Civita Care Center At Danbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Danbury, Connecticut.
- Location
- 107 Osborne Street, Danbury, Connecticut 06810
- CMS Provider Number
- 075274
- Inspections on file
- 28
- Latest survey
- May 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Civita Care Center At Danbury during CMS and state inspections, most recent first.
A resident with intact cognition and multiple chronic conditions was allowed to self-administer medications, including an inhaler and oral packets, without a required assessment or physician's order. Medications were kept unsecured at the bedside, and staff confirmed that no formal evaluation or authorization for self-administration had been completed, contrary to facility policy.
The facility did not ensure that two residents' wishes regarding code status were properly documented and honored. One resident was not educated or asked to sign code status forms upon admission, and another resident's DNR preference was not updated in the EMR, leading staff to follow outdated full code instructions. Nursing staff relied on inaccurate records, and the facility did not follow its own policy for documenting and communicating advance directives.
A resident with multiple health conditions developed a new non-blanchable area on the sacrum, but the facility did not notify the physician or resident representative as required. Documentation of follow-up assessments and implementation of planned interventions was also lacking, and the resident was not added to the wound care rounds for further evaluation.
A resident with a history of depression, bipolar disorder, and opioid dependence was admitted and prescribed medication for opioid dependence. The facility failed to incorporate PASARR Level 2 recommendations, including support group participation and mental health counseling, into the resident's care plan. The responsible social worker did not review or act on the PASARR recommendations, resulting in the resident not being offered or referred to appropriate support services.
A resident with a history of stroke and cognitive decline was later diagnosed with a psychotic disorder with delusions and mild intellectual disabilities. Despite these significant changes, the facility did not notify the state designated authority as required, due to a misunderstanding by the social worker responsible for PASARR coordination and poor communication between the psychiatric group and facility staff.
A resident with dementia and a history of traumatic brain injury exhibited ongoing combative and aggressive behaviors towards staff, as documented in psychiatric consults and staff reports. Despite these behaviors, the care plan was not revised to include interventions for aggression, and enhanced monitoring was only implemented after the resident was involved in a physical altercation with another resident. Facility staff interviews revealed gaps in communication and care plan updates, and required policy for care plan revision was not provided.
Two residents did not receive care according to physician orders: one did not have a required valproic acid level obtained after starting Depakote, despite documentation indicating otherwise, and another received oxygen therapy post-hospitalization without a physician's order, even though hospital recommendations called for it. Facility staff and APRNs confirmed these omissions and documentation errors during interviews and record reviews.
A resident was not transferred according to physician orders, resulting in a fall, and two residents in a supervised smoking program were not properly monitored or provided with secure smoking materials. Staff left smoking materials unattended, failed to account for a lighter, and did not redirect a resident to use a metal ash receptacle. The smoking area lacked required fire extinguisher inspections and proper disposal of cigarette butts, and there was no documentation of staff education on smoking safety.
A resident with end stage renal disease on dialysis and a physician-ordered fluid restriction did not have their intake and output consistently monitored or documented by staff. Despite care plans and orders specifying a 1,000 ml daily fluid limit, staff failed to record intake and output on multiple occasions, and the resident did not meet the restriction as required. Key staff and providers were unaware of these lapses, and the dialysis center was not informed of the inconsistent monitoring.
The facility did not resolve a controlled medication discrepancy in a timely manner, failed to ensure individual-use medications were properly labeled and dated, and did not consistently complete required shift-to-shift controlled drug audits. These deficiencies were identified through observations, documentation review, and staff interviews, revealing lapses in medication management and accountability.
A resident with multiple comorbidities and moderate risk for pressure ulcers developed a non-blanchable area of redness on the sacrum, but the facility failed to document weekly assessments, notify the physician or resident representative, or ensure follow-up by the wound care team. Required interventions and evaluations were not consistently implemented or recorded, resulting in incomplete management and documentation of the pressure ulcer.
