Civita Care Center At Cheshire
Inspection history, citations, penalties and survey trends for this long-term care facility in Cheshire, Connecticut.
- Location
- 745 Highland Avenue, Cheshire, Connecticut 06410
- CMS Provider Number
- 075222
- Inspections on file
- 22
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Civita Care Center At Cheshire during CMS and state inspections, most recent first.
A dependent, cognitively impaired resident with multiple psychiatric and physical diagnoses, including poor memory and total dependence for all ADLs, was found by a family member lying flat in bed completely undressed and uncovered. During the morning shift, a NA providing care left the room to obtain cream, closing the door and pulling the curtain but leaving the resident without any covering. The RN supervisor learned of the incident from the family member and was told by the NA that she had left to get cream but denied leaving the resident uncovered. The DON later confirmed that the incident was not reported to her at the time and that leaving the resident exposed violated the facility’s Resident Rights policy requiring treatment with dignity and respect.
A dependent, cognitively impaired and fully incontinent resident with multiple diagnoses, including a pressure ulcer, was care planned for toileting and incontinent care at least every two hours and at specific times throughout the day. A family member later found the resident saturated in urine and feces and reported this to an LPN, who learned from a NA that incontinent care had not been provided since the beginning of the shift, nearly five hours earlier, despite facility policy and the resident’s care plan requiring regular check-and-change. The DON reported she had not been informed of the incident and stated that incontinent care or monitoring should occur multiple times each shift, with the charge nurse responsible for ensuring NAs follow the incontinence policy.
A resident dependent on staff for transfers and requiring a mechanical lift with two-person assistance was transferred by a single nurse aide, contrary to care plan and facility policy. Following this unsupervised transfer, the resident sustained multiple skin tears, bruising, and an acute hip fracture. The incident was confirmed through clinical records and staff interviews.
A resident with an amputation, impaired cognition, and type 2 diabetes requiring insulin and extensive assistance with ADLs was admitted without a baseline care plan addressing their needs for ADL support and diabetes management. Despite multiple assessments and physician orders detailing these requirements, the baseline care plan failed to include them, as confirmed by staff interviews and record review.
A resident with diabetes experienced multiple episodes of low blood sugar, during which nursing staff administered treatments and performed follow-up checks. However, the clinical record did not consistently document these interventions, follow-up blood glucose readings, or provider notifications as required by facility policy. Staff interviews confirmed that some actions were performed but not recorded, resulting in incomplete and inaccurate medical records.
The facility did not ensure dietary staff consistently monitored and documented food temperatures before meal service, as required by policy. Several Service Line Checklists lacked temperature records, and the Dietary Manager was aware but had not addressed the issue. The Administrator was also unaware of the missing documentation.
A resident with hemiplegia following a stroke experienced a violation of their rights when a nurse aide made a disrespectful comment regarding food preferences. The aide suggested the resident eat the meal tray before cookies, which was inappropriate and disregarded the resident's right to choose. The facility's policy requires treating residents with respect and dignity, which was not followed in this case.
A facility failed to hold interdisciplinary care conferences for a resident, missing six quarterly meetings over a year and a half. The resident, with intact cognition and independence in some activities, expressed a desire to attend these meetings. Staff interviews revealed systemic issues, with the MDS coordinator unable to attend due to time constraints and the social worker conducting one-on-one meetings instead of interdisciplinary conferences, contrary to facility policy.
A resident's representative was not informed of their rights upon admission to the facility. Despite attempts by the Admissions Director to contact the representative, the necessary admission documents remained unsigned and undated. The DNS confirmed that the admitting nurse should have ensured the completion of the paperwork, but this was not done, leading to a deficiency.
The facility failed to obtain timely physician orders for advance directives for three residents. One resident's DNR status was not documented in a physician's order until 11 months after admission. Another resident's Full Code status was not reflected in the care plan or physician's orders until after surveyor inquiry. A third resident's advance directives were not reviewed upon admission, and the admitting nurse did not complete the necessary paperwork within the expected timeframe.
A resident with severe cognitive impairment and dependent on tube feeding was transferred to the hospital twice due to gastrostomy tube dislodgement. The facility failed to notify the resident's representative of these transfers, leading to distress when the representative was informed by hospital staff instead. The RN involved believed he had contacted the representative but lacked documentation to confirm this.
