Harbor Village North Health And Rehabilitation Cen
Inspection history, citations, penalties and survey trends for this long-term care facility in New London, Connecticut.
- Location
- 78 Viets St Extension, New London, Connecticut 06320
- CMS Provider Number
- 075196
- Inspections on file
- 25
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Harbor Village North Health And Rehabilitation Cen during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse when two residents with dementia and documented behavioral issues, including prior aggression and a history of anger and yelling, were placed together as roommates despite known personality incompatibilities. During a disagreement over room temperature, one resident reported that the other grabbed their neck, and the alleged aggressor admitted to putting hands on the peer and justified the action based on the peer’s language. A roommate witness confirmed seeing hands placed on the victim’s shoulders and an altercation occurring. This incident occurred in the context of existing care plans and staff knowledge that both residents had behavioral and mood-related risks, contrary to the facility’s zero-tolerance abuse policy.
A resident with dementia, cognitive impairment, and Parkinson’s disease with dyskinesia, who required extensive assistance with ADLs and mechanical-lift transfers, was found seated at the nurse’s station with an unwitnessed hematoma on the forehead. Staff assumed the resident had struck their head on the bed’s headboard due to dyskinesia, but no one observed the event and the cause was not confirmed. The ADNS interviewed only two NAs from the prior shift and did not interview the unit nurse who had recently interacted with the resident, despite facility policy requiring a broader 72-hour inquiry for injuries of unknown source. After the ADNS relayed an assumed explanation to a regional RN, the event was not reported to the State Agency as an injury of unknown origin, contrary to the facility’s abuse and reporting policy.
A resident with dementia, cognitive deficits, and Parkinson's disease with dyskinesia, who was dependent on staff for most ADLs and required two-person mechanical lift transfers, was found with an unwitnessed hematoma on the forehead while seated at the nurse’s station. No staff witnessed the incident, and only two NAs from the prior shift were interviewed, whose statements were inconclusive and based on an assumption that the resident hit their head on the bed’s headboard due to dyskinesia. The ADNS did not follow policy requiring a 72-hour look-back and broader staff interviews, did not interview the unit nurse who had interacted with the resident minutes before the injury was noted, and, after discussing with a regional RN, did not report the event to the State Agency as an injury of unknown origin based on the unverified assumption of cause.
The facility failed to conduct thorough investigations into multiple resident-to-resident abuse incidents. In one case, a resident with schizophrenia struck another with dementia, but staff statements were missing. Another incident involved a resident with intellectual disabilities threatening their roommate, yet staff documentation was incomplete. A third case saw a resident with schizoaffective disorder being punched, but again, staff statements were not obtained. The DNS acknowledged the investigations were incomplete, contrary to facility policy.
The facility failed to provide timely social services support to residents involved in abuse incidents. A resident with paranoid schizophrenia was not met by social services until a day after an incident, with follow-ups lacking. Another resident with vascular dementia had no documented social worker interaction regarding the incident. Similar deficiencies were noted for other residents, with social workers failing to meet within 24 hours and not following up daily for 72 hours.
The facility failed to maintain a clean kitchen environment and did not discard expired foods. Observations included dust-covered fans, dirty walls, and expired food items in storage. The Food Service Manager, new to the position, had not yet updated the cleaning schedule or checked expiration dates. The Administrator was aware of the issues and had made some improvements.
The facility failed to resolve cleanliness issues in the kitchen identified during environmental rounds from January to June 2024. The ICN noted these issues, but there was no evidence of resolution within the required 10-day period. Additionally, significant lint debris was observed in the laundry area, with no documentation of recent cleaning. The Laundry Manager, temporarily covering the position, could not provide cleaning records, indicating a failure to maintain cleanliness as per policy.
The facility failed to notify the physician of significant changes in the conditions of two residents. One resident with multiple co-morbidities experienced worsening symptoms, including abdominal pain and labored breathing, without timely assessment or physician notification, leading to hospitalization and eventual death. Another resident with congestive heart failure gained 35.1 pounds over two weeks without re-weighing or physician notification, potentially contributing to lower leg edema. Staff interviews revealed gaps in monitoring and documentation, highlighting deficiencies in care processes.
The facility failed to assess, care plan, and obtain consents for residents on a secured dementia unit. Observations showed restricted access requiring a code, with no criteria for placement or physician's orders. Clinical records lacked consent and documentation of the least restrictive setting, and care plans did not reflect secured unit placement.
A resident with paraplegia experienced pain due to long, thickened, and brittle toenails, despite regular podiatrist visits. The facility failed to provide specific foot care beyond shower care, and the podiatrist did not prescribe anti-fungal treatment due to the resident's age and co-morbidities. The facility's foot care policy and healthcare service agreement required appropriate care, but the resident's toenail condition persisted, indicating a deficiency.
