Grimes Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 1354 Chapel St, New Haven, Connecticut 06511
- CMS Provider Number
- 075275
- Inspections on file
- 15
- Latest survey
- December 5, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Grimes Center during CMS and state inspections, most recent first.
A resident with multiple blood disorders, cancer, and on medications known to increase bruising risk was admitted with existing bruises and developed further bruising during their stay. Despite clear documentation and staff awareness of the resident's high risk for bruising, the care plan did not include specific interventions to address this risk, contrary to facility policy.
A nurse aide failed to notify the charge nurse after observing purple discoloration to a resident's groin and upper inner thighs, despite the resident's complex medical history and facility policy requiring immediate reporting of significant changes in condition. The issue was discovered after the resident was hospitalized and the bruising was reported by hospital staff.
The facility did not ensure that their designated Infection Control Nurse, RN #4, completed the required CDC Infection Prevention Course. Although RN #4 had completed a certificate of achievement course in infection control, she had not finished two modules or taken the final exam for the CDC course. The Administrator and DNS were unaware of this incomplete training. RN #4 was the sole certified infection control nurse since her hire date.
The facility failed to complete advanced directive forms for three residents, resulting in incomplete documentation and lack of proper signatures and witness verification as required by policy.
The facility failed to notify the Office of the State LTC Ombudsman when three residents were transferred to the hospital. Interviews revealed a lack of awareness and miscommunication regarding the correct procedure for notifying the Ombudsman, and the facility did not provide a policy on the notification process.
The facility failed to provide adequate supervision for a resident, resulting in a fall and fracture, and did not ensure consistent monitoring for another resident with recurrent falls. Staffing issues and inconsistent documentation contributed to these deficiencies.
A resident with Alzheimer's, dementia, dysphagia, and diabetes experienced significant weight loss over several months. Despite documented weight decreases, the dietitian did not reassess the resident or bring the issue to the interdisciplinary team for intervention until months later, violating facility policy.
The facility failed to provide adequate nursing staff for a resident with multiple falls, leading to inconsistent 1:1 monitoring. Despite a care plan intervention, the resident was often left unsupervised due to staffing issues, resulting in multiple falls. Staff interviews confirmed that monitoring levels fluctuated based on staffing availability, and the DNS was unaware of these adjustments.
The facility failed to monitor targeted behaviors for a resident on antipsychotic medication. Despite directives to document specific behaviors, the behavior flow sheets were not individualized, and documentation was inconsistent. This failure to properly monitor and document behaviors led to a deficiency in care.
An LPN failed to properly sanitize a glucometer and perform hand hygiene as per facility policy, leading to a deficiency in infection control practices. The LPN did not know the correct procedure and did not allow for the required dwell time for sanitization, necessitating intervention from a supervisor.
A resident with a history of heart conditions did not receive anticoagulant medication for 13 days due to a missed INR test, resulting in a significant medication error. The facility's policy required INR testing per physician's order, but the nursing staff failed to follow up, leading to the resident missing the medication. The resident's INR level was found to be below the therapeutic range when tested later.
Failure to Implement Comprehensive Care Plan for Resident at Risk of Bruising
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with appropriate interventions for a resident at risk for bruising. The resident had multiple complex diagnoses, including blood disorders, lymphoma, anemia, amyloidosis, and was taking medications such as Brukinsa (Zanubrutinib) and an antiplatelet, both of which increase the risk of bruising. Upon admission, the resident was noted to have multiple bruises and discoloration, and subsequent medical notes documented further bruising and purpura of unknown etiology, with concerns raised about medication side effects and possible trauma. Despite these findings and the resident's high risk for bruising, the care plan only addressed impaired skin integrity related to decreased mobility and incontinence, without specific interventions for bruising risk. Interviews with clinical staff, including the APRN and DNS, confirmed that the resident was at increased risk for bruising due to their diagnoses and medications, and that a comprehensive care plan addressing this risk should have been in place. The facility's care plan policy requires a care plan based on identified needs, strengths, and preferences, including measurable goals and interventions, but this was not followed for the resident in question. The deficiency was identified through review of clinical records, facility documentation, and staff interviews.
