Civita Care Northbridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, Connecticut.
- Location
- 2875 Main Street, Bridgeport, Connecticut 06606
- CMS Provider Number
- 075413
- Inspections on file
- 30
- Latest survey
- December 2, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Civita Care Northbridge during CMS and state inspections, most recent first.
A resident with a history of behavioral issues and prior altercations was placed on 1:1 monitoring but was left unsupervised when the assigned NA left the room. During this time, the resident entered a common area and physically assaulted another resident with hemiplegia, causing distress and anxiety. Staff interviews and documentation confirmed that required supervision was not maintained, leading to the incident.
A resident who was alert, oriented, and able to communicate was restricted from going outside after a conservator revoked outdoor privileges, despite prior assessments indicating no elopement risk and facility policy supporting resident rights. Staff enforced the restriction, leading to increased agitation and aggressive behavior from the resident, without updating the care plan or conducting a new elopement assessment.
A resident with diabetes, anxiety, depression, and mobility issues, who was cognitively intact and independent, did not have a timely or documented discharge plan despite an active discharge goal and referral to a community program. The care plan lacked discharge planning details, and there was no evidence of follow-up on referrals or alternative discharge options, contrary to facility policy.
Two residents with intact cognition and court-appointed conservators maintained a close relationship, including private visits, but staff failed to document or implement a care plan addressing their interactions. Despite staff awareness and facility policy requiring individualized care plans, no interventions or monitoring guidance were included, resulting in a deficiency.
Two residents with intact cognition and independent mobility, one with a history of trauma and the other with prior inappropriate sexual behavior, were allowed to visit unsupervised in a private room. Staff, including NAs, social workers, and the DON, were aware of these unsupervised visits but did not monitor or intervene, despite the known risk. One resident later reported non-consensual sexual contact during these visits, and documentation confirmed that no preventive measures were in place.
A resident with multiple medical conditions sustained a first-degree burn during a shower and did not immediately inform staff. When the injury was later identified, the RN supervisor was notified only by a vague text message and did not follow up, resulting in no timely RN assessment being completed. The administrator confirmed that an RN assessment should have occurred and documentation was lacking.
A resident with cognitive impairment and multiple diagnoses was subjected to verbal abuse by a NA, who responded to the resident's use of foul language with similar expletives. Although the resident did not report feeling offended, the exchange was overheard and confirmed through interviews and documentation, constituting a failure to protect the resident from verbal abuse as required by facility policy.
A resident with cognitive impairments and a history of elopement risk exited a facility without staff knowledge and was found by law enforcement 0.6 miles away. The facility failed to reapply a wander guard bracelet upon the resident's readmission and did not follow protocols for missing residents. Staff did not communicate the resident's elopement risk effectively, and the equipment to monitor wander guards was not functioning. These lapses resulted in a finding of Immediate Jeopardy.
The facility failed to document competencies for Nurse Aides and Licensed Nurses from 2022 to the present, despite completing mandatory in-service training. The absence of a Staff Development Coordinator since March 2023 contributed to this deficiency, with the Administrator and other staff continuing in-servicing without documented competencies.
The facility failed to consistently document the pH levels of the manual sanitizer in the kitchen's three-bay sink, essential for ensuring proper sanitizing levels. A dietary aide struggled to demonstrate the procedure and interpret test results due to a vision problem. The logs showed missing documentation on several occasions, which the Dietary Director attributed to staff possibly forgetting to record results.
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training. Documentation lacked details on training duration and conductors, and there was no tracking system in place. The absence of a Staff Development Coordinator since March 2023 further contributed to this deficiency.
The facility failed to maintain CPR certification for several staff members and did not complete Code Blue logs for two residents who required CPR. This lack of documentation and certification violates facility policy and potentially compromises emergency care quality.
A resident with pneumonia, COPD, and asthma was found unresponsive, leading to CPR initiation. An NA, uncertified in CPR, took over from an LPN, contrary to facility policy allowing only certified personnel to perform CPR. The facility confirmed the NA was not trained or certified, breaching protocol.
