Cobalt Lodge Health Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cobalt, Connecticut.
- Location
- 29 Middle Haddam Rd, Cobalt, Connecticut 06414
- CMS Provider Number
- 075232
- Inspections on file
- 22
- Latest survey
- September 29, 2025
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Cobalt Lodge Health Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a recent change to non-ambulatory status suffered a serious fall and injuries after staff used a walker for transfer, as the nurse aide care card was not updated to reflect the resident's current mobility needs. The aide, unaware of the updated status, did not use a gait belt and assisted the resident to ambulate, resulting in a fall with significant injuries.
A resident with dementia and other conditions was transferred to the hospital after elopement, but the facility failed to provide timely bed hold and discharge notices to the resident and responsible party, did not complete a discharge summary, and refused to readmit the resident when ready for return. The facility also backdated the discharge notice and did not follow required consultative or appeal processes, as confirmed by interviews with the conservator, hospital social worker, and ombudsman.
Multiple deficiencies occurred when two residents at risk for elopement were not adequately protected—one was able to leave the facility undetected due to lack of a care plan and delayed response, while another exited through a malfunctioning Wanderguard door and suffered serious injuries. Additionally, a resident dependent on staff for transfers was moved by a single agency aide without required assistance or equipment, resulting in a femur fracture.
A resident with dementia and significant cognitive impairment became agitated in the dining room and was approached by an LPN. Despite the resident holding a fork and being visibly upset, the LPN continued to engage and ultimately pushed the resident, causing a fall that resulted in arm fractures. The incident was confirmed by video and witness accounts, and it was determined that the staff member's actions violated the facility's abuse prevention policy.
Five nurse aides did not receive the required twelve hours of annual in-service training, with no documentation found in their personnel files. Facility leadership confirmed that annual in-service training had not been conducted since the departure of the Staff Development Coordinator, and no records of recent training could be located. Facility policy mandates annual in-service education for all staff, including job-specific training.
Annual performance evaluations were not completed or properly documented for multiple nurse aides, with missing or unsigned reviews and no evidence of evaluations in recent years. The DON and ADON confirmed the requirement for yearly evaluations but were unaware of the lapses due to lack of HR staff and could not provide a relevant policy.
A resident with dementia, Parkinson's disease, and osteoarthritis experienced new left leg pain and swelling, which was reported by a nurse aide to an RN during morning care. Despite repeated notifications, the RN delayed assessment and provider notification for approximately eight hours, even as the resident's symptoms worsened. The resident was eventually found to have a significant femur fracture and was transferred to the hospital only after further staff intervention.
The facility did not complete required weekly skin audits for a resident with significant cognitive and physical impairments, and failed to perform quarterly elopement risk assessments for another resident identified as high risk for wandering. These omissions were not in accordance with facility policy, as confirmed by the DON, and were documented through record review and staff interviews.
The facility failed to review its infection control policies annually and did not conduct monthly environmental rounds since June 2024. The new IP nurse was unaware of the environmental rounds policy, and the DNS confirmed the rounds were not conducted due to the absence of an IP nurse. Additionally, the facility did not adhere to its Water Management Plan Policy, lacking documentation and testing for legionella, as the previous maintenance director took all related documents.
The facility did not address resident council concerns, as meeting minutes lacked documentation of resolutions, and interviews revealed no formal follow-up. The Recreation Director failed to document or communicate resolutions, and the President/Owner confirmed the absence of documentation, violating facility policy.
The facility failed to maintain professional standards in medication administration for two residents. One resident did not receive Eliquis as ordered due to stock issues, and the physician was not notified. Another resident experienced discrepancies in Lorazepam administration records, with the MAR and CSDR showing inconsistencies. The Charge Nurse responsible was new and lacked adequate training. The facility's medication pass policy was not followed, leading to these deficiencies.
The facility failed to reconcile controlled medications, as the DNS stored unused substances in her office without conducting required audits. Since starting in August 2024, the DNS had not destroyed or reconciled any drugs, and the storage drawer was overflowing with medications. The facility's policy mandates regular audits to prevent drug diversion, but none were completed due to the DNS's workload.
The medication storage room on Wing 2 was found unsecured, with the door open and various medications and supplies accessible. A resident was observed in the hallway while the Charge Nurse was administering medication. The Nursing Supervisor confirmed the room should be closed, and the night shift Nursing Supervisor admitted to leaving it open. The DNS reiterated the policy that medication storage areas must be locked when not in use.
The facility failed to post accurate menus and announce changes, as observed during a lunch service where the meal served did not match the posted menu. Two residents reported that the menu was not followed and food often ran out. The head cook used improper utensils for portion control, and the dietician noted that this could affect nutritional intake. The facility's policy requires approved menus to be posted and changes announced, but the president/owner admitted the wrong menu was posted.
The facility lacked written policies and procedures for feedback, data collection, and monitoring, including adverse event monitoring. The President and DNS acknowledged this deficiency, noting reliance on an anonymous suggestion box and customer surveys, with concerns typically addressed in person. There was no formal tracking system unless a pattern was noticed, and issues were brought to the QAA committee, which met quarterly.
