Civita Care Center At Salmon Brook
Inspection history, citations, penalties and survey trends for this long-term care facility in Glastonbury, Connecticut.
- Location
- 72 Salmon Brook Drive, Glastonbury, Connecticut 06033
- CMS Provider Number
- 075060
- Inspections on file
- 32
- Latest survey
- November 26, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Civita Care Center At Salmon Brook during CMS and state inspections, most recent first.
The facility did not provide evidence of a completed background check for a Recreation Aide. Interviews and document reviews revealed that the employee's file lacked the required background check, and facility staff were unable to produce the documentation despite multiple attempts.
The facility failed to keep laundry equipment in working order, leading to ongoing shortages of clean washcloths and towels and significant delays in returning personal laundry to residents. Multiple residents and staff reported that only one washing machine was consistently operational for months, with other machines and a dryer out of order for extended periods. Staff described hazardous workarounds and repeated, unaddressed requests for more linens and repairs, while administrative staff did not arrange for alternative laundry solutions or regular linen audits.
The facility failed to maintain laundry equipment and ensure an adequate supply of linens, resulting in residents experiencing delays in receiving clean personal laundry and a shortage of washcloths and towels for care. Staff and residents reported ongoing issues with laundry turnaround and linen availability, with only one washing machine functioning for months and some equipment out of order for years. Despite repeated reports to administration, the facility did not take effective action to address the shortages or utilize alternative solutions.
A resident identified as high fall risk experienced a fall out of bed, and although the care plan called for a floor mat to be placed to the left side of the bed, there was no immediate physician order or documentation on the MAR/TAR to confirm the intervention was implemented. The order for the floor mat was delayed, and staff interviews confirmed that the intervention should have been initiated and documented right after the fall.
A resident admitted with a stage 2 pressure injury and high risk for further skin breakdown did not receive timely or documented interventions such as an air mattress or scheduled turning and repositioning, as required by facility policy. The resident's wounds worsened and new pressure injuries developed, with staff unable to explain the lack of orders or documentation for these preventative measures.
A resident with dementia and other complex needs, who required staff assistance for ADLs, did not have consistent or complete Nurse Aide documentation for care tasks over a two-month period. Observations showed the resident was well cared for, but documentation for essential care activities was missing or inconsistent on most days. The DNS was unaware of these documentation lapses, and no facility policy for Nurse Aide documentation was provided.
A resident with diabetes and neuropathy developed an infection in the left great toe, prompting an APRN to order antibiotics and a priority podiatry consult. Despite these orders and communication attempts, the resident was not added to the podiatrist's priority list and was not seen as scheduled, due to a failure in the facility's scheduling process.
A resident with Alzheimer's and a high risk for wandering was unaccounted for over four hours due to inadequate supervision and security measures. The resident exited through an unalarmed door and was found outside near the kitchen entrance. Despite previous reports of wandering behavior and broken locks, the facility failed to implement effective interventions, resulting in Immediate Jeopardy.
The facility failed to timely obtain physician orders for wander guard bracelets for two residents identified as high wander risks. One resident with Alzheimer's disease did not have a wander guard applied until 12 days after being assessed as high risk. Another resident with Parkinsonism and dementia lacked a current order to check the wander guard's function nightly, contrary to facility policy.
The facility failed to ensure only authorized personnel had access to medication keys and did not maintain proper storage for controlled drugs. An RN left keys in an unlocked drawer, accessible to others, and a medication refrigerator was found unsecured. The DNS was unaware of the proper procedures, and the facility lacked a policy for narcotic storage.
The facility failed to effectively manage resources and provide proper administrative oversight, resulting in multiple deficiencies. There was no Governing Body, and the Medical Director was not appointed by one. The facility did not notify the State Agency of a reportable event timely, and clinical records were incomplete. A resident with a known wander risk accessed an unlocked egress, and medication security was inadequate. Annual in-service training and policy reviews were not completed timely, leading to differing policies. Interviews revealed a lack of oversight processes, compromising resident well-being.
The facility failed to establish a governing body responsible for management and operation, as evidenced by missing documentation and inconsistent Elopement Policies. Interviews confirmed the absence of a governing body and lack of annual policy reviews, despite existing By-Laws outlining these responsibilities.