Two residents reported dissatisfaction with the food quality and preparation at the facility. One resident, with dementia and other conditions, noted a lack of variety and flavor, while another resident with spinal cord injury and paraplegia expressed similar concerns. Observations confirmed issues such as undercooked pork, mushy zucchini, and raw quiche crust. The food service manager attributed some problems to the use of frozen vegetables and a late delivery. The facility's policy on cooking temperatures did not ensure food safety during plating and transport.
The facility failed to maintain a pest-free environment, with fruit flies observed in resident rooms and the hallway of the Northeast wing, and rodent droppings found in the kitchen's emergency food storage area. Despite previous pest control treatments, the issues persisted, indicating inadequate pest management and sanitation practices. Interviews with staff revealed a lack of awareness and documentation regarding pest control efforts.
A resident with cognitive impairments was exposed to the hallway during morning care due to an open door, and was spoken to disrespectfully by a nursing assistant. The incident was witnessed by a surveyor, and staff interviews confirmed the failure to maintain privacy and dignity, contrary to facility policy.
A resident with dementia and other conditions was not provided privacy during morning hygiene care, as observed by a surveyor. The resident was exposed to the hallway with the door open, and the care plan's privacy interventions were not followed. Staff interviews confirmed the expectation of privacy, aligning with the facility's policy on resident dignity.
The facility failed to monitor and assess two residents for changes in their health conditions. A resident with multiple co-morbidities experienced worsening symptoms without proper assessment or physician notification, leading to an emergency hospital transfer and subsequent death. Another resident with CHF had a significant weight gain, indicating potential fluid overload, but was not reassessed or reported to a physician in a timely manner. Staff interviews revealed communication lapses and protocol failures.
The facility failed to implement pharmacy recommendations for two residents, leading to deficiencies in medication management. One resident's PRN Miralax order lacked frequency clarification despite agreement from the APRN, while another resident's Seroquel prescription required orthostatic BP monitoring, which was not conducted. Communication lapses between the pharmacy consultant, DNS, ADNS, and APRN contributed to these oversights.
A medication error occurred when an LPN crushed and administered medications to a resident, despite instructions not to crush enteric coated and extended-release medications. The resident, who was severely cognitively impaired, received Aspirin EC, Bupropion HCl ER, and Metoprolol Succinate ER in crushed form, leading to a facility medication error rate of 12%. The LPN admitted to not fully reading the medication instructions, and the RN Supervisor confirmed the error.
A facility failed to maintain complete medical records for a resident with GERD, bipolar disorder, and COPD. Signed pharmacist recommendations from several months were missing from the resident's chart, contrary to facility policy. Interviews revealed inconsistencies in the handling and filing of these documents, leading to incomplete records.
A facility failed to prevent altercations between two residents, one with dementia and behavioral disorders and another with moderate cognitive impairment. Despite known risks and previous incidents, interventions such as a Velcro cloth stop sign were not consistently implemented, leading to physical altercations. The oversight resulted in a deficiency related to abuse prevention.
Failure to Prevent Resident-to-Resident Physical Abuse Between Roommates
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from physical abuse by allowing two residents with known behavioral issues to be placed together as roommates, which led to a physical altercation. Resident #15 had diagnoses including vascular dementia with behaviors, schizophrenia, and paranoid personality disorder, with a care plan noting potential for behaviors related to dementia, paranoia, delusions, a history of physical aggression, and a prior resident-to-resident altercation. Resident #40 had diagnoses including unspecified dementia, bipolar II disorder, and anxiety, with a care plan identifying risk for mood and behavioral issues such as rummaging, anger, yelling at staff, increased delusions, and confusion. Despite these documented behavioral risks, the residents were roomed together. Prior documentation showed that Resident #15 had a past reportable event involving an alleged altercation with a roommate, where words were exchanged and there was an allegation that Resident #15 grabbed the roommate’s arm, though both residents later denied physical contact and no injuries were found. Nursing and psychiatry notes following that earlier event did not identify ongoing resident-to-resident altercations, and subsequent notes up to the time of the later incident did not document further altercations. However, the care plan for Resident #15 continued to reflect a history of physical aggression and a prior resident-to-resident altercation. On the date of the cited incident, Resident #40 reported to a nurse aide that Resident #15 grabbed them around the neck after Resident #40 adjusted the room thermostat. Resident #15 admitted to putting hands on Resident #40 and justified the action by stating that the other resident had a foul mouth and deserved it. A roommate witness reported seeing Resident #15 place hands on Resident #40’s shoulders and confirmed that an altercation occurred. Staff interviews described Resident #40 as someone who could get mad, loud, and unpleasant with others and as having a feisty personality, and Resident #15, usually quiet, was identified as the aggressor who grabbed Resident #40’s neck during a disagreement over room temperature. The facility’s abuse prohibition policy required a zero-tolerance environment free from abuse, but the placement of these two residents together, despite known behavioral histories and personality incompatibility, led to a physical abuse incident in which Resident #15 grabbed Resident #40 around the neck.