Douglas Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Windham, Connecticut.
- Location
- 103 North Road, Windham, Connecticut 06280
- CMS Provider Number
- 075258
- Inspections on file
- 25
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Douglas Manor during CMS and state inspections, most recent first.
A resident with dementia, muscle weakness, and a history of falls sustained a laceration after falling from a wheelchair and striking their head on a roommate's travel wheelchair that was left in the room. Staff observed the resident's repeated forward-leaning and rocking behaviors but did not report these to therapy or nursing leadership, and the care plan interventions were not updated. The unattended wheelchair created an environmental hazard, and facility protocols for fall risk assessment and clutter-free environments were not followed.
A resident with dementia, muscle weakness, and a history of falls did not receive a required quarterly Fall Risk Evaluation, despite facility policy and ongoing risk factors. During the period when the evaluation was missed, the resident sustained an unwitnessed fall resulting in a head injury that required ED evaluation. The DON confirmed that the assessments were not completed as required.
A resident with multiple medical and psychiatric diagnoses was not provided a timely PASRR Level 2 screening after the initial short-term approval expired. This oversight delayed the resident's transfer to another facility and resulted in an extended private pay stay until the required screening was completed.
A resident with multiple chronic conditions and significant care needs was not provided with baseline and comprehensive care plans, nor was a care plan meeting held with the resident or family, within 48 hours of admission as required. Documentation and staff interviews confirmed that the care plan and meeting were not provided until two months after admission, contrary to facility policy and resident rights.
A resident with multiple chronic conditions exhibited symptoms of a urinary tract infection, but staff failed to collect a urine specimen as ordered or notify the physician of the delay. The urine sample was not obtained until several days after the initial order, resulting in a delay in diagnosis and treatment. Facility documentation and staff interviews confirmed that established protocols for timely specimen collection and physician notification were not followed.
A resident with multiple medical conditions was not included in the development or implementation of their person-centered care plan, as required by facility policy. The care plan lacked discharge planning, and the resident was not invited to care plan or discharge meetings, despite being ready for discharge. Staff interviews and documentation review confirmed the absence of care plan meetings and resident participation after a certain date.
Residents repeatedly reported unresolved issues with dietary services, extended call bell wait times, difficulty locating staff, and inappropriate staff language and conduct. Despite these concerns being documented in Resident Council meetings and brought to the attention of facility leadership, the same issues persisted over an extended period, indicating a failure to effectively address and resolve resident grievances.
The facility did not allow residents to access their personal funds outside of posted banking hours, as confirmed by staff interviews and facility policy review. Residents requesting funds after hours had to wait until the next day, and the policy did not address access outside designated times.
The facility did not consistently update or document resident care plans and care conferences within the required timeframe after comprehensive assessments. Several residents with complex medical conditions had changes in their assistance needs that were not reflected in their care plans, and care conferences were either not held or not documented as required. Staff interviews confirmed that care plan meetings and revisions were not completed according to facility policy.
Two residents with complex medical needs and a desire to return to the community through the Money Follows the Person (MFP) program did not receive necessary discharge planning or support due to the absence of a dedicated social worker, lack of staff knowledge about the MFP process, and no facility policy for MFP discharges. As a result, their care plans did not include appropriate discharge planning, and staff failed to communicate or assist with their transition out of the facility.
Medication and treatment carts were repeatedly left unlocked and unattended in resident care areas, with both prescription and non-prescription drugs accessible and, in one case, unidentified pills left on top of a cart. Nursing staff admitted to forgetting to lock the carts despite being aware of facility policy, and some kept cart keys inside the carts. The DON confirmed the expectation that carts be locked when not in view, and the facility policy requires nurses to keep keys in their possession at all times.
The facility did not ensure that an LPN and three nursing assistants completed and had documentation for required annual in-service trainings on Resident Rights, Communication, and Behavioral Health. Interviews with the Staff Development RN and DON confirmed that these trainings were not documented as completed, despite being required by facility policy.
A resident with mobility and postural issues was not allowed to use a preferred electric wheelchair provided by family, despite being cognitively intact and expressing a desire to use it. Facility staff cited safety and functional concerns but did not conduct or document a formal assessment of the resident using the electric wheelchair, failing to honor the resident's right to choose personal mobility equipment.
A resident with multiple medical conditions and a documented DNR status did not have their code status entered into the electronic health record as required by facility policy. Both an LPN and the DON confirmed the absence of this information in the system, despite the facility's policy that advance directives be prominently displayed in the medical record.
Two residents experienced failures in timely reporting of abuse and neglect allegations. One cognitively intact resident reported missing funds to a nurse aide, but the incident was not documented or investigated by nursing or administration. Another resident with severe cognitive impairment suffered delayed incontinence care, leading to skin issues, with the neglect allegation not reported to the state agency within the required timeframe.
The facility did not investigate a report of missing funds for a resident with a history of stroke and depression, despite the incident being reported to staff. In a separate case, a resident with dementia and incontinence did not receive timely care, and the facility delayed and inadequately investigated the neglect allegation, allowing the accused staff member continued access to the resident. Both incidents lacked proper documentation and thorough investigation as required by policy.
