Complete Care At Glendale
Inspection history, citations, penalties and survey trends for this long-term care facility in Naugatuck, Connecticut.
- Location
- 4 Hazel Ave, Naugatuck, Connecticut 06770
- CMS Provider Number
- 075240
- Inspections on file
- 21
- Latest survey
- February 3, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Complete Care At Glendale during CMS and state inspections, most recent first.
A resident with a left humerus fracture, chronic kidney disease, and type 2 diabetes was discharged from the hospital with a left arm sling, but the facility did not obtain physician orders for the sling or include its use in the resident’s care plan or nurse aide care card. The resident was cognitively intact but dependent on staff for dressing and transfers, and the existing care plan only addressed self-care deficit and fall risk with one-person assistance for dressing, omitting any sling-related interventions. A complaint later alleged the resident was seen without the sling, and staff interviews revealed that while an LPN, NA, and COTA understood the sling was to be worn at all times and believed directions should have been reflected in orders and the RCP, the DON confirmed the facility failed to follow its care plan policy requiring inclusion of necessary services and treatments.
A resident with moderate cognitive impairment and risk factors for malnutrition had a critical sodium lab result. While the physician and APRN were involved and new treatment orders were communicated to the family, there was no documentation that the family was specifically informed of the critical lab value, contrary to facility policy.
A resident with a history of hyponatremia experienced a critical drop in serum sodium. Although a provider ordered a follow-up BMP, delays and miscommunication in processing and notifying the lab resulted in the blood draw occurring much later than intended. The resident was later found unresponsive and required hospital transfer for severe electrolyte imbalances and acute respiratory failure.
The facility failed to maintain nourishment refrigerators in a clean and sanitary manner, with various unlabeled, undated, and expired food items found during an inspection. The Director of Dietary acknowledged the responsibility for cleanliness and adherence to labeling policies, but multiple violations were observed.
The facility failed to conduct a required background check for an LPN hired, as the personnel file lacked the state-required ABCMS background check, including fingerprinting. The Director of HR confirmed the oversight during an interview.
The facility failed to submit a PASSAR when a resident received a new diagnosis. The resident was initially admitted with mild or situational depression and later diagnosed with dementia, anxiety disorder, and other conditions. The oversight was acknowledged by the MDS Coordinator and social worker, who admitted that a new PASSAR should have been completed but was missed.
The facility failed to complete a required status change Level 1 PASRR screen for a resident with major depressive disorder and other diagnoses, despite continued behavioral health symptoms and recommendations for reevaluation. Interviews confirmed the oversight, and the facility's policy was not followed.
A resident with muscle weakness and dementia was found self-propelling in a wheelchair without leg rests, causing discomfort due to a new, higher cushion. Staff interviews confirmed the absence of leg rests and lack of communication about their unavailability, contrary to facility policy.
The facility failed to timely apply a low air loss mattress for a high-risk resident and did not complete an RN assessment on a newly identified skin issue. Despite a physician's order, the mattress was delayed, and the new pressure injury was not assessed by an RN within the required timeframe.
The facility failed to follow manufacturer recommendations for cleaning and storing a CPAP machine for a resident with obstructive sleep apnea. The CPAP mask was found unbagged and undated, and the resident reported that the mask and tubing had never been changed since admission. The DNS was unable to provide clear answers on the frequency of changing and cleaning the CPAP components, leading to the deficiency.
The facility failed to have physicians' orders signed in a timely manner for a resident with multiple diagnoses, including obstructive sleep apnea and epilepsy. Despite the facility's policy requiring timely signatures, the orders were not signed for several months, and staff interviews confirmed the oversight.
The facility failed to ensure that the attending physician reviewed and responded to the pharmacy consultant's recommendations for a resident with heart failure and atrial fibrillation. Despite repeated recommendations to evaluate the resident's Amiodarone dosage, there was no documented follow-up or action taken by the cardiologist or facility staff, indicating a lapse in communication and adherence to policy.
The facility failed to monitor medication refrigerator temperatures as per policy, with multiple instances of missing or incomplete temperature recordings over three months. An RN responsible for the logs was unsure of the requirements, and the facility policy was not followed.
A resident with a sacral pressure ulcer did not receive proper infection control and hand hygiene during a dressing change. The LPN placed dressing supplies on an unclean dresser, used unclean bandage scissors, and failed to perform hand hygiene after glove changes. The RN identified these actions as deviations from the facility's policies, which require a clean field, proper hand hygiene, and the use of clean instruments.