The facility failed to offer pneumococcal vaccines to two residents with severe cognitive impairment, as required by policy. Both residents' admission assessments indicated their vaccinations were not up to date, and reviews of their records showed no evidence of the vaccine being offered. The Infection Preventionist, new to the role, was unsure of the responsibility for offering the vaccine and could not locate the necessary consents.
A resident's advance directive indicating a preference for CPR was not accurately reflected in the physician's order, which stated a DNR status. Despite being alert and oriented, the resident's wishes were contradicted by a form signed by the responsible party. Facility staff failed to resolve this inconsistency, and the signed advance directive was not found in the designated location.
A resident experienced significant weight loss, but the facility failed to notify the dietician and physician as required. Despite physician's orders to monitor weight changes, the staff did not follow the protocol for reporting significant weight loss. Interviews revealed a lack of awareness and training among staff regarding the facility's weight loss policy.
A resident with severe cognitive impairment and multiple diagnoses was found with a bruise of unknown origin, which the facility failed to report to the state survey agency. The DNS believed the cause was known but lacked documentation or witness statements to support this. The facility's policy to investigate such injuries as potential abuse was not followed, and the incident was not properly documented or discussed.
A resident with severe cognitive impairment was found with a bruise below the left eye, but the facility failed to conduct a thorough investigation or report the incident to the state survey agency. Despite the DNS believing the cause was known, no documentation or witness statements were provided, violating the facility's abuse/neglect policy.
A facility failed to develop a comprehensive care plan for a resident on anticoagulant therapy, Eliquis, despite the resident's diagnoses of peripheral vascular disease and acute coronary thrombosis. The care plan did not address the anticoagulant use or its potential side effects, such as bruising and bleeding, as recommended by a pharmacy consultant. The facility's policy required daily updates to care plans, but this was not followed, resulting in a deficiency.
A facility failed to administer medications accurately for a resident with anxiety disorder, leading to incorrect dosages and missed doses of Lorazepam. Additionally, another resident with respiratory issues received incorrect oxygen flow rates, and lung assessments were not documented as required. These deficiencies were due to inadequate staff training and failure to follow physician's orders and facility policies.
A resident with dementia and risk for contractures did not have their splint applied as per physician's orders. Observations showed the resident without the splint during required times. Staff interviews revealed misunderstandings and lack of training on splint application, despite facility policy requiring clear orders and training.
A resident with multiple health conditions experienced significant weight loss, but the facility failed to ensure timely assessment by the dietician or physician. Despite orders for regular weight checks and notifications, the weight loss was not addressed, and staff interviews revealed a lack of clarity on the facility's weight loss policy.
A facility failed to ensure that a resident's medication regimen was appropriately managed. The resident, with diagnoses including long-term anticoagulant use, had pharmacy recommendations for monitoring that were not incorporated into their care plan. The MAR and TAR did not reflect these recommendations, and the DNS had not been receiving pharmacy recommendations since August. The facility's policy required documentation and communication of pharmacy recommendations, but this process was not followed.
A resident with atrial fibrillation and hypertension was prescribed Metoprolol Succinate ER, which should not be crushed. An LPN was observed crushing the medication before administration, contrary to the physician's order. The LPN admitted to this practice, realizing the error only after re-reading the medication packaging. The facility's policy requires adherence to the five rights of medication administration and a physician's order for any change in medication form.
A facility failed to offer a COVID-19 booster vaccine to a resident with severe cognitive impairment and multiple diagnoses, including Parkinson's disease and dementia. The new Infection Preventionist was unsure of the responsibility for offering the vaccine and could not find the necessary consent documentation. Facility policy requires offering the vaccine unless contraindicated or already administered.
The facility did not provide monthly notifications to the state Regional Ombudsman's Office about resident transfers and discharges. A review showed 34 residents were transferred or discharged without proper reporting. A social worker acknowledged receiving training on this process but could not explain the lack of submissions. The facility also lacked a policy for notifying the Ombudsman.
The facility failed to label and date opened food items in the kitchen's dry storage area, including dry mashed potato flakes, cornstarch, peanut butter, granola, chocolate baking chips, and walnuts. Additionally, two squeeze bottles with a brown syrup-like substance were found without labels or dates. The Food Service Director, newly hired for almost three months, acknowledged the requirement for labeling but was unaware of the facility's specific policy. The facility's kitchen policy mandates proper labeling and dating of all food items.
The facility failed to document competencies for four nursing staff members, including two NAs, an LPN, and an RN, despite policy requirements for initial competency assessments upon employment. Personnel files lacked documentation, and interviews revealed that competencies were not retained, with the DNS unable to provide evidence of completed assessments.
The facility did not complete performance reviews for three nurse aides, as required by its policy. Personnel records lacked evaluations for 2024, 2023, and 2022. A business office staff member and the DON confirmed the absence of reviews, which should occur at the end of probation and annually.
The facility did not ensure that nurse aides received required annual in-service training, as personnel files for two aides lacked documentation of such training. Interviews revealed that training records were not maintained in employee files, and the Director of Nursing Services confirmed that annual in-service training had not been completed for the past year. The facility's policy requires annual in-service education to comply with regulations and best practices.