A resident with a permcath for dialysis was not placed on enhanced barrier precautions (EBP) as required by facility policy. Staff did not use PPE during care, and there was no signage or physician order for EBP, despite the presence of an indwelling medical device. The deficiency was confirmed through record review and staff interviews.
Several residents with complex medical histories were not timely offered or properly documented for pneumococcal vaccination. An LPN responsible for infection prevention missed vaccine offers due to inconsistent practices, such as not re-offering after refusal, not providing education on all vaccine types, and failing to document vaccine status. The facility's policy required assessment and education on admission, but these steps were not consistently followed.
Multiple residents with cognitive and behavioral issues were involved in incidents of verbal and physical abuse, including one resident grabbing another by the neck and another throwing a remote control that caused injury. Staff intervened during the incidents, but not all staff received education on managing such behaviors, and the facility did not adequately prevent or monitor for resident-to-resident abuse as required by policy.
Two residents with significant medical conditions were transferred to the hospital on multiple occasions, but the required written notice of the bed hold policy was not provided to them or their representatives at the time of transfer. Interviews confirmed that nursing staff were responsible for this task, but the bed hold policy form was not completed or included in the transfer packet as required by facility policy.
The facility did not complete annual performance reviews for a nurse aide, with the last evaluation occurring five years prior, contrary to facility policy requiring yearly assessments for all employees. The lapse was attributed to frequent staff turnover and responsibility for evaluations rested with the DNS and ADNS.
A resident with impaired mobility and high fall risk, who required a Hoyer lift and two-person assistance for transfers, was transferred by a nurse aide without following the care plan. The aide did not review the resident's transfer requirements and attempted to use a standing scale, resulting in the resident falling and sustaining multiple fractures. Facility documentation and staff interviews confirmed that the established transfer protocol was not followed.
A resident with impaired mobility, who required a mechanical lift and two staff for transfers, was improperly transferred by a nursing assistant using a standing scale, resulting in a fall and fractures. After the fall, the resident was moved by staff, including the DON and two nursing assistants, without an RN assessment, contrary to facility policy and care plan directives.
A resident with severe cognitive impairment and behavioral symptoms was found with a privacy curtain loosely wrapped around their neck and upper body, while another resident with a history of disruptive behaviors was observed holding the curtain, squeezing the resident's arm, and pushing them with a walker. Staff responded to the incident after hearing screaming and separated the residents, with no injuries reported. The event was documented as resident-to-resident abuse without injury, and the facility failed to ensure residents were free from abuse.
A resident with paraplegia and an indwelling catheter did not have urine output consistently documented over several days, despite care plans and facility policy requiring accurate intake and output records. Staff interviews revealed confusion over documentation responsibilities, and facility leadership confirmed that output should be recorded each time the catheter is emptied, even if the amount is zero.
The facility failed to ensure licensed staff documented the administration of medications at the time they were given, as required by professional standards. This deficiency was identified through clinical record reviews, facility documentation, and interviews for 20 residents. The DON speculated that an RN may have administered the medications but failed to save her signature in the system, resulting in the absence of documentation.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including hyperkalemia, end stage renal disease requiring dialysis, and chronic obstructive pulmonary disease was admitted to the facility and expressed a desire to self-administer medications. The resident had intact cognition but required maximum assistance with activities of daily living such as toileting, dressing, and personal hygiene. Despite the resident's request and ongoing self-administration of medications, including an inhaler and oral medication packets, the facility did not complete a self-administration assessment or obtain a physician's order as required by facility policy. Observations revealed that the resident kept multiple medications, including an inhaler and Lokelma packets, at the bedside and in an open dresser drawer. The resident reported independently using these medications, obtaining them from nursing staff as needed, and not having a lock box for secure storage. The resident stated that the nurse provided the inhaler for use as needed and that they had been self-administering Lokelma with each meal since admission. Interviews with facility staff, including the DNS, confirmed that no self-administration assessment had been completed for the resident and that the resident was not officially permitted to self-administer medications. Facility policy required a self-administration observation, a physician's order, care plan documentation, and secure storage for any medications kept at the bedside, none of which had been implemented for this resident prior to the survey findings.
