Complete Care At Meriden
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 845 Paddock Ave, Meriden, Connecticut 06450
- CMS Provider Number
- 075192
- Inspections on file
- 22
- Latest survey
- April 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Complete Care At Meriden during CMS and state inspections, most recent first.
A resident with mental health diagnoses and requiring ADL assistance was involved in a verbal altercation with a nurse aide, during which the aide spoke loudly, used inappropriate language, and repeated the resident's foul language back to them. Witnesses, including a dietary aide and an LPN, confirmed the aide's unprofessional conduct, which did not align with facility policies on resident rights and dignity.
A resident with cognitive impairment and a known risk for elopement exited the facility unsupervised after staff failed to properly investigate an emergency exit door alarm. Despite care plans and interventions such as a wander guard and scheduled visual checks, staff did not follow elopement protocols, resulting in delayed search and notification. The resident was later found by police at a nearby location after experiencing chest pain.
A resident with cognitive impairment and a history of wandering did not have a physician's order or care plan in place for a wanderguard, despite staff notes indicating its use and ongoing wandering behavior. Facility staff were unclear about when the device was applied, and required documentation and assessments were missing prior to the resident's elopement from the facility. The necessary care planning and monitoring interventions were only implemented after the resident was found outside the facility.
The facility experienced issues with food storage practices in the dry storage area, including an open bag of chocolate chips and detergent bottles stored alongside food items. Inconsistent documentation of daily meal temperatures was also observed, with missing entries in the logs. Improper food handling was noted, such as a cook using bare hands to handle hamburger rolls during plating. Additionally, maintenance issues with ice machines were identified, including pink debris buildup on the ice outlet and water overflow onto the floor. The buildup was attributed to improper use of ice containers with juice residue. Cleaning practices were found to be insufficient, with wet floors in the nourishment room and the need for manual emptying of ice machine catch trays. Housekeeping staff were unsure of the frequency for tray emptying.
The facility failed to obtain consent and physician's orders for bed rails for six residents, did not perform annual bed rail inspections, and did not follow its policy for bed rail use and maintenance.
The facility failed to ensure that a resident with dementia had their diagnosis reflected in their care plan and did not include a facial hematoma in another resident's care plan despite a physician's order to monitor it. Interviews confirmed that it was the responsibility of the MDS Coordinator and nurses to update care plans as needed.
The facility failed to revise the care plan for a resident with dementia and Alzheimer's disease regarding the utilization of side rails in a timely manner. Observations identified that the resident's bed had two half side rails up, contrary to the care plan. An interview with the DNS revealed that the care plan had not been revised since 2020 and lacked a physician's order.
The facility failed to provide a discharge transition plan for a resident discharged AMA. Despite the resident's severe cognitive impairment and need for assistance, the responsible party took the resident home without receiving a proper discharge plan, as confirmed by the RN and DON.
A resident with multiple diagnoses, including chronic pain syndrome, experienced a fall and later reported new hip pain. The nursing staff administered pain medication but did not reassess the resident, attributing the pain to the chronic condition. An x-ray was ordered but not obtained before the resident was transferred to the ER for an unrelated issue. Interviews revealed that the RN should have reassessed the resident, and the facility did not provide a policy for RN assessments.
A resident with multiple diagnoses and a moderate fall risk was left unattended in an unsafe position with a high bed, leading to a fall. The resident had reported a malfunctioning side rail, which was not addressed over the weekend. The facility's failure to ensure timely maintenance and appropriate supervision resulted in the resident's fall and transfer to an acute care facility.
The facility failed to communicate a resident's fall to the community center providing specialized services. The resident, who had multiple diagnoses including end-stage renal disease, fell out of bed and the incident was not documented in the communication book. This led to the specialized service center withholding heparin and transferring the resident to the Emergency Department post-treatment.
The facility failed to ensure timely review and follow-up of pharmacy recommendations for two residents. One resident had no follow-up on recommendations for alternative medications due to swallowing difficulties, and another resident had delayed action on a recommendation to evaluate and consider discontinuation of lorazepam PRN due to the lack of a stop date.