Failure to Update Care Card Leads to Resident Fall and Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to update the nurse aide care card to reflect a resident's current non-ambulatory status. The resident, who had diagnoses including unsteadiness on feet, polyneuropathy, atrial fibrillation, and cognitive communication deficit, was dependent on staff for transfers and toileting. Physician orders and therapy documentation indicated the resident was not functionally ambulatory and required assistance for transfers, but the care card did not specify the resident's ambulation status, leaving the section blank. The care card only listed a walker and wheelchair as assistive devices, without clarifying that the resident should not ambulate independently or with a walker. On the day of the incident, a nurse aide, assigned as the resident's caregiver, assisted the resident out of bed using a walker to ambulate to the bathroom. The aide did not use a gait belt and was unaware of the resident's non-ambulatory status, as the care card was not updated. During the transfer, the resident lost balance while reaching to turn on the bathroom light, causing the walker to topple and resulting in a fall. The resident sustained a traumatic subarachnoid hemorrhage, a right femoral neck fracture requiring surgery, and a right distal clavicle fracture. Interviews and documentation confirmed that the physical therapist had communicated the resident's non-ambulatory status to nursing staff and updated the physician orders, but the nurse aide care card was not revised accordingly. The Director of Nursing acknowledged that the care card failed to reflect the resident's ambulation status both before and after the change, contributing to the incident. Facility policy required care plans and care cards to accurately reflect residents' functional status, transfer methods, and ambulation ability, but this was not followed in this case.
Failure to Provide Required Transfer, Discharge, and Bed Hold Notices
Penalty
Summary
A resident with diagnoses including dementia, anxiety, and a history of alcohol abuse, who rarely or never made decisions regarding daily living, eloped from the facility and was subsequently sent to the hospital for evaluation and treatment. The facility failed to provide a bed hold notice to the resident or their conservator upon transfer to the hospital, and there was no documentation of a discharge summary in the clinical record. Additionally, the discharge notice provided to the resident was dated several weeks after the actual discharge date, and the notice was not issued to the resident, conservator, or ombudsman on the day of discharge as required. Interviews revealed that the hospital social worker received documentation from the conservator regarding a meeting with the facility to discuss a safe discharge plan, but later received a letter from the facility refusing to readmit the resident. The ombudsman confirmed that the facility did not follow the required consultative and involuntary discharge processes, failed to issue timely discharge notices, and did not allow the resident to return while an appeal was pending. The conservator reported not receiving or signing discharge paperwork and indicated that the resident's bed and belongings remained at the facility, with no bed hold notice issued. The facility administrator acknowledged not issuing the required notices at the appropriate time and not initiating the consultative process with the hospital. The administrator also confirmed that the discharge notice was backdated and only filed after being informed of the correct process by the ombudsman. The facility continued to refuse readmission of the resident during the appeal process, contrary to regulatory requirements and facility policy.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to ensure the safety of residents at risk for elopement and those requiring assistance with transfers, resulting in multiple deficiencies. For one resident with dementia and severe cognitive impairment, the facility identified a risk for wandering but did not develop or implement a care plan or interventions to address this risk. When the resident was discovered missing, staff did not follow the facility's elopement policy, including failing to call a missing person code or notify the police and DON promptly. The resident was eventually found by police several miles away after walking along a dangerous road, but only after a significant delay in response. Another resident, identified as an elopement risk with Alzheimer's disease, was able to exit the facility through a Wanderguard-alarmed door that was not properly closed and latched. The door had a history of malfunctioning, and staff failed to ensure it was secured after use. As a result, the resident exited into the parking lot and sustained serious injuries, including head lacerations, a subdural hematoma, a subarachnoid hemorrhage, and a nondisplaced fracture, after falling. Interviews revealed ongoing issues with the door hardware, which had not been addressed by the facility owners despite repeated concerns from maintenance staff. A third resident, dependent on staff for transfers due to dementia and Parkinson's disease, was transferred by a single agency nurse aide without the required two-person assistance or use of a mechanical lift, contrary to physician orders and care plan directives. The aide did not check the assignment sheet or care card before performing the transfer and did not use a gait belt. The resident subsequently sustained a significant femur fracture, requiring transfer to a trauma center for surgical intervention. The investigation confirmed that the aide was unaware of the resident's transfer requirements and failed to follow established protocols.
