Complete Care At Kimberly Hall-south
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor, Connecticut.
- Location
- 1 Emerson Drive, Windsor, Connecticut 06095
- CMS Provider Number
- 075237
- Inspections on file
- 26
- Latest survey
- May 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Kimberly Hall-south during CMS and state inspections, most recent first.
A resident with dementia and a history of falls experienced two unwitnessed falls, after which neurological checks were ordered by both nursing staff and a physician. However, there was no documentation that these neurological assessments were completed as required by facility policy, and the DNS could not provide the missing records.
A resident receiving hospice care with orders for as-needed morphine did not receive timely or effective pain management during the dying process. Despite clear signs of distress and repeated family requests, staff failed to administer additional morphine for approximately six hours after an ineffective dose, and did not document follow-up assessments or notify the physician as required by facility policy.
A resident with multiple medical conditions and moderate cognitive impairment developed several wounds, including pressure ulcers and skin tears, which were documented in clinical records. However, staff did not update the care plan to address these actual skin integrity issues, instead maintaining only a plan for risk of impairment. Facility staff confirmed the care plan should have included the resident's current wounds and specific interventions.
A resident with end stage renal disease experienced significant bleeding from an AVF dialysis access site after hemodialysis. Facility staff applied pressure dressings but did not manually apply pressure or remove the dressing to directly assess if bleeding had stopped, relying instead on the appearance of the dressing. The resident suffered recurrent bleeding, was sent to the hospital in hemorrhagic shock, and required multiple blood transfusions. The facility lacked specific training and guidelines for managing bleeding dialysis accesses.
A resident with end stage renal disease and an AVF experienced significant bleeding from the access site. Nursing staff applied dressings but did not initially use manual pressure or verify bleeding had stopped, leading to further blood loss and emergency intervention. Staff interviews revealed a lack of training and knowledge regarding proper AVF bleeding management, and the facility lacked formal guidelines or documented training on this issue.
A resident with significant mobility and cognitive impairments was transferred from bed to wheelchair using a Hoyer Lift by two aides. After the transfer, the lift tilted and its overhead bar struck the resident's head, causing a scalp abrasion. Staff interviews confirmed proper training and two-person assistance, but the cause of the tilt was not identified.
A nursing assistant failed to perform hand hygiene between glove changes while providing incontinent care to a resident with diabetes and a UTI, despite facility policy requiring hand hygiene after glove removal. The lapse was observed during care, and the staff member acknowledged forgetting the required step.
A resident with quadriplegia and intact cognition expressed dissatisfaction with a nurse aide due to personality conflicts and delayed care, specifically being assisted to bed later than the physician-ordered time. Despite the resident's repeated requests to not have this aide provide care, the facility continued to assign the aide, citing staffing assignments and the need for assistance with transfers. The facility's policy on resident rights was not followed, as the resident's preference was not accommodated until after surveyor inquiry.
The facility failed to properly review and document advance directives for two residents, leading to deficiencies in honoring their treatment preferences. One resident's DNR wishes were delayed due to communication issues with their conservator, while another resident's advance directive was signed by an unidentified individual, and not reviewed with the actual representatives. These oversights highlight a lack of adherence to the facility's policy on advance directives.
Two residents experienced deficiencies in care at an LTC facility. A resident with dementia and renal disease had a forehead scab that was not properly assessed or reported, violating the facility's skin assessment policy. Another resident reported an abuse incident involving a nurse aide, but their conservator was not notified, breaching the notification of changes policy. Staff interviews confirmed the lack of documentation and communication in both cases.
A facility failed to conduct quarterly resident care conferences for a resident with multiple health conditions, including congestive heart failure and chronic kidney disease. Despite the care plan identifying the resident's risk for limited engagement, the facility did not document required RCCs from admission through a specified period. Interviews revealed informal meetings occurred, but official RCCs were missed, contrary to facility policy.
The facility failed to document an RN assessment for a resident with a recurring forehead wound and did not set another resident's specialty air mattress according to the physician's order. The first resident's wound was not properly assessed by an RN, despite a physician's order for a wound consult. The second resident's mattress was set significantly below their actual weight, contrary to the care plan. These deficiencies highlight a lack of adherence to facility policies and physician orders.