The facility failed to update care plans for two residents after multiple feeding tube dislodgements. One resident with a GJ tube and another with a gastrostomy tube experienced dislodgements, but their care plans were not revised with new interventions. The DNS acknowledged the oversight, and the facility's policy requires care plan updates after significant changes, which were not followed.
A resident with hemiplegia following a stroke did not receive necessary meal setup assistance as per their care plan. The resident, who required substantial assistance, reported feeling intimidated and reluctant to ask for help when a nurse aide occasionally failed to set up their food tray. The aide admitted to providing assistance only if remembered and when requested, contrary to facility policy requiring staff to offer help with meals to all residents.
Two residents in an LTC facility experienced unwitnessed falls and a head strike, but the required neurological assessments were not completed. One resident had an initial check documented, but no further assessments were recorded. Another resident had multiple incidents where assessments were incomplete or not conducted, and refusals were not properly managed. The DNS and staff interviews revealed a failure to adhere to the facility's neurological assessment policy.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive weekly skin assessments as ordered, leading to the development of a stage 3 pressure ulcer. The facility failed to complete these assessments on several occasions, as confirmed by staff interviews and documentation review.
A facility failed to provide adequate supervision and assistive devices, resulting in multiple incidents. A resident with brain damage eloped despite being low risk, and another with dementia left the facility unnoticed. A resident with obesity was injured during a hoyer lift transfer, and another fell during therapy due to poor wheelchair positioning. Additionally, a resident fell due to a broken wheelchair seat belt.
A resident with a GJ tube experienced repeated dislodgement due to the facility's failure to ensure the use of an abdominal binder and inadequate education of the resident's spouse. Despite the care plan's recommendation, the binder was not consistently used, and the spouse, who faced a language barrier, removed it. The facility did not utilize available resources to communicate the importance of the intervention, leading to repeated hospital visits for tube replacement.
The facility failed to serve meals at appetizing temperatures, as residents frequently complained about cold food. The FSD acknowledged these complaints and ongoing efforts to deliver hot food timely. A temperature check revealed several hot food items were served below the expected 140°F, with some as low as 106.7°F. The DNS was aware of these complaints and expected adequate food temperatures. The facility's policy required maintaining proper temperatures to prevent foodborne illness.
The facility failed to follow infection control policies, including hand hygiene after glove removal and proper medication dispensing. An LPN did not wash hands after glove removal before touching items near a resident, and another LPN touched medication with her hands instead of dispensing it directly into a cup. Additionally, the facility missed several months of required environmental infection control rounds.
The facility failed to offer and document influenza and pneumococcal vaccinations for two residents, including education on benefits and side effects. One resident with pneumonia and stroke, and another with chronic obstructive pulmonary disease, had no records of being offered or receiving the vaccines. The Infection Preventionist confirmed the lack of documentation and contact with representatives, contrary to facility policy.
The facility failed to offer COVID-19 vaccinations and track the vaccination status for two residents. One resident with severe cognitive impairment was not offered a booster dose despite being eligible, and another resident's vaccination status was not documented upon admission. The Infection Preventionist did not follow up on these cases, leading to a deficiency in the facility's vaccination protocol.
The facility failed to submit the 4th quarter PBJ report on time due to a delay caused by corporate staff instructions to hold the report for review. The report was submitted after the deadline, and no policy for PBJ submission was provided.
A resident's $2,000 in cash was misappropriated due to the facility's failure to secure the safe where the money was stored. The safe had been left unlocked for at least two years, and multiple staff members had access to the business office key, compromising the security of residents' belongings.