Failure to Protect Resident from Physical Abuse Resulting in Injury
Penalty
Summary
A resident with vascular dementia, psychosis, and major depressive disorder, who had significant cognitive impairment and required moderate assistance with transfers and ambulation, was involved in an incident in the dining room. The resident, who had been confused and argumentative, was observed sitting at a table before standing up with a fork in hand. A staff member, an LPN, approached the resident despite the resident's agitated state. The LPN and the resident exchanged words, and the LPN continued to walk towards the resident. Video surveillance and witness interviews indicated that the LPN made physical contact by pushing the resident, causing the resident to fall to the floor. As a result of the fall, the resident sustained fractures to the right distal radius and ulna, requiring medical intervention and hospitalization. Facility documentation and interviews confirmed that the LPN should not have engaged with the resident while agitated and should have avoided physical contact. The facility's abuse and neglect policy states that residents have the right to be free from abuse, including physical abuse by staff. The incident demonstrated a failure to protect the resident from physical abuse, as the staff member's actions directly resulted in harm to the resident.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that five sampled nurse aides received at least twelve hours of annual in-service training, as required by state and federal regulations. Review of the personnel files for these nurse aides showed no documentation of completed annual in-service training. Interviews with the DON and ADON revealed that the facility had been without a Staff Development Coordinator since the previous coordinator was terminated for not fulfilling job requirements, and that annual in-service training had not been conducted since at least December 2024. Additionally, the facility was unable to locate any in-service records from the past year. The facility's own policy requires all employees to complete annual in-service education, including job-specific training for nurse aides.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three out of five nurse aides reviewed. Specifically, one nurse aide's last documented performance review was in 2023, with no available documentation for the required 2024 review. Another nurse aide had an annual performance review from 2019 that was unsigned by both the employee and evaluator, with no subsequent reviews available. A third nurse aide had a performance review from 2021, also unsigned by both parties, and no documentation of later reviews could be found. Interviews with the DON and ADON confirmed that annual evaluations are required but acknowledged that they were unaware of the lapses due to the absence of Human Resources staff and could not provide a facility policy for nurse aide performance evaluations.
Delayed Provider Notification After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to promptly notify a provider of a resident's change in condition. The resident, who had diagnoses including dementia with behavioral disturbances, Parkinson's disease, and osteoarthritis, was dependent on staff for mobility and had a physician's order for transfer with a mechanical lift. During morning care, the resident complained of left leg pain and swelling, which was unusual for this individual. The nurse aide immediately reported these symptoms to the supervising RN, but the RN did not assess the resident until several hours later. Despite repeated notifications from the nurse aide regarding the resident's pain and swelling, the supervising RN delayed both assessment and provider notification. The resident's pain and swelling increased throughout the day, and it was not until the afternoon that the RN assessed the resident and noted significant symptoms, including a large bruise and deformity of the leg. The RN still did not notify the provider or administer pain medication until approximately eight hours after the initial complaint. Other staff, including an LPN and the DON, became involved later in the day when it was apparent the resident's condition was serious. The facility's fracture management policy required immediate stabilization and provider notification for suspected fractures, but this protocol was not followed. The delay in assessment and notification resulted in a significant delay in the resident being transferred to the hospital, where a periprosthetic femur fracture was diagnosed.
Failure to Complete Required Skin and Elopement Assessments
Penalty
Summary
The facility failed to complete required assessments for two residents in accordance with its own policies. For one resident with dementia, Parkinson's disease, and osteoarthritis, weekly skin audits were not documented for two consecutive weeks, despite facility policy requiring weekly monitoring and documentation in the electronic health record. The resident was dependent on staff for mobility and had a low BIMS score, indicating significant cognitive impairment. The Director of Nursing confirmed that weekly body audits are required for all residents and could not provide documentation for the missed weeks. For another resident with dementia and a history of restlessness and agitation, quarterly elopement risk assessments were not completed as required. The resident was identified as high risk for wandering, but the clinical record did not show that Wandering Risk Scale evaluations were performed during two required quarters. This resident was later reported missing, with staff discovering an open window and screen in the resident's room. The DON acknowledged that quarterly assessments for elopement risk are required and could not explain the missed evaluations. Facility policy directs that all residents be assessed for wandering risk on admission and quarterly, with appropriate interventions if risk is identified.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to review its infection control program policies and procedures annually for the years 2022, 2023, and 2024. The Infection Preventionist (IP) nurse, who started working at the facility on November 13, 2024, was unable to locate documentation confirming the annual review of these policies. The facility's Infection Prevention Program policy mandates that these policies be reviewed annually and signed off by the Medical Board. Additionally, the facility did not conduct monthly environmental rounds as per its practice, with the last documented round occurring in June 2024. The new IP nurse was unaware of the facility's policy regarding environmental rounds, and the Director of Nursing Services (DNS) acknowledged that these rounds were not conducted due to the absence of an IP nurse for a period of time. The facility also failed to adhere to its Water Management Plan Policy, which includes maintaining logs for various maintenance activities to prevent water-borne pathogens. The Director of Maintenance had no information or documentation regarding the water management plan and could not confirm if the facility had tested for legionella. The administrator reported that the previous maintenance director took all related documents, leaving the facility without records of completed maintenance or water testing. The facility's Water Management Plan Policy requires that sampling, management plans, and results be retained, emphasizing the facility's commitment to preventing water-borne contaminants.