A facility failed to monitor fluid intake and output for a resident with end-stage renal disease and congestive heart failure, who was on a fluid restriction and required hemodialysis. The care plan included specific fluid restrictions, but documentation of daily fluid intake was missing. Staff interviews revealed a lack of awareness and communication regarding the resident's fluid restrictions and the absence of a system for documenting fluid intake and output.
The facility failed to notify the Office of the State LTC Ombudsman about hospital transfers for six residents with various medical conditions. Staff interviews revealed a lack of awareness about the notification requirement, and the facility's policy on transfers and discharges was not followed, leading to a deficiency in compliance.
Failure to Complete and Document Neurological Checks After Unwitnessed Falls
Penalty
Summary
A deficiency occurred when the facility failed to complete and document neurological checks after an unwitnessed fall for one resident reviewed for falls. The resident, who had diagnoses including encephalopathy, dementia, and adult failure to thrive, was assessed as having moderately impaired cognition and was at risk for falls due to dementia-related forgetfulness and impulsive behavior. The care plan included specific fall prevention interventions, and after two separate unwitnessed falls, nursing notes and physician orders directed that neurological checks be performed per facility protocol. Despite these directives, review of the accident and incident forms, medical records, and facility documentation did not show evidence that neurological checks were completed or documented following either fall. The Director of Nursing Services was unable to provide the required neurological check documentation for the relevant dates. Facility policy required neurological assessments at specific intervals after an unwitnessed fall, but these were not found in the resident's records.
Failure to Provide Timely and Effective Pain Management During Hospice Care
Penalty
Summary
A deficiency occurred when a resident receiving hospice care, with diagnoses including encephalopathy, dementia, and failure to thrive, did not receive appropriate pain management during the dying process. The resident had a provider order for morphine to be administered by mouth every two hours as needed for pain, and later, the order was changed to every hour as needed. On the day in question, the resident was noted to be unresponsive, with vital signs indicating distress, including tachycardia, increased respirations, and low oxygen saturation. The medication administration record showed that morphine was given at 9:45 AM and documented as ineffective, but there was no evidence of follow-up interventions or reassessment for several hours. Family members observed the resident to be agitated, air hungry, and sweating, and repeatedly requested additional morphine administration and a change in dosing frequency. Despite these requests and the resident's ongoing symptoms, no further morphine was administered until approximately six hours after the initial dose. During this period, there was a lack of documentation regarding assessment, intervention, or communication with the physician or hospice team about the ineffective pain control. Nursing staff interviews confirmed that standard procedures for ineffective as-needed medication, such as notifying the physician and documenting follow-up, were not followed. Facility policies required staff to assess for pain, monitor effectiveness of interventions, and update care plans as necessary. The failure to administer prescribed morphine in a timely manner, reassess the resident's pain, and communicate with the physician or hospice team as required by policy led to prolonged unmanaged pain and discomfort for the resident during the end-of-life process.
Failure to Update Care Plan for Actual Skin Integrity Alterations
Penalty
Summary
Staff failed to develop and implement a comprehensive care plan addressing an actual alteration in skin integrity for a resident with multiple complex medical conditions, including hemiplegia, diabetes, chronic kidney disease, and heart failure. The resident was assessed as having moderate cognitive impairment, required total assistance for activities of daily living, and was frequently incontinent. Although the care plan identified a risk for skin integrity impairment and included general interventions such as pressure-relieving devices and scheduled repositioning, it did not address the resident's actual wounds and skin alterations that were documented in clinical records. Clinical documentation revealed the presence of moisture-associated skin damage to the left buttock and scrotum, a skin tear on the left arm, multiple pressure ulcers on the buttocks, an open area near the G-tube, and an unstageable wound to the left sacrum. Despite these findings, the care plan was not updated to reflect these actual skin integrity issues. Interviews with facility staff confirmed that the care plan should have been revised to include the resident's current wounds and specific interventions for their management, as required by facility policy.