Failure to Honor Resident Code Status Preferences
Penalty
Summary
The facility failed to honor residents' wishes regarding code status for two residents reviewed. For one resident with multiple complex diagnoses, including end stage renal disease and mental health conditions, the clinical record and care plan indicated full code status. However, the resident reported that since admission, no staff had discussed or educated them about code status, nor had they been asked to sign any related forms. The Director of Nursing Services (DNS) confirmed that there was no code status designation in the medical record and that the resident had not signed a code status form, despite facility policy requiring this on admission. For another resident with moderately impaired cognition and several chronic conditions, there was conflicting documentation regarding code status. Although the resident had signed a Do Not Resuscitate (DNR) form after discussing it with staff and a physician, the electronic medical record (EMR) and care plan continued to list the resident as full code. Interviews with nursing staff revealed that they would have initiated CPR based on the EMR, which had not been updated to reflect the resident's most recent wishes for DNR status. The DNS acknowledged that the nurse who witnessed the DNR form should have ensured the physician order was updated in the EMR, but this was not done. Facility policy required that residents be provided with information about their right to accept or refuse medical treatment and that advance directives be documented. In both cases, the facility did not ensure that residents' code status preferences were properly documented, communicated, and honored, resulting in a failure to respect their rights regarding medical interventions.
Failure to Notify Physician and Resident Representative of New Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to notify both the physician and the resident representative after a newly identified non-blanchable area of redness was found on a resident's sacrum. The resident, who had a history of hemiplegia, insulin-dependent diabetes, and dementia, was at moderate risk for pressure ulcers and required moderate assistance with activities of daily living. The non-blanchable area was discovered by the prior DNS during an overnight shift while assisting with incontinent care, and interventions such as a specialty mattress, turn schedule, and barrier paste were planned. Despite these interventions, there was no documentation that the physician or resident representative was informed of the new skin issue, as required by facility policy. Additionally, there was no evidence that a physical or occupational therapy evaluation was requested or completed, nor that the specialty mattress was implemented. The clinical record also lacked follow-up assessments or documentation regarding the sacral area after the initial finding, and the resident was not added to the weekly wound round list for further evaluation by the wound physician. Interviews with facility staff confirmed that the appropriate notifications and follow-up assessments did not occur. The APRN and wound nurse were not informed of the new skin issue, and the wound nurse indicated that the resident should have been added to the wound rounds for further assessment. Facility policy required notification of significant changes in a resident's condition to both the physician and resident representative within 24 hours, but this was not documented or carried out in this case.
Failure to Incorporate PASARR Recommendations into Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to incorporate the recommendations from a Level 2 Preadmission Screening and Resident Review (PASARR) determination into the assessment and care plan for a resident with a history of depression, anxiety, bipolar disorder, and opioid dependence. The resident was admitted with these diagnoses and was prescribed Buprenorphine-Naloxone for opioid dependence. The PASARR Level 2 outcome specifically recommended that the resident be provided with services and support, including access to a support group for recovery from substance abuse and mental health counseling. Despite these recommendations, the facility did not update the resident's care plan to reflect the need for a support group or mental health counseling. The social worker responsible for PASARR compliance did not review the Level 2 PASARR recommendations and was unaware of the requirement to provide support group services. As a result, the resident was not offered or referred to a support group for recovery from substance abuse, nor was this intervention included in the care plan. Interviews with facility staff confirmed that the social worker did not submit the PASARR within the required timeframe and did not follow up on the recommendations after receiving the Level 2 approval. The facility's policy requires that PASARR recommendations be incorporated into the resident's assessment and care planning, but this was not done in this case, resulting in a failure to coordinate assessments and services as required.