Failure to Care Plan and Obtain Orders for Required Arm Sling After Humerus Fracture
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan and corresponding physician orders for a resident who required a left arm sling following a humerus fracture. The resident’s diagnoses included a left humerus fracture, chronic kidney disease, and type 2 diabetes. Hospital discharge documents dated 11/21/25 indicated the resident was fitted with a left arm sling due to the fracture. However, review of physician orders from 11/21/25 through 12/2/25 showed no order for a left arm sling. A five-day MDS assessment identified the resident as cognitively intact with a BIMS score of 13 and dependent on staff for dressing and transfers. The Resident Care Plan dated 11/27/25 documented a self-care deficit and fall risk with an intervention for one-person assistance with dressing, but it did not include the use of a sling or interventions specific to the left arm fracture. The nurse aide care card also lacked instructions that the resident was to wear a left arm sling at all times. A complaint filed on 1/2/26 reported that during a visit on 12/3/25, the resident was observed without the sling. In interviews, an LPN recalled that the resident had a sling that was to be worn all the time and stated that directions for sling use should have been on the physician’s order or the care plan. A nurse aide reported that the resident wore the sling all the time except when being changed, and that she learned sling directions from the therapist and believed they were on the care card, while also noting the sling sometimes came off with the resident’s independent movement. The COTA stated she was informed of sling orders by the OT and that such orders should have appeared on the physician’s orders, care plan, and care card. The DON acknowledged that directions for sling use should have been on the physician’s orders or the care plan and that the facility failed to follow its Care Plan Policy, which requires care plans to include instructions and services/treatments needed to provide effective, person-centered care.
Failure to Notify Family of Critical Lab Value
Penalty
Summary
The facility failed to notify the family member of a resident regarding a critical lab value. The resident, who was moderately cognitively impaired and at risk for malnutrition due to hyponatremia and other medical conditions, had a critical serum sodium level of 99 identified in lab results. Although nursing notes documented that the resident was seen by a physician and an APRN, and that new orders were communicated to the family member, there was no documentation that the family member was specifically informed of the critical sodium level. Subsequent nursing notes indicated the initiation of intravenous hydration and further lab testing, with continued documentation that the family member was aware of new orders. However, at no point did the records show that the family member was notified of the critical lab value itself, as required by the facility's Notification of Changes policy. This omission constituted a failure to promptly inform the resident's representative of a significant change in the resident's condition.
Failure to Ensure Timely Follow-Up Labs for Critical Sodium Levels
Penalty
Summary
The facility failed to ensure timely follow-up laboratory testing for a resident with a history of hyponatremia and other medical conditions following a critical lab result. The resident, who was moderately cognitively impaired and at risk for malnutrition, was discharged from the hospital with improved sodium levels but later had a critical serum sodium level of 99 identified in the facility. Although a provider ordered a Basic Metabolic Panel (BMP) to be drawn the following day, the order was canceled and replaced with a STAT order later that morning after it was discovered the initial lab had not been drawn. The STAT order was not entered into the lab portal until one hour and thirty minutes after being written, and the required notification to the lab service provider was not documented. The blood draw did not occur until late that evening, and the results again showed a critical sodium level. Interviews with facility staff revealed a lack of communication and understanding regarding the urgency and process for STAT lab orders, especially on non-routine lab days. The Director of Nursing acknowledged the facility's failure to process the initial BMP order, and the lab service provider confirmed that STAT orders required both entry into the portal and direct notification. The resident was ultimately found unarousable and transferred to the hospital with multiple critical diagnoses, including severe electrolyte imbalances and acute respiratory failure.