A resident with Alzheimer's and delusional disorders, identified as an elopement risk, was found outside the facility after being reported missing. Despite the facility's interventions, there was no documented RN assessment following the incident, violating the facility's documentation policy.
The facility did not ensure that two nurse aides hired in 2023 received the required 12 hours of annual in-service training. One aide only received education on IV therapy, while the other had training on resident rights, abuse/retaliation, and dementia, but neither met the 12-hour requirement. The DNS confirmed the training shortfall but could not explain the deficiency.
A staff member recorded and posted videos of a resident with Alzheimer's and other residents on social media, capturing unprofessional interactions and personal care without consent. This violated facility policies on privacy and abuse, as the residents' rights to confidentiality and dignity were not protected.
A resident with severe cognitive impairment and behavioral issues was found to have a right wrist fracture of unknown origin. The facility did not complete a thorough investigation, as required by policy, by failing to conduct a 72-hour look back and limiting staff interviews to only one shift.
The facility did not complete or document required neurological assessments after unwitnessed falls for two residents, and failed to document wrist stabilization as recommended by an APRN for another resident with a fracture. Despite facility policies mandating neurological checks and adherence to treatment recommendations, these protocols were not followed or documented in the cited cases.
Annual performance evaluations were not conducted for two nurse aides, as required, with the last documented evaluations occurring nearly a year prior. Administrative changes and lack of communication contributed to the oversight, and no evaluation policy was provided when requested.
A resident with significant mobility impairments and a care plan requiring frequent repositioning and assistance out of bed did not receive timely care after using the call bell for an extended period. The facility failed to conduct a thorough investigation into the resident's allegation of neglect, did not collect statements from all involved staff, and lacked documentation of care provided during the shift.
A resident with significant mobility and continence needs was not provided with required turning, repositioning, or incontinent care for over three hours, despite activating the call bell and having care needs documented in the care plan and physician orders. Staffing shortages contributed to the delay, and care was not documented or provided as required during the morning shift.
A resident with spina bifida and neurogenic bladder did not receive required turning, repositioning, or incontinence care for several hours due to insufficient staffing. The resident's call bell went unanswered for an extended period, and only one NA was present for 22 residents until additional staff arrived later in the morning. As a result, the resident had to move themselves to the bathroom and developed a stage 3 pressure ulcer. Staff interviews and documentation confirmed that the facility was understaffed and unable to meet the resident's care needs as outlined in the care plan and physician orders.
Failure to Provide Background Check Documentation for Employee
Penalty
Summary
The facility failed to provide evidence that a background check had been conducted for one employee, specifically a Recreation Aide. During interviews and a review of facility documents, it was determined that no background check information was found in the employee's file. The current Human Resource Manager, who had recently started, noted that several files were missing background checks and explained that the previous Human Resource Manager worked remotely and did not print or file the necessary forms. Despite attempts by the Administrator and Assistant Director of Nursing Services to locate or obtain the background check, no documentation was produced for the Recreation Aide.
Failure to Maintain Laundry Equipment Results in Linen Shortages and Delayed Personal Laundry
Penalty
Summary
The facility failed to maintain laundry equipment in proper working order, resulting in significant shortages of clean linens and delays in returning personal laundry to residents. Multiple residents reported not receiving their personal laundry for extended periods, with some having to wear dirty clothing due to the lack of clean items. Residents and nursing assistants consistently described a shortage of washcloths and towels, with some staff resorting to using sheets as towels and having to rush to secure available linens at the start of their shifts. Observations confirmed that linen carts and closets were frequently empty or inadequately stocked during care times. Interviews with staff revealed that only one washing machine was consistently operational for several months, while other machines and a dryer remained out of order for extended periods—up to two years for one washer and four years for a dryer. Laundry aides reported that the turnaround time for personal laundry far exceeded the expected 24 hours, often taking up to 72 hours or more, and that they were unable to keep up with the facility's laundry needs due to equipment limitations. Staff also described hazardous workarounds, such as using a pen to operate a broken washing machine latch, and reported that repeated requests for additional linens and equipment repairs were not addressed in a timely manner. Administrative staff acknowledged the ongoing equipment issues and linen shortages, citing delays in obtaining parts and a lack of alternative arrangements, such as sending laundry to outside facilities or borrowing linens from sister facilities. There was no evidence of regular audits of linen levels prior to the survey, and maintenance staff were unclear about the status of equipment repairs and linen inventory. The facility's own infection control policy required the maintenance supervisor to ensure the safe status of equipment, which was not upheld in this instance.
