Civita Care Center At West River
Inspection history, citations, penalties and survey trends for this long-term care facility in Milford, Connecticut.
- Location
- 245 Orange Avenue, Milford, Connecticut 06460
- CMS Provider Number
- 075377
- Inspections on file
- 19
- Latest survey
- January 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Civita Care Center At West River during CMS and state inspections, most recent first.
The facility failed to ensure the Infection Preventionist (IP) completed the necessary specialized training. The IP, who had served for 10 months, did not pass the final test required for certification, despite completing the training course. This oversight was discovered during a survey, leading to the Assistant Director of Nursing Services temporarily overseeing infection control duties.
The facility failed to timely administer COVID-19 vaccines to residents who had consented, due to miscommunication and lack of awareness among staff about vaccine availability. Despite having vaccines in stock, several residents received their vaccinations only after surveyor inquiry.
A resident with severe cognitive impairment was left unsupervised during a meal, contrary to a physician's order for 1:1 feeding assistance. The resident attempted to self-feed in an undignified manner, highlighting a failure to provide proper care and adhere to facility policies on dignified dining experiences.
A facility failed to align a resident's advance directive choice of DNR with the physician's orders, which incorrectly listed the resident as full code. Despite the resident's representative signing a DNR form, the discrepancy persisted, and the clinical record lacked a care plan related to the advance directive. Interviews with staff revealed uncertainty about the inconsistency, and the facility could not provide a policy for maintaining accurate records.
Two residents in a facility experienced deficiencies in care due to the facility's failure to notify physicians and relevant parties of significant changes in their conditions. One resident with end-stage renal disease exceeded their fluid restriction for most days over two months without the physician or dialysis center being informed. Another resident experienced significant weight loss over four months, yet the physician, APRN, and dietitian were not notified in a timely manner. The facility's policies for monitoring and notifying changes in residents' conditions were not followed, leading to a lack of appropriate interventions.
A facility failed to notify the State-designated authority when a resident was diagnosed with and later had a mental health condition discontinued. The resident was initially admitted with anxiety, depression, and dysthymic disorder, later diagnosed with schizoaffective disorder, and the facility did not update the PASARR Level 1 screen. The Director of Social Services was not informed of these changes, leading to non-compliance with PASARR requirements.
A facility failed to maintain proper air mattress settings for a resident with a pressure ulcer, did not provide required meal supervision for a resident with dementia, and inaccurately documented weights for a resident with specific physician orders. Staff interviews revealed lapses in following physician orders and facility policies, leading to deficiencies in resident care and supervision.
A resident with Alzheimer's and recurrent pressure ulcers did not receive weekly Braden Scale assessments or the recommended zinc oxide-based barrier cream due to staff oversight. Upon readmission after hospitalization, the facility failed to conduct a thorough RN assessment of the resident's pressure ulcers, as indicated in the hospital discharge paperwork.
A resident experienced significant weight loss over several months, but the facility failed to notify the physician or dietitian in a timely manner, as required by policy. Despite a physician's order to report weight loss, the staff did not document or communicate the changes, leading to a delay in addressing the resident's nutritional needs. The dietitian was not informed until a quarterly assessment, missing earlier opportunities for intervention.
A facility failed to monitor and manage the fluid intake of a resident with end-stage renal disease on peritoneal dialysis, who had a physician-ordered fluid restriction of 1000 ml per day. The resident exceeded this restriction on most days over two months, and the facility did not notify the physician or provide education to the resident. Interviews revealed a lack of adherence to policies for monitoring fluid intake and notifying medical personnel.
A facility failed to implement gradual dose reductions for a resident's antipsychotic medication after the diagnosis of schizoaffective disorder was discontinued. Despite recommendations for a GDR trial, the resident continued receiving Abilify throughout 2024. The social worker was unaware of the diagnosis change, and the APRN was not informed, leading to continued medication use based on an outdated diagnosis.
A resident with dementia and a stroke did not receive required adaptive eating equipment, such as a scoop plate and sippy cup, due to miscommunication among staff and an EMR transition glitch. Nursing aides failed to verify meal trays, assuming it was the kitchen's responsibility, while the new EMR system did not correctly transfer adaptive equipment orders.