Resident Left Uncovered and Exposed During Personal Care
Penalty
Summary
A resident with schizophrenia, depression, anxiety, adult failure to thrive, muscle weakness, poor memory recall, and total dependence on staff for all ADLs, including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting, was found undressed and fully exposed in bed. The resident’s care plan directed staff to allow extra time to complete tasks, encourage the resident to make choices as able, praise efforts, and report changes in functional ability to the physician. A family member reported entering the resident’s room and finding the resident completely undressed, lying flat in bed with nothing covering the body. The 7AM–3PM nurse aide assigned to the resident stated that while providing care she left the room to obtain cream, pulling the curtain and closing the door but leaving the resident on the bed without any covering. The 7AM–3PM RN supervisor reported that the family member informed her that the resident had been found exposed, and that the nurse aide told her she had left the room to get cream but denied leaving the resident uncovered. The DON stated it had not been reported to her that the resident was found exposed, and confirmed that facility policy requires all residents to be treated with dignity and respect. The DON acknowledged that the resident was not treated with dignity when left in bed without being covered and that the nurse aide made an error in judgment. The facility’s Resident Rights policy states that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Failure to Provide Timely Incontinent Care per Care Plan and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide incontinent care according to the resident’s care plan and facility policy for one dependent resident. The resident had diagnoses including schizophrenia, depression, anxiety, adult failure to thrive, and muscle weakness, and was care planned on 1/21/26 as needing assistance with all ADLs due to cognitive and physical deficits, having urinary incontinence, and a pressure ulcer. The care plan directed staff to check the resident for incontinence every two hours and as needed, assist with toileting, and provide resident-specific toileting upon rising, after meals, at bedtime, and at five specified times each day (8:00 AM, 10:30 AM, 2:00 PM, 6:30 PM, and 9:00 PM). A Significant Change in Condition MDS assessment documented that the resident had poor memory recall, was always incontinent of bowel and bladder, and was dependent for all ADLs including bed mobility, transfers, bathing, dressing, personal hygiene, eating, and toileting hygiene. On 2/21/26 at approximately 10:30 AM, a family member arrived and found the resident saturated in urine and feces and reported this to the charge nurse (LPN). During interview, the 7AM–3PM NA stated incontinent care should be provided every two hours and as needed for incontinent residents but could not recall specific details of the incident. The 7AM–3PM charge nurse later reported that, on the date of the incident, the family member told her the resident was soaked in urine; when the LPN asked the NA when care was last provided, the NA stated she had been busy and had not provided incontinent care since first rounds at the beginning of the shift at 7:00 AM, nearly five hours earlier. The DON stated she was not informed of the concern and explained that incontinent care or monitoring should occur during first rounds and at least four times per shift, including at the end of each shift, and that it is the charge nurse’s responsibility to ensure NAs provide care per policy. The facility’s urinary continence and incontinence policy directed that management of incontinence follow relevant clinical guidelines and that a check-and-change strategy be used at regular intervals to maintain dignity, comfort, and skin protection, which was not followed in this case.
Failure to Follow Mechanical Lift Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with diagnoses including unspecified dementia and anxiety, who was dependent on staff for all transfers and required a mechanical lift with the assistance of two staff members, was transferred by a single nurse aide using the mechanical lift. The resident's care plan and physician's orders specified the use of a Hoyer lift with two staff for all transfers, and facility policy also required at least two nursing assistants for safe use of the mechanical lift. Despite these directives, the nurse aide performed the transfer alone, which was later confirmed during the facility's investigation. Following this unsupervised transfer, the resident was found to have multiple new skin tears on the hands, arm, and back of the head, as well as bruising on the thigh and pubic region. Subsequent assessment revealed an acute fracture of the left intertrochanteric hip. The incident was identified through clinical record review, staff interviews, and facility documentation, confirming that the transfer was not conducted according to the resident's care plan and established safety protocols.
Failure to Implement Baseline Care Plan for ADLs and Diabetes Management
Penalty
Summary
A deficiency was identified when the facility failed to implement a baseline care plan for a resident who required assistance with activities of daily living (ADLs) and had type 2 diabetes mellitus with hyperglycemia. Upon admission, the resident was noted to have an amputation of the right lower leg, required extensive assistance with transfers, and was non-ambulatory. Multiple assessments by nursing, occupational therapy, and physical therapy documented the resident's need for moderate to extensive assistance with ADLs, use of a Hoyer lift for transfers, and rehabilitation services. The resident also had moderately impaired cognition, was always incontinent of bowel, occasionally incontinent of bladder, and required insulin and other medications for diabetes management. Despite these documented needs, the baseline care plan in place from admission did not address the resident's requirements for ADL assistance or diabetes management. Physician orders specified the need for assistance with ADLs and transfers using a Hoyer lift, as well as a detailed regimen for diabetes medications and insulin administration. However, the baseline care plan failed to reflect these needs. Interviews with facility staff confirmed that the expectation was for a baseline care plan to be developed and implemented upon admission to address ADL status and disease management, but this was not done for the resident in question.