The facility failed to maintain accurate clinical records for two residents involved in an alleged physical mistreatment incident. A resident with dementia expressed pain when a nurse aide forcefully attempted to put them to bed, witnessed by another resident. The incident was not documented in the clinical records, contrary to facility policy.
The facility failed to ensure that PBJ data was complete and accurate for multiple quarters, identifying excessively low weekend staffing. The Administrator revealed that the data inputted automatically through payroll did not capture hours worked by agency or shared staff, and agency staff did not punch in. This issue had been fixed for 2024.
The facility's QAA committee meetings lacked the required attendance of the Medical Director and Infection Preventionist for three consecutive months. The Administrator and DNS confirmed that the Medical Director attends quarterly medical staff meetings instead, and the Infection Control Nurse does not attend QAPI meetings due to her part-time schedule.
Failure to Treat Resident with Respect and Dignity During Verbal Exchange
Penalty
Summary
A deficiency occurred when a resident with a history of depressive episodes, anxiety, delusional disorders, and auditory hallucinations was not treated with respect and dignity during an interaction with a nurse aide (NA). The resident, who required assistance with activities of daily living (ADLs) and had a BIMS score of 13/15, became upset during an incident involving spilled food. Witnesses reported that the NA spoke to the resident in a loud and harsh manner, questioning the resident's ability to clean themselves and using inappropriate language. The resident responded with foul language, and the NA repeated the phrase back to the resident, further escalating the situation. Multiple staff members, including a dietary aide and an LPN, overheard the exchange and confirmed that the NA's tone and volume were inappropriate. Facility documentation and interviews indicated that the NA's conduct did not align with the facility's policies on resident rights and professional behavior. The NA engaged in a verbal exchange with the resident, raising her voice and repeating the resident's foul language, rather than de-escalating the situation or maintaining professionalism. The incident was reported to supervisory staff, who acknowledged that the NA's actions were unprofessional and did not uphold the resident's right to be treated with respect and dignity.
Failure to Prevent Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, a history of wandering, and a documented risk for elopement was able to exit the facility unsupervised. The resident had diagnoses including metabolic encephalopathy, alcohol-induced dementia, and anxiety, and required supervision for activities of daily living. The care plan and risk assessments identified the resident as being at moderate risk for elopement, with interventions such as a wander guard bracelet and visual checks every 1-2 hours. Despite these measures, the resident was able to leave the building without staff knowledge. On the day of the incident, the resident was last seen in the hallway, and shortly after, the emergency exit door alarm sounded. A nurse aide responded to the alarm, reset it, but did not investigate the cause or check outside to see if anyone had exited. The nurse aide was unaware that the alarm required further investigation, despite having received prior education on the policy. The resident was not located during subsequent checks, and staff did not immediately follow the facility's elopement protocol, such as initiating a facility-wide search or alerting the appropriate personnel in a timely manner. The resident was eventually found by police at a nearby facility, having complained of chest pain and requiring emergency department evaluation. Interviews with staff revealed gaps in knowledge and execution of elopement protocols, including failure to investigate door alarms and delays in notifying supervisors and initiating search procedures. The emergency exit door in question was not equipped with a wander guard alert system, and staff responses did not align with facility policy for elopement prevention and management.
Failure to Implement and Document Wanderguard Use for Resident with Wandering Behavior
Penalty
Summary
The facility failed to ensure that a resident with a known history of wandering had appropriate physician's orders and a care plan in place for a wanderguard, as required by facility policy. The resident was admitted with diagnoses including metabolic encephalopathy, alcohol-induced dementia, and anxiety, and was identified as having moderately impaired cognition and requiring assistance with activities of daily living. Despite multiple nursing and psychiatric notes documenting the resident's wandering behavior and the use of a wanderguard, there was no evidence in the medical record of an elopement assessment, progress note, or care plan addressing the use of the wanderguard prior to the resident's elopement event. Staff interviews revealed uncertainty regarding when the wanderguard was initially placed on the resident and a lack of documentation for the required physician's order, elopement assessment, and care plan updates. The facility's own policies directed that residents at risk for elopement should have care plans indicating such risk, with detailed monitoring interventions, and that the use of a wanderguard should be supported by physician orders and documented checks for functionality. However, these steps were not completed prior to the resident's elopement. The deficiency was further highlighted when the resident was found missing from their room and later located wandering outside the facility, requiring police and hospital involvement. Only after this incident was a physician's order for the wanderguard documented, and the care plan updated to reflect the resident's elopement risk and necessary interventions. Prior to the event, the lack of proper assessment, documentation, and care planning failed to address the resident's known wandering behavior and elopement risk.