Infection Preventionist Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), RN #1, completed the necessary specialized training in infection prevention. RN #1 was hired on November 30, 2015, and had been serving as the facility's IP for 10 months. During a survey conducted on January 26, 2024, it was discovered that RN #1 had not completed the final test required to obtain the Infection Preventionist certification, despite having completed the Nursing Home Infection Preventionist Training Course on April 23, 2024. The facility was unable to provide documentation that RN #1 had been awarded the certification with contact hours, which is a requirement for the role. Interviews with RN #1 and the Director of Nursing Services (DNS) revealed a misunderstanding regarding the certification requirements. RN #1 believed that completing the training course fulfilled all the necessary requirements for the IP role. It was only after the surveyor's inquiry that RN #1 realized a final test was required for certification. Although RN #1 attempted to take the test, she did not pass. Consequently, RN #1's last day as the full-time IP was January 27, 2025, and the Assistant Director of Nursing Services (ADNS), who had been certified since September 4, 2020, was to oversee infection control duties until a new IP was hired.
Delayed COVID-19 Vaccination for Consented Residents
Penalty
Summary
The facility failed to ensure that residents who consented to receive the COVID-19 vaccine were vaccinated in a timely manner. Several residents, including Resident #2, #18, #79, #87, #88, and #100, had consented to receive the vaccine, but there were delays in administration. The facility's Preventative Health Care Report indicated that these residents received their vaccinations only after surveyor inquiry, highlighting a lapse in the timely administration of vaccines. The Infection Preventionist (RN #1) was unable to provide surveillance data on resident COVID-19 vaccinations and indicated that vaccines were dispensed in quantities of 10 at a time by the pharmacy. However, the pharmacy manager clarified that there was no policy limiting the number of vaccines supplied and that more could be provided if needed. Despite this, RN #1 and the DNS were unaware of the available vaccines in the facility's refrigerator, which contributed to the delay in vaccinating consented residents. Interviews with facility staff, including the Administrator and DNS, revealed a lack of awareness and communication regarding the availability and administration of COVID-19 vaccines. The DNS was unaware of the multiple residents who had consented to the vaccine but had not yet received it, and the ADNS was unaware of the available vaccines in the facility. This lack of coordination and oversight led to the deficiency in ensuring timely vaccination for residents who had consented to receive the COVID-19 vaccine.
Failure to Provide 1:1 Feeding Assistance
Penalty
Summary
The facility failed to provide feeding assistance according to the physician's order for a resident with severe cognitive impairment, resulting in a lack of dignified dining experience. The resident, who was admitted with diagnoses including dementia and cognitive communication deficit, had a physician's order for 1:1 feeding assistance with all meals due to cognitive decline. Despite this order, a nursing assistant left the resident unsupervised with a meal tray, leading to the resident attempting to self-feed in an undignified manner. During the observation, the nursing assistant placed a meal tray in front of the resident, opened a yogurt container, and then left the resident to assist another resident, leaving the resident unsupervised. The resident attempted to self-feed by inserting fingers into the yogurt and using a spoon without proper assistance. This was contrary to the care plan and physician's order, which required a staff member to sit with the resident throughout the meal to provide necessary prompts and assistance. Interviews with staff, including the LPN and dietitian, confirmed the resident's need for 1:1 feeding assistance due to cognitive deficits. The facility's policies on resident rights and assistance with meals emphasized the importance of providing dignified care and meeting individual needs, which were not adhered to in this instance. The deficiency highlights a failure to ensure the resident's right to a dignified existence and proper feeding assistance as per the physician's directive.
Inconsistency in Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that the physician's orders were consistent with Resident #48's advance directive choice of do not resuscitate (DNR). Upon admission, the resident's representative signed a health care instruction form indicating a DNR status, but the physician's order incorrectly listed the resident as full code. This discrepancy persisted even after the resident was hospitalized and returned to the facility, with the physician's order still not reflecting the resident's DNR choice. The clinical record did not contain a care plan related to the resident's advance directive choice, and the facility was unable to provide a policy related to maintaining a clear and accurate clinical record. Interviews with facility staff revealed a lack of clarity and responsibility in reconciling the resident's advance directive choices with the physician's orders. The admitting nurse and regional nurse both acknowledged the inconsistency but were unsure why the physician's order did not match the resident's documented wishes. The facility's policy on advance directives stated that the resident's treatment preferences should be prominently displayed in the clinical record and that the care plan should align with these preferences, which was not adhered to in this case.
