Davis Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Danielson, Connecticut.
- Location
- 111 Westcott Rd, Danielson, Connecticut 06239
- CMS Provider Number
- 075423
- Inspections on file
- 27
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Davis Place during CMS and state inspections, most recent first.
A resident who was alert, oriented, and planned for discharge home was admitted with an automatic physician order prohibiting leave of absence (LOA), consistent with the facility’s practice of entering default no-LOA orders for all admissions. Multiple staff, including an LPN, RNs, social services, and PT, reported that residents could only leave on LOA if they specifically requested it, after which nursing would seek a one-time LOA order from a physician/APRN and require a PT assessment, a process that could take a day or more and was partly attributed to insurance reimbursement concerns. The resident expressed a desire to go on LOA to visit grandchildren and was unaware LOAs were permitted. Facility admission materials referenced LOA information on specific pages of the Admissions Agreement, but the pages were unnumbered and did not contain the referenced LOA details, and leadership confirmed there was no formal LOA policy, only this restrictive process, resulting in interference with the resident’s right to exercise LOA.
A resident with severe cognitive impairment and ambulating with a cane exited their room as a food service cart was being pushed by a NA. The resident's cane struck the cart's bumper, causing a fall and resulting in a left femoral fracture. The NA reported checking both sides but could not see over the cart, leading to the accident.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific circumstances or individuals involved.
A resident with severe cognitive impairment received a significant overdose of hydroxyurea after a nurse supervisor incorrectly transcribed hospital discharge orders into the EMR, resulting in administration of 30,000 mg more than ordered. The error was not detected by the provider or during the verification process, leading to critical lab abnormalities and hospitalization for neutropenic fever and multiple infections.
Two residents did not have their care plans updated to address significant clinical needs, including pain management, unauthorized medication use, seizure management, and a blood disorder, despite new diagnoses and physician orders. The care plans lacked measurable goals and interventions for these issues, and were not revised following changes in condition as required by facility policy.
Physician or APRN orders were not reviewed and signed monthly for multiple residents with chronic and complex conditions, as required by facility practice. Documentation showed that in several instances, monthly reviews were missed, and the ADNS could not explain the lapses. The facility also lacked a policy specifying the required frequency for these reviews.
Surveyors identified deficiencies involving two residents: one did not receive timely physician communication and lab result forwarding related to hematology care, and another was not administered an antibiotic as ordered, with the medication left unattended despite the resident's inability to self-administer. These issues were confirmed through record review and staff interviews.
The facility failed to provide residents with the opportunity for in-person dining in the main dining rooms, despite repeated requests during resident council meetings. Residents were observed eating in their rooms or small unit dining spaces. Staff cited illness outbreaks and staffing issues as reasons for the closure, although some units were unaffected by recent outbreaks. The dietary manager was working on logistics to reopen the dining rooms, but challenges persisted.
The facility failed to maintain a safe smoking area as the outdoor concrete patio had multiple holes, creating an uneven surface. The Administrator was unaware of the issue until it was pointed out, despite the Maintenance Director knowing about it for a week but not informing the necessary parties. This oversight led to the deficiency being identified.
A resident with severe cognitive impairment reported missing prescription glasses, but the facility failed to address the grievance promptly. The issue was communicated to the Director of Social Services, who misunderstood the situation, leading to delays in replacing the glasses. The facility did not follow its policy for handling reported losses.
A facility failed to develop a comprehensive care plan for a resident using oxygen therapy, despite the resident's COPD diagnosis and dependency on staff. The care plan lacked necessary interventions, and responsibility for care plan development was unclear. Additionally, another resident with dysphagia was repeatedly given unsafe food items, despite being on a minced/ground diet. The care plan was not updated to address safe food consumption, even after multiple incidents. The facility did not follow its policy for revising care plans as residents' conditions changed.
A facility failed to ensure blood sugar levels were monitored before administering morning insulin to a resident with diabetes. The resident had orders to hold insulin if blood sugar was below 90, but the blood sugar was checked after the insulin was given, not before. This discrepancy led to a deficiency as the facility did not comply with physician orders, potentially compromising the resident's safety.