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address resident concerns and grievances as evidenced by a review of resident council meeting minutes and interviews. The minutes from August, September, and October 2024 did not document how concerns were addressed by the facility administration, nor did they include any follow-up on old business. Interviews with the Resident Council group revealed that concerns raised during meetings were not formally addressed or followed up on in subsequent meetings. The residents noted that they only became aware of any follow-up actions if they observed changes within the facility. The Recreation Director, responsible for facilitating the resident council meetings, admitted to not documenting resolutions to the concerns expressed by the group. Although concerns were discussed during morning meetings, there was no written or verbal communication back to the resident council to indicate that issues were addressed. The President/Owner also confirmed that while concerns were discussed, there was no documentation of the issues addressed or their resolutions. The facility's policy requires the Recreation Director to act as a liaison and ensure proper communication between the council and facility leadership, which was not adhered to in this case.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain professional standards in medication administration for two residents. For one resident with a history of atrial fibrillation and on anticoagulant therapy, the facility did not administer Eliquis as ordered due to the medication being out of stock. The Licensed Practical Nurse (LPN) did not notify the physician about the missed dose, which could have led to alternative arrangements for medication. The medication was reordered on a routine basis rather than emergently, and the physician was not informed of the situation until later. Another resident, who was prescribed Lorazepam for anxiety, experienced multiple discrepancies in medication administration records. The Medication Administration Record (MAR) and the Controlled Substance Disposition Record (CSDR) showed inconsistencies in the administration and documentation of Lorazepam doses. The resident's MAR indicated doses were given, but the CSDR did not reflect these administrations accurately. The Charge Nurse responsible for these discrepancies was new to long-term care and had not received adequate orientation or competency training. Interviews with staff revealed a lack of communication and documentation regarding medication administration. The physician was not informed of the discrepancies in medication administration for the second resident until after the survey. The facility's medication pass policy requires immediate documentation and notification of any withheld or refused medications, which was not adhered to in these cases.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were periodically reconciled to prevent diversion. The Director of Nursing Services (DNS) admitted to storing returned and unused controlled substances in her office drawer, which had not been reconciled since the previous DNS left. The DNS, who started working at the facility in August 2024, had not destroyed or reconciled any controlled drugs. A folder containing Controlled Substance Disposition Records was found on her desk, with both yellow and white copies of the records that had not been matched. The storage drawer was observed to be overflowing with blister packets, patches, and bottles of liquid controlled substances, making it difficult to open. The DNS acknowledged that audits of controlled substances should be conducted monthly, but none had been completed since her employment began. She was unable to locate any audits conducted by the previous DNS. The facility's policy requires thorough documentation of all controlled substance transactions and mandates regular audits to prevent drug diversion. However, the DNS had not reconciled or destroyed the returned/unused controlled substances due to her workload. The facility's failure to adhere to its policy and procedure for controlled medications resulted in a deficiency related to the prevention of drug diversion.
Medication Storage Room Security Lapse
Penalty
Summary
The facility failed to ensure the security of the medication storage room on Wing 2, as observed on 11/17/24. The door to the medication room was found open more than 12 inches, exposing various unsecured items including over-the-counter medications, overflow prescription medications, and treatment supplies. Additionally, a filled sharps container was on the counter, and lower cabinets and drawers containing medical supplies were not secured. A functioning refrigerator without a securement device contained a locked box, a tuberculin vial, an unopened insulin vial, and other medications. During the observation, a resident was seen ambulating in the hallway while the Charge Nurse was administering medication from the medication cart. The Nursing Supervisor confirmed the medication room was left open and unsecured, acknowledging it should be kept closed. The night shift Nursing Supervisor admitted to leaving the door open after accessing the room earlier. The Director of Nursing Services (DNS) confirmed that the medication room should remain closed at all times, even when nurses are at the nursing station, as per the facility's Medication Storage policy, which mandates that all medication storage areas must be locked when not in use.
Failure to Post Accurate Menus and Ensure Portion Control
Penalty
Summary
The facility failed to post accurate menus and announce changes to the daily menu, as observed during a lunch service. The posted menu indicated garlic cheddar chicken, broccoli, pasta, and roll, but the meal served included pulled pork, noodles, carrots, and teriyaki chicken. No announcements were made regarding these changes, and the menu was not updated to reflect the substitutions. Additionally, the facility did not utilize measured serving utensils, which could affect portion control and nutritional intake. Two residents, one with chronic obstructive pulmonary disease and osteoporosis, and another with type 2 diabetes and dementia, reported that the menu was not being followed and that food often ran out before reaching their rooms. The head cook confirmed that the staff used slotted spoons and tongs instead of portion control utensils, and the president/owner acknowledged that menu changes were announced overhead but not posted. The dietician, who works part-time, indicated that the Maryland Diet Manual is used for dietary requirements, but the last menu review was in June. The facility's policy requires approved menus to be posted visibly and any changes to be announced or posted before meal service. However, the president/owner admitted that the wrong menu was posted and that the head cook orders food based on experience rather than precise measurements. The dietician noted that improper serving utensils could lead to meals not meeting the required calorie intake, potentially causing issues like weight loss. The facility's failure to adhere to its policies and ensure accurate menu postings and portion control led to the identified deficiencies.