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Agency as required by policy and regulation. One resident with dementia with agitation, cognitive communication deficit, and Parkinson’s disease with dyskinesia had significant ADL and mobility deficits and required extensive staff assistance, including two-person assist and a mechanical lift for transfers. The resident’s care plan reflected these needs. On the morning of 2/18/26, while the resident was seated in a wheelchair at the nurse’s station, an LPN observed a hematoma on the left side of the resident’s forehead. No one had witnessed how the injury occurred, and the cause was unknown at the time it was discovered. Staff concluded that the resident had likely hit their head on the bed’s headboard earlier in the morning due to intermittent dyskinesia. The Assistant Director of Nursing (ADNS) consulted with the Regional Director of Clinical Services (RN #3) and reported that the injury could be explained by dyskinesia, leading RN #3 to determine that the event did not need to be reported as an injury of unknown origin within the 24-hour reporting window. The ADNS did not follow the facility’s abuse policy requirement to conduct a complete investigation by interviewing all staff with access to the resident in the prior 72 hours; instead, only the two NAs from the previous shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. The facility’s policy defined an injury of unknown source as one not observed or not explainable by the resident and suspicious due to its extent or location, and directed reporting of such events to the State Agency within specified time frames. Because the investigation was incomplete and the source of the injury remained unwitnessed and unexplained, the injury met the facility’s definition of an injury of unknown origin, but it was not reported to the State Agency.
Failure to Thoroughly Investigate Resident Head Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for Resident #47, who had dementia with agitation, cognitive communication deficit, and Parkinson's disease with dyskinesia. The resident had moderate cognitive impairment and required extensive assistance, including two-person assist with a mechanical lift for all transfers and dependence for most ADLs. On the morning of 2/18/26, staff observed an unwitnessed hematoma on the left side of the resident’s forehead while the resident was seated in a wheelchair at the nurse’s station. No one had witnessed how the injury occurred, and the two NA statements were inconclusive, only assuming the resident had hit his/her head on the bed’s headboard earlier in the morning due to dyskinesia. The ADNS reported that, after conferring with the Regional Clinical Director (RN #3) and indicating the cause was believed to be related to dyskinesia, it was determined the injury did not need to be reported to the State Agency as an injury of unknown origin within the 24-hour reporting window. The ADNS acknowledged not following the facility’s abuse policy requirement to conduct a thorough investigation, including going back 72 hours and interviewing all staff with access to the resident; instead, only the two NAs from the prior shift were interviewed, and the unit nurse who had interacted with the resident minutes before the hematoma was noted was not interviewed. RN #3 stated she believed a complete and thorough investigation had been done and that the cause was known, and that she would have had the injury reported as an injury of unknown origin had she known the investigation was incomplete. The facility’s abuse policy required a thorough investigation of alleged abuse or neglect by the Administrator and/or DON to determine if conduct violated standards of care, which was not carried out in this case.
Incomplete Investigations into Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into multiple incidents of resident-to-resident abuse involving five residents. In one incident, a resident with paranoid schizophrenia and antisocial personality disorder struck another resident with vascular dementia and behavioral disturbances. The facility's reportable event documentation lacked statements from staff who witnessed the incident, and the acting Director of Nursing Services (DNS) was unable to explain why these statements were not obtained. The nursing supervisor on duty did not have a clear list of caregivers assigned to the involved residents, which contributed to the incomplete investigation. Another incident involved a resident with severe intellectual disabilities threatening to harm their roommate, who had dementia and schizophrenia. Although the residents were separated and emergency services were notified, the facility's documentation did not include statements from the staff responsible for the residents' care during the incident. The DNS acknowledged the lack of complete documentation and was unsure why the necessary statements were not collected. A third incident involved a resident with schizoaffective disorder being punched by another resident. The nursing supervisor documented the physical injuries sustained by the victim but failed to obtain statements from staff present during the altercation. The DNS admitted that the investigations into these incidents were incomplete due to missing staff statements and a lack of documentation regarding the residents' status before the incidents. The facility's policy required a thorough investigation by the DNS or Social Services department, which was not fulfilled in these cases.