A resident with diabetes, arthritis, and depression was not assessed for self-medication administration, despite requesting to have medications left at their bedside. The resident separated the medications into two cups, indicating which they intended to take. An LPN left the medications with the resident without confirming an evaluation for self-administration had been conducted. The DON confirmed no evaluation had been done, contrary to facility policy requiring such an assessment and nurse supervision during medication administration.
A resident with dementia and osteoporosis experienced a fall and subsequent pain, but the LTC facility failed to notify the physician promptly. Despite orders to assess and manage pain, the resident's moderate pain was not communicated to the physician until hours later. Nursing staff did not immediately assess or report the pain, and interviews revealed a lack of recall about the incident.
A resident with a history of depression was verbally abused by an LPN, who called them derogatory names. The incident was reported, and an investigation was initiated, leading to the LPN's removal from the facility. The facility's abuse prohibition policy was not upheld, as residents have the right to be free from abuse.
A facility failed to report a verbal abuse allegation involving a resident to an outside state agency in a timely manner. The resident, with a history of depression and other medical conditions, was verbally abused by an LPN. Although the incident was reported to the police, the facility did not notify the required state agency as per their policy.
A facility failed to update care plans for two residents, leading to deficiencies in care. One resident, with cognitive impairments, eloped due to the lack of a wander guard bracelet after hospital readmission. Another resident's care plan was not updated to reflect a change to Full Code status, despite physician orders and discussions with the responsible party. These oversights highlight the facility's failure to ensure timely care plan revisions.
The facility failed to timely evaluate a resident's significant weight loss, assess another resident's safe food consumption with broken dentures, apply ACE wraps as prescribed, and communicate a change in code status to hospice. These deficiencies highlight lapses in following medical orders and ensuring resident safety.
A resident experienced a significant weight loss, but the facility failed to obtain a re-weight and did not evaluate the resident's nutritional needs promptly. The LPN documented the weight discrepancy but did not recall taking further action, and the dietitian was not informed until nine days later. The facility's policy required immediate re-weight and notification of the dietitian, which did not occur, leading to a delay in addressing the resident's nutritional needs.
The facility failed to change and label oxygen tubing weekly for three residents requiring oxygen therapy, as per its policy. Observations revealed undated tubing for residents with conditions such as congestive heart failure and respiratory failure. Interviews with LPNs confirmed the policy requirement, which was not adhered to.
A resident with severe cognitive impairment and under hospice care was not appropriately medicated for pain despite exhibiting daily indicators of discomfort. Physician orders required hourly pain assessments and medication as needed, but records showed consistent zero pain levels until a day when moderate pain was noted multiple times without adequate intervention. The DNS acknowledged the need for better pain management and investigation following the resident's recent fall and hip fracture.
A resident with dementia and dysphagia had broken dentures, and despite a request from the responsible party for evaluation, the facility failed to provide necessary dental services. Dental consults noted the issue but did not recommend repair or replacement. Interviews revealed a lack of communication and follow-up, with the DNS and Medical Records Associate unaware of the request. The facility's policy required prompt referral for dental services, which was not followed.
A resident with a stage 3 pressure ulcer and ESBL resistance received wound care without proper infection control practices. An LPN and NA failed to wear gowns and did not perform hand hygiene between glove changes, despite facility policies and signage indicating the need for enhanced barrier precautions. The LPN admitted to oversight and lack of awareness regarding hand hygiene requirements.
The facility did not effectively communicate its Compliance and Ethics program to all staff. The Administrator could not find records of initial or annual in-service training for the Corporate Compliance program, and 4 out of 6 employee files lacked the Compliance Certificate Statement, indicating missing documentation of compliance training.