Failure to Notify State Authority of New Psychiatric and Intellectual Disability Diagnoses
Penalty
Summary
The facility failed to notify the state designated authority when a resident received new diagnoses of psychotic disorder with delusions and mild intellectual disabilities. The resident, who was initially admitted with diagnoses including stroke, metabolic encephalopathy, diabetes, and cognitive decline, later received additional psychiatric and intellectual disability diagnoses as documented in various clinical notes and physician orders. Despite these significant changes in the resident's condition, the required notification to the state authority was not made. The social worker responsible for PASARR coordination believed that because the resident already had a Level 2 PASARR, there was no need to update the state authority when new diagnoses were made. However, upon contacting the state designated authority, it was clarified that the resident did not have a Level 2 PASARR and that any new psychiatric diagnosis should have been reported so the state could evaluate the need for specialized services. This misunderstanding led to a failure in updating the PASARR process as required by policy. Throughout the period in question, there was a lack of communication between the psychiatric group and the social worker, which contributed to the oversight. The facility's policy requires the social worker to track, make referrals, care plan, and update PASARR with any changes, but these steps were not followed when the resident's diagnoses changed. Interviews with facility staff confirmed the breakdown in communication and the failure to notify the state authority as required.
Failure to Revise Care Plan for Resident with Escalating Combative Behaviors
Penalty
Summary
The facility failed to ensure that appropriate interventions, including enhanced monitoring, were implemented for a resident with a documented history of combative behavior towards staff. The resident, who had diagnoses of dementia and a history of traumatic brain injury, exhibited ongoing combative and aggressive behaviors as documented in multiple psychiatric consults and staff reports. Despite these documented behaviors, the care plan did not include specific interventions to address the resident's aggression towards staff, and there was no evidence that the care plan was revised in response to the escalating behaviors. The care plan only addressed wandering and intrusiveness, with interventions such as encouraging diversional activities and walking with staff, but did not address the resident's combative actions. The deficiency was further evidenced when the resident became the aggressor in a physical altercation with another resident, resulting in the need for 1:1 enhanced monitoring only after the incident occurred. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's combative behaviors, and there was no policy provided for care plan revisions based on changes in condition. The facility's policy required the interdisciplinary team to document and adjust interventions based on behavioral changes, but this was not followed in the case of this resident.
Failure to Follow Physician Orders for Lab Monitoring and Oxygen Therapy
Penalty
Summary
The facility failed to follow physician's orders and ensure appropriate monitoring and documentation for two residents. For one resident with chronic obstructive pulmonary disease, major depressive disorder with psychotic features, and dementia, the facility did not obtain a required valproic acid level after the initiation of Depakote, despite a physician's order and pharmacy recommendation. Documentation in the medical record indicated the lab was completed, but interviews and record review confirmed that no specimen was collected and no lab result was available. The APRN who ordered the lab was unable to locate any evidence of the result and acknowledged uncertainty about why documentation indicated the lab had been reviewed. For another resident with congestive heart failure and dementia, the facility failed to obtain a physician's order for oxygen therapy following a hospitalization for respiratory failure, sepsis, and pneumonia. Although the hospital discharge summary recommended continued oxygen therapy with specific parameters, the admission orders did not include oxygen. Nursing notes showed the resident continued to receive oxygen without a corresponding physician's order, and the APRN later acknowledged the omission was an oversight. Documentation errors also occurred, with a progress note incorrectly stating the resident no longer required oxygen, despite ongoing administration. Facility policies required that all services, including medication administration and lab monitoring, be documented accurately and that orders for treatments such as oxygen specify rate, flow, route, and rationale. The failures in both cases were confirmed through interviews with nursing and APRN staff, review of clinical records, and facility documentation, demonstrating a lack of adherence to physician orders and facility policy regarding medication and treatment management.