Incomplete Documentation of Hypoglycemia Management
Penalty
Summary
The facility failed to ensure that the medical record for a resident with diabetes was complete and accurate in documenting the treatment of multiple hypoglycemic episodes. The resident, who had a history of type 2 diabetes, cognitive impairment, and other significant health conditions, experienced several instances where blood glucose levels were critically low. On multiple occasions, blood sugar readings were recorded as being below 60, and interventions such as administration of Glucagon and nutritional supplements were provided. However, the clinical record did not consistently reflect timely rechecks of blood glucose levels within 15 minutes as required, nor did it always document the interventions taken, the resident's response, or provider notifications. Nursing staff interviews revealed that although follow-up blood sugar checks were reportedly performed and the resident was monitored, these actions were not always entered into the resident's clinical record. The responsible LPN admitted to forgetting to document some of the follow-up blood sugar results, despite performing them. Additionally, the RN supervisor acknowledged that updates to the provider were sometimes only recorded in supervisor reports rather than in the resident's clinical record, leading to incomplete documentation of the care provided and the communication with the provider. The Director of Nursing confirmed that the facility's expectation and policy required nurses to document all blood sugar readings, interventions, resident responses, and follow-up actions in the clinical record, especially when blood glucose levels were below 70. The review of the facility's hypoglycemia management policy further supported the need for thorough documentation of interventions and follow-up blood glucose checks. The lack of complete and accurate documentation in the resident's medical record constituted a failure to maintain records in accordance with accepted professional standards.
Failure to Document Food Temperatures Before Meal Service
Penalty
Summary
The facility failed to ensure that dietary staff consistently monitored and documented food temperatures prior to meal service. Specifically, the Service Line Checklists from 12/1/24 through 1/12/25 did not record food temperatures on several dates, including 12/2/24, 12/23/24, 12/25/24, 12/31/24, 1/1/25, 1/2/25, and one undated checklist. During an observation and interview on 1/14/25, a dietary staff member confirmed that temperatures are typically taken once food is on the steam table, but the documentation was missing for the specified dates. The Dietary Manager acknowledged awareness of the incomplete checklists and admitted that she had not followed up with the responsible cook due to a busy schedule. She believed that the cook likely took the temperatures but failed to document them. The facility's policies require that food temperatures be monitored to ensure safety and quality, yet these procedures were not adhered to. The Administrator was unaware of the missing documentation and expected that temperatures would be recorded for every meal, as per the facility's policies on food preparation and service.
Resident Rights Violation Due to Disrespectful Interaction
Penalty
Summary
The facility failed to ensure that a resident was treated in a respectful and dignified manner, as required by resident rights. Resident #39, who had a history of hemiplegia/hemiparesis following a stroke and was at risk for falls, was involved in an incident where a nurse aide (NA #12) made a disrespectful comment. During an interview, Resident #39 reported that after requesting a food item, NA #12 responded with a comment about not understanding food deprivation because he was not from an African American background, which the resident found disrespectful. NA #12, during an interview, denied making the specific statement but acknowledged discussing the resident's meal choices. He recalled suggesting that Resident #39 eat the meal tray before consuming cookies. The Director of Nursing Services (DNS) confirmed that NA #12 had advised the resident to eat the meal first, which was deemed inappropriate as it disregarded the resident's right to food preferences. The facility's policy on Resident Rights mandates that all residents be treated with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Conduct Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to consistently hold interdisciplinary resident care conferences and invite the resident to participate, as required for person-centered care planning. Resident #45, who was admitted in November 2020 with various diagnoses including chronic embolism, thrombosis, and major depression, had intact cognition and was independent in certain activities of daily living. Despite this, the facility did not conduct the required quarterly interdisciplinary care conferences for over a year and a half, with the last one held on April 13, 2023. This resulted in six missed quarterly conferences, and the resident expressed a desire to attend these meetings, which had not been held for about two years. Interviews with facility staff revealed systemic issues in scheduling and conducting these care conferences. RN #7, the MDS coordinator, admitted to not attending the meetings due to time constraints and a lack of additional staff support, despite being aware of the expectation to attend. The responsibility for scheduling these conferences was placed on the social worker, who also faced challenges in ensuring the attendance of the interdisciplinary team. The social worker confirmed that only she attended the scheduled meetings with Resident #45, which did not meet the requirements for a comprehensive interdisciplinary care conference. The facility's policy mandates that a comprehensive, person-centered care plan be developed and implemented by an interdisciplinary team, including the resident and their representative. However, the lack of participation from key team members, such as the attending physician, registered nurse, and dietitian, among others, led to a failure in meeting these requirements. The social worker documented these meetings as interdisciplinary care conferences, although they were essentially one-on-one meetings, highlighting a significant deficiency in the facility's care planning process.