The facility failed to maintain a clean and sanitary kitchen, with observations of dried spillage, improper food storage, and inadequate cleaning practices. The FSD acknowledged the unsanitary conditions and lack of cleaning schedules, while the facility's policy directed proper cleaning and sanitizing to minimize microorganism growth.
Two residents did not receive the pneumococcal vaccine as per their requests and CDC guidelines. One resident, admitted with diabetes and hyperlipidemia, was not offered the updated PCV20 vaccine despite being eligible. Another resident, admitted with Parkinson's disease, did not receive the vaccine despite giving consent. The DNS acknowledged the oversight and noted reliance on electronic health records without an excel tracking sheet.
The facility failed to maintain kitchen equipment, with non-functional ovens and steam table wells, and a freezer operating above required temperatures. Interviews revealed delays in ordering replacements and repairs, and the maintenance policy was not followed.
The facility failed to provide a dignified dining experience for three residents during breakfast, as they were positioned in the hallway outside their rooms, with some feeding themselves and others being fed by staff. This practice was intended to allow staff to multitask but was not in line with the facility's Meal Service Policy, which emphasizes a quiet, pleasant dining environment. Concerns were raised by the Dietician and DNS about the appropriateness and safety of this practice.
A resident with a history of acute kidney failure and respiratory issues experienced vomiting and potential choking, but the facility failed to notify the physician or conduct an appropriate assessment. Despite the resident's family raising concerns, the nursing staff did not follow the facility's policy for significant changes in condition, leading to a deficiency in care.
A resident with cognitive impairment was found with a medication cup left at their bedside without an order or assessment for self-administration. The LPN admitted to leaving the medication and signing off on the MAR without ensuring the resident took it. The DNS confirmed that medication should not be left at the bedside without a self-administration assessment.
A facility failed to apply adaptive devices for a resident with hemiplegia and hemiparesis as per physician's orders. The resident's care plan required the application of left hand and elbow splints to prevent contractures, but observations showed these were not applied. Staff interviews revealed a lack of communication and verification regarding the resident's care, with no reported skin integrity issues to justify the omission.
A resident receiving IV antibiotics had an outdated peripheral IV line in the left forearm, which was not removed when a new line was placed in the right forearm. The facility failed to obtain physician orders for flushing and monitoring the IV site, contrary to its policy requiring catheter replacement every 72-96 hours and flushing every 12 hours.
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen therapy management. One resident used oxygen without a physician's order due to an oversight during readmission, while another resident's oxygen tubing was not changed weekly as required. Interviews with staff confirmed these lapses, and the DNS acknowledged the need for proper orders and equipment care.
The facility failed to implement proper infection control measures, as staff did not adhere to PPE protocols for a resident on contact precautions, and another resident with a history of MDROs was not placed on Enhanced Barrier Precautions. Observations showed staff entering rooms without required gowns, and the facility's MDRO log did not include a resident with a history of VRE and MRSA. Interviews revealed a lack of adherence to infection control policies despite annual education.
A resident admitted with Parkinson's disease and other conditions requested the pneumococcal vaccine upon admission. Despite being cognitively intact and consenting to the COVID-19 vaccine, the resident did not receive it. The DNS, also the infection preventionist, indicated it was the Infection Preventionist nurse's responsibility to select the vaccine and obtain a physician order, but could not explain why the vaccine was not administered.
The facility failed to submit discharge assessments to state and federal agencies on time for two residents. One resident's Death in Facility MDS was not submitted due to an incorrect setting, discovered 110 days late. Another resident's Discharge MDS was submitted 76 days late due to oversight. The RAI manual requires these assessments to be transmitted within 14 days.