Failure to Maintain Laundry Equipment and Provide Adequate Linens
Penalty
Summary
The facility failed to maintain building equipment and provide adequate linens, resulting in a lack of a clean, comfortable, and homelike environment for residents. Multiple residents reported significant delays in receiving their personal laundry, with some waiting over a week and being forced to wear dirty clothing due to the unavailability of clean items. Residents and nursing assistants consistently described a shortage of washcloths and towels, with staff sometimes resorting to using sheets for bathing and being unable to provide proper care due to insufficient linens. Observations confirmed that linen carts and closets were frequently empty or severely understocked during care shifts. Staff interviews revealed that the facility had only one consistently functioning washing machine for several months, making it impossible to keep up with both facility linens and residents' personal laundry. Laundry aides reported that the turnaround time for personal laundry was significantly delayed, often taking up to 72 hours instead of the expected 24 hours. Despite repeated reports of linen shortages and equipment failures to the Administrator and Director of Housekeeping, no effective action was taken to resolve the issues, and the facility did not utilize available options such as sending laundry to outside facilities or borrowing linens from sister facilities. Further investigation found that some laundry equipment had been out of order for extended periods, with one washing machine nonfunctional for almost two years and a dryer for nearly four years. The Director of Housekeeping was unaware of the full extent of the equipment failures and did not have authority over repairs or purchasing. The facility also lacked policies addressing residents' rights to a clean, homelike environment and did not provide requested policies on laundry or environmental standards.
Failure to Timely Implement and Document Fall Prevention Intervention
Penalty
Summary
A resident with diagnoses including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure was identified as a high fall risk and experienced a fall out of bed. The resident's care plan specified interventions such as ensuring the call bell was within reach, encouraging its use, and placing a floor mat to the left side of the bed. Despite these interventions being documented in the care plan and accident investigation, there was no evidence that a physician's order for the floor mat was obtained or transcribed immediately after the fall. The order for the floor mat was not entered until six days after the incident, and there was no documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to confirm that nursing staff ensured the mat was in place as required. Interviews with facility staff, including the Director of Nursing Services (DNS) and a regional nurse, confirmed that the expected protocol was to obtain and transcribe a physician's order for the intervention immediately after the fall and to ensure it was reflected on the TAR for staff accountability. The facility's Accident and Incident Investigation policy also required that interventions to prevent further incidents be identified and implemented promptly. The failure to timely implement and document the fall intervention according to the care plan and physician order constituted the deficiency.
Failure to Implement and Document Pressure Ulcer Prevention and Care Interventions
Penalty
Summary
A resident with multiple diagnoses, including altered mental status, muscle weakness, atherosclerotic heart disease, and congestive heart failure, was admitted to the facility with a stage 2 pressure injury to the coccyx. Upon admission, the resident was assessed as high risk for pressure injuries using the Braden Scale and required substantial assistance for bed mobility, personal hygiene, and transfers. Despite these findings, there was no evidence that preventative interventions, such as an air mattress or a scheduled turning and repositioning regimen, were initiated or documented in the days following admission, as required by facility policy. The resident's care plan, initiated five days after admission, included interventions for pressure injury prevention and treatment, but physician orders and nursing documentation did not reflect the implementation of these interventions. The pressure injury progressed to an unstageable wound, and a new facility-acquired unstageable pressure injury developed on the resident's left heel. Throughout the resident's stay, there was a lack of documentation indicating that an air mattress was provided or that a turning and repositioning schedule was followed, even after the wounds worsened and new wounds developed. Additionally, weekly skin observation tools were either not completed or not documented as required by facility policy. Interviews with facility staff, including the DNS, wound physician, and wound nurse, confirmed that interventions such as air mattress placement and frequent turning and repositioning should have been implemented immediately upon admission and after wound deterioration. Staff were unable to explain why these interventions were not ordered or documented. The facility's policy clearly directed these interventions for residents with stage 2 or greater pressure injuries, but the required actions were not taken or recorded, leading to the identified deficiency.