Deficiency in Quality Improvement Processes
Penalty
Summary
The facility was found to have deficiencies in its quality and performance improvement processes due to the lack of written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. During an interview, the facility's President and Director of Nursing Services (DNS) acknowledged the absence of these written protocols. They noted that the facility relied on an anonymous suggestion box and customer surveys for feedback, and concerns were typically addressed in person due to the facility's small size. However, there was no formal system for tracking issues unless a pattern was observed. The DNS mentioned that any identified problems would be brought to the Quality Assessment and Assurance (QAA) committee, which met quarterly, but there was no structured approach to ongoing monitoring and documentation of quality deficiencies.
Failure to Offer Pneumococcal Vaccines to Residents
Penalty
Summary
The facility failed to ensure that the pneumococcal vaccine was offered and/or assessed for two residents, leading to a deficiency in immunization practices. Resident #33, who was admitted with diagnoses including Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies, was identified as having severe cognitive impairment. The admission MDS assessment indicated that Resident #33's pneumococcal vaccination was not up to date, and a review of the resident's immunization consents and records failed to show that the vaccine was offered. Similarly, Resident #35, admitted with major depression, dementia, and anxiety, also had severe cognitive impairment. The admission MDS assessment for Resident #35 similarly indicated that the pneumococcal vaccination was not up to date, and a review of the resident's records showed no evidence that the vaccine was offered. The Infection Preventionist, who had recently started in her position, was unsure of the responsibility for offering the vaccine and could not find the necessary consents for these residents. The facility's policy required that all residents be assessed for eligibility to receive the pneumococcal vaccine within 30 days of admission unless medically contraindicated or the vaccine series was already completed.
Discrepancy in Resident's Code Status and Advance Directive
Penalty
Summary
The facility failed to ensure that the physician's order accurately reflected a resident's chosen code status, leading to a discrepancy between the resident's advance directive and the physician's order. The resident, who was admitted with acute respiratory failure, congestive heart failure, and Alzheimer's disease, had a physician's order indicating a Do Not Resuscitate (DNR) status. However, an advance directive form signed by the resident indicated a preference for CPR. This inconsistency was not identified or resolved by the facility staff, leading to confusion about the resident's true wishes. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Medical Director, revealed that the resident was alert and oriented and should have been able to make decisions regarding their advance directive. Despite this, a form signed by the resident's responsible party contradicted the resident's wishes. The facility's policy required that all signed advance directives be kept in a code book and uploaded into the electronic chart, but the signed form for the resident was not found in the designated location. The Medical Director and Social Worker confirmed that the resident was capable of making their own decisions, and the discrepancy between the advance directive and the physician's order was not explained.
Failure to Notify Physician and Dietician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the dietician and physician regarding a significant weight loss for Resident #31, who had diagnoses including congestive heart failure, kidney disorder, depression, anxiety, and atrial fibrillation. Physician's orders required weight checks three times per week and notification for weight changes of 3 pounds or more. Despite a weight loss of 15.2 pounds on 10/3/24 and 19 pounds on 10/14/24, which constituted a significant weight loss, there was no documentation that the physician or dietician was informed. The resident's care plan included monitoring dietary intake and weight, but these measures were not effectively implemented. Interviews with facility staff revealed a lack of awareness and training regarding the policy for reporting significant weight loss. MD #1 and the DNS both acknowledged that the dietician and physician should have been notified. LPN #1 was unsure of the facility's policy and had not been trained on what constituted significant weight loss or when to report it. The facility's weight loss policy clearly stated the thresholds for significant weight loss and the requirement to notify relevant parties, but this protocol was not followed, leading to the deficiency.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with Parkinson's, dementia, and insomnia to the state survey agency. The resident was severely cognitively impaired, non-ambulatory, and required total assistance for various activities. A nurse's note documented a bruise below the resident's left eye, but the facility did not report this to the state survey agency, despite the bruise's unknown origin. The facility's documentation was incomplete, lacking signatures from the Administrator and DNS, and there was no evidence of an investigation or accident report. Interviews with the DNS and nursing staff revealed inconsistencies and a lack of documentation regarding the incident. The DNS believed the bruise's cause was known, but could not provide evidence or witness statements to support this. The facility's policy required that injuries of unknown origin be investigated as potential abuse, but this protocol was not followed. The DNS admitted to not having documentation to confirm the bruise's origin, and the incident was not discussed in the morning meeting as per usual practice.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for Resident #13, who was found with a bruise below the left eye. Resident #13, diagnosed with Parkinson's, dementia, and insomnia, was severely cognitively impaired and required total assistance for mobility and personal care. Despite the nurse's note documenting the bruise and notifying the appropriate parties, the facility did not complete the necessary investigation forms with signatures from the Administrator or DNS. Additionally, the incident was not documented in the 24-hour report, and the bruise was not reported to the state survey agency as required. Interviews with the DNS and nursing staff revealed a lack of clarity and documentation regarding the incident. The DNS initially believed the cause of the bruise was known and witnessed, but could not provide evidence or identify who witnessed the incident. The facility's policy on abuse/neglect requires that injuries of unknown origin be investigated and reported if the source is not observed, the resident cannot explain the occurrence, and the injury is suspicious. The DNS admitted to not having documentation to support the claim that the bruise was witnessed, and the necessary investigation and reporting procedures were not followed.