Failure to Notify Physician of Fluid Restriction and Weight Loss
Penalty
Summary
The facility failed to notify the physician and specialized treatment center regarding a resident with end-stage renal disease who consistently exceeded their prescribed fluid restriction. The resident, who required peritoneal dialysis, had a physician's order limiting fluid intake to 1000 ml per day. However, records showed that the resident exceeded this limit on 54 out of 59 days, and there was no documentation indicating that the physician or dialysis center had been informed. Interviews with staff revealed that the responsibility for monitoring and notifying the physician lay with the night supervisor, but this protocol was not followed, and the facility lacked a specific policy for dialysis residents on fluid restrictions. Another resident, admitted with diagnoses including stroke, dysphasia, and dementia, experienced significant weight loss without appropriate notification to the physician, APRN, or resident representative. The resident's weight dropped from 156 lbs to 138 lbs over four months, with a notable 12 lbs loss in one month. Despite a physician's order to notify the physician if weight loss exceeded certain thresholds, there was no record of such notifications or dietitian consultations until much later. Interviews confirmed that the dietitian was unaware of the weight loss until reviewing the clinical record months later, and the facility's policy required nursing to notify the dietitian of significant weight changes. The facility's failure to adhere to its policy of promptly notifying relevant parties of significant changes in residents' conditions resulted in deficiencies in care. The lack of documentation and communication regarding the residents' fluid intake and weight loss highlights a breakdown in the facility's processes for monitoring and responding to changes in residents' medical conditions. This oversight could potentially impact the residents' health and well-being, as timely interventions were not initiated.
Failure to Notify State Authority of Mental Health Diagnosis Changes
Penalty
Summary
The facility failed to notify the State-designated authority when a resident was diagnosed with a new mental health condition and when the diagnosis was later discontinued. The resident, who was initially admitted with anxiety, depression, and dysthymic disorder, was later diagnosed with schizoaffective disorder by a psychiatric evaluation. This diagnosis was added on 10/20/21, but the facility did not update the PASARR Level 1 screen to reflect this change. Furthermore, when the diagnosis of schizoaffective disorder was discontinued on 10/13/23, the facility again failed to notify the State-designated authority. The Director of Social Services, responsible for overseeing PASARRs, indicated that she was not informed of the changes in the resident's diagnosis. The facility's policy requires coordination with the PASARR program to ensure that any significant changes in a resident's mental health status are promptly reported to the appropriate state authority. This oversight resulted in a failure to comply with the PASARR requirements, as the facility did not update the necessary documentation or notify the state authority of the changes in the resident's mental health diagnosis.
Deficiencies in Resident Care and Supervision
Penalty
Summary
The facility failed to ensure proper settings for an air mattress for a resident with a stage 4 pressure ulcer. The resident was readmitted with diagnoses including stroke and was dependent on staff for personal care. A physician's order specified the air mattress should be set at 210 lbs, but observations on multiple occasions revealed it was set at 270 lbs. Interviews with staff confirmed the discrepancy, and it was noted that the setting should be checked every shift, but this was not adhered to. Another deficiency involved a resident with dementia who required close supervision during meals. The resident was observed with an untouched breakfast tray and was not visible from the doorway due to a privacy curtain. Staff interviews revealed a misunderstanding of the supervision requirements, with aides leaving the resident unsupervised and planning to return later. The facility's policy required visual supervision during meals, which was not followed, leading to the resident being left unattended. The third deficiency concerned a resident who required weights to be obtained as per physician's orders. The clinical record lacked documentation of weights on specified dates, despite being signed off as completed. An LPN admitted to signing off weights without actually obtaining them, intending to do so later. This practice was against the facility's policy, which required weights to be documented in the resident's medical record immediately after being obtained.
Failure to Implement Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to adhere to the physician's order to complete the Braden Scale weekly for Resident #37, who was admitted with diagnoses including Alzheimer's dementia, muscle weakness, and anemia. The initial Braden Scale assessment on 11/14/22 indicated that the resident was not at risk for pressure ulcers, but subsequent weekly assessments were not documented. Additionally, the care plan identified the resident as at risk for skin breakdown due to incontinence, yet the necessary interventions were not fully implemented. The facility also did not implement the wound care physician's recommendation to apply Dermaseptin, a zinc oxide-based barrier cream, to protect the resident's skin from moisture and breakdown. This oversight was attributed to the wound care nurse's overwhelming workload and failure to enter the order into the clinical record. Consequently, the resident did not receive the prescribed treatment, which was crucial given their history of recurrent pressure ulcers. Upon the resident's readmission to the facility following a hospitalization for a gastrointestinal bleed, the facility failed to conduct a thorough RN assessment of the resident's pressure ulcers. The hospital discharge paperwork indicated a stage IV pressure ulcer and a deep tissue injury, but these were not properly assessed or documented by the facility staff. The RN supervisor did not review the hospital discharge paperwork adequately, resulting in incomplete documentation and assessment of the resident's wounds upon readmission.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address a significant weight loss for a resident, identified as Resident #84, according to professional standards and facility policy. Resident #84, who was admitted with diagnoses including stroke, dysphasia, and dementia, experienced a weight loss of 18 lbs. over four months. Despite a physician's order to notify the physician or APRN if the resident lost more than 2 lbs. in a day or 5 lbs. in 7 days, the facility did not notify the physician or dietitian of the weight loss in a timely manner. The resident's weight records showed a loss of 12 lbs. in one month, yet there was no documentation indicating that the physician or dietitian was informed of this significant change. The facility's policy required that any weight change of 5% or more be retaken the next day for confirmation, and if verified, the dietitian should be notified immediately. However, the dietitian was not informed of the weight loss until the quarterly MDS assessment, despite being present in the facility four days a week. Interviews with the dietitian and medical staff revealed that the lack of communication and documentation prevented timely intervention. The dietitian indicated that had she been notified earlier, she would have conducted a complete evaluation to determine the cause of the weight loss. The deficiency was further highlighted by the facility's failure to follow its own Weight Assessment and Intervention Policy, which mandates immediate notification of the dietitian and physician upon verification of significant weight loss. The nursing staff did not document the notification of the physician or dietitian, and the LPN responsible for weighing the resident was unaware of the weight loss due to limitations in the computer system. This lack of communication and adherence to policy resulted in a delay in addressing the resident's nutritional needs.