Failure to Ensure Complete and Accurate Nurse Aide Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation by Nurse Aides for a resident with multiple diagnoses, including dementia, altered mental status, anxiety disorder, and malnutrition. The resident was assessed as having moderately impaired cognition and required staff assistance for activities of daily living (ADLs), including eating, personal care, bed mobility, and transfers. Observations confirmed that the resident appeared clean, well-dressed, and had access to water and reading material. However, a review of Nurse Aide documentation for April and May revealed significant inconsistencies in recording care tasks such as behavior symptoms, transferring, bed mobility, bowel movements, toileting hygiene, intake and output, toilet use, oral hygiene, personal hygiene, showering/bathing, snacks, eating, and amount eaten. Documentation was incomplete for the majority of days reviewed in both months. During an interview, the Director of Nursing Services (DNS) was unaware of the inconsistent documentation and acknowledged that Nurse Aides should be documenting all tasks every shift. The facility was unable to provide a policy for Nurse Aide documentation when requested. The deficiency centers on the lack of consistent and complete documentation of care provided to a dependent resident, as required by accepted professional standards.
Failure to Ensure Timely Podiatry Care for Resident with Toe Infection
Penalty
Summary
A resident with diabetes and polyneuropathy, who was dependent on staff for personal care and had a history of memory recall deficits, developed redness, swelling, and pain in the left great toe. The care plan required daily foot checks and prompt reporting of any abnormalities. After a family member reported the toe issue, an Advanced Practice Registered Nurse (APRN) evaluated the resident, diagnosed an infection, and ordered antibiotics, warm soaks, and a podiatry consult. The APRN also directed that the resident be placed on the podiatrist's priority schedule for an upcoming visit. Despite these orders, the facility failed to ensure the resident was added to the podiatrist's priority list. Although the scheduling secretary reported emailing the podiatry office to include the resident, the facility's podiatry list for the scheduled visit did not reflect the resident's name. As a result, the resident was not seen by the podiatrist as intended. Interviews with facility staff and the podiatrist confirmed that the resident should have been prioritized and that Medicare coverage was not a barrier to timely care.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident identified as high risk for wandering, resulting in the resident being unaccounted for over four hours. The resident, diagnosed with Alzheimer's disease and delusional disorders, was known to have exit-seeking behaviors and had previously been found wandering in unauthorized areas. Despite being identified as a high wander risk, the resident's care plan interventions, such as using a wander guard bracelet and offering diversions, were insufficient to prevent the resident from leaving the facility unnoticed. On the day of the incident, the resident was last seen by a nursing assistant at 3:15 AM, and it was discovered that the resident was missing at 4:00 AM. The facility's search efforts were delayed, and the police were not notified until 6:00 AM, contrary to the facility's policy of notifying authorities within 5 to 7 minutes if a resident is not located. The resident was eventually found outside near the rear kitchen entrance, having exited through an unalarmed and unlocked door, and was believed to have been in a dryer service room that was also unlocked. Interviews and observations revealed that several doors within the facility, including those leading to the kitchen and laundry areas, had broken locks or were unalarmed, allowing the resident to exit the building. Staff had previously reported the resident's wandering behavior and the broken locks, but no room change or additional monitoring orders were implemented. The facility's failure to maintain secure exits and promptly address the resident's wandering risk resulted in a finding of Immediate Jeopardy.