Resident Rights Restricted by Automatic No-LOA Orders and Unclear Leave of Absence Process
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s rights to self-determination and to exercise the right to take a leave of absence (LOA) without undue interference. One resident admitted with a right femur fracture and diabetes was alert, oriented, able to make needs known, and assessed as not at risk for elopement. The resident’s care plan anticipated discharge home in several weeks, and the admission MDS documented that going outside for fresh air in good weather was somewhat important to the resident. Despite this, a standing physician order entered at admission directed that the resident may not go out on LOA. The facility’s practice, as described by multiple staff, was to enter automatic “no LOA” orders for all residents upon admission, both short-term and long-term. Staff, including LPNs, RNs, social services, and PT, consistently reported that residents could only leave on LOA if they specifically requested it, at which point nursing would contact the physician/APRN for a one-time LOA order and then require a PT assessment before the resident could leave. Staff also indicated that this process could take a day or more and that the electronic medical record defaulted to no LOA orders for all residents. One nurse and a unit manager stated that the rationale for this automatic restriction was related to insurance reimbursement. The resident interviewed stated a desire to go on LOA to visit grandchildren and reported not being aware that LOAs were allowed. Review of the facility’s Welcome Book showed it referenced LOAs and directed residents to pages 2–3 of the Admissions Agreement for more information, but the Admissions Agreement pages were not numbered and did not contain the referenced information about LOA privileges or the requirement to request LOA 24 hours in advance. The Admissions Agreement did include a clause about the facility assuming no responsibility for injury or deterioration while a resident is temporarily absent, but there was no clear, accessible explanation of LOA rights or procedures. The DNS and ADNS confirmed there was no written LOA policy, only a process in which all residents received no LOA orders at admission and had to obtain physician approval and PT evaluation before any LOA, which interfered with the resident’s ability to exercise the right to leave the facility.
Resident Fall Due to Unsafe Food Cart Handling
Penalty
Summary
Staff failed to safely maneuver a food service cart, resulting in a resident fall with injury. The resident involved had diagnoses including dementia, glaucoma, and schizoaffective disorder, and was care planned to ambulate independently with a cane but required supervision due to severe cognitive impairment. On the day of the incident, the resident exited their room as a food service cart was being pushed down the hallway. The resident's cane came into contact with the bumper of the cart, causing the resident to lose balance and fall onto their left side. The staff member pushing the cart reported checking both sides for residents but was unable to see over the cart, and did not see the resident exiting the room before the collision occurred. The fall resulted in a left femoral fracture, requiring hospital transfer and surgical intervention. Prior to the incident, the resident had no history of falls. The facility's policy directed staff to make the environment as free from accident hazards as possible, but the staff member was unable to ensure the pathway was clear due to the size of the cart and limited visibility. The deficiency was identified through observations, interviews, and review of clinical records and facility documentation.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Significant Medication Error Due to Incorrect Transcription of Chemotherapy Orders
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and multiple diagnoses, including dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies, was readmitted to the facility. The resident required substantial assistance with daily activities and had a care plan that included medication review and administration per physician order. Upon readmission, the hospital discharge summary specified hydroxyurea dosing by gastrostomy tube with different doses and frequencies for specific days of the week. However, the nurse supervisor responsible for entering the hospital discharge orders into the electronic medical record (EMR) failed to accurately transcribe the hydroxyurea orders. Instead of entering the correct number of doses per day as specified, the nurse entered significantly higher doses—three times the intended dose on some days and four times on others. The facility physician signed off on these orders, believing them to be accurate, and the error was not detected during the verification process. As a result, the resident received a total of 41,000 mg of hydroxyurea over a 14-day period, which was 30,000 mg in excess of the hospital's order. This overdose led to a critical decline in the resident's white blood cell and platelet counts, resulting in a change of condition that required hospitalization. The resident was admitted to the hospital with neutropenic fever and multiple infections, and laboratory results confirmed critically low blood counts. Interviews with facility staff and review of facility policy revealed that the required process for transcription and verification of medication orders was not properly followed, and the facility was unable to provide a policy specifically addressing the transcription/verification process.