Failure to Maintain Clean and Sanitary Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain nourishment refrigerators in a clean and sanitary manner, as observed during a tour with the Director of Dietary. The inspection revealed various issues, including dried liquid and splatter marks inside the refrigerators, partially eaten and unlabeled food items, and expired food. Specific items found included minestrone soup, sausage cubes, cheese cubes, a chicken sandwich, a peanut butter and jelly sandwich, brown pudding, applesauce, a small round cheesecake, cheese sticks, and tangerines, all of which were either not labeled, not dated, or expired. Additionally, the second nourishment refrigerator had crumbs, liquid spots, a torn freezer seal, and various unlabeled and undated items such as a frozen yogurt, a metal water bottle, a red liquid in an Arizona bottle, a half-eaten ice cream caramel cookie crunch, a pitcher of liquid, a sandwich, and soup in a bowl with a lid. The Director of Dietary indicated that it was the responsibility of the kitchen and housekeeping to keep the nourishment refrigerators and freezers clean. She usually cleaned them daily but was off on Friday, Saturday, and Sunday, during which time the cook was responsible. The Director of Dietary acknowledged that all items in the nourishment refrigerator should be discarded after three days and that all staff and visitors were aware of the labeling and dating requirements. Despite this, the inspection found multiple violations of the facility's policy on maintaining and labeling food items in the nourishment refrigerators, leading to the identified deficiencies.
Failure to Conduct Required Background Check for LPN
Penalty
Summary
The facility failed to conduct a required background check for one of five personnel files reviewed. Specifically, an LPN hired on 1/17/22 consented to a background check on 1/6/22, but the personnel file did not contain the state-required ABCMS background check, including fingerprinting. During an interview on 1/26/24, the Director of HR acknowledged that the required background check was not completed prior to the LPN's hire and was unable to provide a reason for this oversight, as it occurred before her employment at the facility. The facility's policy mandates that all employment offers are contingent upon clear results from a thorough background check, including state-specific requirements.
Failure to Update PASSAR for New Diagnosis
Penalty
Summary
The facility failed to submit a Pre-Admission Screening and Resident Review (PASSAR) when a resident received a new diagnosis. Resident #40 was initially admitted with diagnoses including mild or situational depression, myocardial infarction, and urinary tract infection. A PASSAR Level 1 assessment identified mild or situational depression with no major mental illness or dementia, granting a 120-day short-term approval. Upon readmission, Resident #40 had new diagnoses including anxiety disorder, congestive heart disease, depression, and cerebral infarction. The care plan and annual MDS indicated severely impaired cognition, dementia, anxiety disorder, depression, and psychotic disorder, with the resident receiving antidepressants daily. However, the social worker's annual assessment did not consider the resident for a Level 2 PASSAR process for serious mental illness or intellectual disability. Interviews revealed that the MDS Coordinator and social worker acknowledged the oversight. The MDS Coordinator noted that the resident was admitted without a dementia diagnosis, which was later identified in October 2022. The social worker admitted that a new PASSAR should have been completed when the new diagnosis was identified but was missed. The oversight was not caught during an audit by a previous social worker. The current social worker submitted a new PASSAR only after the surveyor's request, which resulted in a Level 1 exemption due to the new dementia diagnosis. The facility's policy mandates that social services ensure appropriate pre-admission screening and updates for mental illness and intellectual disability, which was not adhered to in this case.
Failure to Complete Required PASRR Screening
Penalty
Summary
The facility failed to ensure a status change Level 1 PASRR screen was completed for Resident #83, who was admitted with diagnoses including neoplasm of the brain, anxiety, and major depressive disorder. The initial PASRR Level 1 Outcome report indicated that if Resident #83's symptoms did not improve within 30-60 days, an updated status change Level 1 screen should be submitted. Despite this recommendation, no updated screen was submitted even though Resident #83 continued to exhibit behavioral health symptoms and was on antidepressant medication as noted in the care plan and annual MDS. Interviews with the social workers confirmed that four Level of Care evaluations had been completed since admission, but the required updated PASRR screen was not submitted. The facility's policy directs staff to ensure appropriate pre-admission screening for mental illness and/or intellectual/developmental disability, but this was not followed in Resident #83's case. The Director of Social Services acknowledged the oversight and indicated that an audit would be conducted to ensure no other residents had missed screenings or evaluations.
