Civita Care Center At Milford
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Connecticut.
- Location
- 2028 Bridgeport Ave, Milford, Connecticut 06460
- CMS Provider Number
- 075213
- Inspections on file
- 34
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Civita Care Center At Milford during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of arthritis sustained a fall resulting in a major injury. Despite clear signs of pain observed by therapy and nursing staff, pain medication ordered by the physician was not administered or documented at the time of injury or prior to transfer to the ED. Staff interviews and record reviews revealed missed opportunities for pain management and inadequate documentation, in violation of facility policy.
A resident with multiple mobility impairments experienced a fall and subsequently showed signs of pain in the right femur and ankle. Although x-rays were ordered and performed, the facility did not promptly obtain or communicate the results of the hip and pelvis imaging, which revealed an acute femoral neck fracture. The diagnostic provider also failed to immediately notify the facility of the abnormal findings, and the facility lacked a policy for timely retrieval of such results, resulting in a delay in care.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that services provided met professional standards of quality, as evidenced by observations and record reviews showing inconsistent adherence to accepted guidelines.
A resident with dementia and a history of elopement, who refused a wander guard and was known to wander, exited the facility unsupervised when a staff member entered the building. The resident was later found at a nearby gas station. A housekeeper saw the resident leave but did not report or follow, as required by policy. Documentation showed the resident was only permitted to leave with a specific family member and conservator approval.
A resident's controlled medication, Pregabalin, was discovered missing from the medication cart during a routine narcotic count. The medication disposition sheet was present, but the blister pack containing three capsules was gone. Despite a thorough search and involvement of a DEA agent, the missing medication was not found. The resident continued to receive all prescribed doses from an emergency supply.
A resident prescribed Pregabalin for chronic pain, dementia, and diabetes had a blister pack of medication go missing after staff failed to follow the required shift-to-shift controlled substance count procedure. Interviews and documentation showed that the count was not conducted by two licensed nurses together, as one nurse left early and another arrived late, resulting in improper medication accountability.
The facility failed to adhere to professional standards and physician's orders, resulting in deficiencies in medication administration, hospital transfer, and weight monitoring. Two residents did not receive required bloodwork and medication as prescribed, a resident was transported to the wrong hospital for surgery, and another experienced significant weight loss without timely intervention.
The facility failed to follow food safety and hygiene protocols, with observations of staff not wearing beard guards, personal items in the refrigerator, and undated food items. Additionally, food temperature logs were incomplete, indicating a failure to monitor and document food temperatures as required.
During a Covid-19 outbreak, the facility failed to ensure staff adhered to infection control protocols, with staff entering rooms of Covid-19 positive residents without PPE and neglecting hand hygiene. Additionally, a resident's lunch tray was placed next to urinals containing urine, violating infection control and dignity standards. The lack of consistent training and monitoring contributed to these deficiencies.
The facility failed to invite two residents and/or their representatives to participate in quarterly care plan conferences, as required. One resident with dementia and schizophrenia did not have conferences held in several months of 2024, and their conservator reported inconsistent notifications. Another resident with intact cognition was not invited to conferences in March and June 2024. MDS coordinators acknowledged the lack of documentation and adherence to policies requiring resident participation.
The facility failed to document and honor the advance directives and code status for two residents with severe cognitive impairments. One resident was admitted with a full code status but was placed on hospice without a signed DNR order until 74 days later. Another resident had a DNR status indicated but lacked a signed directive from the POA for over a year. The facility did not ensure proper documentation and communication with resident representatives, violating their rights to make informed medical decisions.
The facility failed to notify the physician and resident representative after a significant weight loss was identified for a resident with CHF, hypotension, and dementia. Despite weight changes being flagged, there was no documentation of notification or interventions. Additionally, the facility did not notify a resident representative when a new opioid medication was initiated for another resident, leading to concerns about increased lethargy. The facility's policies on weight assessment and change of condition were not followed, resulting in deficiencies.
The facility failed to protect two residents from involuntary seclusion by placing them on a locked unit without proper clinical criteria or documentation. Both residents, who had intact cognition and were capable of independent mobility, were not provided with a method for independent egress. The care plans did not reflect their placement on the locked unit, and there was no documentation of their involvement in the decision-making process. The facility lacked policies for placing residents on locked units and ensuring ongoing assessments.
The facility failed to update the PASARR for two residents with new mental health diagnoses. One resident was readmitted with schizoaffective disorder, but the PASARR was not updated. Another resident was diagnosed with bipolar disorder, but communication issues prevented the PASARR update. The facility's policies require a Level II PASARR for new serious mental illness diagnoses, which was not followed.
A facility failed to conduct a PASARR rescreen for a resident with bipolar disorder and anxiety following admission. The resident was admitted with diagnoses requiring psychiatric treatment, yet no PASARR level II evaluation was documented. The social worker was unaware of the oversight, which was against facility policy requiring such evaluations for serious mental disorders.
A resident with a new bipolar disorder diagnosis did not have their care plan updated to reflect this change. The facility's communication breakdown between psychiatric providers and the Director of Social Services led to the omission of necessary interventions and goals for the resident's bipolar disorder, resulting in a deficiency.