Failure to Update Comprehensive Care Plans for Residents with Changing Clinical Needs
Penalty
Summary
The facility failed to update and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies in addressing their clinical needs. For one resident with a history of periprosthetic fracture, left knee pain, and depression, the care plan did not identify pain as a problem or include goals and interventions for pain management, despite multiple physician orders for various pain medications and documented administration of these medications for moderate to severe pain. Additionally, the care plan did not address the resident's use of unauthorized controlled substances found in their room, nor did it include interventions for monitoring or education related to this issue. Another resident, admitted with diagnoses including dysphagia, epilepsy, and neurocognitive disorder with Lewy bodies, had a care plan that failed to address seizure management and chronic myeloproliferative disorder, both of which were documented in hospital discharge records. The care plan did not include goals or interventions for seizure control or for the management and monitoring of the blood disorder, despite new orders for medication and the need for ongoing monitoring of blood cell and platelet counts. Interviews and policy reviews confirmed that the care plans were not updated following significant changes in the residents' conditions or upon receipt of new diagnoses and treatment orders. Facility policy required care plans to be revised to reflect changes in condition and to ensure continuity of care, but this was not done for the residents in question.
Failure to Complete Monthly Physician Order Reviews
Penalty
Summary
The facility failed to ensure that physician or advanced practice registered nurse (APRN) orders were reviewed and signed monthly for eleven out of sixteen residents reviewed for physician's orders. Clinical record reviews, interviews, and facility documentation revealed that for these residents, there were multiple months where medical orders were not reviewed or signed as required by the facility's standard practice. The residents involved had various diagnoses, including heart failure, dementia, anxiety, Alzheimer's disease, cerebral palsy, and other chronic conditions. Specific months were identified for each resident where the required monthly review and signature of medical orders did not occur. An interview with the Assistant Director of Nurses (ADNS) confirmed that it was the responsibility of the physician or APRN to review and sign orders monthly, and that this was the facility's standard of practice. However, the ADNS was unable to provide a reason for the missed reviews and signatures. Additionally, the facility could not provide a policy detailing the frequency for reviewing physician's orders, further contributing to the deficiency.
Deficiencies in Physician Communication and Medication Administration
Penalty
Summary
The facility failed to ensure timely and appropriate communication and response to physician orders and lab results for two residents. For one resident with a history of dysphagia, epilepsy, neurocognitive disorder, and myeloproliferative disorder, the facility did not respond promptly to a physician's inquiry regarding the resident's hydroxyurea dosage after a concerning drop in white blood cell count was noted. Additionally, the facility did not consistently forward lab results to the hematologist/oncologist in a timely manner, with some results delayed and others not received at all. The facility was unable to provide a policy regarding physician communications or faxes, and interviews confirmed that the standard practice was not followed in these instances. Another resident with dementia, diabetes, and major depressive disorder was not administered an ordered dose of Levaquin for pneumonia as prescribed. The medication was left unattended on the resident's bedside table and not given as required, despite the resident's inability to self-administer medications. The error was discovered the following morning by an LPN, who found the medication cup and reported the incident to the nurse supervisor. The facility's policy directed that medications be administered in a safe and effective manner, which was not followed in this case. These deficiencies were identified through review of clinical records, interviews with staff and physicians, and examination of facility documentation and policies. The failures included lack of timely response to physician requests, delayed or missing communication of lab results to consulting specialists, and improper medication administration practices.
Failure to Provide In-Person Dining Opportunities
Penalty
Summary
The facility failed to ensure residents had the opportunity to participate in their choice of in-person community dining, as identified during a resident council meeting. Residents expressed their concerns about the lack of in-person dining in the main dining rooms, which had been closed for approximately a year. Despite these concerns being raised multiple times in resident council meetings, the facility had not implemented in-person dining in the main dining rooms. Observations during lunch service showed residents eating in their rooms or in small dining spaces on the unit, rather than in the main dining areas. Interviews with residents and staff revealed that the main dining rooms had been closed since the previous year, with satellite dining areas being used for residents needing assistance or supervision. Residents who were independent ate in their rooms. The dietary manager, who started in July 2024, was working on a seating chart and identifying residents who wanted to eat in the dining rooms. However, the process was delayed due to various logistical challenges, including arranging trays and updating tickets. The facility's administrator and director of nursing cited outbreaks of illness and staffing issues in the dietary department as reasons for the prolonged closure of the main dining rooms. The director of nursing noted that outbreaks required isolating units to prevent the spread of infection, which limited group activities, including dining. Despite these challenges, some units were not affected by the most recent COVID outbreak, and in-person recreation activities had resumed. However, the main dining rooms remained closed, and no policy for Resident Council/Committees was provided upon request.