Failure to Provide Adequate Supervision During 1:1 Monitoring Results in Resident-to-Resident Assault
Penalty
Summary
The facility failed to protect a resident from mistreatment and did not ensure adequate supervision of a resident who was on one-to-one (1:1) observation, resulting in a resident-to-resident physical altercation. One resident with a history of anxiety, combative behaviors, and prior incidents of resident-to-resident abuse was placed on 1:1 monitoring following multiple behavioral incidents, including altercations and attempts to remove safety devices. Despite these interventions, the resident was left unattended by the assigned staff member, who left the room to obtain coffee, leaving the resident unsupervised. During this period of unsupervised time, the resident left their room and entered the dining area, where another resident with hemiplegia and hemiparesis was present. The unsupervised resident approached and struck the other resident in the face, knocking off their glasses and using derogatory language. The incident was witnessed by staff and reported by the affected resident, who expressed feeling unsafe and anxious following the event. Facility documentation and interviews confirmed that the staff member responsible for 1:1 monitoring was not present with the resident at the time of the incident, contrary to facility policy and the intended purpose of continuous observation. The affected resident, who was dependent on assistance for activities of daily living due to stroke-related impairments, reported increased anxiety and distress as a result of the altercation. Facility records and staff interviews corroborated that the assigned staff member failed to maintain constant visual supervision, which directly led to the opportunity for the physical assault to occur. The facility's policies on 1:1 monitoring and abuse prevention were not followed, resulting in a failure to protect the resident from mistreatment.
Failure to Honor Resident's Right to Self-Determination and Outdoor Access
Penalty
Summary
The facility failed to honor a resident's right to self-determination and a dignified existence by not allowing an alert and oriented resident to leave the facility at will. The resident, who had diagnoses including dementia, sensorineural hearing loss, anxiety, and depression, was assessed as alert and oriented with a BIMS score of 15/15 and was able to communicate daily needs using a communication board. The care plan and physician orders permitted the resident to go on leave of absence with medications and a responsible party, and the resident was not considered at risk for elopement. Despite this, after an incident where the resident attempted to board a city bus, the court-appointed conservator revoked outdoor privileges, and facility staff subsequently restricted the resident from going outside, even though the resident had previously been allowed to do so to feed birds and had not attempted to leave the premises before. Facility documentation and interviews confirmed that staff, including the DON and social worker, enforced the conservator's directive to restrict the resident from going outside, despite acknowledging the resident's rights and alert status. The restriction led to increased agitation and aggressive behaviors from the resident, culminating in a physical altercation and transfer to the hospital. The facility did not update the resident's care plan or conduct a new elopement and wandering assessment after the change in outdoor privileges. The facility's own policy states that residents have the right to make choices about their activities and participate in community life both inside and outside the facility, but this was not upheld in this case.
Failure to Develop and Implement Timely Discharge Plan
Penalty
Summary
A deficiency was identified regarding the facility's failure to develop and implement a timely discharge plan for a resident with diagnoses including diabetes mellitus, anxiety, depression, and difficulty walking. The resident was cognitively intact and independent with personal care, transfers, and ambulation. Although the Minimum Data Set (MDS) indicated an active discharge plan and a referral to the local contact agency, the resident's care plan did not include a discharge plan, and there was no documentation of referrals for potential discharge to another level of care. The interdisciplinary care plan meeting marked discharge planning as not applicable, with only a handwritten note referencing Money Follows the Person (MFP). Interviews revealed that a referral to MFP was made approximately 20 months prior, but the resident remained in the facility without further discharge planning or follow-up contacts regarding MFP or alternative settings. When the resident later requested a transfer to another nursing home, a referral was made and the resident was placed on a waiting list, but no additional follow-up was documented. The facility's discharge planning policy requires that discharge planning be addressed upon admission and throughout the resident's stay, particularly for those expressing a desire to return to the community, which was not consistently followed in this case.
Failure to Develop and Implement Care Plan for Resident Relationship
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the relationship between two residents, both of whom had intact cognition and court-appointed Conservators of Person (COP). One resident had a history of trauma and the other had a prior incident of allegedly inappropriate touching of a peer. Despite staff awareness of the ongoing friendship and frequent private visits between the two residents, there was no documentation in either resident's care plan addressing their relationship or providing guidance for staff on monitoring or managing their interactions. Multiple staff members, including nursing assistants, social workers, LPNs, and the administrator, confirmed knowledge of the residents' friendship and private visits, often with the door closed and without staff monitoring. Both residents' COPs were aware of the relationship, and one resident reported feeling uncomfortable after previously consenting to intimate contact. Facility policy required care plans to reflect resident preferences and needs, but no care plan interventions were documented to address the relationship, resulting in a deficiency.