Two residents in the facility did not have quarterly care conferences as required, and there was no evidence that they or their representatives were invited to participate. Despite having significant medical conditions, these residents expressed a desire to be involved in their care planning. The facility's policies were not followed, and staff interviews revealed a lack of coordination in scheduling these meetings.
The facility failed to implement appropriate smoking interventions for a resident with COPD and dementia, who was found smoking in their room despite being on continuous oxygen. Additionally, another resident was found with smoking contraband, indicating lapses in supervision and adherence to smoking policies. The facility's inconsistent documentation and lack of a clear policy for monitoring residents contributed to these deficiencies.
The facility failed to adhere to respiratory care protocols for three residents, including improper management of oxygen tubing and CPAP usage. A resident with pneumonia and dementia had undated oxygen tubing, while another with COPD used tubing unchanged for six weeks and lacked a humidifier. A third resident with sleep apnea did not have a CPAP machine in the facility, despite physician orders, and the facility inaccurately documented its use. These deficiencies highlight non-compliance with physician orders and facility policies.
The facility failed to educate staff on the use of a smoking blanket during resident smoking sessions. Two nurse aides supervising a session were unaware of the blanket's existence, confirmed by the DNS. The smoking blanket was found in the smoking lockbox, and the Regional Nurse Consultant admitted the training lacked this information. The facility's smoking policy was not provided.
A resident with hypotension, CHF, and COPD experienced medication administration errors due to the facility's failure to address pharmacy recommendations. Midodrine was often held or administered outside prescribed parameters without proper documentation. The facility's staff, including the APRN and DNS, did not effectively communicate or review pharmacy recommendations, leading to ongoing medication errors.
A medication cart was found unlocked and unattended with a resident nearby, while the responsible LPN was in the nourishment room. The cart contained multiple expired medications, which the LPN admitted to not regularly checking. The ADNS and DNS confirmed that the cart should be secured at all times and expired medications discarded, as per facility policy.
A resident experienced a choking event and was recommended by an APRN to see a dentist due to being edentulous. The facility failed to follow this recommendation and did not ensure the resident received annual dental services since admission. The DNS was unaware of the APRN's recommendation, and the dental provider had not received any requests for services for the resident.
A facility failed to document a resident's meal intake accurately, missing records for breakfast and lunch over 47 days and dinner for 38 days. The resident, with dementia and diabetes, required assistance to sit but could eat independently. Despite a regular diet order, nurse's aides did not document meals, which the Dietitian noted is crucial for monitoring weight changes.
A resident with dysphagia was given a ham sandwich, not compliant with their prescribed diet, leading to a choking incident. A nursing assistant provided the sandwich after checking with an LPN, who failed to verify the resident's diet orders. The resident began choking, and an abdominal thrust was performed to expel the food. The facility's guidelines required verification of diet orders, which was not followed, resulting in Immediate Jeopardy.
The facility failed to protect residents from abuse in two separate incidents involving residents with cognitive impairments. In the first incident, a resident was attacked by their roommate, resulting in slight redness and discomfort. In the second incident, a resident was punched in the face by their roommate. Both incidents were not witnessed by staff, and the facility's investigation was unable to determine the cause of the second incident.
A facility failed to maintain a resident's ambulation program as recommended by physical therapy. The resident, with a history of brain injury and other conditions, was discharged from therapy with a plan for nursing staff to assist with ambulation. However, the resident's records showed no ambulation activities occurred, and the program was not implemented. The DNS did not inform the physical therapist of the resident's inability to ambulate due to COVID-19, and the necessary order was not entered into the clinical record.
A resident at risk for elopement left the facility unescorted when the front doors were opened for EMS, despite attempts by the receptionist to stop them. In a separate incident, another resident sustained a minor head injury during a Hoyer lift transfer due to operator error, as the lift straps were not properly secured. Both incidents highlight deficiencies in managing elopement risks and ensuring safe transfer procedures.
A facility failed to maintain accurate clinical records for a resident with a Stage 4 pressure ulcer. The resident, with anoxic brain disorder and seizures, required extensive assistance and had a pressure ulcer covered with eschar. The facility lacked documentation for weekly wound assessments and care as ordered by the physician. Critical records, including the Resident Care Plan and wound documentation, were missing, and the DON confirmed the inability to locate these records, violating the facility's medical record retention policy.
The facility failed to update the care plans for two residents involved in a consensual relationship. Despite being alert and oriented, and having been counseled on behaviors, the care plans did not reflect their relationship. Staff were aware of the relationship but did not update the care plans accordingly.