Failure to Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to ensure proper positioning in a wheelchair for Resident #74, who was admitted with diagnoses including muscle weakness, difficulty in walking, and dementia. The resident was identified as a fall risk and dependent on staff for footwear. An occupational therapy note indicated the resident could sit unsupported for 30 seconds but was unable to stand unsupported. A physician's order directed the use of a pressure redistribution cushion, and the care plan included applying pressure redistribution surfaces to the chair. However, observations revealed that the resident was self-propelling in a standard wheelchair without leg rests, causing discomfort as the resident's legs were dangling above the floor due to the new cushion's height. Interviews with staff confirmed the absence of leg rests and the lack of communication regarding their unavailability. The Director of the Rehabilitation Department acknowledged the issue, noting that the new cushion was higher than the previous one, causing the resident's feet to be 4 inches from the floor. The resident expressed discomfort and requested leg rests. Despite the resident's inability to self-propel with their legs, the wheelchair lacked leg rests, contrary to the facility's policy. The staff development nurse confirmed that nursing staff are educated on the requirement for leg rests if a resident cannot self-propel with their legs. Further interviews and observations confirmed that the resident was later provided with a smaller cushion and leg rests, improving comfort. The facility's policy on wheelchair use emphasized the importance of proper sizing and the use of leg rests for non-ambulatory residents. The deficiency was identified due to the failure to adhere to this policy, resulting in the resident's discomfort and potential risk for further complications.
Failure to Timely Apply Low Air Loss Mattress and Complete RN Assessment
Penalty
Summary
The facility failed to ensure timely application of a low air loss mattress for a resident at high risk of skin breakdown and did not complete an RN assessment on a newly identified skin issue. Resident #29, who was admitted with a wound vac for a right hip abscess, had a high risk of developing pressure ulcers as identified by the Braden Scale. Despite a physician's order on 12/5/23 to apply a low air loss mattress, the mattress was not placed until 12 days after admission. Additionally, a newly identified sacral pressure injury on 12/17/23 was not assessed by an RN until 12/19/23, contrary to facility policy requiring RN assessment within 24 hours of a new skin issue being identified by an LPN. Interviews with facility staff revealed confusion and lack of documentation regarding the placement and settings of the low air loss mattress. LPN #2 and RN #3 were unsure about the exact timing and documentation of the mattress placement. The facility's system did not have a record of the mattress request, and the Regional Clinical Manager could not determine when it was applied. Furthermore, the facility failed to provide policies on Braden Scale assessments, newly identified skin issues, or low air loss mattresses when requested. The care plan for Resident #29 included interventions for skin breakdown due to decreased mobility, incontinence, and existing wounds. However, the facility did not adhere to these interventions promptly. The resident's representative expressed concern about the development of a new pressure ulcer, feeling that the facility should have had preventive measures in place given the resident's history with wounds. The DNS confirmed that an RN assessment should have been completed for the new skin issue, and the facility policy was not followed in this instance.
Failure to Follow CPAP Cleaning and Storage Guidelines
Penalty
Summary
The facility failed to follow the manufacturer recommendations in the cleaning and storage of a CPAP machine for a resident with obstructive sleep apnea. The resident's care plan indicated the need for CPAP maintenance, but the physician's orders lacked specific instructions on cleaning and changing the CPAP components. During an observation, the resident's CPAP mask was found unbagged and undated, and the resident reported that the mask and tubing had never been changed since admission. The Director of Nursing Services (DNS) was unable to provide clear answers on the frequency of changing and cleaning the CPAP components and subsequently discarded the mask and tubing without following proper procedures. The facility's CPAP/BiPAP Cleaning Policy was not adhered to, as the CPAP mask and tubing were not cleaned or stored according to the manufacturer's guidelines. The policy required the CPAP frame to be cleaned when visibly soiled, covered with a plastic bag when not in use, and the equipment to be replaced routinely. The manufacturer manual specified that the filter should be rinsed every two weeks and replaced after 30 nights of use, and the tubing and mask should be hand-washed daily. These procedures were not followed, leading to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Timely Sign Physician's Orders
Penalty
Summary
The facility failed to have physicians' orders signed in a timely manner for Resident #102, who was admitted with diagnoses including obstructive sleep apnea, stroke, heart disease, and epilepsy. The care plan identified the resident was at risk for seizures, requiring medication per physician order and monitoring effectiveness. However, a review of physician's orders from 8/31/23 to 10/31/23 and from 12/1/23 to 12/31/23 revealed that the physician/APRN had not signed and dated the orders. Interviews with various staff members, including RN #3, RN #4, Medical Records Person #1, and the DNS, confirmed that the physician's orders were not signed as required, either electronically or in the paper chart. MD #2, responsible for signing the orders, acknowledged the oversight and indicated he only signed the orders electronically on 11/8/23 and 1/10/24, missing the required signatures for other months. The facility's policy required physicians to sign admission orders within 48 hours and then monthly for the first three months, followed by every 30 or 60 days. Despite this policy, the orders for Resident #102 were not signed for several months. Medical Records Person #1 admitted to not knowing how to check the electronic medical record for signatures, and MD #2 confirmed that he did not sign the admission orders or the monthly orders for September, October, and December 2023. The deficiency was further highlighted by the lack of a specific policy regarding the signing of physician's orders, as requested but not provided by the facility.