Failure to Properly Assess and Manage Dialysis Access Bleeding Results in Immediate Jeopardy
Penalty
Summary
A deficiency occurred when staff failed to adequately assess and manage a resident's arteriovenous fistula (AVF) dialysis access site following hemodialysis. The resident, who had end stage renal disease and moderately impaired cognition, returned from dialysis with no visible bleeding at the AVF site. Several hours later, staff were alerted to bleeding at the site. The initial response involved applying a pressure dressing, but staff did not apply manual pressure or remove the dressing to directly visualize the access site to confirm that bleeding had stopped. Instead, they relied on the appearance of the dressing to determine if bleeding had ceased. Subsequent checks by staff continued to assess only the external dressing, without removing it to inspect the actual puncture sites. The resident experienced recurrent bleeding, with blood saturating the dressings and soiling the bed linens. At this point, staff applied additional dressings and eventually manual pressure, but only after significant blood loss had occurred. Emergency medical technicians arrived to find the resident with heavily blood-soaked bandages and applied effective pressure to control the bleeding. During transport, the resident experienced a sudden change in condition, requiring emergency intervention. The resident was transported to the hospital and diagnosed with hemorrhagic shock, necessitating transfusion of four units of blood and one unit of fresh frozen plasma. Interviews with facility staff and leadership revealed that there was no specific training or guideline in place for managing bleeding dialysis accesses, and that staff did not follow professional standards of practice for assessing and managing AVF bleeding. The facility's own policy required care consistent with professional standards, but this was not followed in the incident.
Failure to Ensure Staff Competency in Managing Bleeding Dialysis Access
Penalty
Summary
The facility failed to ensure that nursing staff and nurse aides were adequately educated and competent in managing bleeding from an arteriovenous fistula (AVF) in a resident receiving hemodialysis. The resident, who had end stage renal disease and moderately impaired cognition, was care planned for monitoring and intervention related to dialysis access, including instructions to apply pressure and notify a physician if bleeding occurred. Despite these directives, when the resident was found bleeding from the AVF, staff actions did not align with professional standards or the care plan. Nursing staff, including an LPN and an RN, responded to the bleeding by applying dressings and securing them, but did not initially apply manual pressure to the site as required. Both staff members relied on absorbent pads and pressure dressings without verifying that the bleeding had stopped by visualizing the access site. The situation escalated when the bleeding recurred, resulting in soaked bandages and blood loss, at which point emergency services were called. Upon arrival, EMTs found the resident with multiple blood-soaked bandages and controlled the bleeding with direct pressure, but the resident experienced a sudden decline in condition, requiring emergency intervention and subsequent hospitalization for hemorrhagic shock and blood transfusion. Interviews with staff revealed a lack of knowledge and training regarding the appropriate response to AVF bleeding. One LPN was unsure of the correct procedure and mentioned the use of a clamp, which is not standard practice for AVF management. The Staff Development Nurse confirmed that there was no formal training or guideline provided to staff on managing bleeding dialysis accesses, and no documentation was available to show that staff had received such training. The facility's policy stated that care should be consistent with professional standards and physician orders, but this was not reflected in staff actions or training.
Injury During Mechanical Lift Transfer Due to Hoyer Lift Tilting
Penalty
Summary
A deficiency occurred when a resident with a history of transient ischemic attack, cerebral infarction, difficulty walking, syncope, and moderate cognitive impairment was transferred from bed to wheelchair using a Hoyer Lift by two nurse aides. The resident was dependent on staff for transfers and required a mechanical lift with two-person assistance, as documented in the care plan. During the transfer, after the resident was placed in the wheelchair, the Hoyer Lift tilted and the overhead bar struck the resident's head, resulting in an abrasion to the scalp. Interviews with staff revealed that both aides were present and had been trained in the use of the Hoyer Lift, with one guiding the resident and the other moving the lift. However, neither the Regional Resource Nurse nor the Director of Nurses could identify the cause of the Hoyer Lift tilting after the transfer. The incident was documented, and the resident's injury was assessed and treated.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
A deficiency was identified when a nursing assistant (NA) failed to perform hand hygiene in accordance with facility policy during incontinent care for a resident. The resident had diagnoses including Type 2 diabetes mellitus without complications and a urinary tract infection, and was assessed as having moderate cognitive impairment with frequent incontinence and dependence on staff for toileting hygiene. The resident's care plan required extensive assistance for toileting hygiene. During observation, the NA prepared for incontinent care by gathering supplies and donning gloves, then removed the resident's brief and performed cleaning. After removing gloves, the NA applied a new set of gloves without performing hand hygiene, applied barrier cream, and again changed gloves without hand hygiene before applying a clean brief. Hand hygiene was only performed after the care was completed and gloves were removed. The NA acknowledged in an interview that facility policy required hand hygiene after glove removal during incontinence care and admitted to forgetting this step. Review of the facility's glove policy confirmed the requirement to wash hands after removing gloves.