Failure to Administer and Document Pain Medication Following Resident Injury
Penalty
Summary
A resident with a history of bilateral osteoarthritis, muscle wasting, and cognitive impairment sustained a fall resulting in a head injury and later discovered femoral neck fracture. Following the fall, the resident exhibited signs of pain, including facial grimacing and withdrawal upon touch, as documented by therapy and nursing staff. Despite a physician's order for acetaminophen as needed for discomfort, the medication was not administered when pain was observed, nor was it documented as given prior to transfer to the emergency department. Nursing staff, including an LPN and the ADON, noted the resident's pain but did not provide pain medication. The ADON reported offering acetaminophen, which the resident refused, but did not document this interaction or make further attempts to administer pain relief, despite the resident's cognitive impairment. Other staff members were unaware of the resident's injury or need for pain management prior to transfer, and the medication administration record did not reflect that acetaminophen was given at the appropriate times. Facility policy required staff to identify and manage pain, reassess regularly, and document all care and changes in the resident's condition. Interviews with staff and review of records confirmed that pain management was not provided or documented as required, and that communication among staff regarding the resident's pain and injury was insufficient. The failure to administer and document pain medication as ordered and indicated by the resident's condition constituted the deficiency.
Delay in Obtaining and Communicating X-ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to obtain and promptly communicate x-ray results for a resident who experienced a fall with major injury. The resident, who had diagnoses including bilateral osteoarthritis of the knees, muscle wasting, and muscle weakness, was found on the floor with a head injury and later exhibited pain and tenderness in the right femur and ankle. Despite orders for bilateral lower extremity x-rays following the onset of pain, the facility did not receive or follow up on the hip and pelvis x-ray results in a timely manner. The x-rays, performed after the resident showed signs of injury, revealed an acute right femoral neck fracture, but the results were not accessed by the facility until several hours after they became available. The delay was compounded by the diagnostic provider's failure to immediately notify the facility of the abnormal findings, as required. The facility also lacked a policy regarding the timely retrieval of x-ray results. Interviews confirmed that the diagnostic provider did not fax or call the facility with the positive results until hours after the report was available, and the facility did not proactively obtain the results until later. This sequence of events resulted in a delay in care for the resident, as the abnormal x-ray findings were not communicated to the practitioner or acted upon promptly.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and record reviews indicating that the care and services delivered did not consistently adhere to accepted professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved or their medical conditions, were not provided in the report. The report notes a general failure to meet professional standards but does not include further factual observations or events related to the deficiency.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
A deficiency occurred when a resident with a history of elopement, vascular dementia, chronic paranoid delusions, bipolar disorder, and psychosis exited the facility unsupervised. The resident was assessed as an elopement risk, refused to wear a wander guard bracelet, and was known to wander throughout the facility. Despite interventions such as diversional activities, quarterly elopement assessments, and staff supervision, the resident was able to leave the facility through the front entrance when a staff member was entering the building. The resident was later found across the street at a gas station, sitting on a bench and smoking a cigar. The resident reported leaving the facility to relieve neuropathy discomfort by walking and did not understand why walking alone was not permitted. Staff interviews revealed that a housekeeper observed the resident exiting the building but did not immediately report the incident or follow the resident, as required by facility policy. The housekeeper was distracted by an emergency phone call and only later reported seeing the resident exit when questioned by the administrator. The facility's elopement policy defines elopement as a patient leaving the facility unnoticed and unsupervised, which occurred in this case. Documentation confirmed that the resident was allowed to leave only with a specific family member and with conservator permission, which was not the case during this incident.
Controlled Medication Misappropriation
Penalty
Summary
A deficiency occurred when a resident's controlled medication, Pregabalin, was found to be missing from the medication cart. The medication was prescribed for chronic pain, dementia, and diabetes mellitus, and was to be administered three times daily. During a routine shift-to-shift count of controlled substances, it was discovered that the blister pack containing three capsules of Pregabalin was missing, although the medication disposition sheet remained in the narcotic book. The last documented administration of the medication was the previous evening, and the missing capsules were intended for the following morning dose. Despite an extensive search of the medication carts and the building, the missing blister pack could not be located. The incident was reported, and a Drug Enforcement Agent was involved but was unable to determine the whereabouts of the missing medication. Interviews confirmed that the medication was present during the last administration and that the resident did not experience any interruption in receiving their prescribed doses, as the medication was dispensed from an emergency supply. Facility documentation and policy reviews defined the event as misappropriation, which is the wrongful use or removal of a resident's belongings or medication without consent.
Failure to Follow Controlled Substance Shift-to-Shift Count Procedures
Penalty
Summary
The facility failed to ensure that the shift-to-shift count of controlled medications was conducted by two licensed nurses as required by policy. For one resident with chronic pain, dementia, and diabetes mellitus, a physician had ordered Pregabalin to be administered three times daily. On one occasion, a blister pack containing three capsules of Pregabalin was found missing from the medication cart. Documentation and interviews revealed that, although the controlled substance count sheet was signed, the required procedure of having both the outgoing and incoming licensed nurses count the medications together was not followed. Specifically, one nurse left early and another arrived late, resulting in the count not being performed jointly as per policy. Further interviews with nursing staff confirmed that the shift-to-shift count was not properly conducted for the relevant medication cart. One LPN counted the medications with another nurse before the next shift nurse arrived, and the incoming nurse later counted the medications alone and signed the count sheet. This deviation from protocol led to the discovery of the missing medication, and the facility was unable to account for the whereabouts of the missing Pregabalin blister pack. The deficiency was identified through clinical record review, facility documentation, and staff interviews.