Failure to Supervise Residents with Known Risk Leading to Sexual Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident sexual incident involving two residents, both of whom had intact cognition and were independently mobile. One resident had a history of trauma and the other had a documented prior incident of inappropriate touching of another resident. Despite this history, both residents were allowed to visit each other unsupervised in a private room with the door closed, and staff were aware of these visits but did not monitor or check on them during these times. Multiple staff members, including nursing assistants, social workers, and the Director of Nursing, acknowledged awareness of the friendly relationship and unsupervised visits between the two residents. Staff interviews revealed that no interventions were implemented to prevent inappropriate contact during these visits, even though one resident had a known history of inappropriate sexual behavior. The facility's abuse prohibition policy defined sexual abuse as non-consensual sexual contact of any type with a resident, yet there was a lack of preventive measures in place. The incident came to light when one resident reported feeling uncomfortable and stated that the other resident had touched them in a manner they did not consent to, despite having previously had a consensual relationship. The resident reported telling the other to stop, but the inappropriate touching continued. Documentation and interviews confirmed that staff were aware of the risk factors and the unsupervised nature of the visits but failed to implement or explain any interventions to ensure resident safety during these interactions.
Failure to Ensure Timely RN Assessment After Resident Burn
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely notification of the RN supervisor and completion of an RN assessment after a resident experienced a change in condition. The resident, who had diagnoses including type 2 diabetes, anemia, and Charcot's joint, independently showered and sustained a first-degree burn to the right lower extremity after using a hot washcloth during a shower. The resident did not immediately report the injury to staff and later requested lotion for the affected area. Upon identification of the burn by staff, the RN supervisor was notified only via a non-urgent text message, which did not specify the nature of the incident. The RN supervisor did not follow up, and no RN assessment was completed at the time the burn was discovered. The administrator confirmed that an RN assessment should have been performed and that there was no documentation of such an assessment when the injury was first identified. The facility was unable to provide an assessment policy for review.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with Parkinson's disease, unspecified dementia, and generalized anxiety disorder, who was moderately cognitively impaired and required assistance with activities of daily living, was subjected to verbal abuse by a nursing assistant (NA). The incident occurred when the resident, who was incontinent and dependent on staff for transfers, repeatedly requested to get out of bed. The NA responded to the resident's requests with foul language after the resident used similar language towards the NA. Facility documentation and interviews confirmed that the NA replied to the resident with the same expletive the resident had used, and this exchange was overheard by staff. Interviews with the resident, the NA, and other staff revealed that such exchanges were not uncommon between the resident and the NA, and the resident did not express feeling offended or fearful. However, the facility's investigation substantiated that verbal abuse had occurred, as the NA engaged in inappropriate language with the resident, contrary to facility policy prohibiting abuse, neglect, and exploitation. The incident was documented in the nurse's notes and corroborated by multiple interviews and facility records.
Failure to Implement Elopement Interventions Leads to Resident's Unauthorized Exit
Penalty
Summary
The facility failed to implement necessary interventions for a resident identified at risk for elopement, resulting in the resident exiting the facility without staff knowledge and being found 0.6 miles away by law enforcement. The resident, who had diagnoses including paranoid schizophrenia, dementia, depression, anxiety disorder, and psychosis, was moderately cognitively impaired according to a recent assessment. Despite being identified as at risk for elopement, the resident's care plan interventions, such as the application of a wander guard bracelet, were not effectively implemented. On the day of the incident, the resident's wander guard was removed prior to a hospital transfer, and upon readmission, the facility failed to reapply the wander guard or implement other measures to monitor the resident's location. The facility's investigation revealed multiple lapses in protocol and communication. Staff did not follow the facility's policy to page a Dr. Hunt when the resident was identified as missing. The wander guard bracelet was not reapplied upon the resident's readmission, and there was no evidence of physician orders for its reapplication. Additionally, the receptionist, who was responsible for monitoring exits, did not notice the resident leaving the building, and the dietary aide who accompanied the resident on the elevator did not recognize the resident as being at risk for elopement. Interviews with staff indicated a lack of awareness and adherence to the facility's elopement policies. The charge nurse and RN supervisor failed to communicate the resident's elopement risk and need for a wander guard to the appropriate parties. The facility's transmitter used to check the function of wander guard bracelets had been broken for several months, and there was a delay in obtaining a replacement. These failures in communication, policy adherence, and equipment maintenance contributed to the resident's elopement and the subsequent finding of Immediate Jeopardy.