Staff did not complete required weekly skin assessments for a resident with impaired mobility, failed to follow a prescribed wheelchair positioning plan for another resident with severe cognitive impairment, and did not report a change in skin condition for a resident with a recent fracture. Additionally, two residents did not receive timely incontinent care, with one left in a saturated brief for several hours. These deficiencies involved missed documentation, failure to follow care plans, and lack of communication among staff.
A resident with dementia and mobility issues, identified as a fall risk, did not have required floor mats on both sides of the bed as specified in the care plan. Staff were unaware of the facility's policy regarding floor mats, and there was no physician's order or proper documentation for the intervention, resulting in incomplete implementation of fall prevention measures.
A resident with recent admission and multiple diagnoses was given oxygen therapy without a physician's order. Nursing staff, including an LPN and a weekend RN supervisor, administered oxygen after the resident experienced unexpected desaturation, but failed to obtain the required provider order as mandated by facility policy.
A resident with multiple medical conditions was not properly assessed for oral status upon admission, resulting in inaccurate documentation in both the care plan and MDS, and was not provided with required dental services or a dental consultation despite being edentulous and requesting dentures. Nursing staff were unaware of the resident's dental needs, and facility policy for oral assessment and dental referrals was not followed.
Two residents with a history of MDRO and one with an indwelling medical device did not have appropriate Enhanced Barrier Precautions reflected in their care plans or physician orders. Incorrect precaution signage was posted outside their shared room, and staff were unclear about the correct procedures for posting and following precaution signs. The Infection Preventionist and nursing staff demonstrated inconsistent processes for ensuring proper infection control signage and communication, and the facility could not provide relevant infection control policies when requested.
The facility did not ensure that resident personal funds held in the Resident Trust Account were fully protected by a surety bond, as account balances regularly exceeded the $80,000 bond coverage. Staff interviews revealed unclear responsibility for monitoring account balances and ensuring adequate insurance, resulting in periods where resident funds were not fully covered.
The facility did not provide required quarterly financial statements to multiple residents and their representatives for personal funds managed by the facility. This failure affected individuals with varying cognitive abilities, including those with legal representatives, and was due to the Business Office Manager's misunderstanding of requirements and a lack of oversight.
A resident with cognitive and mobility impairments reported to two RNs that a nurse aide had grabbed their arm during a transfer, resulting in bruising. Both RNs observed the injury but did not ensure the allegation was immediately reported to the DON or Administrator, nor was the incident reported to the state agency within the required timeframe. The nurse aide was not promptly removed from duty, and the facility failed to follow its abuse reporting policy.
A resident with hemiplegia and decreased mobility, who required two-person assistance and use of a Sara lift for transfers, was transferred by a nurse aide alone and without the mechanical device, resulting in a bruise. The aide admitted to not following the care plan, despite being aware of the requirements, and the incident was reported to the DON.
A resident with nicotine dependence was found smoking outside and later had lighters discovered in their room, but staff did not confiscate the smoking materials or conduct a room search as required by facility policy. Interviews confirmed that nursing staff and supervisors failed to take timely action to remove the smoking paraphernalia in a smoke-free facility.
A resident with a history of falls was not assessed after a fall, despite complaints of pain. The nursing supervisor instructed staff to move the resident without conducting a thorough assessment. The resident was later found to have a hip fracture, indicating a significant oversight in care.
A cognitively impaired resident with a history of falls and requiring assistance was left unattended in the bathroom by a Nurse Aide, resulting in a fall and injury. Despite documented needs for supervision, the resident attempted to self-transfer, leading to a laceration and vertebra fracture. Staff interviews confirmed the failure to adhere to the care plan and supervision requirements.
Failure to Maintain Clutter-Free Environment and Adhere to Fall Prevention Care Plan
Penalty
Summary
A deficiency occurred when staff failed to adhere to a resident's care plan and maintain a safe, clutter-free environment, resulting in a fall and injury. The resident, who had diagnoses including dementia, muscle weakness, a history of falls, and macular degeneration, was identified as being at high risk for falls. Despite care plan interventions such as keeping the area clutter-free and monitoring for fatigue, staff did not report or address the resident's repeated behaviors of leaning forward and rocking in the wheelchair. Multiple staff members observed these behaviors but did not notify therapy or nursing leadership, and the behaviors were not incorporated into the resident's care interventions. On the day of the incident, a travel wheelchair belonging to the resident's roommate was left in the room, creating an obstruction. The resident, who required substantial assistance with transfers and verbal cues to navigate obstacles, was found to have fallen forward out of the wheelchair, striking their head on the brake handle of the unattended travel wheelchair. This resulted in a laceration to the left eyelid, requiring emergency department evaluation and sutures. The fall was unwitnessed, and the presence of the extra wheelchair in the room was confirmed by staff interviews and facility documentation. Facility policy required staff to identify and address environmental hazards and resident-specific risk factors for falls, including mobility and cognitive status. However, the interdisciplinary team was not informed of the resident's ongoing forward-leaning and rocking behaviors, and the environmental hazard posed by the improperly stored wheelchair was not addressed. The lack of communication and failure to follow established protocols contributed directly to the resident's fall and injury.
