party of a significant weight loss in another resident who was admitted with diagnoses including failure to thrive, protein-calorie malnutrition, and dementia. This resident experienced a weight loss of 9.9 pounds in one week and a total of 22.7 pounds over two weeks. The care plan included monitoring for nutritional status and weighing per physician orders. Despite documentation of the weight loss by the dietician, there was no evidence that the family was notified. Interviews revealed confusion among staff regarding who was responsible for family notification, with the dietician believing it was nursing's responsibility and the Director of Nursing stating it was the dietician's role. The facility policy indicated the dietician should discuss undesired weight loss with the family, but this did not occur. Both deficiencies were identified through review of clinical records, facility documentation, and staff interviews. The failures were contrary to physician orders and facility policies, which required timely notification of significant changes in resident condition to the appropriate medical provider and family members.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the State Agency after a resident reported $14.00 missing from an envelope on their nightstand. The resident, who had diagnoses including chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure, was cognitively intact and required assistance with personal hygiene and mobility. Upon the resident's report, a room search was conducted, nursing staff were questioned, and the money was not found. The incident was documented, and the resident was reimbursed for the missing amount. The Director of Social Services completed the investigation and discussed the resolution with the resident, while the Administrator signed off on the documentation. Despite the facility's internal investigation and reimbursement, the incident was not reported to the State Agency as required by facility policy and state regulations. Interviews with facility staff revealed that the Director of Social Services did not consider the missing money as misappropriation due to the resident's uncertainty about losing it, and the Administrator cited too many unknowns to confirm the loss. The Director of Nursing Services was unaware of the incident. Facility policy directs that all reports of theft or misappropriation of resident property must be promptly investigated and reported to the State Agency within two hours, which was not followed in this case.
Failure to Thoroughly Investigate Allegation of Misappropriation of Resident Money
Penalty
Summary
The facility failed to identify and thoroughly investigate an allegation of misappropriation of money for one resident. The resident, who had diagnoses including chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure, reported missing $14.00 from an envelope on the nightstand. The facility's documentation did not include a comprehensive investigation, as required by policy. Specifically, there was no documentation of which nursing staff were interviewed, the date and time the resident last saw the money, the varying amounts reported missing, the amount of money in the resident's possession during the investigation, or which staff had access to the resident's room across all shifts. Interviews with the Director of Social Services and the Administrator revealed that neither could recall or had documented key details of the investigation, such as the names of staff interviewed or the specifics of the resident's last appointment. The Administrator acknowledged not interviewing all relevant staff, including the nurse aide who accompanied the resident to an appointment, and could not provide a reason for the lack of documentation. The facility's abuse prohibition policy required a prompt and thorough investigation, including interviews with all relevant parties and a room search, but these steps were not fully documented or completed.
Failure to Develop and Implement Comprehensive Care Plans for Fall Risk and ADL Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies related to fall risk management and adherence to required assistance for activities of daily living. One resident with chronic obstructive pulmonary disease, cervical radiculopathy, and congestive heart failure had a history of falls and was identified as having impairments in strength and mobility. Despite a fall and subsequent risk assessment indicating the resident was at risk for falls, the care plan did not reflect this risk or include appropriate interventions until after another fall occurred. Documentation revealed that the fall risk care plan had previously been marked as resolved without clear justification, and staff responsible for care planning were unaware of the absence of an active fall risk plan prior to the incident. Another resident with adjustment disorder, anxiety, and psychotic disorder was care planned to require two staff members for all direct care due to behavioral concerns. Observations showed that this intervention was not consistently followed, with nurse aides providing care alone on multiple occasions. Interviews with staff indicated a lack of awareness regarding the continued need for two-person assistance, and staffing patterns made it difficult to comply with the care plan directive. The care card for the resident continued to specify the need for two staff members, but this was not adhered to in practice. Facility policy required the development and ongoing updating of individualized care plans, with staff expected to follow the most current plan of care. In both cases, the facility did not ensure that care plans accurately reflected residents' needs or that staff consistently implemented the specified interventions, leading to deficiencies in resident care.