Deficiency in Staff Competency Documentation
Penalty
Summary
The facility failed to ensure that competencies were conducted for Nurse Aides and Licensed Nurses to confirm that staff was competent to provide care for and meet the needs of all residents. During interviews and reviews of facility documentation, it was revealed that while mandatory in-service training was completed for all staff in 2022 and 2023, the facility was unable to provide any competencies for Nurse Aides or Licensed Nurses from 2022 to the present. The Administrator acknowledged the absence of a Staff Development Coordinator since March 2023, despite ongoing efforts to fill the position. The Administrator, along with the nursing supervisor and the Infection Preventionist, continued monthly and annual in-servicing. However, the lack of documented competencies persisted, indicating a deficiency in ensuring staff competency as required by the facility's assessment.
Inconsistent Documentation of Sanitizer pH Levels in Kitchen
Penalty
Summary
The facility failed to consistently document the pH levels of the manual sanitizer used in the kitchen's three-bay sink, which is essential for ensuring that sanitizing levels are adequate to effectively remove harmful bacteria on food contact surfaces. During a kitchen tour, it was observed that a dietary aide was unable to explain or demonstrate the procedure for checking the sanitizer concentration without prompting. The dietary aide also had difficulty interpreting the results of the pH test strip due to a vision problem, which was noted by the Dietary Director. A review of the daily temperature logs revealed that pH testing of the manual sanitizer was not documented on several occasions, including specific meals on multiple days. The Dietary Director acknowledged that there would have been pots to sanitize on those days and suggested that staff might be forgetting to record their results. The facility's policy requires staff to perform pH tests and record the results to ensure proper sanitizing levels, but this was not consistently followed, leading to the deficiency.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that all nurse aides received at least 12 hours of annual in-service training, as required. During an interview and review of facility documentation with the Administrator, it was identified that while in-service training sessions were conducted, many of the in-service sheets lacked details such as the duration of the training and the identity of the person who conducted it. Furthermore, the facility did not have a system in place to track or monitor whether each nurse aide completed the required annual training hours. Additionally, the facility had been unable to fill the Staff Development Coordinator position since March 2023, despite ongoing efforts to advertise the vacancy. This lack of a dedicated staff development coordinator contributed to the failure in monitoring and ensuring compliance with the training requirements for nurse aides.
Deficiencies in CPR Certification and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and certification for CPR among its staff, which is a critical component of emergency response in a healthcare setting. Specifically, the facility did not have a copy of the CPR certification card for several licensed staff members, including LPN #4 and NA #1, as required by facility policy. LPN #4's CPR certification had expired, and there was no evidence of renewal, while NA #1 could not confirm their certification status. Additionally, LPN #13 was not certified at the time of the incident but was scheduled to attend a CPR class. The facility's practice of discarding CPR certifications upon employee termination further complicated the issue, as it hindered the ability to verify staff qualifications. The report also highlights the facility's failure to complete the Code Blue transcription log for residents who required CPR, which is a breach of their own policy. For Resident #286, who was a full code and required CPR after being found unresponsive, the facility did not maintain a Code Blue log in the resident's file. Similarly, for Resident #288, who was also a full code and required CPR, the Code Blue log was missing from the clinical documentation. This lack of documentation is contrary to the facility's CPR policy, which mandates that a Code Blue log be completed and included in the resident's clinical record. These deficiencies were identified through clinical record reviews, facility documentation, policy review, and staff interviews. The absence of proper documentation and certification not only violates the facility's policies but also potentially compromises the quality of care provided to residents in emergency situations. The facility's failure to adhere to its own policies regarding CPR certification and documentation reflects a significant oversight in maintaining professional standards of quality care.
Untrained Staff Administered CPR Against Facility Policy
Penalty
Summary
The facility failed to ensure that an employee who administered CPR was appropriately trained according to facility practice and policy. This deficiency was observed in the case of a resident with diagnoses including pneumonia, COPD, and asthma, who was identified as a full code. The resident was found unresponsive with no pulse, heartbeat, or respiration, prompting the initiation of CPR and a call to 911. However, the nurse aide who took over CPR from the LPN was not certified to perform CPR, as per facility policy, which only allows RNs, LPNs, or any personnel with valid CPR certification to perform such procedures. The nurse aide admitted to not knowing how to call a code and took over CPR from the LPN, despite being aware that nurse aides are not supposed to perform CPR according to facility policy. The facility's administration confirmed that the nurse aide was not trained or certified to perform CPR at the time of the incident. The facility's CPR policy mandates that CPR should be performed by trained registered or licensed practical nurses or any other personnel who have completed CPR training, highlighting a breach in protocol during the incident with the resident.