Failure to Complete Quarterly Fall Risk Evaluation
Penalty
Summary
The facility failed to ensure that a Fall Risk Evaluation was completed quarterly for a resident with multiple risk factors for falls, including dementia, anxiety, muscle weakness, a history of falls, and macular degeneration. The resident's care plan identified several fall risk factors and included interventions such as instructing the resident to request assistance, maintaining a clutter-free and well-lit environment, and providing rest periods. Despite these measures, documentation review revealed that no Fall Risk Evaluation was completed during a four-month period, which overlapped with a comprehensive assessment. During this period, the resident experienced an unwitnessed fall, resulting in a head injury that required emergency department evaluation. Interviews with the DON confirmed that facility policy requires fall risk assessments on admission, quarterly, after falls, and with any health changes, and acknowledged that the required evaluations were not completed as scheduled. The facility's policy also directed that fall risk assessments be performed at these intervals, but there was no documentation of such assessments during the specified timeframe.
Failure to Complete Timely PASRR Level 2 Screening Delays Resident Transfer
Penalty
Summary
The facility failed to complete a PASRR Level 2 screening for a resident whose initial PASRR Level 1 approval was valid for only seven days. The resident, who had diagnoses including congestive heart failure, COPD, depression, PTSD, and bipolar disorder, was admitted with a PASRR Level 1 that did not require a Level 2 referral at the time. However, upon expiration of the initial PASRR Level 1, the facility did not initiate the required Level 2 screening, despite the resident's psychiatric diagnoses. This oversight was not identified until after the resident received a Notice of Medicare Non-Coverage and the family sought transfer to a VA-connected facility. The delay in completing the PASRR Level 2 screening resulted in the resident being unable to transfer to the desired facility until the process was finalized. As a result, the resident was required to remain at the current facility as a private pay resident for an additional fifteen days. Interviews with the Director of Social Services and the Administrator confirmed that the facility did not follow the required process for timely PASRR Level 2 screening, which directly impacted the resident's transfer and financial responsibility.
Failure to Provide Care Plans to Resident and Family Within 48 Hours of Admission
Penalty
Summary
The facility failed to provide the baseline and comprehensive care plans to a resident or the resident's family within forty-eight hours of admission, as required to promote continuity of care and communication with staff. The resident in question had multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, depression, and bipolar disorder, and required significant assistance with activities of daily living. The baseline care plan was developed and included interventions such as toileting every two hours, incontinent care, medication administration, and behavioral monitoring. However, a review of the clinical record from the time the baseline care plan was developed through two months later did not show documentation that a meeting was held with the resident or family to discuss the care plan, nor that a copy of the care plans was provided to them until a meeting occurred two months after admission. Interviews with facility staff, including the Director of Social Services and the therapy department, confirmed there was no record of an earlier meeting. Facility policies reviewed indicated residents have the right to participate in their own care planning and treatment, but this was not documented as occurring within the required timeframe.
Delay in Urine Specimen Collection and Physician Notification
Penalty
Summary
A deficiency occurred when staff failed to collect a urine specimen for a resident who was symptomatic for a urinary tract infection, as ordered by the physician. The resident, who had chronic kidney disease, congestive heart failure, diabetes mellitus, a colostomy, and was incontinent of bladder, exhibited symptoms such as lethargy, confusion, and dysuria. Despite a physician's order to obtain a urine specimen and, if necessary, to straight catheterize the resident, there was no documentation of attempts to collect the specimen or notification to the physician regarding the delay over several days. The resident's care plan included interventions for toileting, incontinent care, and obtaining lab work as ordered, but these were not followed in a timely manner. Nursing notes and interviews confirmed that the urine specimen was not collected until four days after the initial order, and the physician was not notified of the delay. The facility's infection control nurse stated that the expectation was to collect a urine sample within twenty-four hours of the order and to notify the physician if there was a delay. The delay in obtaining the specimen resulted in a delay in diagnosis and treatment of the resident's urinary tract infection. Facility documentation and interviews indicated that the failure to follow protocol led to the deficiency.
Resident Not Included in Person-Centered Care Plan Development
Penalty
Summary
A deficiency occurred when a cognitively intact resident with diagnoses including abnormal posture, spinal instabilities, and a sacral pressure ulcer was not included in the development and implementation of their person-centered care plan. The resident required staff assistance for eating, hygiene, toileting, and transfers. The care plan dated 2/4/25 did not address discharge planning, and the resident reported that staff had not discussed discharge or invited them to any care plan or discharge planning meetings, despite the resident being ready for discharge. Interviews with facility staff revealed that there was no current MDS coordinator or Director of Social Work, and care planning responsibilities were shared among the DNS, Rehabilitation Department, and social worker. Review of care conference attendance sheets and progress notes showed no evidence of care plan meetings or resident participation after 10/24/24. The facility's policy required resident participation in care planning, but documentation and staff interviews confirmed that this did not occur for the resident in question.