Failure to Inform Resident Representative of Admission Rights
Penalty
Summary
The facility failed to inform a resident's representative of their rights upon admission, as required by regulations. The resident, who was admitted with conditions including stroke, gastrostomy placement, and dysphagia, had severely impaired cognition and was nonverbal. Despite an admission care conference being held with the resident's representative, the facility did not review or request a review of any admission documents with the representative. The clinical record contained blank admission documents, including consents for treatment, personal item inventory, and various policies, indicating that the necessary paperwork was not completed. The Admissions Director attempted to contact the resident's representative on three occasions but did not succeed and did not make further attempts or notify the DNS or Administrator. The DNS confirmed that the admitting nurse was responsible for completing the admission paperwork within 48 hours and should have ensured its completion by reporting to the next oncoming nurse if necessary. The facility's admission agreement, which was unsigned and undated, outlined the legal obligations and rights of the resident and the facility, but these were not communicated to the resident's representative, leading to the deficiency.
Failure to Obtain Timely Physician Orders for Advance Directives
Penalty
Summary
The facility failed to obtain a physician's order for code status for three residents after their advance directives were communicated and documented. Resident #16, who was admitted with vascular dementia, Alzheimer's disease, and malignant neoplasm, had an Advance Directives-Clarification of Wishes document indicating a Do Not Resuscitate (DNR) status, among other wishes. However, a physician's order reflecting these wishes was not written until 11 months later. The Director of Nursing Services (DNS) expected that advance directives would be addressed within 48 hours of admission, but this was not met for Resident #16. Resident #41, admitted with Alzheimer's disease, epilepsy, and schizoaffective disorders, had a documented wish for Full Code status. Despite this, the care plan and physician's orders did not reflect the resident's advance directives. The DNS confirmed that a physician's order should have been obtained within 48 hours of admission, but it was not until after surveyor inquiry that a physician's order was documented. For Resident #44, who had a stroke and severely impaired cognition, the facility failed to review advance directives upon admission. Although a physician's order for DNR was present, the admission note did not document a discussion of advance directives. The DNS identified that the admitting nurse should have completed the advance directives paperwork within 48 hours, but this was not done. The DNS noted multiple residents lacked signed advance directives, indicating a systemic issue in the facility's process for handling advance directives.
Failure to Notify Resident Representative of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident representative of a change in condition and hospital transfers for a resident with a history of stroke, gastrostomy placement, and dysphagia. The resident was dependent on tube feeding and had severely impaired cognition, requiring staff assistance for daily activities. On two occasions, the resident inadvertently pulled out the gastrostomy tube, leading to hospital transfers for reinsertion. Despite these significant changes in the resident's condition, the facility did not notify the resident's representative promptly as required by their policy. On the first occasion, the resident pulled out the gastrostomy tube, and after an unsuccessful attempt to reinsert it, the resident was sent to the hospital. The clinical record did not show that the resident's representative was informed of this transfer. The representative only learned of the situation from the hospital staff, which caused distress as they were unaware of the resident's departure from the facility. The second incident occurred when the resident again dislodged the gastrostomy tube, resulting in another hospital transfer. The facility failed to notify the resident's representative of this transfer as well. The representative was only informed when the resident was being readmitted to the facility. Interviews with the RN involved revealed that while he believed he had contacted the representative, there was no documentation to support this, and he admitted to not always calling immediately due to the timing of his shifts.