Failure to Review and Respond to Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician reviewed and responded to the pharmacy consultant's recommendations for Resident #65, who was admitted with diagnoses including heart failure, bradycardia, and chronic atrial fibrillation. The consultant pharmacist's medication regimen review on 7/15/23 recommended evaluating the need for the resident's current Amiodarone dosage of 200mg twice daily, suggesting a reduction to 100mg once daily to minimize side effects. However, the facility deferred this recommendation to the consultant cardiologist, and there was no documentation that the cardiologist reviewed or acted upon this recommendation during subsequent visits on 10/25/23 and 11/8/23. The same recommendation was repeated in the pharmacist's review on 12/5/23, with the facility again deferring to the cardiologist without documented follow-up or action taken. Interviews with the consultant cardiologist and facility staff revealed gaps in communication and documentation. The cardiologist could not recall reviewing the pharmacist's recommendations and indicated that he would not have agreed to the dose reduction but would evaluate the resident during his next visit. The Unit Manager, responsible for preparing and communicating the resident's medication list to the cardiologist, could not explain why the pharmacist's recommendations were not documented as reviewed. Similarly, the APRN indicated that she would defer to the cardiologist for recommendations related to Amiodarone dosing but did not provide specific answers without access to her documentation. The facility's policy directs that the consultant pharmacist's recommendations should be communicated and responded to in a timely manner. However, the lack of documentation and follow-up on the pharmacist's recommendations for Resident #65 indicates a failure to adhere to this policy. The Regional Clinical Manager suggested that going forward, the nurse passing along information to the consultant should write a confirmation note if there are no changes to the medication regimen based on the pharmacist's recommendations, highlighting the need for improved communication and documentation practices within the facility.
Failure to Monitor Medication Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure that medication storage refrigerator temperatures were monitored in accordance with facility policy. Observations and reviews of the medication refrigerator temperature logs for the L/M and S/R units identified multiple instances of missing daily temperature recordings over a three-month period. Specifically, for the M/L unit refrigerator, no temperatures were recorded on several days in November, December, and January, and for many days, only one temperature was recorded instead of the required two. Similar issues were found with the S/R unit refrigerator logs, with numerous days missing temperature recordings and many days having only one recorded temperature. Additionally, a future date temperature was documented, indicating a lack of proper monitoring and recording practices. An interview with an RN responsible for collecting and reviewing the medication refrigerator logs revealed uncertainty about the requirement for completing the logs once or twice daily. The RN acknowledged awareness of the missing temperatures and was working with nursing supervisors to ensure compliance. The facility's policy directed that medication refrigerator temperatures be checked twice daily by licensed staff and logged accordingly. However, the observed and documented practices did not align with this policy, leading to the identified deficiency.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to ensure proper infection control techniques and hand hygiene during a dressing change for a resident with a sacral pressure ulcer. The resident, who had a history of cerebral infarction, osteomyelitis of the right femur, and insulin-dependent diabetes, was admitted with a wound vac in place due to a right hip abscess. During the dressing change, the LPN placed dressing supplies directly on an unclean dresser top without a barrier, reached into her pockets with gloved hands, and used unclean bandage scissors. Despite being directed by the RN to correct these actions, the LPN continued to make errors, including not performing hand hygiene after glove changes and using gloved fingers to apply ointment instead of a tongue depressor. The LPN also failed to set up a trash collection bag for soiled items and left a soiled brief on the resident's bed during the procedure. The RN identified these actions as deviations from the facility's policies on clean dressing changes and wound care, which require a clean field, proper hand hygiene, and the use of clean instruments. The LPN admitted to being nervous due to the observation, which contributed to her mistakes. The facility's documentation showed that the LPN had completed annual competencies related to hand hygiene and PPE use, but these were not followed during the dressing change. The facility's policies clearly outlined the correct procedures for dressing changes, including the use of a clean field, proper disposal of soiled items, and the use of clean instruments, all of which were not adhered to during this incident.
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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