Failure to Assess Resident for Self-Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-medication administration, which is a requirement when a resident desires to self-administer medications. Resident #99, who has diagnoses including diabetes mellitus, arthritis, and depression, was observed with medication cups containing pills next to their breakfast tray. The resident had requested the medications to be left in their room while eating breakfast and had separated the medications into two cups, one for the medications they intended to take and another for those they did not want to take that morning. An interview with an LPN revealed that the resident had requested the medications be left at the bedside, and the LPN complied with this request without knowing if the resident had been evaluated for self-administration. The Director of Nursing Services confirmed that Resident #99 had not been evaluated for self-administration of medication, which is a necessary step if a resident wants to have their pills at the bedside. The facility's policy requires the nurse to stay with the resident until the medication is swallowed, which was not adhered to in this instance.
Failure to Notify Physician of Resident's Pain Post-Fall
Penalty
Summary
The facility failed to notify the physician of a resident's new and ongoing pain following a fall. Resident #100, who was severely cognitively impaired and receiving hospice care, experienced a fall and subsequent pain that was not promptly communicated to the physician. Despite a physician's order to assess and manage pain, the resident's pain was not adequately addressed, and the physician was not notified until several hours after the resident first exhibited signs of moderate pain. The resident had a history of dementia, repeated falls, and osteoporosis, and was unable to verbalize pain, relying on vocal complaints and protective body movements as indicators. The nursing progress notes revealed that the resident exhibited moderate pain shortly after an unwitnessed fall, but there was no immediate assessment or notification to the physician. The resident's pain was documented at a level of 5 on multiple occasions, yet the nursing staff did not contact the physician or APRN until hours later. Interviews with staff indicated a lack of recall regarding the incident, and attempts to contact certain staff members were unsuccessful. The DNS acknowledged that there should have been an intervention to address the resident's ongoing pain, especially given the recent fall.
Resident Subjected to Verbal Abuse by LPN
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Licensed Practical Nurse (LPN). The resident, who was cognitively intact and had a history of depression, was verbally abused by being called derogatory names by the LPN. This incident was reported in a nursing progress note, and an investigation was initiated, with the police being notified. The facility's abuse prohibition policy mandates that residents have the right to be free from abuse, but this was not upheld in this case. Interviews conducted during the investigation revealed that the psychiatric consultant agency no longer had records of the incident, and the staff who witnessed it were no longer employed there. The Director of Nursing Services, who was not in the position at the time of the incident, confirmed that the facility's procedures were to remove the staff from the resident's care and start an investigation. The Administrator confirmed that the incident was reported by psychiatric consultant staff, and the LPN involved was removed from the resident's care and is no longer employed at the facility due to the substantiated verbal abuse.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to an outside state agency in a timely manner. Resident #189, who was diagnosed with adjustment disorder, type 2 diabetes mellitus, and hypotension, was identified as cognitively intact and required supervision for eating and limited assistance with bed mobility and transfers. The resident's care plan noted a history of depression, with interventions to encourage verbalization of feelings and provide emotional support. On a specific date, a nursing progress note documented that a report was received about verbal abuse by a charge nurse, and an investigation was initiated with the police being notified. The reportable event indicated that an LPN called the resident derogatory names. However, the facility administrator later indicated that the incident was not reported to an outside state agency, as required by the facility's Abuse Prohibition policy, which mandates reporting to the Connecticut Department of Social Service if abuse is confirmed.