Failure to Resolve Ongoing Resident Concerns with Dietary, Call Bell Response, and Staff Conduct
Penalty
Summary
The facility failed to address and resolve ongoing concerns raised by residents during Resident Council meetings over a period of at least one year. Documented issues included repeated complaints about dietary services, such as dissatisfaction with food taste, inconsistent availability of certain items (e.g., eggs), improper food temperature, and poor food presentation with liquids from vegetables mixing with other foods. Residents also reported persistent problems with extended call bell wait times, including an incident where a resident waited 20 minutes and nearly fell, as well as concerns that call bells were being turned off at the nurses' stations. Additional complaints included difficulty locating staff for assistance, staff taking breaks simultaneously, staff using cell phones on the units, and a staff member being found sleeping in a cubby. Residents also reported staff using inappropriate or foul language and excessive noise levels created by staff. Despite these ongoing concerns being documented in Resident Council minutes and brought to the attention of facility leadership, including the Administrator and DNS, the issues persisted over multiple months. The facility's Concern, Complaint and/or Grievance policy directs that concerns should be actively resolved, but the repeated nature of the complaints indicates that effective resolution did not occur. Interviews with facility leadership confirmed awareness of the issues and acknowledged that in-services and monitoring had taken place, but the same concerns continued to be reported by residents.
Failure to Provide Resident Access to Personal Funds Outside Posted Banking Hours
Penalty
Summary
The facility failed to provide residents with access to their personal funds outside of posted banking hours. Observations revealed a sign at the reception desk listing specific banking hours, and interviews with the Business Office Manager and reception staff confirmed that residents could only access their funds during these designated times. The Business Office Manager and three receptionists had keys to the petty cash lock box, but residents requesting funds outside of banking hours were required to wait until the next day. Additionally, the facility's policy on residents' rights regarding personal funds did not specify how residents could access their funds after posted hours.
Failure to Timely Update and Document Resident Care Plans and Conferences
Penalty
Summary
The facility failed to ensure that resident care plans (RCPs) were developed, reviewed, and revised within the required timeframe following comprehensive assessments for all residents reviewed. Documentation was lacking for quarterly Resident Care Conferences (RCCs), and care plans were not consistently updated within 7 days of the Minimum Data Set (MDS) assessments. For multiple residents with complex medical conditions such as Parkinson's disease, dementia, heart disease, epilepsy, hemiplegia, chronic obstructive pulmonary disease, multiple sclerosis, and depression, the care plans did not reflect changes in their required assistance with activities of daily living (ADLs) as identified in their MDS assessments. For one resident with Parkinson's disease and dementia, the care plan was not updated to reflect increased assistance needs, and there was no documentation of a care conference following a recent MDS assessment. Interviews with staff revealed that care plan meetings were not being held on a quarterly basis, and the responsible staff could not provide reasons for these omissions. Another resident with epilepsy and hemiplegia had changes in ADL needs documented in the MDS, but the care plan was not revised accordingly, nor was there evidence of timely care conferences. Additional residents with cardiac and respiratory conditions, as well as those with multiple sclerosis and chronic pain, also experienced lapses in care plan updates and documentation of care conferences. In several cases, care plan meetings were either not held within the required timeframe or not documented at all, and staff interviews confirmed that the facility did not meet the expected schedule for care plan reviews and revisions. Facility policy required care plans to be developed within 7 days of a completed MDS, but this standard was not met for the residents reviewed.
Failure to Provide Medically-Related Social Services for Discharge Planning
Penalty
Summary
The facility failed to provide medically-related social services to assist residents in achieving the highest possible quality of life, specifically by not facilitating discharge planning for two residents who wished to return to the community through the Money Follows the Person (MFP) program. One resident, with diagnoses including abnormal posture, spinal instabilities, and a sacral pressure ulcer, was cognitively intact and had a documented goal to return to the community. Despite this, the resident's care plan did not include a discharge plan, and there was no evidence of active discharge planning. Multiple interviews revealed that the facility lacked a Director of Social Work, and the available social worker was only present eight hours per week and was not familiar with the MFP process. Other staff, including the Administrator and Director of Rehabilitation, were unaware of any discharge plans, and the resident was not kept informed about MFP appointments or discharge meetings. A second resident, with diagnoses of atherosclerotic heart disease, COPD, and major depressive disorder, also expressed a desire to discharge using the MFP program. The care plan referenced MFP, but the resident reported being told that no one could assist with the request. Interviews with facility staff, including the DON and a regional clinical RN, revealed a lack of awareness of the resident's discharge wishes and the MFP process. The facility did not have a policy for MFP discharges, and the social worker confirmed that assistance with MFP paperwork and follow-up was not provided as required. The facility's own discharge policy indicated that social services should set up services and develop a discharge care plan, but this was not followed in these cases. Both residents experienced a lack of communication and support regarding their discharge planning, with staff either unaware of their wishes or unable to assist due to staffing shortages and lack of knowledge about the MFP program. The absence of a dedicated social worker and the lack of a clear policy or process for handling MFP discharges resulted in residents not receiving the medically-related social services necessary to facilitate their transition back to the community.