Food Storage and Handling Deficiencies Noted in Dry Storage and Ice Machine Maintenance
Penalty
Summary
The facility failed to ensure proper food storage practices in the dry storage area, as observed during the survey. This included finding an open bag of chocolate chips, detergent bottles, and scrub pads stored alongside food items. Additionally, there was a lack of consistent documentation of daily food meal temperatures, with missing entries noted in the temperature logs. The report also highlighted instances of improper food handling, such as a cook using bare hands to handle hamburger rolls during plating, contrary to recommended food safety practices. Furthermore, observations revealed issues with the maintenance of ice machines, with pink debris buildup noted on the ice outlet and water overflow from the machines onto the floor. The maintenance director attributed the buildup to improper use of ice containers with juice residue. The report also pointed out deficiencies in cleaning practices, as evidenced by wet floors in the nourishment room and the need for manual emptying of ice machine catch trays to prevent overflow. Housekeeping procedures were found to be lacking, with staff unsure of the frequency of tray emptying.
Failure to Obtain Consent and Physician's Orders for Bed Rails
Penalty
Summary
The facility failed to acquire consent and physician's orders prior to the initiation of bed rails for six residents. For Resident #27, the facility did not obtain the necessary consents and physician's orders upon admission, only doing so after surveyor inquiry. Similarly, Resident #28 had bed rails in place without prior consent or physician's orders, which were only obtained after the surveyor's inquiry. Resident #34 also had bed rails without the required documentation, and the bed rail inspection was outdated, with the last inspection being over a year old before a new inspection was conducted after surveyor inquiry. Resident #87 had bed rails in place without documented consent or physician's orders, and the bed rail inspection was not updated annually as required. The Director of Maintenance admitted to not having completed the inspection since the previous year. Resident #212 had bed rails in place without any indication for use or consent obtained, and Resident #215 had bed rails without consent, with the last inspection being outdated by over a year. The facility's policy required annual inspections and obtaining consent and physician's orders, which were not followed. Interviews with the Director of Nursing Services (DNS), Director of Operations, and the Medical Director revealed that they were unaware of the lapses in obtaining consents and physician's orders for bed rails. The facility's policy directed that upon admission, each resident would be assessed for the need for bed rails, consent/education would be obtained prior to installation, and maintenance staff would complete an annual review of the condition and conduct any necessary maintenance. These steps were not followed, leading to the deficiencies identified by the surveyors.
Failure to Reflect Dementia Diagnosis and Facial Hematoma in Care Plans
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dementia was properly reflected in the resident's care plan. Resident #28, who had diagnoses of dementia and Alzheimer's disease, exhibited behaviors such as yelling and striking out at staff and was resistant to care. The care plan dated 3/11/2024 did not mention dementia or Alzheimer's disease, despite the Minimum Data Set (MDS) assessment identifying cognitive loss. Interviews with RN #4 and RN #3 confirmed that the care plan did not reflect the dementia diagnosis and that it was the responsibility of the MDS Coordinator and nurses to update care plans as needed. A care plan addressing dementia was only added after the deficiency was identified during the survey on 4/2/2024. Additionally, the facility failed to develop a care plan for a facial hematoma present on admission for Resident #212. The resident, who had diagnoses including heart failure and diabetes mellitus, was admitted with a facial hematoma and a physician's order to monitor the area every shift. However, the care plan dated 3/22/2024 did not include the hematoma, despite the presence of a physician's order and the identification of the hematoma in the electronic record. Interviews with the ADNS and RN #4 confirmed that the care plan should have included the hematoma, and it was the responsibility of the MDS Coordinator and nurses to update care plans as needed. The facility did not provide a policy for baseline care plans when requested.