Failure to Update Care Plans After Feeding Tube Dislodgements
Penalty
Summary
The facility failed to update the comprehensive care plan for two residents following multiple displacements of feeding tubes. Resident #37, who had a gastrostomy-jejunostomy (GJ) tube, experienced two dislodgements of the tube. Despite these incidents, the care plan was not updated with new interventions. The Director of Nursing Services (DNS) acknowledged that the care plan should have been revised after each dislodgement, and the nursing staff had implemented different interventions, such as frequent checks and positioning techniques, but these were not documented in the clinical record. Resident #44, who had a gastrostomy tube, also experienced two dislodgements. The care plan did not reflect these incidents or include interventions to address them. Although the MDS Coordinator reviewed and revised the care plan, the revision did not address the tube dislodgements. The DNS identified that it was the responsibility of the nursing staff to complete care plan revisions related to such incidents, and the MDS Coordinator was responsible for revisions related to hospitalizations or transfers. The facility's policy on comprehensive care plans directs that the care plan must be reviewed and updated when there is a significant change in the resident's condition, when the resident is readmitted from a hospital stay, and at least quarterly. However, the care plans for both residents were not updated as required, leading to a deficiency in the facility's compliance with its own policy and regulatory requirements.
Failure to Provide Meal Setup Assistance
Penalty
Summary
The facility failed to provide necessary setup and assistance with meals for a resident with hemiplegia/hemiparesis following a stroke, as per the comprehensive assessment and plan of care. The resident, who was cognitively intact, required substantial assistance with bed mobility, two-person assist with transfers using a mechanical lift, and setup assistance with eating. Despite these needs, the resident reported that a nurse aide occasionally dropped off the food tray without opening or setting up food items, leaving the resident feeling intimidated and reluctant to request the needed assistance. The nurse aide involved stated that he provided setup assistance to all residents assigned to him but was not usually assigned to this particular resident. He admitted to providing setup assistance with meals only if he remembered and when requested. The Director of Nursing Services (DNS) confirmed that staff were expected to ask all residents if assistance was needed with meals, regardless of assignment. The facility's policy for Activities of Daily Living (ADL) Support mandates that residents be provided with care and services appropriate to maintain or improve their ability to carry out ADLs, including dining support and assistance.
Failure to Complete Neurological Assessments After Falls
Penalty
Summary
The facility failed to ensure that neurological assessments were completed for two residents after unwitnessed falls and a head strike. Resident #12, who had a history of falls and was admitted with vascular dementia and other conditions, experienced an unwitnessed fall on 5/28/24. Although an initial neurological check was documented, no further assessments were recorded as required by the facility's policy. The DNS, who was not in position at the time of the incident, confirmed that neurological checks should have been completed and documented on the flowsheet, but no such documentation was found. Resident #48, admitted with Parkinson's Disease and a history of falls, experienced multiple unwitnessed falls and a head strike incident. On several occasions, neurological assessments were either incomplete or not conducted at all. For instance, on 8/11/24, 13 out of 24 assessments were not completed following an unwitnessed fall. Similarly, on 11/29/24 and 12/2/24, neurological assessments were not completed as required. On 1/7/25, after a head strike incident, 10 out of 24 assessments were not completed, and the resident's refusal to undergo assessments was not properly managed or documented. Interviews with the DNS and nursing staff revealed a lack of adherence to the facility's neurological assessment policy. The DNS expected that all sections of the neurological assessments would be completed after unwitnessed falls or head injuries. However, staff failed to follow the protocol, and there was a lack of communication and documentation regarding the residents' refusals and the inability of staff to perform the assessments due to other duties. The facility's policy required that any changes in neurological status be reported to a physician, but this was not consistently done.
Failure to Conduct Weekly Skin Assessments Leads to Pressure Ulcer
Penalty
Summary
The facility failed to ensure that weekly skin assessments were completed for a resident with a high risk of developing pressure ulcers, as per the physician's order. The resident, who had severe cognitive impairment and was dependent on staff for mobility and hygiene, was admitted with multiple diagnoses including cerebral infarction and hemiplegia. The physician's order required weekly skin observations on shower days, specifically on Mondays during the 3:00 PM to 11:00 PM shift. However, documentation revealed that these assessments were not completed during several weeks, specifically on 10/14, 10/28, 11/4, 11/11, and 11/25. The resident was transferred to the hospital on 11/29 due to vomiting and a protrusion in the abdomen, and upon return to the facility on 12/4, was found to have a stage 3 pressure injury on the sacral region. Interviews with the LPN and DNS confirmed the lack of completed skin assessments during the specified weeks. The facility's policy required weekly full body audits to be documented in the resident's medical record, which was not adhered to, leading to the development of a pressure ulcer.