Failure to Prevent Accidents and Ensure Safe Smoking Practices
Penalty
Summary
A deficiency occurred when a resident with a history of falls, impaired cognition, and multiple comorbidities was not transferred according to the physician's order, which required the assistance of two staff members and specific footwear. Instead, a nurse aide attempted the transfer alone, resulting in the resident falling in the bathroom. There was no documentation confirming whether a gait belt or the prescribed footwear was used at the time of the fall. The Director of Nursing Services (DNS) confirmed that the nurse aide did not follow the care plan or physician's order, and the Administrator was unaware of the two-person assist requirement at the time of the incident. Another deficiency was identified regarding the supervision and safety of a resident participating in a supervised smoking program. The facility failed to ensure that smoking materials, including lighters, were properly secured and accounted for. During observation, a staff member left a caddy containing cigarettes unattended in an unlocked area, and the lighter was missing and unaccounted for. Additionally, the resident was observed flicking cigarette ash onto a wet cement patio and wood mulch, rather than using the designated metal ash receptacle, without staff intervention or redirection. Further observations revealed that the fire extinguisher in the smoking area had not been inspected or documented for several months, and there was no evidence of monthly checks or related policies available. The smoking area also contained a wooden planter with multiple discarded cigarette butts, indicating improper disposal of smoking materials. The facility lacked documentation of staff education or in-service training on smoking supervision and safety prior to the survey, and the required quarterly smoking assessments for the resident were not found in the clinical record.
Failure to Consistently Monitor and Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of intake and output for a resident with end stage renal disease who was on a physician-ordered fluid restriction of 1,000 ml per day and received dialysis. The care plan and physician's orders specified the fluid restriction, but staff did not consistently document the resident's intake and output, and the resident did not meet the prescribed fluid restriction on multiple occasions across several months. The intake and output records for March, April, and early May showed repeated failures in both documentation and adherence to the fluid restriction, with staff not recording intake and output as required. Interviews with nurse aides revealed that intake and output were to be documented electronically, but there were lapses in documentation. The regional clinical support LPN and the DNS both acknowledged awareness of non-compliance with the intake and output policy, despite prior education provided to staff. Neither the DNS nor the LPN was aware that the resident was not meeting the fluid restriction as ordered. Additionally, the physician's orders did not initially specify the breakdown of fluid allocation between nursing and dietary services until after surveyor inquiry. Further, the dialysis center RN was not notified by the facility about the inconsistent monitoring of intake and output, and both the attending physician and APRN were unaware that the physician's order for fluid restriction was not being followed. The facility's policy required accurate and timely documentation of fluid intake, but this was not consistently performed, leading to the deficiency in care for the resident requiring specialized dialysis services.
Failure to Ensure Timely Controlled Substance Discrepancy Resolution and Medication Labeling
Penalty
Summary
The facility failed to ensure proper management and accountability of controlled medications, as evidenced by an unresolved discrepancy in the electronic medication cabinet. An alert indicating a discrepancy was present on the medication cabinet for at least four days, and neither agency staff nor regular nursing supervisors had the access or authority to resolve it. The Director of Nursing Services (DNS) was ultimately responsible for investigating and resolving such discrepancies but had not accessed the cabinet or performed any inventory of controlled substances for a period of 20 days. The discrepancy, related to the count of Oxycodone 10 mg, was only resolved after surveyor intervention, revealing a lack of timely oversight and investigation as required by facility policy. Additionally, the facility failed to ensure that medications intended for individual resident use were properly labeled and dated. During an observation of a medication cart, a bottle of saline nasal spray was found without any resident identifying information, and the nurse present could not confirm to whom the medication belonged. The facility's policy required all multi-dose over-the-counter medications to be labeled and dated, but this was not followed, and the medication was subsequently disposed of after the deficiency was identified. The facility also did not consistently complete required controlled drug/change of shift audits. Review of audit forms for multiple medication carts over several months revealed numerous missing shift-to-shift controlled substance counts, with many forms either incomplete or not provided at all. Facility policy mandated that licensed nurses from both outgoing and incoming shifts jointly conduct and document these counts, but this process was not reliably followed, resulting in gaps in documentation and accountability for controlled substances.