Deficiencies in Medication Administration, Hospital Transfer, and Weight Monitoring
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice, physician's orders, and facility policy for several residents. For two residents, the facility did not ensure that bloodwork was obtained per the physician's order and failed to administer medication as prescribed. One resident, who was on Valproic Acid, did not have the required blood level checks, and there was no documentation of refusal or notification to the APRN. Another resident was administered Midodrine outside of the prescribed blood pressure parameters, and there was no documentation of a review or adjustment of the medication order despite pharmacy recommendations. A resident scheduled for surgery was transported to the wrong hospital, resulting in a rescheduled procedure. The facility's documentation did not reflect the hospital transfer or the error, and there was no investigation provided. The transportation error was due to miscommunication and lack of proper documentation, leading to the resident being dropped off at the incorrect location. Another resident experienced significant weight loss without an RN assessment or intervention. The facility failed to document or address the weight loss in a timely manner, and the dietitian and APRN were not notified until weeks later. The facility's policy required reweighing and notification of significant weight changes, but these steps were not followed, leading to a lack of timely intervention for the resident's nutritional needs.
Food Safety and Hygiene Protocols Not Followed
Penalty
Summary
The facility failed to adhere to food safety and hygiene protocols, as observed during a survey. The Food Service Director (FSD) and a male employee were seen without beard guards, which is against the facility's policy for kitchen hygiene. Additionally, the refrigerator contained an employee's personal water bottle and undated opened containers of almond milk, ravioli, and pepperoni. The refrigerator log for December 2024 showed missing afternoon temperature entries on two dates, indicating a lapse in monitoring and documenting refrigeration temperatures as required by the facility's food sanitation policy. Further observations revealed incomplete food temperature logs for several dates, with missing entries for breakfast, lunch, and dinner temperatures. This lack of documentation suggests a failure to consistently monitor and record food temperatures before serving meals, as mandated by professional standards. The FSD, who is new to the facility, acknowledged these issues and indicated ongoing efforts to ensure compliance with food service protocols.
Inadequate Infection Control and Resident Dignity Compromised
Penalty
Summary
The facility failed to provide appropriate education to its staff during a Covid-19 outbreak, leading to multiple instances of non-compliance with infection control protocols. Observations revealed that staff members, including nursing assistants, entered rooms of Covid-19 positive residents without donning personal protective equipment (PPE) and failed to perform hand hygiene. This was attributed to a lack of training and monitoring by the Infection Prevention Nurse, who did not conduct hand hygiene training or monitor PPE use during the outbreak. Additionally, the facility's policy required adherence to standard precautions, including the use of N95 masks, gowns, gloves, and eye protection, which was not followed by the staff. The report also highlighted an incident involving a resident with peripheral vascular disease, type 2 diabetes mellitus, and hypertension, who had moderately impaired cognition and required assistance with personal hygiene. During lunch, a nurse aide placed the resident's lunch tray on a bedside table next to two urinals containing urine. This action was contrary to the facility's policy, which required urinals to be removed and the table sanitized before serving food. The aide admitted to being distracted and forgetting to remove the urinals, which compromised the resident's dignity and infection control standards. Interviews with various staff members, including the Infection Control Nurse and the Director of Nursing Services, confirmed the expectations for infection control practices, such as removing urinals and sanitizing surfaces before serving food. However, the lack of consistent monitoring and education during the outbreak contributed to the deficiencies observed. The facility's failure to adhere to its own policies and provide adequate training and oversight during the Covid-19 outbreak resulted in compromised infection control and resident dignity.
Failure to Invite Residents to Care Plan Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were consistently invited to participate in quarterly care plan conferences, as required. For Resident #25, who was admitted with diagnoses including dementia and schizophrenia, the clinical record showed that care conferences were not held in February, May, and August of 2024. Interviews with the MDS coordinators revealed that the absence of these conferences was due to staffing issues, as one coordinator was on leave. Resident #25 and their conservator reported not being consistently informed about the care plan meetings, with the conservator stating that notifications were often received after the meetings had occurred. Similarly, for Resident #83, who was admitted with conditions such as respiratory failure and diabetes, the facility did not hold care plan conferences in March and June of 2024. Despite having intact cognition, Resident #83 was not invited to participate in these meetings. The MDS coordinators confirmed the lack of documentation for these conferences and acknowledged that the resident should have been invited. The facility's policies emphasize the importance of resident participation in care planning, yet the documentation and interviews indicate a failure to adhere to these policies.
Failure to Document Advance Directives and Code Status
Penalty
Summary
The facility failed to properly ascertain and document the code status and advance directives for two residents, leading to deficiencies in honoring their rights to make decisions about their medical care. Resident #31 was admitted with severe cognitive impairment and was initially identified as a full code upon hospital discharge. However, there was no documented attempt by the facility to contact the resident's representative to confirm or update the code status after readmission. Despite being placed on hospice care, the facility did not have a signed advance directive or physician's order reflecting a do not resuscitate (DNR) status until 74 days after admission. Similarly, Resident #87, who had severe cognitive impairment and a Power of Attorney (POA) for healthcare decisions, had a healthcare instruction form indicating a DNR status, but it was not signed by the resident or the POA. The facility's records over a period of 1 year and 7 months failed to show documentation of a signed advance directive from the POA. The Director of Nursing Services (DNS) was unaware of the incomplete advance directive, and the responsibility to address this was attributed to the admission and floor nurses. The facility's policy on advance directives states that residents have the right to formulate such directives, which should be honored according to state law and facility policy. However, the facility did not ensure that these directives were properly documented and signed, leading to a failure in respecting the residents' rights to make informed decisions about their medical treatment.