Failure to Develop Comprehensive Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who was prescribed an anticoagulant, Eliquis, for conditions including long-term use of anticoagulants, peripheral vascular disease, and acute coronary thrombosis. The physician's order required the administration of 5mg of Eliquis every 12 hours. Despite the resident being cognitively intact and requiring maximal assistance for mobility and personal care, the care plan did not address the use of the anticoagulant or the potential side effects and necessary precautions associated with its use. The care plan for the resident only identified risks related to cardiovascular status, such as elevated blood pressure and chest pain, without mentioning the anticoagulant therapy. A pharmacy consultant recommended monitoring for bruising, bleeding, and signs of thromboembolism, but the clinical record showed no evidence that these recommendations were addressed. The facility's policy required daily updates to care plans by any member of the interdisciplinary team, but this was not done in this case, leading to the deficiency.
Medication and Oxygen Management Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered accurately according to physician's orders for Resident #17, who was prescribed Lorazepam for anxiety disorder. The Controlled Substance Disposition Record and Medication Administration Record (MAR) revealed multiple instances where the incorrect dosage of Lorazepam was administered, or doses were missed entirely. The Charge Nurse and LPN involved did not follow proper procedures for documenting and administering the medication, leading to discrepancies in the records. The LPN admitted to being new to the facility and not receiving adequate orientation or competency training, which contributed to the medication errors. Additionally, the facility failed to follow physician's orders for Resident #26, who required continuous oxygen due to acute respiratory failure with hypoxia. Observations and interviews revealed that the oxygen was set at an incorrect flow rate of 3 liters instead of the prescribed 2 liters. Furthermore, there was a lack of documentation regarding lung assessments in the nursing notes, despite the resident's ongoing respiratory issues. The RN responsible for checking the oxygen admitted to not noticing the incorrect flow rate and only performing lung assessments when the resident showed signs of breathing difficulty. The deficiencies in medication administration and oxygen management highlight a lack of adherence to physician's orders and facility policies. The absence of proper documentation and failure to conduct necessary assessments contributed to the deficiencies observed in the care of both residents. These issues were compounded by inadequate training and orientation for the nursing staff, leading to errors in medication administration and monitoring of residents' conditions.
Failure to Apply Splint as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a resident's splint was applied according to the physician's orders. The resident, who had diagnoses including dementia and delusional disorders, was at risk for contractures in the left upper extremity. The care plan required the splint to be worn at all times except during activities of daily living (ADLs) and patient care. However, observations on multiple occasions revealed that the resident was without the splint during times it should have been applied, such as in the morning and during meals. Interviews with staff, including an LPN and a nurse aide, revealed a lack of understanding and training regarding the splint application. The LPN believed the splint was only to be worn at night, while the nurse aide had not received training on its application. The occupational therapist confirmed the splint was necessary to prevent further contractures and should be worn except during care and ADLs. The facility's splinting policy required clear physician orders and staff training, which were not adequately followed, leading to the deficiency.
Failure to Assess Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely assessment of significant weight loss for a resident with multiple health conditions, including congestive heart failure and depression. Physician's orders required weight checks three times a week and notification for weight changes of 3 pounds or more. Despite these orders, the resident experienced a significant weight loss of over 5 percent within a month, which was not assessed by the dietician or physician. The resident's care plan identified potential nutritional risks, but interventions such as dietician evaluation and monitoring intake were not effectively implemented. Interviews with facility staff revealed a lack of clarity and adherence to the facility's weight loss policy. The Medical Director and Director of Nursing acknowledged the dietician's responsibility to assess weight loss, but neither the dietician nor the physician was notified of the resident's significant weight loss. Additionally, the Licensed Practical Nurse was unaware of the policy for reporting weight loss and had not been trained on identifying significant weight loss. Attempts to interview the dietician were unsuccessful, and the facility's weight loss policy was not followed, leading to the deficiency.
Failure to Implement Pharmacy Recommendations for Resident's Medication Regimen
Penalty
Summary
The facility failed to ensure that medication reviews were provided to the provider and appropriate actions were taken for a resident. The resident had diagnoses including long-term use of anticoagulants, bipolar II disorder, and anxiety disorder. A medication regimen review conducted by the pharmacy consultant on October 4, 2024, recommended monitoring for bruising, bleeding, and signs of thromboembolism due to the resident's use of an anticoagulant. However, these recommendations were not incorporated into the resident's plan of care, nor was there any rationale documented for why the monitoring was deemed unnecessary. The medication administration record (MAR) and treatment administration record (TAR) for October 2024 did not reflect the pharmacy consultant's recommendations. Interviews revealed that the Director of Nursing Services (DNS) had not been receiving pharmacy recommendations since starting in August 2024, and previous recommendations could not be located. The facility had transitioned to a new pharmacy in November 2024, and discussions with the provider regarding the recommendations had only recently occurred. The facility's policy required that each pharmacy recommendation be documented in the resident's medical record and communicated to the attending physician and nursing team. The attending physician was responsible for reviewing the recommendation and deciding whether to implement it. If the physician disagreed with the recommendation, they were to document the rationale for not following the advice. However, in this case, the process was not followed, leading to a failure in ensuring the resident's medication regimen was appropriately managed.