Failure to Supervise Wound Care and Adhere to Physician Orders for Nutrition
Penalty
Summary
The facility failed to ensure proper supervision and adherence to physician orders for two residents, resulting in deficiencies related to wound care and nutritional monitoring. One resident with a history of cellulitis, chronic respiratory failure, and lymphedema was observed self-performing wound care on the left plantar foot without the use of gloves or clean technique. The resident removed a soiled dressing, applied Lidocaine cream, and changed the dressing without hand hygiene or infection control measures. Staff interviews revealed that the nursing team was not aware the resident was self-administering wound care, and no assessment or education had been provided for self-administration. Additionally, there was no physician order permitting self-administration, and documentation of refusals or observations of poor technique was lacking. Facility documentation showed that previous self-administration evaluations for this resident did not include the current wound care or Lidocaine jelly application. The facility's policy required dressings to be applied by licensed nursing personnel using proper hand hygiene, which was not followed in this case. Staff members, including the LPN and RN, acknowledged that they had not communicated or documented the resident's self-care activities or refusals, and the Director of Nursing was unaware of the situation until the surveyor's inquiry. In a separate incident, another resident with diagnoses of failure to thrive, protein-calorie malnutrition, and congestive heart failure was not weighed daily as ordered by the physician. The care plan required daily weights at a specific time, but review of records showed that weights were only recorded on 7 out of 15 required days. Staff interviews confirmed that daily weights were not completed or documented as ordered, and the facility's policy emphasized the importance of regular weight monitoring to prevent and intervene in cases of undesirable weight loss.
Failure to Follow Wound Consultant Recommendations for Pressure Ulcer Care
Penalty
Summary
A deficiency occurred when the facility failed to follow up on wound consultant recommendations for a resident with an unstageable pressure ulcer on the coccyx. The resident, who was bedfast most of the time and required maximum assistance for personal hygiene and bed mobility, had a care plan that included interventions such as a low air loss mattress, skin care protocols, and therapy consultations. However, the care plan did not address the resident's refusals to get out of bed or reposition, and there was no evidence that therapy or dietary consultations recommended by the wound consultant were initiated. The wound consultant had recommended ongoing treatments, optimization of nutrition, and a PT evaluation for support surfaces, but these recommendations were not communicated or acted upon by the therapy, dietary, or nursing staff. Observations showed the resident remained lying flat on their back throughout the day, and interviews with staff revealed that neither therapy nor the DNS were aware of the wound consultant's recommendations. The wound consultant confirmed that she expected therapy and dietary evaluations to have occurred, but was unaware that these had not been completed. Facility policy required rehabilitation screens for residents with significant changes in functional ability, but no such screen or evaluation was found for this resident following the new wound development.
Failure to Follow Infection Control Practices During Pressure Ulcer Dressing Change
Penalty
Summary
A deficiency was identified when a nurse failed to follow infection control practices during a dressing change for a resident with a pressure ulcer who was on Enhanced Barrier Precautions (EBP). The resident, who had diagnoses including a sacral pressure ulcer, dementia, and was bedfast, required maximum assistance for personal hygiene and was at risk for developing pressure ulcers. During the observed dressing change, the nurse did not apply the required personal protective equipment (PPE) such as gown and gloves, as mandated by the facility's EBP policy. The nurse prepared a clean field, applied gloves, removed the soiled dressing, and cleansed the wound, but did not perform hand hygiene after removing gloves or before handling clean dressings. Additionally, the nurse used scissors from her scrub pocket to cut dressing material without sanitizing them, and did not perform hand hygiene before donning new gloves to apply the clean dressing. Interviews with the facility's Infection Preventionist and the nurse confirmed that these actions were not in accordance with facility policy and standard infection control practices. The facility's policies required hand hygiene at multiple steps and the use of sanitized equipment, which were not followed during this dressing change.
Wheelchairs Improperly Stored in Resident Common Areas
Penalty
Summary
Surveyors observed that standard and electric wheelchairs were being stored in resident common areas, specifically the dining room and a resident lounge, during meal times and while residents were present. On multiple occasions, up to nine standard wheelchairs were stored in the dining room while residents were eating lunch, and several wheelchairs, including an electric one that was plugged in and charging, were stored in the Hampshire Unit Lounge while a resident was eating breakfast and watching television. Staff interviews confirmed that wheelchairs were routinely stored in these areas due to insufficient space in resident rooms. The Director of Nursing Services (DNS) acknowledged that the wheelchairs should not be stored in the dining room or lounge and indicated that alternative storage solutions would be sought. The facility was unable to provide a policy regarding the storage of durable medical equipment, specifically wheelchairs, when requested by surveyors. These actions and inactions resulted in a failure to maintain a safe, clean, and homelike environment for residents, as required.