Failure to Report Change in Resident's Skin Condition
Penalty
Summary
A deficiency occurred when a nurse aide observed purple discoloration to the groin and upper inner thighs of a resident with multiple complex medical diagnoses, including Waldenstrom macroglobulinemia, myeloproliferative disease, lymphoplasmacytic lymphoma, amyloidosis, post-traumatic stress disorder, delirium, and depressive disorder. The resident was noted to have moderately impaired cognition, was frequently incontinent, dependent with transfers, and required substantial assistance with activities of daily living. Despite observing the change in skin condition during care, the nurse aide did not report this significant change to the charge nurse, as required by facility policy. The failure to report the change in condition was discovered after the resident was sent to the hospital for abnormal bloodwork, where hospital staff identified bruising in the vaginal area and notified the facility. The facility's Director of Nursing confirmed that the nurse aide should have immediately reported the observed discoloration to the charge nurse, in accordance with facility expectations and policy. The facility's policy requires all significant changes in a resident's condition to be reported to the physician and family.
Infection Preventionist Certification Incomplete
Penalty
Summary
The facility failed to ensure a certified Infection Preventionist was employed, as evidenced by the review of documentation and interviews conducted during the survey. RN #4, designated as the Infection Control Nurse, had completed a certificate of achievement course in infection control in April 2022, which included various topics related to infection prevention. However, it was noted that RN #4 had not completed the final exam associated with a more extensive CDC Infection Control Training course, despite taking several modules. The Administrator and DNS were unaware of this incomplete training, and RN #4 was the only nurse certified for infection control since her hire date in June 2022. During an interview and review of the Infection Control curriculum with RN #4, it was revealed that she had not completed two modules and had never taken the final test to secure a certificate of completion for the CDC Infection Prevention Course. Subsequent to the surveyor's inquiry, RN #4 completed the outstanding modules, took the test, and obtained a certificate certifying completion of the CDC Infection Prevention Course.
Failure to Complete Advanced Directive Forms
Penalty
Summary
The facility failed to ensure the advanced directive forms were completed for three residents. Resident #53 was readmitted with diagnoses including dementia and end-stage renal disease. Despite being alert and oriented, the facility did not discuss the code status with the resident, and the consent form was only signed by one nurse without a witness. The care plan indicated the resident was a full code, but there was no physician's order for the code status, and the advanced directive form lacked proper signatures and documentation of attempts to contact the resident's representative. Resident #58, who had a stroke and moderately impaired cognition, was readmitted to the facility. The resident's representative requested a full code status, but the consent form was signed by only one nurse without a witness. Although a physician's order directed the resident to be a full code, the advanced directive form was incomplete, and there was no documentation of a second witness as required by the facility's policy. Resident #70, admitted with heart failure and severely impaired cognition, had a full code status per the hospital discharge summary. However, the facility did not discuss the code status with the resident's conservator, and the advanced directive form was blank. Despite the conservator visiting the facility, there was no documentation of the conversation or attempts to obtain the advanced directive within the first day or two following admission. The facility's policy required the advanced directive and physician order form to be completed upon admission, which was not adhered to in these cases.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when three residents were transferred to the hospital. Resident #1, who was admitted with chronic kidney disease, myocardial infarction, and atherosclerotic heart disease, was transferred to the hospital on two occasions in February and March 2024. The Action Summary for these periods did not reflect that the Ombudsman was notified of these transfers. Similarly, Resident #18, admitted with congestive heart failure, atrial fibrillation, and chronic kidney disease, was transferred to the hospital twice in March 2024, and the Ombudsman was not notified as required. Resident #71, admitted with Wegener's granulomatosis, epilepsy, and chronic pain syndrome, was transferred to the hospital in November 2023, and again, the Ombudsman was not notified. Interviews with the facility's Administrator, Director of Nursing Services (DNS), and medical record staff revealed a lack of awareness and miscommunication regarding the correct procedure for notifying the Ombudsman. The medical record staff indicated that discharges to the hospital were uploaded to the Ombudsman’s office monthly but were unaware that the incorrect Action Summary was being sent. The facility did not provide a policy regarding the notification process, indicating a systemic issue in ensuring compliance with notification requirements.