Unsafe Smoking Area Due to Uneven Patio Surface
Penalty
Summary
The facility failed to ensure that an outdoor concrete patio used as a smoking area was safe and free of accident hazards. On the specified date, observations revealed that the patio had multiple holes, resulting in an uneven surface. The Administrator, upon being shown the patio, acknowledged that both staff and residents used the area for smoking and admitted to being unaware of its condition. The Maintenance Director had been aware of the patio's condition for a week prior but had not informed the Administrator or the Director of Nursing Services (DNS), citing being busy and planning to acquire supplies for repairs. This lack of communication and delay in addressing the issue led to the deficiency being identified by surveyors.
Failure to Address Resident's Grievance on Missing Items
Penalty
Summary
The facility failed to address a resident's grievance regarding missing prescription glasses in a timely manner. The resident, who had severe cognitive impairment due to dementia and anxiety, reported the missing glasses to the Corporate Admission Staff, who then communicated the issue to the administrative staff, including the Director of Social Services. Despite this, there was no documentation in the nursing or social service progress notes about the missing items, and the Director of Social Services was not aware of the issue until much later. The Director of Social Services referred the matter to the Transportation Staff for scheduling a replacement, but there was a misunderstanding about the nature of the appointment, leading to a delay. The Director of Social Services did not follow up with the resident's family or the Transportation Staff to clarify the situation, resulting in the resident not receiving the replacement glasses promptly. The facility's policy for handling reported losses was not followed, as the Nursing Supervisor was not notified, and a Missing Item Report was not completed.
Deficiencies in Care Planning for Oxygen Therapy and Safe Food Consumption
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident utilizing oxygen therapy. The resident, diagnosed with chronic obstructive pulmonary disease (COPD), metabolic encephalopathy, and muscle wasting and atrophy, was observed using oxygen therapy without a corresponding care plan. The quarterly MDS assessment identified the resident as cognitively intact and dependent on staff for various needs, including oxygen therapy. However, the resident's care plan did not address the use of oxygen or include necessary interventions. Interviews with the nursing supervisor and MDS coordinator revealed that the responsibility for developing and reviewing care plans was not clearly defined, leading to the oversight. Another deficiency was identified for a resident with hemiplegia and dysphagia, who was repeatedly provided unsafe food items despite being on a minced/ground diet. The resident required total supervision with meals due to a swallowing disorder. Observations showed the resident consuming inappropriate food items, such as cookies and donuts, which were not permitted. Interviews with nursing staff and the Director of Rehabilitation indicated that education was provided to caregivers, but the care plan was not updated to include interventions for safe food consumption. The failure to revise the care plan after repeated incidents of unsafe food provision was noted. The facility's policy for care plans requires the development of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet residents' needs. The policy also mandates that care plans be revised as residents' conditions change. In both cases, the facility did not adhere to its policy, resulting in deficiencies related to the lack of appropriate care planning and monitoring for residents with specific medical needs.