Failure to Timely Obtain and Implement Wander Guard Orders for High-Risk Residents
Penalty
Summary
The facility failed to obtain timely physician orders for wander guard bracelets for two residents identified as high wander risks. Resident #1, diagnosed with Alzheimer's disease and delusional disorders, was assessed on 1/10/2025 as a high wander risk with a score of 12. Despite this assessment, a physician order for a wander guard bracelet was not obtained until 1/22/2025, 12 days later. The Director of Nursing Services (DNS) believed a wander guard was applied earlier, but no documentation supported this. The facility's wander guard tracking book also lacked evidence of a bracelet being signed out for Resident #1 before 1/22/2025. Similarly, Resident #2, with diagnoses including Parkinsonism and dementia, was also identified as a high wander risk with a score of 12 on 1/13/2025. Although a physician order was eventually obtained on 1/22/2025 to verify the placement and function of the wander guard bracelet, there was no current order directing staff to check the bracelet's function nightly. The DNS acknowledged the absence of such an order, which contradicted the facility's policy requiring nightly checks by the 11 PM to 7 AM supervisor.
Unauthorized Access to Medication Keys and Improper Storage of Controlled Drugs
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to keys for medication storage, including medication rooms and carts, and did not maintain separately locked, permanently affixed compartments for controlled drugs. During an observation, a registered nurse (RN) was found to not carry the nursing supervisor keys on her person due to their weight, instead keeping them in an unlocked drawer in the supervisor's office. This office was located on a different wing and was accessible to others, including a resident who was present in the office at the time of the observation. The RN demonstrated that the keys provided access to all areas of the facility, including medication storage areas. Further observations revealed that the medication room on the B-unit was unattended, and the refrigerator meant for storing controlled emergency medications was not properly secured. The keypad lock intended for the refrigerator was found sitting on top of it, leaving the refrigerator unlocked. Inside, a locked box containing controlled substances like liquid Morphine and Ativan was chained to the refrigerator. The Director of Nursing Services (DNS) was unable to explain why the RN did not have control of the keys and incorrectly believed that the lock's placement on top of the refrigerator was acceptable. The facility's policy on controlled pharmaceuticals required that keys to controlled substance containers be maintained separately, but there was no policy for the storage of narcotic/controlled medications.
Deficiencies in Administrative Oversight and Resource Management
Penalty
Summary
The facility failed to administer its resources effectively and ensure proper administrative oversight, leading to several deficiencies. There was no Governing Body in place, and the Medical Director was not appointed by such a body. The facility did not notify the State Agency in a timely manner about a reportable event. Clinical records were incomplete and lacked documentation or an RN assessment. A resident with a known wander risk had access to an unlocked egress, and the orders for a wander guard bracelet were neither accurate nor timely. Medications were not secured properly, and unauthorized staff had access to keys. Additionally, annual in-service training was not completed on time, and facility policies were not reviewed or approved annually, resulting in differing and duplicate policies. The facility had three different Elopement Policies in effect, none of which matched, and it was unclear which policy staff had been educated on prior to an elopement incident. Interviews with the DNS, Administrator, and Regional Nurse revealed a lack of process for administrative oversight regarding the Governing Body, Medical Director appointment, medication storage, notification of reportable events, annual training, policy review, physician orders, and resident access to unlocked egress. The facility's failure to utilize resources effectively compromised the residents' well-being, and no facility policy was provided for review.
Lack of Governing Body and Policy Oversight
Penalty
Summary
The facility failed to establish a governing body or designate individuals to function as a governing body responsible for the management and operation of the facility. This deficiency was identified through a review of facility documentation, which did not reveal the existence of a governing body. Additionally, the Administrator's employee file lacked evidence of appointment by a governing body. The facility's policy and procedure manual also failed to show that an annual review of policies was conducted, which is a requirement for maintaining effective management and operation. Further investigation revealed inconsistencies in the facility's Elopement Policies, with three different versions in effect, each from different sources, and no clear indication of which policy staff had been educated on. Interviews with the Director of Nursing Services (DNS), Administrator, and Regional Nurse confirmed the absence of a governing body and the lack of annual policy reviews. Despite the presence of Governing Body By-Laws, which outline the responsibilities of the governing board, the facility did not adhere to these guidelines, leading to a lack of oversight and management of the facility's operations.