Failure to Honor Resident's Care Preferences
Penalty
Summary
The facility failed to honor a resident's choices related to care, specifically regarding the assignment of a nurse aide (NA) to the resident. The resident, who was admitted with diagnoses including quadriplegia, neuralgia, and neurogenic bowel, had intact cognition and was dependent on staff for activities of daily living. The resident had a physician's order to be assisted to bed by 8 PM, but due to issues with NA #1, this was often delayed until 10 PM. The resident expressed dissatisfaction with NA #1, citing personality conflicts and a lack of timely response to call lights, and had refused care from NA #1 multiple times. Despite the resident's repeated requests to not have NA #1 provide care, the facility continued to assign NA #1 to the resident, citing staffing assignments based on seniority and the need for two staff members for transfers. Interviews with various staff members revealed that while some were aware of the resident's preferences, there was no documentation of grievances or actions taken to address the resident's concerns. The Director of Nursing Services (DNS) and the Administrator were not aware of the resident's requests until the time of the surveyor's inquiry. The facility's policy on resident rights emphasizes the importance of respecting residents' choices and preferences, including the right to choose healthcare providers. However, the facility did not adhere to this policy in the case of the resident, as the resident's preference to not have NA #1 provide care was not accommodated. The DNS acknowledged the resident's right to choose their caregiver and indicated that there were no issues with reassigning NA #1 to another unit, yet this was not done until after the surveyor's inquiry.
Failure to Review and Document Advance Directives
Penalty
Summary
The facility failed to properly review and document advance directives for two residents, leading to deficiencies in honoring their treatment preferences. Resident #66, who was admitted with conditions including congestive heart failure and chronic kidney disease, had an advance directive indicating a preference for DNR (Do Not Resuscitate). However, there was a delay in updating and confirming these wishes due to communication issues with the resident's conservator, Person #1. The facility's social worker struggled to contact Person #1, and there was a lack of documentation and follow-up on the resident's initial refusal to sign the advance directive. This resulted in a gap in the completion of the Resident/Patient Health Care Instructions document, which was only resolved after surveyor inquiry. Resident #70, admitted with a history of stroke and severe cognitive impairment, had an advance directive form signed by an unidentified individual. The facility failed to verify the authenticity of the signature or review the advance directives with the resident's actual representatives. Despite having a physician's order for DNR/DNI/RNP, the facility did not ensure that the advance directives were reviewed or updated with the resident's legal representatives since admission. This oversight was only identified after surveyor inquiry, highlighting a lack of adherence to the facility's policy on advance directives. The facility's policy requires that advance directives be reviewed and updated with the resident or their representative during the care planning process and as needed. However, in both cases, the facility did not comply with this policy, resulting in deficiencies in the management of advance directives. The failure to ensure timely and accurate documentation of residents' treatment preferences reflects a significant lapse in the facility's responsibility to support residents' rights regarding treatment and advance directives.
Failure to Notify of Change in Condition and Abuse Allegation
Penalty
Summary
The facility failed to notify the provider or resident representative of a change in condition and an allegation of abuse for two residents. Resident #8, who was admitted with dementia and end-stage renal disease, had a scab on the forehead that was not properly assessed or reported to the appropriate parties. Despite a physician's order for wound consults and regular skin checks, the scab was not documented in the nurse's notes, and there was no RN assessment or notification to the APRN/MD and resident representative. Interviews with staff revealed that the expected protocol for change in condition was not followed, as there was no documentation or notification regarding the scab on Resident #8's forehead. Resident #66, admitted with congestive heart failure and other conditions, reported an incident where a nurse aide allegedly put a washcloth in their mouth. The resident's conservator was not notified of this abuse allegation, and there was no documentation in the nurse's or social service notes about the notification. Interviews with staff indicated that the conservator should have been informed, and the DNS expected documentation of such notifications in the clinical record. However, RN #3 admitted to not documenting the notification attempt, which was against her usual practice. The facility's policies on skin assessment and notification of changes were not adhered to in these cases. The Skin Assessment Policy requires thorough documentation and notification of changes in skin condition, while the Notification of Changes policy mandates informing the resident, physician, and representative of significant changes. Both policies were violated, leading to deficiencies in care and communication for Residents #8 and #66.