Inadequate Supervision and Monitoring Leading to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall resulting in a fracture for Resident #40. Despite being identified as at risk for falls and having interventions in place, Resident #40 experienced an unwitnessed fall in the shower, leading to a displaced fracture at the proximal humerus. The facility did not have documentation that Resident #40 was assessed by therapy to shower independently, and the nursing assistant left the resident alone in the shower, contrary to the expected supervision protocol. This lapse in supervision directly contributed to the resident's fall and subsequent injury. The facility also failed to ensure appropriate observation and monitoring for Resident #37, who had multiple recurrent falls. Despite being identified as requiring 1:1 monitoring after several unwitnessed falls, the facility's documentation revealed significant gaps in the monitoring records. Resident #37 experienced numerous falls without consistent 1:1 monitoring or documented checks, and the facility's staffing issues led to fluctuating levels of supervision. The facility's policy did not require physician orders for frequent monitoring, and the DNS was unaware that staffing shortages were affecting the implementation of the monitoring interventions. Interviews with staff, including the DNS and APRN, confirmed that the facility's monitoring practices were inconsistent and often altered due to staffing issues. The DNS acknowledged that neurological checks should have been completed for unwitnessed falls but were not consistently documented. The facility's failure to provide continuous and adequate monitoring for Resident #37, despite the known risk of falls, resulted in repeated incidents of unwitnessed falls and injuries, highlighting a significant deficiency in the facility's fall prevention and monitoring protocols.
Failure to Follow Up on Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure the dietitian followed up on significant weight loss for a resident diagnosed with Alzheimer's disease, dementia, dysphagia, and diabetes. The resident, who had severely impaired cognition and required meal setup, experienced a notable weight loss over several months. Despite the resident's weight being documented as consistently decreasing, the dietitian did not reassess the resident or bring the issue to the interdisciplinary team for intervention until months later. The resident's weight dropped from 236 lbs. to 219.5 lbs., representing an 8.2% weight loss over a short period. The facility's policy required the dietitian to assess residents experiencing significant weight changes and to update care plans with new interventions. However, the dietitian did not follow this protocol, as there was no documentation of assessment or intervention after the resident's weight loss was noted on multiple occasions. The dietitian's last assessment was on 12/13/23, and the next assessment did not occur until 3/8/24, despite the resident's ongoing weight loss. This failure to act contravened the facility's policy and contributed to the deficiency identified in the report.
Inadequate Staffing and Monitoring for Resident with Fall Risk
Penalty
Summary
The facility failed to ensure adequate nursing staff was available to provide close monitoring for a resident with multiple falls. Resident #37, who had diagnoses including repeated falls, muscle weakness, and dementia, was admitted to the facility and required substantial assistance with daily activities. Despite a care plan intervention for 1:1 monitoring due to a high risk of falls, the facility did not consistently provide this level of supervision. Observations on multiple occasions revealed that the assigned nursing assistant was either not present or was attending to other residents, leaving Resident #37 unsupervised. Interviews with staff confirmed that due to staffing issues, the level of monitoring fluctuated and was not always in line with the care plan requirements. The facility's daily nursing roster and staffing sheets indicated that Resident #37 was supposed to be on 1:1 monitoring, but this was not consistently implemented. On one occasion, the nursing assistant assigned to Resident #37 was observed assisting another resident, and on another occasion, the same nursing assistant was seen attending to Resident #37's roommate, leaving Resident #37 unsupervised. Staff interviews revealed that the facility often adjusted the monitoring levels based on staffing availability, which sometimes resulted in Resident #37 being monitored less frequently than required. The Director of Nursing Services (DNS) and other staff members acknowledged the staffing issues and the inconsistency in monitoring but did not take adequate steps to address the problem. The facility's policy on falls required that residents at risk for falls have appropriate fall prevention measures in place, including 1:1 sitters when necessary. However, the DNS admitted that she was not aware that the staff had adjusted Resident #37's monitoring based on staffing issues and that the monitoring intervention was not always being carried out. The Advanced Practice Registered Nurse (APRN) also confirmed that the monitoring level was determined based on the resident's risk but was not aware that it was being altered due to staffing shortages. The facility's failure to provide consistent 1:1 monitoring for Resident #37, as required by the care plan, led to multiple falls and demonstrated a significant deficiency in ensuring resident safety.