Unattended and Unlocked Medication Carts
Penalty
Summary
Multiple instances were observed where medication and treatment carts were left unlocked and unattended in resident care areas. On several occasions, medication carts were found unlocked in hallways with residents present or nearby, and in one case, a resident rolled past an unattended, unlocked cart in a wheelchair. Both prescription and non-prescription medications, including nystatin, were accessible in these unlocked carts. In another instance, four unidentified pills were found on top of an unattended, unlocked medication cart. Interviews with nursing staff revealed that they were aware of the facility's policy requiring carts to be locked when not in use or not in view, but admitted to forgetting to lock them, often due to being rushed or distracted. Further interviews indicated that some nurses kept keys to the medication carts inside the carts themselves, and there had not been recent in-service training on the policy. The Director of Nursing Services confirmed that carts should be locked when not in the nurse's visual contact and acknowledged that education on this policy had been provided. Review of the facility's Medication Administration Policy confirmed that keys should remain with the nurse at all times and that carts are never to be left unattended or unlocked in resident care areas.
Failure to Document and Complete Mandatory Staff In-Service Trainings
Penalty
Summary
The facility failed to ensure that mandatory employee training and in-service requirements were completed and documented for four out of five reviewed staff members. Specifically, the employee files for an LPN and three nursing assistants did not contain evidence that required in-service trainings on Resident Rights, Communication, and Behavioral Health had been provided from 2023 to the present. Despite requests, the facility was unable to produce documentation confirming completion of these mandatory trainings for the identified staff members. Interviews with the Staff Development RN and the Director of Nursing revealed that it was the responsibility of the Staff Development RN to ensure completion, documentation, and filing of required in-service trainings. Both the Staff Development RN and the Director of Nursing were unable to locate the necessary documentation and acknowledged that the trainings should have been completed upon hire and annually, as per facility policy. The facility's policy on employee in-service trainings was also not provided when requested.
Failure to Accommodate Resident's Choice of Mobility Device
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination and choice by not allowing the use of the resident's preferred electric wheelchair. The resident, who had diagnoses including abnormal posture, spinal instabilities, and a sacral pressure ulcer, was cognitively intact and dependent on staff for transfers and toileting. Despite receiving an electric wheelchair from a family member, the resident was prohibited from using it in the facility. Interviews and record reviews revealed that although the resident expressed a desire to use the electric wheelchair, the facility staff, including the Director of Rehabilitation, determined it was not appropriate without conducting a documented assessment or evaluation of the resident using the device. The facility cited concerns about safety, potential for muscle atrophy, and risks associated with the use of an electric wheelchair, but could not provide evidence of a formal assessment or screening to support these decisions. Observations showed the resident was alert, oriented, and able to self-propel in a non-electric wheelchair, with no evidence of dozing or sleeping while in the wheelchair. The resident reported that the electric wheelchair was more comfortable and did not understand why it was deemed inappropriate, as both wheelchairs reclined. Facility policy and the resident's rights documents indicated that residents have the right to use personal possessions and choose mobility devices, but the facility did not accommodate the resident's preference or provide documentation of a thorough evaluation regarding the use of the electric wheelchair.
Failure to Document Advance Directive in Electronic Health Record
Penalty
Summary
A deficiency was identified when the facility failed to document a resident's code status in the electronic health record as required by facility policy. The resident in question had diagnoses including chronic obstructive pulmonary disease, anemia, and dysphagia, and was assessed as moderately cognitively impaired, requiring substantial assistance with daily activities. The resident's care plan and advance directives form indicated a do not resuscitate (DNR) status, but this information was not reflected in the physician's orders or the electronic health record. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that it is facility policy for advance directives to be entered into the electronic health record within 24 hours of admission. However, both staff members were unable to locate the resident's code status in the electronic system, and acknowledged that in an emergency, staff would have to refer to the physical chart. The facility's Advance Directives Policy requires that such directives be displayed prominently in the medical record, but this was not done for the resident in question.
Failure to Timely Report Allegations of Misappropriation and Neglect
Penalty
Summary
For one resident with a history of depression, stroke, and spinal cord dysfunction, an allegation of misappropriation of funds was not reported or investigated by the facility. The resident, who was cognitively intact and required assistance with activities of daily living, reported $40 missing from a cell phone case to a nurse aide approximately six months prior. The nurse aide searched for the money, reported the incident to a supervisor, and completed a written statement, but there was no documentation of the incident being reported or investigated by nursing staff or administration. Facility leadership, including the administrator and director of nursing, were unaware of the allegation and could not explain why the policy for reporting misappropriation was not followed. In a separate incident, another resident with severe cognitive impairment and total dependence for toileting and mobility experienced a delay in incontinence care, resulting in saturated clothing, a foul odor, and new skin irritation and open areas. The family reported the neglect to a nurse on the day of the incident, but the allegation was not reported to the supervising RN until three days later and to the director of nursing seven days after the initial report. The incident was not reported to the state agency until ten days after it was first known by staff, despite facility policy requiring immediate reporting within two hours.