Failure to Update Care Plans for Elopement and Code Status
Penalty
Summary
The facility failed to revise the care plan for Resident #8 in a timely manner, which contributed to an elopement incident. Resident #8, diagnosed with paranoid schizophrenia, dementia, depression, anxiety disorder, and psychosis, was identified as moderately cognitively impaired with no wandering behaviors noted during a quarterly assessment. However, the resident's care plan indicated a risk of leaving the facility and a tendency to remove the wander guard bracelet. After being transferred to the hospital for a psychiatric evaluation, the resident was readmitted without the necessary elopement precautions being implemented. This oversight led to Resident #8 being found outside the facility by EMS, indicating a failure to update the care plan and apply a wander guard bracelet as required. In another case, the facility did not update the care plan for Resident #88 to reflect a change in code status. Resident #88, diagnosed with dementia and failure to thrive, was initially under hospice care with a DNR/DNI status. However, after discussions with the responsible party, the code status was changed to Full Code, but this change was not reflected in the resident's care plan. The social worker involved did not follow up on the code status change, and the care plan remained outdated, not matching the physician's orders or the resident's current wishes. These deficiencies highlight the facility's failure to ensure timely updates and revisions to residents' care plans, which are crucial for addressing their current medical and safety needs. The lack of communication and follow-up among staff members contributed to these oversights, resulting in inadequate care planning for both residents.
Deficiencies in Resident Care and Communication
Penalty
Summary
The facility failed to timely evaluate the medical needs of Resident #6, who experienced significant weight loss. Despite a documented weight loss of 23.7 lbs, or 17.34%, from the previous month, there was no immediate re-weight or medical evaluation. The Advanced Practice Registered Nurse (APRN) noted the weight discrepancy eight days later, identifying moderate protein-calorie malnutrition. The facility's policy required notification of the interdisciplinary team and implementation of interventions for significant weight loss, which was not promptly followed. Resident #82, who had dementia and dysphagia, was not assessed for safe food consumption while awaiting dental services for broken dentures. Despite a request for a dental evaluation, there was no documented assessment of the resident's ability to eat safely. Interviews revealed that nursing staff could assess chewing and swallowing difficulties, but no such assessment was documented. The facility's policy required prompt referral for dental services and documentation of measures to ensure adequate eating and drinking if the referral was delayed. The facility also failed to apply ACE wraps as prescribed for Resident #126, who had lower extremity edema. Despite a physician's order to apply ACE wraps daily, observations showed the resident without them. An LPN was unaware of the order and could not explain the omission. Additionally, Resident #88's change in code status to Full Code was not communicated to hospice services, as required by facility policy. The Director of Nursing acknowledged the oversight, and the social worker did not follow up on the code status change, leading to a lack of communication with hospice.
Failure to Address Significant Weight Loss in a Timely Manner
Penalty
Summary
The facility failed to ensure that a resident's weight was obtained according to policy and did not evaluate the resident's nutritional needs following significant weight loss in a timely manner. Resident #6, who had diagnoses including dementia, anemia, and hypertension, experienced a significant weight loss of 23.7 pounds or 17.34% from the previous month, as documented on 4/16/24. Despite this significant weight discrepancy, there was no documented re-weight, and the issue was not promptly addressed or communicated to the dietitian. Interviews with facility staff revealed that the Licensed Practical Nurse (LPN) responsible for documenting the weight discrepancy was unable to recall the actions taken to address the issue. The Director of Nursing Services (DNS) and the facility's policy indicated that a re-weight should have been conducted immediately, and the dietitian should have been notified. However, the dietitian was not informed of the weight discrepancy until nine days later, and there was no documented re-weight or immediate dietary intervention. The facility's policy required that any significant weight loss be reviewed by the dietary team, with the interdisciplinary team, dietitian, physician, and family notified. However, the dietitian, who provided services only one day a week, was not informed of the weight discrepancy in a timely manner, and Resident #6's nutritional needs were not addressed promptly. The delay in addressing the weight loss was attributed to the lack of immediate communication and the limited availability of the dietitian.