Failure to Monitor Fluid Intake for Dialysis Resident
Penalty
Summary
The facility failed to consistently monitor and manage the fluid intake of a resident with end-stage renal disease who required peritoneal dialysis and had a physician-ordered fluid restriction of 1000 ml per day. Despite the care plan and physician's orders, the resident exceeded the fluid restriction on 28 out of 31 days in December 2024 and 26 out of 28 days in January 2025. The facility's documentation and interviews revealed that the nursing staff did not notify the physician, APRN, or the resident about these exceedances, nor was there any documentation of education provided to the resident regarding the fluid restriction. Interviews with facility staff, including LPNs and RNs, indicated a lack of adherence to the facility's policy for monitoring fluid intake and notifying appropriate medical personnel when the fluid restriction was exceeded. The Director of Nursing Services (DNS) confirmed that the night supervisor was responsible for calculating daily fluid totals and informing the day supervisor to notify the APRN or physician. However, there was no evidence that these notifications or educational interventions occurred. Additionally, the facility did not provide a specific policy for managing dialysis residents on fluid restrictions, further contributing to the deficiency.
Failure to Implement Gradual Dose Reductions for Antipsychotic Medication
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and non-pharmacological interventions for a resident who was receiving antipsychotic medication, Abilify, after the diagnosis of schizoaffective disorder had been discontinued. The resident was initially diagnosed with anxiety, depression, and dysthymic disorder upon admission and was later prescribed Abilify for schizoaffective disorder. However, a psychiatric evaluation in October 2023 recommended discontinuing the schizoaffective disorder diagnosis and suggested a GDR trial of antipsychotics. Despite this recommendation, the facility did not attempt further GDRs after reducing the Abilify dosage from 5mg to 2mg in November 2023. The resident continued to receive Abilify for schizoaffective disorder throughout 2024, as documented in psychiatric notes. The social worker was unaware that the diagnosis had been discontinued and did not ensure a comprehensive care plan was developed for the use of the antipsychotic medication. Interviews revealed a lack of communication among staff regarding the discontinuation of the schizoaffective disorder diagnosis. The APRN responsible for the resident's care was not informed of the change and continued to prescribe Abilify based on the outdated diagnosis. The facility's policy on antipsychotic medication use was not followed, as the medication was not reviewed or adjusted according to the updated diagnosis and professional standards.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment to a resident, as per the physician's orders and care plan. The resident, who was admitted with dementia and a stroke affecting the right side, required a scoop plate, built-up utensils, and a two-handled sippy cup with every meal. Despite these requirements being documented in the resident's care plan and physician's orders, observations on multiple occasions revealed that the resident's meal trays lacked the necessary adaptive equipment. This deficiency was noted during breakfast and lunch meals, where the resident was observed without the required scoop dish and sippy cup. Interviews with nursing assistants and dietary staff revealed a lack of awareness and responsibility regarding the provision of adaptive equipment. Nursing assistants admitted to not reading meal tickets and assumed it was the kitchen's responsibility to ensure the trays were correct. The dietary staff, including the Director of Dietary and the Dietitian, indicated that while the kitchen staff was responsible for preparing accurate trays, the nursing aides were expected to verify the trays before serving them to residents. This miscommunication and lack of accountability contributed to the resident not receiving the necessary adaptive equipment. The transition to a new electronic medical record (EMR) system in August 2024 further complicated the situation. The Chief Nursing Officer identified an importing glitch during the system changeover, which resulted in the adaptive equipment orders not being transferred correctly. This oversight meant that the resident's need for adaptive equipment was not reflected in the new system, leading to the continued absence of necessary items on meal trays. The facility acknowledged the issue and recognized the need for a comprehensive audit to ensure no other residents were affected by similar discrepancies.
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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