Failure to Monitor Blood Sugar Before Insulin Administration
Penalty
Summary
The facility failed to ensure that the physician orders for blood sugar monitoring and insulin administration were aligned for a resident with diabetes. Resident #57, who had severe cognitive impairment and was insulin-dependent, had a physician's order to administer Tresiba insulin in the morning and evening. However, there was a directive to hold the insulin if the blood sugar was below 90, which was not checked before the morning dose was administered at 6:00 AM. Instead, the blood sugar was scheduled to be checked at 7:30 AM, an hour and a half after the insulin was given, which did not comply with the physician's order to ensure safe administration. Interviews with nursing staff revealed that the resident experienced low blood sugar in the morning, and the hypoglycemic protocol was followed to stabilize the blood sugar level. The facility's policy on physician orders did not specify how orders should be double-checked for accuracy in transcription to medication records. The discrepancy in the timing of blood sugar checks and insulin administration led to the deficiency, as the facility did not monitor blood sugars prior to administering the morning dose of insulin, potentially compromising the resident's safety.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour. The kitchen floor had an excessive amount of dried spillage buildup under all counters and work prep areas, and there was dried spillage along the side and front of the ovens. Food storage practices were inadequate, with a half bag of thawed mango loosely covered and placed on top of a bin of pineapple, leading to leakage. Additionally, opened bags of mozzarella cheese were found without dates. The dishwashing station had ceiling vent covers with a moderate amount of buildup, and the top of the dishwasher had brown crumb-like debris. Sanitizing buckets were improperly used, being stacked empty with cleaning supplies inside. Interviews revealed a lack of structured cleaning schedules for staff, who were only responsible for cleaning immediate surface areas after use. The Food Service Director (FSD), who had been employed for one month, acknowledged the unsanitary conditions and the absence of cleaning schedules. The FSD was aware that foods should be dated and not stacked to prevent leakage, and that a sanitization bucket should be used between food prep tasks. The facility's policy on Dietary Cleaning and Sanitation directed proper cleaning and sanitizing to minimize microorganism growth, but no policy on dating foods was provided.
Failure to Administer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents as per their requests and CDC guidelines. Resident #30, who was admitted in July 2022 with conditions including type 2 diabetes mellitus and hyperlipidemia, was cognitively intact and had previously received the pneumococcal vaccine 23 in 2008. Despite being a candidate for the updated PCV20 vaccine, which the facility began offering in the summer of 2023, there was no record of the vaccine being offered to Resident #30. The DNS, who was not the infection control nurse at the time, acknowledged the oversight and noted the lack of an excel tracking sheet for vaccines, relying instead on the electronic health record system. Resident #105, admitted in April 2024 with Parkinson's disease and muscle weakness, also did not receive the pneumococcal vaccine despite giving consent on 4/12/24. The DNS confirmed that the vaccine was not administered and attributed the responsibility to the Infection Preventionist nurse, who was different at the time. The facility's policy stated that the vaccine should be administered when informed consent is given unless contraindicated, already given, or refused, but this was not followed in Resident #105's case.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a safe and functional manner, as observed during a kitchen tour. Three out of four ovens in a double oven assembly were non-functional, and three of the four ovens lacked vent covers, with visible gray matter and dried brown spillage on exposed components. Additionally, one of the six wells on the steam table was not operational, and the large outdoor freezer had an internal temperature of 8 degrees Fahrenheit, with some frozen items found to be soft and indented. The freezer temperature log showed readings between 5 and 20 degrees Fahrenheit, which is above the required temperature. Interviews revealed that the ovens and steam table well had been non-functional for approximately three months, and the Director of Maintenance had not yet ordered new ovens despite receiving approval. The steam table part was obtained but not installed. The Food Service Director was unaware of the freezer issue until a vendor inspection revealed restricted airflow and a non-working condenser. The facility's maintenance policy requires the maintenance department to ensure equipment is safe and operable, which was not adhered to in this case.
Undignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for three residents during breakfast on the 2West unit. Observations revealed that nurses' aides were providing care and carrying dirty linens while the charge nurse was passing medications. Some residents were positioned in the entryway to their rooms, with two residents seated in wheelchairs in the hallway outside their rooms, feeding themselves breakfast. Another resident was being fed by a nurse aide in the hallway, while other residents watched. This practice was confirmed by a nurse aide who stated that residents needing supervision or assistance were placed in the hallway to allow staff to multitask. Interviews with the Dietician and the Director of Nursing Services (DNS) highlighted concerns about the dignity of the dining experience. The Dietician noted that the small dining areas on the units were intended for residents needing supervision or assistance, and expressed that eating in the hallway was not dignified. The DNS acknowledged that residents should not be fed in the hallway, as it could pose safety issues and that the satellite dining areas or residents' rooms were more appropriate settings. The facility's Meal Service Policy emphasizes providing a dining experience conducive to meal acceptance, including a quiet, pleasant room and positive staff attitudes, which was not adhered to in this instance.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced a change in condition, specifically vomiting and potential choking. The resident, who had a history of acute kidney failure, hypertension, and respiratory issues, vomited and sounded congested, with an oxygen saturation of 93% on room air. Despite these symptoms, the nursing staff did not notify the physician or the on-call provider, and the resident was not assessed until the following day after the family raised concerns. Interviews with staff revealed a lack of communication and appropriate response to the resident's condition. A nurse aide reported the incident to a nurse, but the nurse denied being informed of the vomiting and choking. The resident's family member had to shout for assistance, and although a nurse aide responded, the nurse did not follow up until after the shift change. The APRN, who assessed the resident the next day, expressed concern about the handling of the situation and the delay in notifying a provider. The facility's policy requires notifying the physician of significant changes in a resident's condition, but this protocol was not followed. The DNS confirmed that an assessment should have been conducted, including checking lung sounds, given the report of choking. The failure to notify the physician and conduct an appropriate assessment led to a deficiency in the care provided to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a medication was not left at the bedside of a resident without an order or assessment for self-administration. Resident #157, who had moderate cognitive impairment and was dependent on staff for certain activities, was observed with a medication cup containing 30 ml of a reddish liquid on the overbed table. The resident identified that the nurse would know more about the contents of the cup, as they had not taken any protein with their morning medication. The Charge Nurse confirmed that the liquid was a protein supplement given with the resident's morning medication. The review of the resident's clinical records did not show a physician's order for self-administration or a completed self-administration assessment. The Charge Nurse admitted to leaving the medication on the table and signing off on the medication administration record (MAR) without ensuring the resident took the supplement. The Director of Nursing Services (DNS) confirmed that medication should not be left at the bedside without a self-administration assessment. The Dietician noted that the resident was on a liquid protein supplement to aid wound healing, and not taking it daily could delay this process. The facility's policy stated that medications should be administered safely and documented in the MAR after administration.
Failure to Apply Adaptive Devices as Ordered
Penalty
Summary
The facility failed to ensure that adaptive devices for a resident with limited mobility were applied according to physician's orders. The resident, who had hemiplegia and hemiparesis following a stroke, was supposed to have a left hand and elbow splint applied to prevent contractures. The care plan and physician's orders specified the schedule for applying these splints. However, observations on two separate days revealed that the splints were not applied as required. On one occasion, the left-hand splint was not applied, and on another, the left elbow splint was missing. Interviews with staff revealed a lack of communication and verification regarding the resident's care. A nursing assistant mentioned hearing from another assistant that the splints were not applied due to skin integrity issues, but this information was not verified with a nurse. An LPN confirmed that there were no skin integrity issues reported, and the Director of Nursing stated that staff should follow the splinting schedule as per the physician's orders. The facility's policy required that any skin issues be reported by the nurse, and refusals documented, but this was not adhered to in this case.