Failure to Properly Administer Metoprolol Succinate ER
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Metoprolol Succinate ER. The resident, who had diagnoses including unspecified atrial fibrillation, dysphagia, and long-term use of anticoagulants, was prescribed Metoprolol Succinate ER 50mg twice a day for hypertension. The physician's order explicitly stated that the medication should not be crushed or chewed. However, during a medication administration observation, an LPN was identified as having crushed the Metoprolol Succinate ER before administering it to the resident. The LPN admitted to crushing the medication daily, realizing only after re-reading the blister pack that it was an extended-release medication. The physician confirmed that crushing the medication could be dangerous, as it would release the medication all at once instead of over time. The facility's medication pass policy emphasized the importance of following the five rights of medication administration and required a physician's order for any change in the form of medication. This incident highlights a significant deviation from the prescribed medication administration protocol, posing potential risks to the resident's health.
Failure to Offer COVID-19 Booster Vaccine to Resident
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered and/or assessed for a resident, leading to a deficiency. Resident #33, who was admitted with diagnoses including Parkinson's disease, dementia, malnutrition, and neurocognitive disorder with Lewy bodies, was identified as having severe cognitive impairment. Upon review of the resident's immunization consents and records, it was found that the COVID-19 booster vaccine was not offered to the resident. An interview with the Infection Preventionist (RN #1) revealed that she had recently started her position and was unsure of who was responsible for offering the vaccine when due. She also could not locate the consent for the resident's COVID-19 booster vaccine. The facility's policy indicated that residents should be offered the COVID-19 vaccine unless medically contraindicated or already immunized.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to provide evidence of monthly notification to the state Regional Ombudsman's Office regarding resident transfers and discharge status. A review of the facility's transfer and discharge summary report from May 1, 2024, through November 19, 2024, revealed that 34 residents were discharged or transferred during this period. However, the facility's documentation did not show that these transfers and discharges were reported to the Regional Ombudsman Office on a monthly basis. An interview with a social worker (SW #1) on November 19, 2024, indicated that she had received training on submitting these reports in September 2024 but could not explain why the reports were not submitted. The facility also failed to provide a policy regarding the submission of notices of transfers and discharges to the Regional Ombudsman's office.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to ensure that food items were appropriately labeled and dated when opened, as observed during a survey. In the kitchen's dry storage area, several food items, including a large carton of dry mashed potato flakes, a box of cornstarch, a canister of peanut butter, and a cereal-like substance identified as granola, were found without labels or dates. Additionally, chocolate baking chips and walnuts were stored open without labels or dates, and four butterfly crackers were observed in small plastic cups covered with plastic wrap. Two squeeze bottles containing a brown syrup-like substance were also found without labels or dates. During an interview, the Food Service Director (FSD), who was newly hired almost three months ago, acknowledged that all food should be labeled when opened but was unable to state the facility's policy for labeling and dating foods. The facility's kitchen policy, dated 8/5/24, directed that all food be properly labeled and dated, and manufacturer's recommended use-by dates should be used for any products stored in the kitchen unopened.
Failure to Document Staff Competencies
Penalty
Summary
The facility failed to ensure that nursing staff competencies were completed for four of five sampled staff members, including two nurse aides (NA), one licensed practical nurse (LPN), and one registered nurse (RN). The personnel files for NA #4, NA #6, LPN #4, and RN #8 lacked documentation of completed competencies, despite the facility's policy requiring initial competency assessments upon employment. NA #4 was hired in November 2022, NA #6 in July 1980, LPN #4 in September 2024, and RN #8 in August 2024. Interviews with Business Office Staff #1 and the Director of Nursing Services (DNS) revealed that the competencies were not retained in the employee files, and the DNS could not provide documentation of completed competencies, although she mentioned conducting random observations. The facility's policy, effective November 19, 2024, mandates that all staff possess the necessary competencies to deliver high-quality, safe, and effective care to residents.
Failure to Complete Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure performance reviews were completed for three sampled nurse aides. Personnel records indicated that the nurse aides started their employment on various dates, but their files did not contain performance evaluations for the years 2024, 2023, or 2022. An interview with a business office staff member revealed that she was responsible for part of the employee file but did not retain training or competencies, which were to be completed by the nursing department. The Director of Nursing (DON) confirmed that performance reviews were not being completed and could not be located from before her tenure. The facility's Performance Review policy mandates that all new employees receive a performance review at the end of their probationary period and annually thereafter, unless otherwise required by regulations or contractual obligations.
Failure to Document Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required annual in-service training, as evidenced by the review of personnel files and interviews. Specifically, the personnel files of two nurse aides, one hired in November 2022 and the other in July 1980, lacked documentation of completed annual in-service training. Interviews with the Business Office Staff and the Director of Nursing Services (DNS) revealed that in-service training records were not maintained in employee files and had not been completed for the past year. Additionally, the DNS could not locate any in-service records from before her tenure. The facility's Training Policy mandates that all employees complete annual in-service education to comply with state and federal regulations and to stay updated with best practices.
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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