Failure to Revise Care Plan for Side Rail Utilization
Penalty
Summary
The facility failed to revise the care plan for a resident with dementia and Alzheimer's disease regarding the utilization of side rails in a timely manner. The resident's care plan, dated 3/11/2024, indicated that the bed should be kept in a low position and the side rails tied down to prevent the resident from putting their arms through the rails. However, observations on 4/3/2024 and 4/4/2024 identified that the resident's bed had two half side rails up. An interview and record review with the Director of Nursing Services (DNS) on 4/4/2024 revealed that the care plan intervention for side rails had not been revised since 2020 and did not include an indication for use or a physician's order.
Failure to Provide Discharge Transition Plan for AMA Discharge
Penalty
Summary
The facility failed to ensure a discharge transition plan was provided to the responsible party for a resident who was discharged Against Medical Advice (AMA). Resident #104, who had diagnoses including cerebral vascular disease and mild cognitive impairment, was identified as severely cognitively impaired and required moderate assistance with toileting. On the day of discharge, the responsible party decided to take the resident home, and the family signed the resident out AMA. Although medication and instructions were provided, a discharge transition plan was not discussed or provided to the family, as confirmed by the Registered Nurse (RN) on duty and the Director of Nursing (DON). The facility's policy for AMA discharges requires that a discharge transition plan be provided to the resident or their representative, including community referrals and documentation of the discharge process. However, in this case, the RN on duty did not recall discussing the discharge plan or living arrangements with the responsible party, nor did he provide a discharge transition plan. This failure to follow the facility's policy resulted in a deficiency in the discharge process for Resident #104.
Failure to Reassess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident reporting new pain following a recent fall was properly assessed. Resident #87, who had diagnoses including end-stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity, experienced a fall on 3/18/24. Despite being identified as at moderate risk for falls and having a care plan in place, the resident was not reassessed for pain after the fall. Initially, no injuries or pain were noted, but later, during an occupational therapy session, the resident reported increased right hip pain. The nursing staff administered pain medication, but the resident was not reassessed by the RN on duty, who attributed the pain to the resident's chronic condition. An x-ray was ordered but could not be obtained before the resident was transferred to the Emergency Department for an unrelated issue. Interviews with the nursing staff and the Director of Nursing Services revealed that the RN on duty should have reassessed the resident following the report of new pain. The Advanced Practice Registered Nurse also confirmed that the new pain was different from the resident's chronic pain and warranted further assessment. The facility did not provide a policy for RN assessments when requested, highlighting a gap in their procedures for handling such incidents. This failure to reassess the resident's new pain following a fall constitutes a deficiency in the care provided by the facility.
Failure to Prevent Accident Hazard Leading to Resident Fall
Penalty
Summary
The facility failed to prevent an accident hazard for a resident who sustained a fall after being left in an unsafe position with the bed in a high position. Resident #87, who had diagnoses including end-stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity, was identified as being at moderate risk for falls. Despite this, the resident was left unattended on their left side with the bed in a high position, leading to a fall. The resident had previously reported a malfunctioning side rail, which was not addressed over the weekend, contributing to the incident. On the day of the fall, a nurse aide (NA #2) left Resident #87 in an unsafe position to report a skin integrity issue and the broken side rail to the nurse. During this time, the resident rolled out of bed and fell. The Director of Maintenance was not notified of the broken rail over the weekend, and the rail was only fixed on the morning of the fall. Interviews with staff revealed that the bed rail was in a fixed down position and the bed was in a high position at the time of the fall. The Director of Nursing (DNS) and other staff members acknowledged that the resident should not have been left in an unsafe position and that proper notifications regarding the malfunctioning equipment were not made. The facility's failure to ensure timely maintenance and appropriate supervision resulted in the resident's fall and subsequent transfer to an acute care facility. The incident highlighted lapses in communication and adherence to safety protocols within the facility.