Failure to Investigate Allegations of Misappropriation and Neglect
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of funds for a resident with a history of depression, stroke, and spinal cord dysfunction. The resident, who was cognitively intact and required assistance with activities of daily living, reported $40 missing from a bedside table, which was intended for a hairdresser appointment. The resident stated the missing money was reported to a nurse aide approximately six months prior, but no action was taken by the facility. The nurse aide recalled searching for the money and reporting the incident to a supervisor, including submitting a written statement, but there was no documentation or evidence that the incident was investigated or reported by facility management. The administrator and director of nursing were unaware of the allegation and could not explain why the policy was not followed or why the incident was not investigated at the time it was reported. For another resident with severe cognitive impairment, dementia, and incontinence, the facility failed to thoroughly and promptly investigate an allegation of neglect. The resident's family reported that the resident had not received incontinence care, position changes, or hygiene for many hours, resulting in a saturated brief, foul odor, and new skin irritation and open areas. The incident was reported to staff on the day it occurred, but the investigation was not initiated until eight days later, and the state agency was not notified until ten days after the initial allegation. Written statements from staff were collected days after the event, and the investigation lacked key components, such as summaries of interviews and a conclusion regarding the substantiation of neglect. Additionally, the staff member accused of neglect was not immediately suspended as required by facility policy and continued to have access to the resident for several days following the allegation. The director of nursing indicated that the investigation was incomplete and lacked a summary, root cause, and corrective actions. The decision not to substantiate neglect was based on the family member later expressing comfort with the staff member, rather than on a thorough investigation of the care provided.
Failure to Provide Timely and Appropriate Care per Orders and Resident Needs
Penalty
Summary
Staff failed to perform weekly skin assessments as ordered for a resident with a history of stroke, spinal cord dysfunction, and hemiplegia. The resident's care plan and physician's order required weekly skin checks and completion of a skin evaluation form, but documentation showed that these assessments were missed on two occasions. One LPN signed off on a skin check without actually performing or documenting the assessment, citing being interrupted and not returning to complete the task. The Director of Nursing confirmed that this was a breakdown in communication and that documentation of unperformed tasks was unacceptable. A resident with severe cognitive impairment and abnormal posture was not positioned according to the prescribed wheelchair positioning plan. The plan required the use of a pelvic positioning belt and specific use of leg rests to maintain proper body alignment and safety. Observations revealed the resident self-propelling in the wheelchair without the belt fastened and with leg rests in place when they should have been removed. The assigned nursing assistant did not follow the care card instructions, stating she believed the belt would be a restriction, and failed to apply it as required by the care plan and physician's order. Another resident with osteoporosis and a recent fracture experienced a change in skin condition, including redness and inflammation in the buttocks and genital region, which was not reported to licensed nursing staff as required. The nursing assistant who observed the skin issue did not escalate the finding, despite being aware of the policy to report such changes. Additionally, two residents did not receive timely incontinent care, with one resident left in a saturated brief for over three hours and not repositioned during that time. The assigned nursing assistant admitted to not providing care every 2-3 hours as required, citing oversight, even though staffing levels were normal.
Failure to Implement and Document Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to follow a post-fall care plan for safety interventions for a resident with dementia, lack of coordination, and Parkinsonism. The resident was identified as a fall/safety risk and the care plan required the bed to be kept at the lowest position and floor pads to be placed on each side of the bed. However, after the resident was found on the floor next to the bed following a fall, observations revealed that only one floor mat was present, and the mat was missing from one side of the bed. Staff interviews indicated a lack of awareness regarding the facility's policy on floor mats and uncertainty about the interventions listed in the care plan. Further review showed that there was no physician's order for the floor mats in the resident's clinical record, despite facility policy requiring such an order to alert staff to implement the intervention. The charge nurse was responsible for ensuring interventions were in place, but the required documentation and implementation were not completed as specified in the care plan and facility policy. The facility's policy also directed that documentation in the medical record should include appropriate interventions to prevent future falls, which was not done in this case.
Oxygen Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a newly admitted resident, who had diagnoses including a sacral fracture, muscle weakness, and difficulty walking, was administered oxygen without a physician's order. The resident was cognitively alert, had clear lungs, denied shortness of breath, and was not on oxygen at the time of admission. The care plan included interventions for cardiac risk, such as administering oxygen as ordered, but did not specify the need for oxygen at admission. On observation, the resident was found receiving oxygen at 2 liters per minute via nasal cannula, despite no documented physician's order in the clinical record or on the Medication/Treatment Administration Records. Interviews with nursing staff revealed that the LPN administering the oxygen was unaware of the reason for its use and confirmed that a physician's order was required but not present. The RN supervisor over the weekend had placed the resident on oxygen following an unexpected desaturation but failed to notify the provider or obtain an order. The facility's policy, as reviewed, required staff to verify and review a physician's order before administering oxygen, which was not followed in this instance.