Failure to Notify Physician and Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify the physician and resident representative after a significant weight loss was identified for Resident #50. Resident #50, who had diagnoses including congestive heart failure (CHF), hypotension, and dementia, experienced a series of weight losses following readmission to the facility. Despite the weight being flagged in the electronic clinical record, there was no documentation of notification to the physician or resident representative, nor were there any nursing assessments, reweights, or interventions initiated. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and if verified, the nursing staff should notify the dietitian in writing. However, this protocol was not followed, leading to a significant oversight in Resident #50's care. Additionally, the facility failed to notify the resident representative when a new opioid medication was initiated for Resident #103. Resident #103, who had diagnoses including hypertension, dementia, and rheumatoid arthritis, was prescribed Oxycodone for pain management without prior notification to the resident representative. The representative expressed concerns about the resident's increased lethargy after the medication was administered and requested its discontinuation. The facility's policy on change of condition required prompt notification of the resident representative regarding changes to the resident's medical condition, which was not adhered to in this case. Interviews with facility staff, including the Dietitian, APRN, and DNS, revealed a lack of communication and documentation regarding the significant weight loss of Resident #50 and the administration of Oxycodone to Resident #103. The facility's policies on weight assessment and change of condition were not followed, resulting in deficiencies in the care provided to these residents. The failure to notify relevant parties and document changes in the residents' conditions contributed to the deficiencies identified in the report.
Failure to Ensure Residents' Right to Independent Egress
Penalty
Summary
The facility failed to protect two residents from involuntary seclusion by placing them on a locked unit without proper clinical criteria or documentation. Both residents, who had intact cognition and were capable of independent mobility, were placed on a locked unit without being provided with a method for independent egress. The care plans for these residents did not reflect their placement on the locked unit, nor did they include any ongoing review or revision regarding their continued stay on the unit. Additionally, there was no documentation of the residents' or their representatives' involvement in the decision-making process for their placement on the locked unit. The facility lacked policies or procedures to identify the clinical criteria for placing residents on locked units or to ensure ongoing assessments and discussions with residents or their representatives. Interviews with the facility's Administrator and nursing staff revealed that residents were not given access codes for independent egress and had to request staff assistance to leave the unit. The facility did not have a policy on the placement of residents on a locked unit, and there was no evidence of a least restrictive approach being considered for these residents.
Failure to Update PASARR for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure proper coordination with the Pre-Admission Screening and Resident Review (PASARR) program for two residents who had newly diagnosed mental disorders. Resident #13 was readmitted with diagnoses including depression and dementia, but the PASARR from 2020 did not reflect the updated diagnosis of schizoaffective disorder. Despite a physician's order for a psychiatric evaluation and the addition of schizoaffective disorder to the resident's diagnoses, the PASARR was not updated to determine if a Level 2 evaluation was needed. The social worker responsible for PASARR updates did not review or update the PASARR for Resident #13 after the new diagnosis was made. Resident #96 was admitted with diagnoses including malignant neoplasm of the breast and anxiety. Initially, the PASARR Level I screen indicated no need for a Level II evaluation. However, after a psychiatric evaluation revealed a new diagnosis of bipolar disorder, the PASARR was not updated. The Director of Social Services was unaware of the new diagnosis due to communication issues with psychiatric providers, who used different forms inconsistently. As a result, the necessary PASARR update and Level of Care screening were not completed. The facility's policies require that a Level II PASARR be conducted whenever a new diagnosis indicating a serious mental illness is identified. Both residents' cases demonstrate a failure to adhere to these policies, as the necessary updates and evaluations were not performed following the new diagnoses. This oversight in the PASARR process led to deficiencies in ensuring that residents received appropriate evaluations and care planning based on their current mental health conditions.
Failure to Complete PASARR Rescreen for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a PASARR rescreen was completed for a resident with documented major mental illness following their admission. Prior to admission, a PASARR level I screening indicated no known or suspected mental health diagnoses for the resident. However, upon admission, the resident was diagnosed with bipolar disorder, anxiety disorder, and diffuse traumatic brain injury. The baseline care plan noted the potential for mood and behavior alterations due to bipolar disorder, and interventions included psychiatric services. Physician orders included medications for agitation and a psychiatric evaluation. Despite these diagnoses and treatments, the clinical record did not show any documentation of a PASARR rescreen or a level II evaluation following the resident's admission. Interviews revealed that the social worker was unaware of the missing PASARR level II and acknowledged the need for a rescreen based on the resident's history and treatment requirements. The facility's policy required that residents with possible serious mental disorders be referred for a PASARR level II evaluation, which was not adhered to in this case.