Inadequate Supervision and Assistive Devices Lead to Multiple Incidents
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for several residents. Resident #23, who had a history of anoxic brain damage and psychotic disorder, eloped from the facility despite being assessed as low risk for elopement. The resident was found 0.4 miles away from the facility after the front door alarm sounded. The facility's elopement risk assessments were not completed as required, and there was a lack of supervision at the time of the incident. Resident #26, diagnosed with dementia and cerebrovascular disease, also eloped from the facility. Despite being identified as at risk for elopement, the care plan did not include interventions to address this risk. The resident left the facility without notifying staff and was found by the Admission Director 0.4 miles away. The facility concluded this was an unauthorized leave, but staff were unaware of the resident's departure. Resident #27, with severe morbid obesity and schizoaffective disorder, sustained injuries during a transfer using a hoyer lift. The resident's right leg was bruised and swollen, and it was determined that the injuries occurred when the resident's leg struck the lift during a transfer. The incident was not immediately reported by staff who noticed the injuries. Additionally, Resident #39 experienced a fall during a therapy session due to inadequate positioning in a wheelchair, and Resident #48 had an unwitnessed fall due to a broken wheelchair seat belt.
Failure to Prevent Feeding Tube Dislodgement Due to Inadequate Intervention and Education
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent the dislodgement of a feeding tube for Resident #37, who was admitted with a gastrostomy-jejunostomy (GJ) tube and other medical conditions such as cerebral infarction and hemiplegia. The care plan identified the risk of the GJ tube coming out and recommended the use of an abdominal binder as an intervention. However, observations revealed that the abdominal binder was not consistently used, and alternative measures like covering the tube with a towel were employed instead. The report highlights that the facility did not adequately educate the resident's family on the importance of the abdominal binder to prevent tube dislodgement. Interviews with nursing staff indicated that the resident's spouse, who does not speak English, often removed the binder, and there was a lack of effective communication and education provided to the spouse due to a language barrier. The facility had a language line available for such situations, but it was not utilized to ensure the spouse understood the necessity of the intervention. The deficiency was further compounded by the fact that the nursing staff did not document or communicate the importance of the abdominal binder to the resident's responsible party or spouse. Despite the facility's policy on enteral feeding safety precautions and comprehensive person-centered care planning, the interdisciplinary team failed to implement and communicate targeted interventions effectively, leading to repeated dislodgement of the resident's GJ tube and subsequent hospital visits for replacement.
Failure to Serve Meals at Appetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were served at appetizing temperatures, as observed and reported by residents and staff. Interviews with four residents revealed frequent complaints about cold food. The Food Service Director (FSD) acknowledged occasional complaints and ongoing efforts to deliver hot food timely. The Administrator noted that food was not reaching residents promptly after delivery to the floor. A food temperature check conducted with the FSD showed that several hot food items, including a hamburger, hot dog, and grilled cheese, were served below the expected temperature of 140°F, with some items as low as 106.7°F. The Director of Nursing Services (DNS) was aware of periodic complaints and expected food to be served at adequate temperatures. The facility's policy directed that proper hot and cold temperatures be maintained during food service, with a 'danger zone' for holding temperatures between 41°F and 135°F, which promotes the growth of pathogenic organisms causing foodborne illness.