Failure in IV Site Management and Physician Orders
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident receiving IV antibiotics. Resident #312, who had multiple pressure ulcers including in the sacral region, was prescribed Vancomycin HCL to be administered intravenously every 12 hours for a wound infection. On observation, it was found that the resident had peripheral IV lines in both forearms, with the line in the left arm being 6 days old and showing signs of blood under the dressing. This line should have been removed when a new IV line was placed in the right arm, as per the facility's policy which states that peripheral IV catheters should be replaced every 72-96 hours unless there is contamination or complication. Additionally, the facility did not ensure that physician orders addressed the flushing of the IV site. The facility's policy requires that a peripheral catheter used for intermittent infusion be flushed at least every 12 hours. However, there were no orders obtained for flushing or monitoring the IV site. RN #1 confirmed during an interview that the old IV line should have been discontinued and that orders for flushing and monitoring should have been obtained. This oversight indicates a failure to adhere to the facility's policies regarding IV therapy and site management.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, leading to deficiencies in oxygen therapy management. Resident #6, diagnosed with chronic obstructive pulmonary disease (COPD) and other conditions, was observed using oxygen therapy without a corresponding physician's order. Despite being cognitively intact and dependent on staff for daily activities, the resident's medical records lacked an order for continuous or as-needed oxygen therapy. Interviews with nursing staff revealed that the omission occurred because the admitting nurse did not input the hospital discharge instructions into the resident's records upon readmission. The Director of Nursing Services (DNS) confirmed that a physician's order should have been in place for the resident's oxygen use. Resident #140, with a history of acute respiratory failure and hypoxia, was observed using oxygen with tubing that had not been changed according to physician orders. The resident's care plan indicated a need for weekly tubing changes, but the tubing was dated over two months prior. Interviews with the resident and nursing staff confirmed the daily use of oxygen and the expectation for weekly tubing changes. The DNS acknowledged the requirement for weekly changes, but the facility could not provide a policy for the care of respiratory equipment.
Infection Control Deficiencies in PPE Use and Precaution Tracking
Penalty
Summary
The facility failed to properly implement infection prevention and control measures, specifically in the use of personal protective equipment (PPE) for residents under transmission-based precautions. Resident #127, who had diagnoses including pneumonia, acute kidney failure, and stroke, was placed on contact precautions due to conjunctivitis. However, observations revealed that staff members, including LPN #7 and LPN #6, did not adhere to the required PPE protocols. LPN #7 entered the resident's room with only gloves, misinterpreting the signage, and LPN #6 also entered with only gloves despite the contact precaution sign indicating the need for both gloves and a gown. Additionally, the facility failed to appropriately track and implement Enhanced Barrier Precautions (EBP) for Resident #6, who had a history of urinary tract infections with vancomycin-resistant Enterococcus (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). Despite the resident's history, there was no signage indicating the need for EBP, and the resident was not listed on the facility's MDRO log for August 2024. The DNS acknowledged that Resident #6 should have been on the MDRO list and that appropriate signage should have been posted. Interviews with staff, including the DNS and RN #12, highlighted a lack of adherence to infection control policies and procedures. The facility's policies required clear signage and appropriate PPE use for residents on transmission-based precautions, but these were not consistently followed. The DNS and staff development nurse confirmed that infection control education, including PPE use, was provided annually, yet the deficiencies in practice were evident during the survey observations.
Failure to Administer Requested Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who requested it upon admission. The resident, who was admitted in April 2024, had diagnoses including Parkinson's disease with dyskinesia and fluctuation, muscle weakness, and hyperlipidemia, and was identified as cognitively intact. Despite giving consent for the COVID-19 vaccination on 4/12/24, the resident did not receive the vaccine as requested. An interview with the Director of Nursing Services (DNS), who also serves as the infection preventionist, revealed that the responsibility for selecting the appropriate vaccine and obtaining the physician order lay with the Infection Preventionist nurse. However, the DNS was unable to explain why the vaccine was not administered, noting that a different Infection Preventionist nurse was in place at the time.
Failure to Timely Submit Discharge Assessments
Penalty
Summary
The facility failed to ensure timely submission of discharge assessments to state and federal agencies for two residents. Resident #40 was admitted and later passed away at the facility. The Death in Facility Minimum Data Set (MDS) for this resident was completed but not submitted to the agencies, as the submission setting was incorrectly set to 'do not submit.' This error was identified 110 days after the resident's death. Similarly, Resident #134 was readmitted and later discharged from the facility. The Discharge MDS for this resident was submitted 76 days late, as it was overlooked by the staff. According to the Resident Assessment Instrument (RAI) manual, such assessments must be transmitted within 14 days of the event date.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