Failure to Document and Communicate Pressure Ulcer Assessment and Interventions
Penalty
Summary
A deficiency occurred when the facility failed to document weekly assessments and the healing process of a newly identified non-blanchable area of redness on the sacrum for one resident. The resident, who had a history of hemiplegia, insulin-dependent diabetes, and dementia, was at moderate risk for pressure ulcers and required significant assistance with activities of daily living. A non-blanchable area was discovered during incontinent care, and initial interventions such as a specialty mattress, turn and positioning schedule, and barrier paste were planned. Despite these interventions, the clinical record did not show evidence that a physical or occupational therapy evaluation was requested or completed, nor that a specialty mattress was implemented. There was also no documentation of further assessments of the sacral area after the initial finding, nor any record of physician or resident representative notification regarding the new skin issue. The facility's treatment administration record indicated that weekly skin checks were signed off, but there was no specific observation documentation of the sacral area. Interviews with facility staff confirmed that the wound nurse and the advanced practice registered nurse were not notified of the new skin issue, and the resident was not added to the weekly wound rounds for further evaluation. The facility's policy required assessment and documentation of significant risk factors and physician involvement in identifying and managing pressure ulcers, but these steps were not followed as documented in the clinical record.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
A deficiency was identified when a resident with end-stage renal disease and dependence on renal dialysis, who had a permcath (an indwelling medical device) in place, was not placed on enhanced barrier precautions (EBP) as required by facility policy. The physician's orders directed staff to observe the permcath site every shift and monitor for signs and symptoms of infection, but did not include a directive for the use of EBP. The care plan addressed the risk for complications related to dialysis and included monitoring for bleeding at the port site, but did not mention EBP. The facility's EBP list did not identify the resident as requiring EBP, and there was no signage on the resident's door indicating EBP status. During interviews, staff members, including an LPN and the Infection Preventionist, confirmed that the resident had not been placed on EBP and that personal protective equipment (PPE) was not used during care. The DNS acknowledged that the resident should have been on EBP due to the presence of the permcath and that appropriate orders and signage were missing. Facility policy states that EBP should be used for residents with indwelling medical devices, regardless of MDRO colonization, but this was not implemented for the resident in question.
Failure to Timely Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure timely offering and documentation of pneumococcal vaccines for four out of eight residents reviewed. For several residents with significant medical histories, including dementia, diabetes, stroke, and chronic respiratory conditions, the clinical records and preventative health documentation did not reflect up-to-date pneumococcal vaccine status or evidence that the vaccine was offered as required. In some cases, the vaccine was not offered at all, while in others, only one type of pneumococcal vaccine was offered without education or re-offering of other recommended vaccines. Documentation of vaccine status and education was also missing from the residents' records. Interviews with the infection preventionist LPN revealed inconsistent practices, such as missing vaccine offers due to form discrepancies, not re-offering vaccines after initial refusal, and not considering eligibility based on comorbidities. The facility's policy required assessment and offering of pneumococcal vaccines upon admission or readmission, with proper education and documentation, but these steps were not consistently followed. The medical director confirmed that the residents in question were eligible for vaccination according to CDC guidelines.