Failure to Change and Label Oxygen Tubing Weekly
Penalty
Summary
The facility failed to adhere to its policy of changing and labeling oxygen tubing weekly for three residents who required oxygen therapy. Resident #69, diagnosed with acute on chronic congestive heart failure, pneumonia, and acute and chronic respiratory failure, had a physician's order for oxygen administration via nasal cannula. Observations on June 12, 2024, revealed that the oxygen tubing was not dated, and the Treatment Administration Record indicated that the tubing should be changed every Sunday night shift starting June 23, 2024, after surveyor inquiry. Similarly, Resident #84, with diagnoses including congestive heart failure, cardiomyopathy, and end-stage renal disease, was observed on June 12, 2024, with undated oxygen tubing. Resident #126, diagnosed with heart failure, hypertension, and edema, also had undated oxygen tubing, with no evidence of tubing change on June 9, 2024, as per the Treatment Administration Record. Interviews with LPNs confirmed the requirement to change and document the oxygen tubing weekly, as per the facility's policy updated in 2024, which was not followed in these cases.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who was severely cognitively impaired and unable to verbalize pain. The resident, who had a history of dementia, repeated falls, and osteoporosis, was under hospice care and exhibited daily indicators of pain. Despite physician orders to assess the resident's pain every hour and medicate as needed, the Medication Administration Record (MAR) showed that the resident's pain was consistently recorded as zero from the beginning of the month until mid-month. However, on the day of the incident, the resident was evaluated as having moderate pain multiple times during the early morning hours, yet only received a scheduled dose of Morphine at 4:00 AM. The nursing progress notes indicated that the resident exhibited symptoms of pain, such as holding their left leg and facial expressions of pain, but there was a lack of timely intervention. An LPN noted difficulty in contacting hospice services for further guidance. The Director of Nursing Services (DNS) acknowledged that there should have been an intervention to address the resident's ongoing pain, especially considering the recent fall and subsequent hip fracture identified by an x-ray. The failure to adequately manage the resident's pain and investigate the cause of increased pain led to the deficiency identified in the report.
Failure to Provide Dental Services for Resident with Broken Dentures
Penalty
Summary
The facility failed to provide necessary dental services for a resident with broken dentures, despite a request from the responsible party. The resident, who had diagnoses including dementia, anorexia, and dysphagia, was identified as severely cognitively impaired and independent with activities of daily living. The resident's care plan noted the use of partial dentures and required monitoring for dental issues. On a specific date, the responsible party requested an evaluation for the resident's broken dentures, but the facility did not act on this request. Dental consults conducted on various dates noted broken or missing dentures but did not include recommendations for repair or replacement. Interviews with facility staff revealed a lack of communication and follow-up regarding the dental service request. The social worker confirmed that the issue was discussed in a care plan meeting and an email was sent to the Director of Nursing Services (DNS), but no response was received. The DNS acknowledged that requests for specialty services should be acted upon, and the Medical Records Associate, responsible for scheduling specialty services, stated she had not received any requests for dental evaluation or replacement for the resident. The facility's policy required prompt referral for dental services within three days for lost or damaged dentures, which was not adhered to in this case.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during a dressing change for a resident with a stage 3 pressure ulcer and a history of ESBL resistance. The resident, who had severe cognitive impairment and required extensive assistance with mobility and toileting, was observed receiving wound care without the staff adhering to enhanced barrier precautions. Specifically, LPN #5 and NA #2 did not wear gowns as required, despite signage indicating the need for gloves and gowns when providing care. Additionally, LPN #5 did not perform hand hygiene between glove changes, which is a part of the facility's hand hygiene compliance policy. During interviews, LPN #5 acknowledged awareness of the enhanced barrier precautions but admitted to not wearing the gown due to oversight and was unaware of the necessity for hand hygiene between glove changes. The DNS confirmed the expectation for staff to follow posted instructions regarding personal protective equipment and emphasized the requirement for gown use during wound care. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, contributing to the deficiency in infection control practices.
Failure to Communicate Compliance and Ethics Program
Penalty
Summary
The facility failed to ensure effective communication of its Compliance and Ethics program standards, policies, and procedures to all staff members. During an extended survey, it was found that the Administrator could not locate records of initial or annual in-service training that included communication of the Corporate Compliance program for all staff. The Administrator acknowledged that annual in-service training was scheduled to begin in 2024 and confirmed that the facility's governing body operates five or more buildings. Additionally, a review of employee files with the Human Resources Director revealed that 4 out of 6 employee files were missing the Compliance Certificate Statement. This statement, which should be kept in the employee's personnel file at the time of hire, indicates that the employee received Corporate Compliance training. This deficiency highlights a lack of documentation and communication regarding compliance training within the facility.
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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