Failure to Update Care Plan for New Bipolar Diagnosis
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was newly diagnosed with bipolar disorder. The resident, who was admitted with diagnoses including malignant neoplasm of the left breast, cerebrovascular disease, and anxiety, was later identified to have anxiety disorder, mild neurocognitive disorder, and bipolar disorder. Despite the significant change in the resident's psychiatric condition, the care plan only addressed anxiety related to the cancer diagnosis and did not include goals or interventions for the bipolar disorder. The deficiency was further compounded by a breakdown in communication between the psychiatric providers and the Director of Social Services (SW #1). SW #1 was not informed of the new bipolar diagnosis due to inconsistent use of communication forms by different psychiatric providers. As a result, SW #1 was unaware of the need to update the care plan and conduct a Level II PASARR screen, which would have provided recommendations for the resident's care. This lack of communication and failure to update the care plan led to the deficiency identified by the surveyors.
Failure to Conduct Quarterly Care Conferences and Involve Residents
Penalty
Summary
The facility failed to hold quarterly resident care conferences and ensure that residents or their representatives were invited to participate in these meetings. This deficiency was identified for two residents, both of whom had significant medical histories and conditions that required regular care planning. Resident #47, who was admitted with peripheral vascular disease, type 2 diabetes mellitus, and hypertension, did not have documented care conferences before or after a meeting on June 19, 2024. Despite having moderately impaired cognition, the resident expressed a desire to participate in care discussions, but there was no evidence of quarterly care conferences being held. Similarly, Resident #89, admitted with urinary retention, diabetes mellitus, and a knee dislocation, also lacked documentation of quarterly care conferences from admission through December 2024. This resident, who had intact cognition, recalled attending only one meeting shortly after admission and expressed a desire to be involved in care planning. The facility's policies require that residents and their representatives be encouraged to participate in care planning, but this was not adhered to in these cases. Interviews with facility staff, including the Director of Social Services and the MDS Coordinator, revealed a lack of coordination and responsibility for scheduling these important meetings. The MDS Coordinator, who was responsible for organizing quarterly care conferences, was on leave, and there was no evidence that the responsibility was adequately covered. The facility's policies clearly outline the need for resident involvement in care planning, but these were not followed, leading to the deficiency.
Failure to Implement Smoking Interventions and Supervision
Penalty
Summary
The facility failed to implement appropriate smoking interventions for Resident #265, who was admitted with a history of smoking, moderate dementia, and chronic obstructive pulmonary disease (COPD) requiring continuous oxygen. Despite being on a Nicotine patch and having a history of smoking while on oxygen, the facility did not establish a baseline care plan addressing these risks. On 10/8/24, Resident #265 was found smoking in their room, which was a significant safety hazard given their oxygen dependency. The facility's response included confiscating smoking materials and placing the resident on every 15-minute checks, but these checks were inconsistently documented and not completed as required. Additionally, the facility did not ensure that Resident #104 was free from smoking contraband. Although Resident #104 had a physician's order to smoke at scheduled times under supervision, they were found with a book of matches during a smoking session. The matches were reportedly obtained during an outing to a gas station, where the resident was accompanied by a nursing assistant. This incident indicates a lapse in the facility's protocol to prevent residents from possessing smoking materials unsupervised. Interviews with staff revealed gaps in communication and adherence to the facility's smoking policy. The Director of Nursing Services (DNS) admitted to conducting a smoking assessment for Resident #265 remotely and without direct interaction, relying on second-hand information. Furthermore, the facility lacked a clear policy for conducting every 15-minute checks, contributing to the oversight in monitoring Resident #265 after the smoking incident. These deficiencies highlight the facility's failure to adequately supervise residents with known smoking risks and to enforce its smoking policies effectively.
Failure to Adhere to Respiratory Care Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by the lack of adherence to physician orders and facility policies regarding oxygen tubing and CPAP usage. Resident #30, who was readmitted with pneumonia, heart failure, and dementia, was observed using oxygen tubing that was not dated, and the LPN was unaware of when it was last changed. The facility's policy required weekly changes and dating of oxygen tubing, which was not followed. Resident #265, diagnosed with COPD and oxygen-dependent, was found using oxygen tubing that had not been changed for six weeks, despite physician orders and facility policy requiring weekly changes. Additionally, the resident's oxygen concentrator lacked a humidifier, which was necessary for the prescribed 5 liters of oxygen. The DNS confirmed the requirement for a humidifier but was unsure of the change frequency, indicating a lack of compliance with the facility's oxygen administration policy. Resident #89, with obstructive sleep apnea, was supposed to use a CPAP machine as per physician orders. However, the resident's CPAP machine was not present in the facility, and the resident had not used it for over a year. Despite this, the MAR inaccurately documented CPAP usage on multiple nights. Interviews revealed that the resident had refused CPAP, and the facility failed to document these refusals or ensure the presence of the CPAP machine, contrary to the facility's CPAP policy.
Lack of Staff Training on Smoking Blanket Use
Penalty
Summary
The facility failed to provide necessary education to staff regarding the use of a smoking blanket during resident smoking sessions. During an observation, two nurse aides responsible for supervising a smoking session were found to be unaware of the existence and use of a smoking blanket, which is intended to enhance safety during smoking activities. The Director of Nursing Services (DNS) confirmed the staff's lack of knowledge about the smoking blanket, which was found in the smoking lockbox along with the resident's cigarettes. An interview with the Regional Nurse Consultant revealed that the smoking training provided to staff did not include information about the smoking blanket. The facility's smoking policy was requested but not provided, indicating a gap in the documentation and training process.