Failure to Conduct Quarterly Resident Care Conferences
Penalty
Summary
The facility failed to ensure that resident care conferences (RCC) were completed quarterly for a resident admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and stage 2 chronic kidney disease. The resident was admitted from a short-term general hospital with moderately impaired cognition. The care plan identified the resident as at risk for limited meaningful engagement due to self-isolation, with interventions to provide opportunities for choice during care and activities. However, the social service notes did not document quarterly care conferences from the resident's admission through a specified period, with only a few conferences completed later. Interviews with the resident, the conservator, the social worker, and the MDS Coordinator revealed that while there were frequent informal meetings and communications, official RCCs were not scheduled or documented as required. The MDS Coordinator acknowledged that the resident's initial and subsequent quarterly RCCs were missed, and the DNS expected the first RCC to be completed shortly after admission. The facility's policy mandates that residents and their representatives be part of the interdisciplinary team and participate in care planning, with documentation if they do not participate. This deficiency highlights a lapse in adhering to the facility's policy and regulatory standards for resident care conferences.
Failure to Document RN Assessment and Incorrect Mattress Setting
Penalty
Summary
The facility failed to document an RN assessment for a resident with a non-pressure skin condition. Resident #8, who was admitted with dementia and end-stage renal disease, had a scabbed area on the forehead that was not properly assessed by an RN. Despite a physician's order for a wound consult and treatment, the RN assessments were not documented from 5/13/24 to 7/1/24 and again from 11/17/24 to 11/19/24. Interviews with staff revealed that the area on the resident's forehead had been opening and healing repeatedly without proper documentation or assessment by an RN, contrary to the facility's skin assessment policy. Another deficiency was identified for Resident #68, who was admitted with neuralgia and neurogenic bowel. The resident's specialty air mattress was not set according to the physician's order, which specified it should be adjusted to the resident's weight. Observations revealed that the mattress was set to 220 lbs, significantly below the resident's actual weight of 323.6 lbs. Interviews with staff indicated a lack of awareness and adherence to the physician's order, and the discrepancy was attributed to a recent change in the type of mattresses used by the facility. The facility's policies on skin assessment and support surfaces were not followed, leading to these deficiencies. The lack of RN assessments for Resident #8's recurring forehead wound and the incorrect setting of Resident #68's specialty mattress demonstrate a failure to adhere to established protocols. These oversights were identified during interviews and observations, highlighting gaps in communication and compliance with care plans and physician orders.
Failure to Monitor Fluid Intake for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to ensure proper monitoring of fluid intake and output for a resident with end-stage renal disease, congestive heart failure, and dependence on renal dialysis. The resident was admitted with a care plan that included hemodialysis three times a week and a fluid restriction of 1500 cc per day. However, the facility did not document the daily total of fluid intakes as required by the physician's order and facility policy. The clinical records and facility documentation from October 1 to November 18 did not reflect the necessary documentation of the resident's fluid intake, particularly the dietary intake of 1080 cc during meals. Interviews with various staff members, including the Director of Clinical Operations, unit manager, and charge nurse, revealed a lack of awareness and communication regarding the resident's fluid restrictions and the absence of a system for documenting fluid intake and output. The facility's hemodialysis policy required communication with the dialysis facility about nutritional and fluid management, including monitoring intake and output measurements. However, the facility failed to adhere to these standards, as evidenced by the lack of documentation and awareness among staff members about the resident's fluid restrictions and the necessary monitoring procedures.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding hospital transfers for six residents. These residents had various medical conditions, including diabetes, end-stage renal disease, congestive heart failure, and chronic kidney disease, and were transferred to the hospital for different reasons such as acute encephalopathy, shortness of breath, and abnormal EKG results. Despite these transfers, the facility's action summary reports did not reflect any notifications to the Ombudsman, which is a requirement. Interviews with facility staff revealed a lack of awareness and understanding of the notification requirements. The social worker responsible for updating the Ombudsman indicated that she was not informed about the need to report hospitalizations and only updated the Ombudsman on other types of resident departures, such as those leaving against medical advice or after a respite stay. The Director of Nursing Services was also unaware that hospital transfers were not being reported to the Ombudsman. The facility's policy on transfers and discharges requires that residents and their representatives receive a notice that includes the contact information for the Ombudsman. However, the facility did not maintain evidence that such notices were sent regarding hospital transfers. This oversight led to a deficiency in the facility's compliance with regulatory requirements for notifying the Ombudsman about resident hospitalizations.
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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