Failure to Monitor Targeted Behaviors for Antipsychotic Medication
Penalty
Summary
The facility failed to monitor targeted behaviors for a resident on antipsychotic medication. Resident #16, who was admitted with diagnoses including bipolar disorder, dementia, depressive episodes, and anxiety, was receiving antipsychotics and antidepressants. The care plan included monitoring for side effects and considering dose reduction when clinically appropriate. However, the facility did not document targeted behaviors as required by the physician's order dated 2/21/24, which directed documentation on a behavior monitoring flow sheet every shift. The psychiatric APRN progress notes and physician progress notes indicated specific behaviors to monitor, such as disorganized behaviors, delusions, and restlessness. Despite these directives, the behavior flow sheets were not individualized for Resident #16's specific behaviors. The documentation was inconsistent, with some shifts missing signatures and others signed off by nursing assistants instead of licensed nurses. The DNS confirmed that the behavior monitoring was not tailored to Resident #16's specific needs and that the computerized template used was not individualized. Review of the facility's Antipsychotic Drug Use Indications Policy revealed that antipsychotic drugs should only be used for specific conditions and behaviors, which must be documented. The facility's failure to consistently and accurately document targeted behaviors for Resident #16, as required by the physician's order and facility policy, led to the deficiency. This lack of proper monitoring and documentation could potentially impact the resident's care and the appropriateness of continued medication use.
Failure to Sanitize Glucometer and Perform Hand Hygiene
Penalty
Summary
The facility failed to ensure proper sanitization of the glucometer and adherence to hand hygiene protocols. During an observation, an LPN obtained a blood sugar reading for a resident and placed the glucometer on the medication cart without sanitizing it. The LPN then performed hand hygiene but did not sanitize her hands again after touching the glucometer before preparing insulin for administration. When questioned by the surveyor, the LPN admitted to not knowing the facility's policy for glucometer cleaning. The LPN then attempted to clean the glucometer with a Sani-Purple wipe but did not allow for the required dwell time before using it again. The supervisor had to intervene to instruct the LPN on the correct procedure, which includes a total dwell time of 4 minutes for proper sanitization. Further interviews revealed that agency staff, including the LPN in question, receive an overview of facility policies upon initial entrance, but the LPN failed to follow these protocols. The facility's policy for cleaning and disinfecting the glucometer includes using Sani-wipes or Purple Cap Wipes PDI with a dwell time of 2 minutes. The manufacturer's recommendations for the glucometer suggest using a germicidal bleach wipe with a total dwell time of 2 minutes. Despite these guidelines being available on the medication carts, the LPN did not adhere to them, leading to the deficiency in infection control practices.
Failure to Administer Anticoagulant Due to Missed INR Test
Penalty
Summary
The facility failed to ensure a laboratory test was obtained per physician's order for a resident receiving anticoagulant medication, resulting in a significant medication error. The resident, who had a history of prosthetic heart valve, endocarditis, atherosclerotic heart disease, and congestive heart failure, was admitted in January 2023. The care plan required administering anticoagulant as ordered and scheduling laboratory tests to monitor coagulation factors. However, the resident did not receive the anticoagulant medication, Coumadin, for 13 days due to a missed laboratory test for INR on 2/7/23, which was not followed up by the nursing staff. The resident's Medication Administration Record (MAR) showed that Coumadin was not administered from 2/7/23 to 2/19/23. The INR test, which was supposed to be conducted on 2/7/23, was not performed, and the resident's INR level was found to be below the therapeutic range when tested on 2/20/23. The facility's policy required licensed nursing staff to perform INR testing per physician's order, but this was not adhered to, leading to the medication error. Interviews with the involved staff revealed a lack of follow-up on the INR test, contributing to the resident missing 13 days of anticoagulant therapy.
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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