Failure to Address Medication Irregularities for a Resident
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a thorough monthly drug regimen review for a resident, leading to unaddressed medication irregularities. The resident, who had diagnoses including hypotension, congestive heart failure, and chronic obstructive pulmonary disease, was prescribed Midodrine to manage blood pressure. However, the medication was either held without documented blood pressure measurements or administered outside the prescribed parameters on multiple occasions over several months. Despite the pharmacy's responsibility to identify and report medication irregularities, the pharmacy recommendations often failed to highlight these issues. When irregularities were identified, such as in April and August, there was no documentation that the facility staff reviewed or addressed these recommendations. Interviews revealed a lack of communication and understanding among the facility's staff, including the APRN and DNS, regarding the handling of pharmacy recommendations and the need to adjust medication orders based on the resident's condition. The facility's policies on pharmacy and physician services were not adhered to, as evidenced by the repeated failure to address medication errors and ensure safe pharmaceutical practices. The DNS was unaware of the issues related to the resident's Midodrine administration, and the APRN indicated that changes to the medication order could have been made if the issues had been communicated. This lack of coordination and oversight resulted in ongoing medication administration errors, compromising the resident's care.
Medication Cart Security and Expired Medications
Penalty
Summary
The facility failed to ensure the security and proper management of a medication cart. During an observation, the medication cart was found unlocked and unattended while a resident was nearby. The charge nurse, identified as LPN #13, was in the nourishment room microwaving a resident's food and admitted to not securing the cart before leaving it unattended. Additionally, a review of the medication cart revealed multiple expired medications. LPN #13 acknowledged responsibility for the cart but admitted to not regularly checking for expired medications. The Assistant Director of Nursing Services (ADNS) confirmed the expectation that the cart should be secured at all times and that the charge nurse is responsible for ensuring medications are not expired. The Director of Nursing Services (DNS) reiterated that medication carts must be secured and expired medications discarded, in accordance with the facility's policy on medication storage.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services for a resident following a recommendation from an APRN. The resident, who was admitted in September 2021 with diagnoses including diabetes and anemia, experienced a choking event in July 2023. After the incident, the APRN recommended a referral to a dentist for the resident, who was edentulous and had never worn dentures. However, the facility did not follow through with this recommendation, and the resident did not receive the necessary dental services. Additionally, the facility did not ensure that the resident received routine annual dental services since their admission. Interviews and clinical record reviews revealed that the facility's dental provider had not received any recommendations for dental services for the resident during July and August 2023. The DNS was unaware of the APRN's recommendation and confirmed that the resident had not received annual dental services, which is a requirement according to the facility's dental services policy.
Incomplete Meal Intake Documentation for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident's meal intake, which is a deficiency in safeguarding resident-identifiable information and maintaining medical records according to professional standards. The resident, who was admitted with diagnoses including dementia, diabetes, and osteoarthrosis, had intact cognition and required maximum assistance to sit upright but could eat independently. Despite a physician's order for a regular diet and a care plan directing to report any concerns or changes, the Meal Intake Report showed that breakfast and lunch were not recorded for 47 consecutive days, and dinner was not recorded for 38 of those days. Interviews with the corporate clinical nurse and the Dietitian revealed that nurse's aides were responsible for documenting all meals during their shifts, but this documentation was not completed. The Dietitian emphasized the importance of meal documentation for monitoring weight changes, yet noted that she had not reviewed the resident's meal intakes since admission due to the quarterly MDS not being due. This lack of documentation could potentially impact the resident's care, as meal intake records are crucial for assessing nutritional status and making necessary dietary adjustments.
Failure to Verify Diet Orders Leads to Choking Incident
Penalty
Summary
The facility failed to ensure that staff provided the correct diet texture and verified diet orders for a resident, resulting in a choking episode. The resident, who had diagnoses including dysphagia, dementia, and end-stage renal disease, was on a dysphagia advanced diet. This diet required specific food textures, such as ground meats and soft breads with added moisture. However, the resident was given a ham and cheese sandwich, which was not compliant with the prescribed diet, leading to a choking incident. The incident occurred when a nursing assistant (NA) provided the resident with a ham sandwich after the resident returned from dialysis and expressed hunger. The NA, who was not assigned to the resident, checked with a licensed practical nurse (LPN) before giving the sandwich. The LPN approved the sandwich without verifying the resident's diet orders. As a result, the resident began choking on the sandwich, and an abdominal thrust was performed to expel the food. Interviews with facility staff revealed that the LPN did not check the diet orders before approving the sandwich, despite the facility's guidelines requiring verification of diet orders. The facility had postings in nourishment rooms detailing diet types and allowed foods, but these were not consulted. The Director of Nursing acknowledged that the LPN should have verified the diet orders, and the incident was identified as Immediate Jeopardy due to the potential harm to the resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by two separate incidents involving residents with cognitive impairments. In the first incident, a resident with metabolic encephalopathy and a history of alcohol use was attacked by their roommate, who had dementia and metabolic encephalopathy. The roommate approached from behind and applied pressure to the resident's neck, resulting in slight redness and discomfort. Although the staff did not witness the incident, the facility substantiated the abuse allegation based on the resident's account and physical evidence. In the second incident, a resident with vascular dementia and severe cognitive impairment was involved in an altercation with their roommate, who had dementia and anxiety. The roommate attempted to remove the resident's pillow and then punched them in the face three times. The nursing supervisor responded to the noise and separated the residents, placing the aggressor on one-to-one monitoring. Both residents were assessed with no injuries noted, and the aggressor was transferred to the hospital for psychiatric evaluation. The facility's failure to prevent these incidents highlights a deficiency in ensuring residents' safety and protection from abuse. The incidents were not witnessed by staff, and the facility's investigation was unable to determine the cause of the second incident. The facility's Resident Rights Policy emphasizes the right of residents to be free from abuse, neglect, and exploitation, which was not upheld in these cases.