Failure to Prevent Resident-to-Resident Abuse and Inadequate Staff Education
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, as evidenced by multiple incidents involving residents with cognitive and behavioral disturbances. In one case, a resident with dementia and behavioral symptoms verbally threatened another resident, who responded by physically grabbing the first resident around the neck and pinning them against the wall. Staff intervened to separate the residents, and no injuries were reported. Prior to this incident, there was no documented history of aggression between these residents, but the facility's response to the altercation was limited in scope, as not all staff received education on managing such behaviors. In another incident, a resident with a history of borderline personality disorder and depression, after returning from a hospital evaluation for suicidal ideation, threw a remote control at their roommate, resulting in a bruise to the roommate's face. The roommate reported ongoing verbal abuse and agitation from the resident prior to the physical altercation. Staff and another resident witnessed the event, and the injured resident was assessed and requested a room change. The resident who threw the remote had previously exhibited emotional distress and was evaluated by hospital staff before returning to the facility. The facility's policies define abuse as the willful infliction of injury or intimidation, including resident-to-resident altercations, and require ongoing assessment and care planning to prevent such incidents. However, the events described indicate that the facility did not adequately identify, monitor, or intervene to prevent resident-to-resident abuse, nor did it ensure that all staff were educated on recognizing and managing behaviors that could lead to conflict or harm.
Failure to Provide Bed Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to the resident or their representative at the time of hospital transfers for two residents. One resident with diagnoses including congestive heart failure and dementia was transferred to the hospital on two separate occasions and returned each time, but there was no documentation that the required bed hold policy notice was given during either transfer. Similarly, another resident with hypoxia and Alzheimer's disease was also transferred to the hospital twice and returned, with no evidence that the bed hold policy notice was provided at or after the time of transfer. Interviews with the Administrator and a nursing supervisor confirmed that it was the nursing staff's responsibility to ensure the bed hold policy was provided to the resident or their representative at the time of transfer. The nursing supervisor acknowledged that the bed hold policy form was not completed for one of the residents due to oversight, and that the policy was not included in the transfer packet. The facility's own policy requires that written information about bed hold rights, payment policies, and transfer details be given to the resident and representative prior to transfer, but this was not followed in these cases.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete annual employee performance reviews for at least one certified nurse aide, as required by facility policy. Review of one nurse aide's personnel file showed that her last performance review was conducted five years prior, despite her continued employment. The facility's policy mandates that all employees, regardless of employment status, receive annual evaluations based on their hire date or a facility-defined cycle. During an interview, the Administrator stated that the responsibility for ensuring completion of these evaluations rested with the Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS), and attributed the lapse to frequent staff turnover.
Failure to Follow Transfer Protocol Results in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to follow the established plan of care for a resident with reduced mobility, depression, and anxiety, who was non-ambulatory and required the assistance of two staff members and a Hoyer lift for all transfers. The resident's care plan, ADL records, and physician orders all specified the need for a Hoyer lift and two-person assistance due to high fall risk and impaired physical mobility. Despite these documented requirements, a nurse aide attempted to transfer the resident to a standing scale without reviewing the care plan or confirming the transfer method with the supervising nurse. During the transfer, the nurse aide assumed the resident could stand and transfer independently because the resident had previously moved from bed to wheelchair without assistance. The aide wheeled the resident into the shower room, positioned the wheelchair in front of the standing scale, and assisted the resident to stand and step onto the scale. As the resident attempted to move further onto the scale, their legs buckled, resulting in a fall that caused significant injuries, including fractures to the left tibia, left fibula, and right femur. Facility documentation and interviews confirmed that the nurse aide did not follow the resident's plan of care, which required the use of a Hoyer lift and two staff for transfers. The Director of Nursing Services and the nurse aide both acknowledged that the proper protocol was not followed, and the incident occurred as a result of this failure. The facility's falls protocol policy also directed staff to implement interventions based on assessments to prevent falls, which was not adhered to in this case.