Failure to Document RN Assessment After Resident Elopement
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident following an elopement incident. The resident, diagnosed with Alzheimer's disease and delusional disorders, was identified as an elopement risk and had interventions in place, such as a wander guard bracelet. Despite these measures, the resident was reported missing from their room early in the morning. The facility staff, along with local police, conducted a search and eventually found the resident outside near the rear kitchen entrance, with dryer lint on their clothes, indicating they had been in the laundry area. The deficiency arose because there was no documented RN assessment following the resident's elopement, as required by the facility's Charting and Documentation policy. Although the Director of Nursing Services (DNS) stated that an RN assessment was completed, they could not provide documentation to support this claim. The absence of this documentation in the resident's medical record constitutes a failure to maintain complete and accurate records, as per accepted professional standards.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that two nurse aides, hired in 2023, received the required 12 hours of annual in-service training. The review of the employee file for one nurse aide, hired on August 10, 2023, showed that the only education provided was on Intravenous (IV) therapy, with no additional or general orientation education documented for 2023, 2024, and up to February 27, 2025. Another nurse aide, hired on July 20, 2023, had annual education that included resident rights, abuse/retaliation, and dementia, but still did not meet the 12-hour requirement. An interview with the Director of Nursing Services (DNS) confirmed that all nurse aides should have a minimum of 12 hours of annual in-service training, but the DNS could not explain why the required training was not completed for these two aides. The facility's assessment tool from August 2024 outlined topics for annual education, including abuse, resident rights, confidentiality, and infection control, among others, which were not fully addressed in the training provided to these aides.
Staff Recorded and Posted Inappropriate Resident Videos on Social Media
Penalty
Summary
A staff member at the facility recorded videos of residents, including one resident with Alzheimer's disease, depression, and agitation, who was dependent on staff for transfers, personal hygiene, and dressing. The videos captured the staff member interacting with residents in an unprofessional manner, such as speaking inappropriately to a resident while they were rummaging through bins in the recreation room and referring to the resident as 'thieving.' Other videos included footage of a resident's legs during personal care and a resident being told they were banned from the dining area and recreational activities. These videos were posted on social media without the residents' consent. The facility's policies on resident privacy and abuse explicitly prohibit such actions, stating that residents have a right to privacy and confidentiality and that abuse includes actions facilitated through technology. The incident was brought to the attention of the DON by another staff member, who reported the existence of the videos. The DON reviewed the videos and confirmed the inappropriate conduct and unauthorized recording and posting of residents, which constituted a failure to protect residents from abuse and to uphold their rights to privacy and dignity.
Failure to Conduct Thorough Investigation for Injury of Unknown Origin
Penalty
Summary
A resident with dementia, behavioral issues, and severe cognitive impairment was admitted to the facility and required significant assistance with daily activities. The resident was noted to have a history of physical aggression and attempts to get up unassisted. On a specified date, the resident was found to have increased pain, swelling, and decreased range of motion in the right wrist, which was later diagnosed as a fracture of the right ulnar styloid process. The injury was of unknown origin, and there was no documentation of negative behaviors or incidents in the days leading up to the discovery of the injury. The facility failed to conduct a thorough investigation into the cause of the resident's injury as required by its policy. Specifically, a 72-hour look back was not completed, and staff interviews were limited to only those working one shift on the day before the injury was identified. No staff from other shifts were interviewed, and the investigation did not include a comprehensive review of possible causes. The Director of Nursing acknowledged that the required 72-hour look back was not performed.
Failure to Complete Neurological Assessments and Follow Treatment Recommendations After Accidents
Penalty
Summary
The facility failed to complete required neurological assessments following unwitnessed falls for two residents and did not document wrist stabilization as recommended by an APRN for another resident with a fracture. For one resident with dementia and a history of falls, there was no documentation of neurological checks after an unwitnessed fall, despite facility policy requiring such assessments. The Director of Nursing Services (DNS) confirmed the absence of documentation and could not explain why the assessments were not completed. Another resident with severe cognitive impairment and a right wrist fracture did not have documentation showing that the APRN's recommendation to stabilize the wrist was followed. Although the APRN directed wrist stabilization and pain management, there was no evidence in the nursing notes, physician orders, or treatment records that the wrist was immobilized or how it was stabilized prior to the resident being sent to the emergency room for further evaluation. A third resident with Parkinson's disease and a history of falls experienced multiple unwitnessed falls. Neurological assessments were either incomplete or missing for several shifts following these incidents, contrary to facility policy. The DNS acknowledged that neurological checks were not consistently documented or performed as required after unwitnessed falls. Facility policies clearly directed staff to perform and document neurological checks after any unwitnessed fall, but these protocols were not followed in the cited cases.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance evaluations for two out of four nurse aides reviewed. Personnel files showed that the last performance evaluations for both nurse aides were completed nearly a year prior to the review. Interviews with the Regional Clinical Nurse and the Administrator confirmed that annual evaluations were expected but had not been completed due to administrative changes and lack of awareness by the current leadership. Additionally, the facility was unable to provide an employee performance evaluation policy when requested.
Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an allegation of neglect for a resident with spina bifida, neurogenic bladder, and spinal stenosis. The resident was care planned to be turned and repositioned every two hours and to be assisted out of bed before breakfast. On the date in question, the resident reported using the call bell for one and a half hours without receiving assistance, ultimately moving themselves from bed to wheelchair despite having no feeling from the waist down. The grievance form documented the resident's complaint but did not include a resolution or a comprehensive investigation, such as obtaining statements from all relevant staff or reviewing care provided during the shift. Documentation for the shift lacked evidence of care provided, and interviews revealed confusion regarding staff assignments and care responsibilities. The only NA on the floor was not assigned to the resident and was not interviewed about the incident. The LPN and administrator acknowledged the resident's concerns but did not ensure a thorough investigation or confirm that care was provided as required by the care plan. The facility's abuse reporting policy requires all alleged violations to be reported and investigated, but this process was not followed in this case.
Failure to Provide Timely Incontinent Care and Repositioning
Penalty
Summary
A resident with spina bifida, neurogenic bladder, and spinal stenosis, who was non-ambulatory and incontinent, required extensive assistance with activities of daily living, including turning and repositioning every two hours and timely incontinent care, as documented in the care plan and physician orders. On the morning in question, the resident activated the call bell at 8:33 AM to request incontinent care, but did not receive assistance until between 10:30 and 11:00 AM, resulting in a delay of approximately two hours. During this period, the resident was not turned, repositioned, or provided with incontinent care from the start of the shift at 7:00 AM until care was finally given, totaling a lapse of 3.5 hours. Documentation for the shift did not reflect care provided, and the resident was not assisted out of bed for breakfast as per their care plan. Staff interviews revealed that only one NA was present for 22 residents on the unit until 9:00 AM, and the assigned NA did not provide care to the resident during the relevant period. The resident reported having to move themselves to their wheelchair, despite being assessed as unable to do so due to lack of sensation from the waist down. The facility was also found to be understaffed on the day in question, with a deficit of 23 nursing and NA hours for the census. The failure to provide timely care and assistance was confirmed by staff and resident interviews, review of care documentation, and facility records.
Failure to Provide Adequate Staffing Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of a resident with significant medical conditions, including spina bifida, neurogenic bladder, and spinal stenosis. Physician orders and the resident's care plan required turning and repositioning every two hours, early morning care before breakfast, and prompt incontinence care to prevent pressure ulcers. On the day in question, the resident activated the call bell for assistance at 8:33 AM but did not receive care until after 10:30 AM, despite repeated requests. Documentation showed no care was provided from the start of the shift at 7:00 AM until 10:30 AM, and the resident had to move themselves to the bathroom due to lack of assistance. Staffing records revealed only one nursing assistant was present for 22 residents on the resident's unit until 9:00 AM, and overall facility staffing was below the required hours per state regulations. Interviews with staff confirmed that the assigned nursing assistant was not available for the resident, and the replacement did not arrive until later in the morning. The resident was not turned, repositioned, or provided incontinence care for at least 3.5 hours, contrary to the care plan and physician orders. The resident subsequently developed a stage 3 pressure ulcer. The facility's documentation and staff interviews corroborated that the lack of sufficient staffing directly resulted in unmet care needs for the resident, including delayed response to call bells and failure to provide timely incontinence and mobility assistance.
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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