Failure to Document Family Notification of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to document family notification regarding a significant change in condition for a resident with multiple diagnoses, including diabetes, Parkinson's disease, and Alzheimer's disease. The resident was assessed by an APRN for a congested cough with thick secretions, and a chest x-ray revealed modest left basilar pneumonia. Following this, an antibiotic was ordered and initiated. However, there was no documentation in the clinical record that the family or responsible party was notified about the change in condition, the diagnostic testing, the results, or the new treatment. Interviews with the Director of Nursing Services (DNS) and a Registered Nurse (RN) confirmed that it was the nurse or nurse supervisor's responsibility to notify the family and document this in the clinical record. Although the daily nursing supervisor report indicated that a message was left for the family, this report was not part of the resident's clinical record. The RN involved stated she was unaware of the requirement to document family notification in the clinical record. Facility policy required that such notifications and changes be documented in the electronic record, but this was not done in this instance.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete required annual performance evaluations for two nurse aides, as evidenced by the absence of any such evaluations in their personnel files. Both nurse aides had been employed at the facility for multiple years and had worked several shifts during the review period. Despite requests, the facility was unable to provide documentation of completed annual evaluations for either employee. The Director of Nurses confirmed that performance evaluations should have been present in the personnel files and acknowledged that they had not been completed, attributing the oversight to a lapse in tracking and scheduling by human resources. No written facility policy on performance evaluations was provided when requested. This deficiency was identified through interviews and review of employee files, as well as time punch records confirming the ongoing employment and work activity of the nurse aides in question.
Failure to Assess Blood Glucose During Change in Mental Status
Penalty
Summary
A resident with diagnoses including bacteremia, liver carcinoma, and diabetes mellitus experienced a change in mental status and became unresponsive. The resident's care plan and physician's orders required fingerstick blood glucose monitoring twice daily and as needed if symptoms of hypo- or hyperglycemia were present. On the day of the incident, the resident was noted to be drowsy and later had a significant drop in oxygen saturation, prompting staff to apply supplemental oxygen and notify the primary care provider. Although a blood glucose check had been performed earlier in the day, no additional fingerstick blood glucose was obtained at the time of the mental status change, despite facility policy and care plan interventions directing staff to do so when symptoms of hypo- or hyperglycemia occurred. The Director of Nursing and the LPN involved both confirmed that a blood glucose check was not performed at the time of the resident's acute change in condition. The resident was subsequently sent to the emergency department, where a critically low blood glucose level was identified. Facility documentation and interviews revealed that the required assessment for blood glucose was omitted during the episode of altered mental status, which was inconsistent with both physician orders and facility policy.
Failure to Address Resident Room Change Request
Penalty
Summary
A deficiency occurred when the facility failed to act on a resident and family request for a room change in a timely manner. The resident, who had diagnoses including surgical aftercare and Parkinson's disease, was assessed as alert but with severe cognitive impairment and agitation. On admission, the resident required assistance with activities of daily living and transfers. Documentation shows that the family, who held power of attorney, requested a room change due to the roommate's disruptive nighttime behavior, which caused the resident anxiety and sleep disturbance. The request was noted by nursing staff and the supervisor was made aware, but there was no evidence in the record that the request was addressed or that a room change was made prior to the resident's discharge. Interviews with social work and the director of nursing revealed a lack of awareness and follow-up regarding the room change request. The social worker was not informed of the initial request and only became aware during a care conference focused on discharge planning, while the director of nursing only learned of the request on the day of discharge. Facility policy requires reasonable accommodation of resident needs and preferences, but the documentation and interviews failed to show that the facility took action to address the resident's or family's concerns about the room assignment.
Failure to Address Resident Grievances Regarding Call Light Response
Penalty
Summary
Residents repeatedly expressed concerns during multiple resident council meetings about call bells not being answered in a timely manner, particularly during the second shift. These concerns were documented in the meeting minutes over several months, with residents noting that the issue was ongoing. The Director of Nursing Services (DNS) was aware of these grievances, as they were discussed during the meetings, and acknowledged the residents' dissatisfaction with call light response times. Despite being aware of the issue, the facility failed to provide documentation showing that the residents' grievances regarding lengthy call bell wait times were addressed or acted upon. Although the DNS indicated that audits were being conducted to monitor call light response and that staff education was being considered, there was no evidence that these actions had been implemented prior to the surveyor's inquiry. Additionally, the facility was unable to provide a resident council policy when requested.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a resident with diagnoses including type 2 diabetes mellitus and thrombocytopenia experienced a change in condition that was not promptly reported to the physician or advanced practice registered nurse (APRN). The resident, who required assistance with activities of daily living and had intact cognition, reported symptoms such as malaise, body aches, chills, no appetite, and a low raspy voice. An LPN documented these symptoms and noted a white coating on the resident's tongue, suggestive of the onset of oral thrush. However, the LPN did not notify the physician or APRN at the time of the change in condition, instead placing a note in the APRN's book and assuming the APRN would see the resident the following day. Three days later, the APRN assessed the resident at the family's request and diagnosed oral thrush, subsequently initiating antifungal treatment. Interviews with facility staff confirmed that the LPN did not make a direct notification to the physician or APRN regarding the resident's change in condition, and the observed symptoms were not fully documented in the APRN book. The facility's policy required that any change in a resident's condition be reported to the physician, which was not followed in this instance.