Failure to Ensure RN Assessment Prior to Transfer After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with reduced mobility, depression, and anxiety, who was care planned and ordered to require a mechanical lift with two staff for all transfers, experienced a fall with injury during an attempted transfer. The resident was non-ambulatory and required maximal assistance with activities of daily living, as documented in the care plan, physician's orders, and care card. Despite these directives, a nursing assistant attempted to obtain the resident's weight using a standing scale, resulting in the resident's legs buckling and a subsequent fall that led to a left ankle and right femur fracture. Following the fall, multiple staff, including the DON, ADON, and two nursing assistants, were present in the shower room where the incident occurred. The DON and ADON did not conduct or ensure an RN assessment was performed prior to the resident being moved from the scale to the wheelchair. Instead, the nursing assistants, with the DON present, lifted the resident back into the wheelchair without an assessment, despite facility policy and staff expectations that a resident should not be moved after a fall until an RN assessment is completed. Interviews with staff and review of facility documentation confirmed that no RN assessment was conducted prior to transferring the resident after the fall. The facility's fall protocol requires a nurse to assess, document, and report on the resident's condition following a fall, including vital signs, musculoskeletal function, and pain assessment. The failure to follow these protocols and the resident's care plan led to the deficiency identified in the report.
Failure to Protect Resident from Abuse During Resident-to-Resident Altercation
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and behavioral symptoms was involved in an incident with another resident who had moderately impaired cognition and a history of disruptive behaviors. The incident involved one resident being found with a privacy curtain loosely wrapped around their neck, upper back, chest, and shoulders, while the other resident was observed holding the curtain and squeezing the resident's arm, as well as using a walker to push into the resident. Staff responded to screaming and yelling from the room, immediately separated the residents, and found no injuries. Multiple staff interviews confirmed that the curtain was wrapped around the resident's neck and that the resident was being physically restrained and pushed by the other resident. The resident who was the subject of the incident was unable to explain how the curtain became wrapped around their neck, and staff noted that this resident lacked the dexterity to do so themselves. The other resident made a statement indicating intent, saying the other "deserved it." Despite the lack of direct witnesses to the start of the incident, facility documentation and staff interviews consistently described the physical altercation and the presence of the curtain around the resident's neck. The facility's investigation was unable to substantiate how the curtain was placed, but the event was documented as resident-to-resident abuse without injury. The facility's policy requires protection from all forms of abuse, but the incident demonstrated a failure to ensure that residents were free from abuse.
Failure to Accurately Document Foley Catheter Output
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with paraplegia and an indwelling catheter, as required by professional standards and facility policy. The resident's care plan included interventions to monitor intake and output, and the facility's urinary catheter care policy directed staff to maintain an accurate record of daily output. However, clinical record review revealed that no urine output was documented for the resident over a four-day period, and on a subsequent day, output was only partially recorded. Additionally, there was no documentation of urine output on the day the resident was sent out for further evaluation due to an abdominal mass and lack of urine output. Interviews with nursing staff and nursing assistants indicated confusion and lack of clarity regarding responsibility for documenting urine output. One LPN stated she did not record the output because she believed it was the nursing assistant's responsibility, while the nursing assistant could not recall if she had documented or reported the output. Facility leadership confirmed that output should be documented in the computer system whenever a foley catheter is emptied, even if the amount is zero, but could not explain the gaps in documentation. These failures resulted in incomplete and inaccurate medical records for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to ensure licensed staff documented the administration of medications at the time they were given, as required by professional standards. This deficiency was identified through clinical record reviews, facility documentation, and interviews for 20 of 28 sampled residents. Specifically, on the 2 [NAME] Unit, multiple instances of missed signatures were noted for scheduled medication doses during the 7:00 AM to 3:00 PM shift. The Corporate Nurse Consultant and the Director of Nursing (DON) confirmed that the facility policy mandates signing off on medications immediately after administration, which was not adhered to by RN #1 on the specified date. The DON speculated that RN #1 may have administered the medications but failed to save her signature in the system, resulting in the absence of documentation. Despite attempts, an interview with RN #1 could not be obtained. The facility policy, last revised in April 2019, clearly directs that the individual administering the medication must initial the resident's medication administration record (MAR) after giving each medication and before administering the next ones. This policy was not followed, leading to the identified deficiency.
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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