Failure to Maintain Resident's Ambulation Program
Penalty
Summary
The facility failed to provide necessary treatment and services to maintain the ambulation status of a resident with a history of diffuse traumatic brain injury, weakness, seizure disorder, and depression. The resident was discharged from physical therapy on a functional maintenance ambulation program, with recommendations for nursing staff to assist the resident in ambulating with a rolling walker and minimal assistance. However, the resident's ADL flow sheets indicated that ambulation activities did not occur over a month-long period, and the resident's care plan was not updated to reflect the need for continued ambulation support. Interviews revealed that the physical therapist communicated the need for a functional maintenance program to the Director of Nursing Services (DNS), but the program was not implemented. The DNS acknowledged that the resident was not on the program as recommended and cited the resident's positive COVID-19 status and subsequent weakness as reasons for not ambulating. The DNS did not inform the physical therapist of the resident's inability to ambulate, and the necessary order for the functional maintenance program was not entered into the resident's clinical record.
Elopement and Transfer Safety Deficiencies
Penalty
Summary
The facility failed to prevent the elopement of a resident identified as at risk for elopement. The resident, diagnosed with schizoaffective disorder and generalized muscle weakness, was noted to have intact cognition and was independent with activities of daily living. Despite being identified as at risk for elopement, the resident was able to leave the facility unescorted when the front doors were opened for EMS. The receptionist attempted to stop the resident but was unsuccessful, and the resident was later found by police at a nearby store. In another incident, the facility failed to ensure the safety of a resident during a Hoyer lift transfer, resulting in a minor head injury. The resident, who had anoxic brain disorder, seizures, and dysphagia, required extensive assistance and was wheelchair-bound. During a transfer from the bed to the chair, one of the straps of the Hoyer lift came loose, causing the resident to fall. The incident was attributed to operator error, as the loops on the Hoyer hooks were not properly attached. Both incidents highlight deficiencies in the facility's ability to manage residents at risk for elopement and ensure safe transfer procedures. The facility's policies on wandering, elopement, and mechanical lift use were not adequately followed, leading to these safety breaches. The facility's failure to implement effective interventions and ensure proper equipment use contributed to these incidents.
Failure to Maintain Accurate Clinical Records for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for a resident with a Stage 4 pressure ulcer to the coccyx. The resident, who had diagnoses including anoxic brain disorder and seizures, required extensive assistance with activities of daily living and had a pressure ulcer covered with eschar. Despite physician orders for weekly wound assessments and specific wound care, the facility did not have documentation to demonstrate that these assessments and care were conducted as ordered. Additionally, the facility was unable to provide several critical records, including the Resident Care Plan, Care Conference Note, physician orders, and wound documentation for the relevant period. The deficiency was further highlighted by the facility's inability to locate requested records, such as the wound risk assessment and hospital records from a specific hospital admission. The Director of Nursing confirmed via email that the facility could not find these records, indicating a failure to adhere to their policy for the retention of medical records. This lack of documentation and record retention is a significant deficiency in maintaining professional standards for resident care.
Failure to Update Care Plans for Consensual Relationship
Penalty
Summary
The facility failed to ensure the comprehensive care plan reflected a consensual relationship between two residents with the capacity to consent. Resident #1, diagnosed with schizophrenia and diabetes mellitus, was alert and oriented, and had a consensual sexual interaction with Resident #2. Despite being counseled on behaviors and acknowledging understanding, the care plan did not reflect this relationship. Additionally, Resident #1 had bruising on the upper extremities noted upon re-admission, which was not addressed in the care plan. Interviews with staff confirmed awareness of the relationship but revealed that the care plan had not been updated accordingly. Resident #2, diagnosed with schizoaffective disorder and a displaced fracture of the tibial tuberosity, was also involved in the consensual relationship. Despite moderate cognitive impairment, Resident #2 was independent with activities of daily living and expressed feelings for Resident #1. Staff observed the residents engaged in consensual activity and provided education on safe sexual practices. However, the care plan for Resident #2 also failed to reflect the relationship. Interviews with staff and the residents confirmed the consensual nature of the relationship and the need for a private place for interactions, but the care plans remained unchanged.
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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