Infection Control Deficiencies in Hand Hygiene and Medication Administration
Penalty
Summary
The facility failed to adhere to infection control policies in several instances, leading to deficiencies in care. For Resident #50, who was at risk for pressure ulcers, an LPN did not perform hand hygiene after removing gloves and before touching items on the resident's bedside table. This was observed by the Infection Preventionist, and both the LPN and the Infection Preventionist acknowledged the lapse in protocol. The facility's policy clearly states that hand hygiene should be performed after removing gloves and between tasks, which was not followed in this instance. Additionally, during medication administration for Resident #5, an LPN failed to maintain infection control standards by touching medication with her hands instead of dispensing it directly into a medication cup as per facility policy. This oversight was acknowledged by the LPN and the Director of Nursing, who confirmed the expectation for safe infection control practices. Furthermore, the facility did not conduct monthly environmental infection control rounds consistently, as required, with several months missing documentation. The Infection Preventionist, responsible for these rounds, could not provide records for multiple months, indicating a lapse in the facility's infection control oversight.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to two residents, provide education regarding the benefits and potential side effects of these immunizations, or document in the clinical records whether the residents received or declined the vaccinations. Resident #44, who was admitted with diagnoses including pneumonia and stroke, did not have documentation in the clinical record from 9/30/24 to 1/14/25 indicating that the influenza vaccine was offered or administered. The Preventative Health Report also failed to show that Resident #44 received the influenza or pneumococcal vaccines. The Infection Preventionist (RN #3) acknowledged the lack of documentation and confirmed that the resident's representative was not contacted regarding the influenza vaccine. Similarly, Resident #61, admitted with chronic obstructive pulmonary disease and other conditions, was not offered the influenza or pneumococcal vaccines, and there was no documentation of education or vaccination status in the clinical record from 9/30/24 to 1/14/25. The Preventative Health Report did not reflect that Resident #61 received the vaccines. RN #3 confirmed that the vaccination forms were blank and not addressed upon admission. The facility's policies require that residents be offered these vaccines and educated about them, with documentation of education and vaccination status in the medical record, which was not adhered to in these cases.
Failure to Offer and Track COVID-19 Vaccinations for Residents
Penalty
Summary
The facility failed to ensure that two residents, Resident #44 and Resident #61, were offered COVID-19 immunizations and that their vaccination statuses were properly tracked. Resident #44, who was admitted with diagnoses including pneumonia, stroke, and a feeding tube, had severely impaired cognition. The Preventative Health Report indicated that Resident #44's COVID-19 vaccine was last administered on January 15, 2023, and was not up to date. The Infection Preventionist, RN #3, acknowledged that although the resident could receive a booster dose, he did not reach out to the resident's representative to educate and offer the vaccine. Resident #61, admitted with chronic obstructive pulmonary disease, acute respiratory failure, and insulin-dependent diabetes, had moderately impaired cognition. The Preventative Health Report did not document Resident #61's COVID-19 immunization status, and the COVID-19 vaccine form was left blank in the chart. RN #3 admitted that he was responsible for following up on the vaccination status but failed to do so. The Director of Nursing Services and the Regional Clinical Nurse confirmed that RN #3 was responsible for ensuring that all residents were offered the COVID-19 vaccine or boosters upon admission and when doses were due, but this was not done for Resident #61.
Late Submission of PBJ Report
Penalty
Summary
The facility failed to submit the 4th quarter Payroll Based Journal (PBJ) report on time. The report, covering the period from July 1, 2024, to September 30, 2024, was due by October 14, 2024, at 11:59 PM but was instead submitted on October 15, 2024, at 10:47 AM. This delay occurred because the Director of Human Resources, following instructions from a corporate staff member, held the report to wait for all PBJ reports from all sites to be reviewed before submission. Consequently, the PBJ submission was not timely, and the facility could not provide a policy for PBJ submission when requested.
Failure to Secure Resident's Money
Penalty
Summary
The facility failed to ensure the security of a resident's money that was placed in their possession. Resident #1, who had diagnoses including cerebrovascular disease and dementia, entrusted $2,000 in cash to the facility's business office. The money was stored in a safe that was unable to be locked due to staff not knowing how to operate the dial lock. The safe had been left unlocked and unsecured for at least two years. On 10/23/23, when Resident #1 requested their money, it was discovered that the envelope containing the $2,000 was empty. The facility was unable to determine who misappropriated the money. The business office door was always locked, but the key was accessible to multiple staff members, including those in maintenance, which compromised the security of the safe's contents. The Administrator admitted that despite previous attempts to contact locksmiths, no documentation was provided to support these efforts. The facility's policy directed that reasonable efforts should be made to safeguard residents' personal property, but this was not adhered to in this case. The Business Manager confirmed that the safe's door was closed but not locked, and the money was last observed on 10/12/23. The facility's failure to secure the safe and properly safeguard the resident's money led to the misappropriation incident.
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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