Failure to Assess and Provide Dental Services for Edentulous Resident
Penalty
Summary
The facility failed to provide or obtain appropriate dental services for a resident with diagnoses including epilepsy, left-sided hemiplegia, and chronic obstructive pulmonary disease. Upon admission, the nursing clinical assessment did not include an examination of the resident's oral or dental status, and the assessment inaccurately documented that the resident had all natural teeth. The resident's care plan did not address the edentulous status, and the Minimum Data Set (MDS) assessments, both at admission and subsequently, failed to identify that the resident was without teeth. The clinical record did not show that the resident had been seen by a dentist, despite the resident expressing a desire for dentures and reporting that previous dentures had been discarded prior to admission. Observations and interviews confirmed the resident was edentulous and had not received dental services or been offered a dental consultation. Nursing staff, including the RN responsible for the admission assessment, were unaware of the resident's true dental status and acknowledged inaccuracies in the documentation. The Director of Nursing Services and other staff confirmed that oral assessments should have been completed at admission and before each MDS, and that edentulous residents should receive dental consultations, but could not explain why these steps were missed. Facility policy required physical assessment of teeth and gums and timely referral for dental services if dentures were lost, but these procedures were not followed for this resident.
Failure to Ensure Correct Precaution Signage and Infection Control Practices
Penalty
Summary
The facility failed to ensure appropriate infection prevention and control practices for two residents with a history of Multi Drug Resistant Organism (MDRO) and one resident with an indwelling medical device. For both residents, the care plans indicated a history of Extended Spectrum Beta-Lactamase (ESBL) in the urine, but the care plans lacked current problems or interventions for Enhanced Barrier Precautions related to this history. Physician orders did not consistently reflect the need for special precautions, and there was no current order for Enhanced Barrier Precautions for the resident with an indwelling medical device. Observations revealed that incorrect precaution signage was posted outside the residents' shared room. Initially, a sign for droplet and contact precautions for unknown Covid-19 was displayed, which did not accurately reflect the residents' needs. Staff interviews confirmed that the sign was used due to the MDRO history, but staff did not follow the PPE requirements listed on the sign, and there was confusion about which precautions were appropriate. The sign was later changed to enteric contact precautions, which also did not match the residents' conditions. Staff were unable to clearly articulate the policy or procedure for posting precaution signs and relied on shift handoff reports for information about resident precautions. Further interviews with nursing staff and the Infection Preventionist revealed inconsistent processes for ensuring correct signage and communication to staff and visitors regarding required precautions. The Infection Preventionist was responsible for posting and auditing precaution signs but did not provide a clear rationale for the signage used. The facility was unable to provide policies for Enhanced Barrier Precautions, Contact Precautions, or Droplet Precautions when requested.
Failure to Maintain Adequate Surety Bond Coverage for Resident Trust Accounts
Penalty
Summary
The facility failed to ensure that all resident personal funds deposited with the facility were adequately protected by a surety bond. Review of the Resident Trust Account (RTA) balances over a six-month period revealed that the account balance consistently exceeded the $80,000 surety bond coverage, with monthly balances ranging from $50,280.00 to $122,434.28. Despite these high balances, the surety bond remained at $80,000, leaving a significant portion of resident funds uninsured during this period. Interviews with facility staff indicated a lack of clear responsibility for monitoring the RTA balances and ensuring they did not surpass the bond limit. The Business Office Manager stated she was not responsible for reviewing monthly statements or monitoring the balances, while the Regional Director of Accounts Receivable noted that the previous director, who had recently left, would have been responsible for this task. The Facility Administrator was also unaware of who was responsible for monitoring the RTA and was not aware that the account frequently exceeded the bond coverage.
Failure to Provide Quarterly Financial Statements for Resident Personal Funds
Penalty
Summary
The facility failed to provide quarterly financial statements to residents and/or their representatives for personal funds held by the facility. This deficiency was identified through a review of the facility's Personal Funds Account, documentation, and interviews involving 13 sampled residents. The residents affected had a range of cognitive abilities, with some being responsible for themselves and others having legal representatives or being conserved. Despite the facility managing their personal funds, neither the residents nor their representatives received the required quarterly statements. Interviews revealed that at least one resident's Power of Attorney (POA) had not received quarterly banking statements and had previously requested them without success. The Business Office Manager confirmed that she did not send out the statements, believing them unnecessary since she was the representative payee. This practice was applied to all affected residents for whom the facility managed personal funds, regardless of their cognitive status or legal representation. The Administrator was unaware that the statements were not being provided and attributed the issue to a breakdown in training and orientation for the Business Office Manager. The facility's own Resident Rights documentation specifies that residents have the right to a quarterly review of their account, which was not upheld in these cases.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to immediately report an allegation of potential physical abuse involving a resident with a history of traumatic brain injury and left-side hemiplegia. The resident, who required maximum assistance for mobility and was at risk for falls, reported to two RNs that a nurse aide had grabbed their arm during a transfer, resulting in a bruise. Both RNs observed the injury and were aware of the allegation, but neither ensured that the incident was reported to the Director of Nursing (DON) or the Administrator as required by facility policy. The nurse aide in question was not immediately removed from duty, and the incident was not promptly investigated. Facility documentation and interviews revealed that the DON was not informed of the allegation until the following day, and the required report to the state agency was not made within the mandated two-hour timeframe. The facility's policy specifies that suspected abuse must be promptly reported to management and the appropriate authorities, but this protocol was not followed. The delay in reporting and failure to initiate an immediate investigation constituted a deficiency in the facility's response to the abuse allegation.