Failure to Communicate Resident Fall to Specialty Service Center
Penalty
Summary
The facility failed to ensure that a recent fall experienced by a resident was communicated to the community center providing specialized services. Resident #87, who had diagnoses including end-stage renal disease, hypertension, chronic pain syndrome, anxiety, and morbid obesity, fell out of bed on 3/18/24 after being positioned on their left side by a nurse aide. The fall was noted in the nurse's notes, but there was no documented communication to the Specialty Service Center regarding the incident. This lack of communication led to the resident reporting the fall and a head strike to the specialized service center, which subsequently withheld heparin and transferred the resident to the Emergency Department post-treatment. Interviews with the Licensed Practical Nurse and the Director of Nursing Services revealed that the nursing staff did not document the fall in the communication book that accompanies the resident to the community center. The facility's policy for Specialized Treatment Communication Form directs staff to ensure the completion of the communication form to coordinate care between the center and the facility. The failure to document and communicate the fall represents a deficiency in the facility's adherence to its own policies and procedures, potentially compromising the resident's care and safety.
Failure to Ensure Timely Review and Follow-Up of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely review and follow-up of pharmacy recommendations for two residents. For Resident #27, who had diagnoses including COPD, dementia, and bipolar disorder, a pharmacy note dated 6/26/23 recommended alternative medications for divalproex and pantoprazole due to swallowing difficulties and clarifying administration directions for potassium chloride. However, there was no physician response or follow-up on these recommendations. The DNS confirmed the absence of follow-up for the Drug Regimen Review dated 6/26/23 and could not provide a reason for the missing follow-up. For Resident #28, who had diagnoses including dementia, Alzheimer's disease, and delusional disorders, a pharmacy consultant document dated 11/28/23 recommended evaluating and considering discontinuation of lorazepam PRN due to the lack of a stop date, as per CMS guidelines. This recommendation was not addressed timely, resulting in a second recommendation on 1/30/24. The DNS could not explain why the initial recommendation was not addressed, leading to a delay in action. The facility's policy indicated that pharmacy recommendations should be acted upon within 10 working days, which was not adhered to in these cases.
Failure to Document Alleged Physical Mistreatment Incident
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for two residents involved in an alleged physical mistreatment incident. Resident #156, who had dementia and muscle weakness, was identified as severely cognitively impaired and required assistance with activities of daily living. Resident #159, who had an aneurysm of the artery of the lower extremity, was moderately cognitively impaired and required assistance with bed mobility and transfers. On the evening of 11/2/22, Resident #159 allegedly witnessed a nurse aide, NA #3, forcefully attempting to put Resident #156 to bed against their will, causing Resident #156 to express pain. This incident was reported, and NA #3 was removed from the building pending investigation. However, there was no documentation of this incident in the clinical records of either resident. An interview with RN #2, who was the nursing supervisor on duty during the incident, confirmed that she was notified of an altercation and observed Resident #159 kicking NA #3, who was holding Resident #159's wrists to prevent further assault. RN #2 intervened and learned that Resident #159 had concerns about the care provided to Resident #156. A skin check was conducted for Resident #156, and the Director of Nursing Services (DNS) was notified. Both RN #2 and the DNS acknowledged that the incident should have been documented in the clinical records of both residents, as per the facility's policy for charting and documentation.
Incomplete and Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to ensure that Payroll Based Journal (PBJ) data was complete and accurate for Quarter 4 of 2023, Quarter 3 of 2023, Quarter 2 of 2023, and Quarter 1 of 2023. The PBJ submissions for these quarters identified excessively low weekend staffing. An interview with the Administrator revealed that the data for the PBJ is inputted automatically through payroll, and the facility did not capture the hours worked by agency or shared staff. Additionally, the Administrator indicated that agency staff do not punch in, and this issue had been fixed for 2024. A review of the facility policy for Nursing Services and Sufficient Staff identified that the facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal system.
Failure to Include Required Members in QAA Committee
Penalty
Summary
The facility failed to have a Quality Assessment and Assurance (QAA) committee consisting of the minimum required members. The QAPI meeting sign-in sheets for three consecutive months identified the attendance of the Administrator, Director of Nursing Services (DNS), and other staff members, but the Medical Director and Infection Preventionist were not in attendance. During an interview, the Administrator and DNS confirmed that the Medical Director does not attend the monthly QAPI meetings but attends the quarterly medical staff meetings, which are different from the QAPI meetings. Additionally, the Infection Control Nurse, who is a corporate nurse and works at the facility three days a week, does not attend the QAPI or medical staff meetings as they occur on Fridays, a day she does not work.
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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