Failure to Prevent Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse between two residents, both of whom had diagnoses of dementia and other cognitive impairments. The care plans for both residents acknowledged a consensual, friendly relationship that was approved by family members, with specific interventions in place such as allowing hand-holding, hugging, and kissing, but not sexual acts. There were also environmental cues, such as yellow tape at the room threshold, to remind one resident not to enter the other's room unaccompanied, and social services were tasked with monitoring the relationship to ensure compliance with family guidelines. Despite these interventions, an incident occurred in which one resident was found by a staff member touching the genital area of the other resident in the latter's room. At the time, the resident whose room it was had their pants and brief pulled down, while the other resident was fully dressed and seated in a wheelchair. Both residents were assessed as having significant cognitive impairment, with one scoring a 4 and the other a 15 on the Brief Cognitive Assessment Tool, and both had dementia diagnoses. Staff interviews confirmed that prior to this event, there had been no previous sexual contact between the two residents, and both were aware of the boundaries set by family and staff. The incident was reported to supervisory staff and documented in the facility's accident and incident report. The family member with power of attorney for one resident had previously approved only non-sexual physical contact and did not consent to sexual acts. The facility's policy required staff to monitor residents for inappropriate behaviors, but the supervision and interventions in place were insufficient to prevent the sexual contact that occurred, resulting in a failure to protect the resident from abuse as required.
Controlled Medications and Disposition Records Wrongfully Removed by Nurse
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings, specifically controlled medications and their corresponding disposition records. For five of seven sampled residents, it was found that their controlled medications, including Oxycodone and Dilaudid, as well as the controlled substance disposition sheets, were removed from the facility by a licensed nurse without authorization. These residents had various diagnoses such as fractures, muscle weakness, anxiety, peripheral vascular disease, and multiple myeloma, and all were alert, oriented, and receiving pain medications as ordered by their physicians. The deficiency was identified when a charge nurse reported that a resident's Oxycodone and the associated disposition record were missing during a shift-to-shift narcotic count. Subsequent audits revealed that controlled medications and disposition records for four additional residents were also missing. The Director of Nursing conducted a search of medication carts and storage areas for expired or discontinued medications but was unable to locate the missing items. The investigation determined that a licensed nurse had removed the controlled medications and disposition records from the facility. The incident was reported to the Department of Consumer Protection, Drug Enforcement Division, which took over the investigation. Facility policy defines misappropriation of resident property as the wrongful, temporary, or permanent use of a resident's belongings without consent, which was substantiated in this case.
Failure to Implement Hospital Discharge Order for Cryocuff Therapy
Penalty
Summary
A deficiency occurred when the facility failed to implement a hospital discharge order for a cryocuff (cold compress) treatment for a resident admitted with a left knee replacement, pain, and osteoarthritis. The hospital discharge summary included a specific order for cryocuff application to the affected knee every four hours and as needed, but this order was not transcribed into the facility's admission orders. The resident's care plan identified a risk for pain and included interventions for pain management, but did not address the cryocuff treatment. The resident reported never receiving ice to the left knee and stated that nursing staff indicated there was no order for ice when asked. The DON confirmed that the hospital discharge summary is reviewed and orders are placed by the attending physician or APRN, but could not explain why the cryocuff order was omitted. The facility was unable to provide a policy for transcribing orders when requested. This failure to address and implement the hospital's discharge recommendation for a specific treatment order resulted in the resident not receiving the prescribed cryocuff therapy upon admission.
Failure to Provide Resident Identification Bracelets
Penalty
Summary
The facility failed to ensure that residents had identification bracelets or another form of visible identification, as observed during a survey. On the date of observation, three out of five residents seated in wheelchairs in the common area did not have any visible identification, and two residents confirmed they had never worn an identification bracelet. Further observations across three facility units and the recreation area revealed multiple residents without identification bracelets. The DON stated that the expectation was for each resident to have a name band for identification, particularly for medication administration, and that charge nurses were instructed to audit and ensure compliance. A review of the facility's audit showed that 52 out of 75 residents did not have an identification bracelet or other visible identification. The facility did not have a policy for resident identification when requested.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
Trusted data from CMS and state health departments
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