Failure to Follow Care Plan for Safe Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic brain injury and left-side hemiplegia, who was care planned for two-person assistance and transfer with a mechanical device (Sara lift), was transferred by a nurse aide without the required assistance or equipment. The resident's care plan, nurse aide care card, and quarterly assessment all specified the need for two staff members and the use of the Sara lift for transfers due to the resident's decreased mobility and risk for falls. Despite this, the nurse aide transferred the resident alone and without the mechanical device, which was contrary to the documented plan of care and facility policy. As a result of this improper transfer, the resident sustained a bruise to the upper arm, which was reported to the Director of Nursing the following day. The resident stated that the nurse aide was angry and grabbed the arm during the transfer. The nurse aide admitted to being aware of the care plan requirements but frequently transferred the resident alone because it was easier. The Director of Rehabilitation confirmed that the recommendation for two-person assistance and use of the Sara lift was made for the safety of both the resident and staff.
Failure to Remove Smoking Paraphernalia in Smoke-Free Facility
Penalty
Summary
Staff failed to remove smoking paraphernalia from a resident who was found in possession of cigarettes and lighters in a smoke-free facility. The resident, who was responsible for self-care and had diagnoses including anxiety, depression, and nicotine dependence, was observed by a nurse aide leaving the building and smoking outside. The nurse aide did not confiscate the cigarette or lighter, and upon returning inside, the incident was reported to the RN supervisor later in the shift. The RN supervisor did not take possession of the smoking items, nor did the charge nurse conduct a search for additional paraphernalia. The resident's care plan specified that all smoking materials should be kept by nursing staff in a secured cart, and the facility's policy identified it as a non-smoking environment. Further review revealed that the following day, the resident's family found two lighters in the resident's room and notified the supervisor. Interviews with staff and facility leadership confirmed that no immediate action was taken to confiscate the smoking materials or search the resident's room after the initial incident. The Director of Nursing and Administrator were unaware of the incident until later and acknowledged that staff should have removed the smoking paraphernalia and conducted a room search when the resident was first observed smoking.
Failure to Assess Resident Post-Fall
Penalty
Summary
The facility failed to complete an assessment on a resident who experienced a fall with subsequent injuries. The resident, who had a history of falls and was identified as a fall/safety risk, was transferred to the hospital following the incident. Despite the resident's complaints of head and left hip pain, there was no documentation of a post-fall assessment in the clinical records or the post-fall evaluation form. Interviews with nursing assistants revealed that the resident was found on the floor and was in pain, particularly in the left hip area. The nursing supervisor, RN #3, instructed the staff to clean the resident and move them to the toilet without conducting a thorough assessment. The resident was difficult to move and expressed significant pain during the process, indicating a possible injury. The Director of Nursing Services confirmed that the clinical record lacked documentation of an assessment following the fall. The facility's policy requires a registered nurse to assess the resident for injuries and document the findings, which was not done in this case. The resident was later found to have sustained a left hip intertrochanteric fracture and underwent surgery, highlighting the severity of the oversight.
Failure to Supervise Cognitively Impaired Resident Leads to Fall
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, resulting in a fall with injury. Resident #2, who had a history of dementia, transient ischemic attack, cerebral infarction, muscle weakness, and unsteadiness, was identified as a high fall risk. The resident required extensive assistance for mobility and toileting, as documented in the Minimum Data Set (MDS) assessment and Resident Care Plan. Despite these documented needs, the resident was left unattended in the bathroom by a Nurse Aide (NA), leading to a fall. On the night of the incident, NA #1 escorted Resident #2 to the bathroom and left the resident alone, despite the resident's need for assistance and poor safety awareness. The NA instructed the resident to use the call light or yell for help when ready to leave the bathroom. However, the resident attempted to self-transfer from the toilet, resulting in a fall. The fall caused a laceration to the resident's occipital lobe and an acute L1 vertebra fracture, necessitating hospital transfer. Interviews with facility staff revealed that NA #1 did not verify the resident's care needs before leaving the resident unattended. The Director of Nursing Services (DNS) and the Rehab Director confirmed that residents requiring assistance should not be left alone and should remain within arm's reach of staff. The incident highlighted a failure to adhere to the resident's care plan and supervision requirements, contributing to the fall and subsequent injury.
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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