Failure to Provide Timely Social Services Support After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide timely social services support to residents involved in resident-to-resident abuse incidents. Five residents were reviewed for such incidents, and it was found that the facility did not ensure that social services met with the residents within the required timeframe. For instance, Resident #1, diagnosed with paranoid schizophrenia and other disorders, was involved in an incident on 8/7/24 but was not met by social services until the following day. Subsequent follow-ups were also lacking, as there were no social service notes from 8/9/24 through 8/11/24 and from 8/13/24 through 8/20/24. Resident #2, who has vascular dementia and other behavioral issues, was also involved in the same incident on 8/7/24. However, there was no documentation of any social worker interaction with this resident regarding the incident throughout the entire month of August. Social Worker #1 admitted to not remembering meeting with the resident, which resulted in the absence of documentation. This lack of timely intervention and documentation was a recurring issue for other residents involved in similar incidents. Residents #3, #4, and #5 also experienced deficiencies in social services follow-up after incidents of resident-to-resident abuse. For example, Resident #3 was involved in an incident on 8/30/24, but follow-up documentation was missing from 9/1/24 through 9/8/24. Similarly, Resident #4, involved in the same incident, had no further social service documentation after the initial meeting on 8/30/24. The facility's social workers failed to consistently meet with residents within 24 hours of incidents and did not follow up daily for the required 72 hours, as confirmed by interviews with the social workers and the facility administrator.
Deficiencies in Kitchen Cleanliness and Food Expiration Management
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not discard expired foods, as observed during a tour of the Dietary Department. The inspection revealed a ceiling fan covered with dust blowing over washed silverware and mugs, walls in the dishwashing area coated with dust, and a foul odor emanating from the sink area due to grime and dirt accumulation. Additionally, the vent above the stove was dusty while food was being prepared, and the cleaning schedule did not include fans, walls, or ceiling tiles. The Food Service Manager, who had been in the position for four weeks, acknowledged the need for steam cleaning the kitchen and had reported the cleanliness issues in meetings. However, the cleaning schedule did not cover all necessary areas, and the responsibility for cleaning certain areas was unclear between the kitchen staff and the maintenance department. The Sanitarian had previously identified cleanliness issues during an inspection and noted that staff were cleaning the kitchen during a follow-up visit. Expired food items were found in the emergency food supply and the walk-in freezer, including cereal, pudding, canned fruits, and meats. The Food Service Manager admitted to not checking expiration dates yet and stated that it was the responsibility of the staff stocking the freezer. The Dietician noted that serving expired food could make residents ill. The Administrator was aware of the cleanliness issues and had made some improvements but acknowledged that the cleaning schedule needed updates.
Failure to Address Cleanliness Issues in Kitchen and Laundry Areas
Penalty
Summary
The facility failed to address cleanliness issues identified during monthly environmental rounds from January 2024 to June 2024. The Infection Control Nurse (ICN) and other staff were responsible for conducting these rounds, and they noted cleanliness issues in the kitchen. However, there was no evidence that these issues were resolved within the 10-day timeframe as required by the facility's policy. The ICN confirmed that the cleanliness of the kitchen remained an issue throughout this period, indicating a lack of follow-through on identified problems. Additionally, during an observation in the laundry area, significant lint debris was found on the back wall, ceiling wall, metal pipe, and floor where the washing machines were located. The Laundry Manager, who was temporarily covering the position, could not provide documentation of when these areas were last cleaned. This indicates a failure to maintain a clean laundry area, as required by the facility's Environmental Rounds Best Practice policy, which mandates that problem areas be resolved and documented within 10 days.
Failure to Notify Physician of Significant Changes in Residents' Conditions
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of two residents, leading to deficiencies in care. Resident #16, who had multiple co-morbidities including chronic anemia, cirrhosis, and heart failure, experienced a significant change in condition with symptoms such as abdominal pain, vomiting, and labored breathing. Despite these symptoms, there was a lack of timely and thorough assessment by the nursing staff, and the physician was not notified of the resident's worsening condition. This oversight resulted in the resident being sent to the hospital in a critical state, where they later expired. Resident #43, diagnosed with congestive heart failure, diabetes, and dementia, experienced a significant weight gain of 35.1 pounds over two weeks. The facility failed to re-weigh the resident or notify the physician of this significant change, as required by their weight policy. The oversight in monitoring and reporting the resident's weight gain potentially contributed to the resident's lower leg edema, which was noted in the clinical record. The lack of communication and follow-up on the resident's condition highlights a deficiency in the facility's care processes. Interviews with facility staff, including the ADNS, LPNs, and the dietician, revealed gaps in the monitoring and documentation of the residents' conditions. The staff acknowledged the failure to conduct thorough assessments and notify the physician of significant changes. The facility's policy on changes in a resident's condition or status was not adhered to, resulting in a lack of timely intervention and appropriate care for the affected residents.
Failure to Assess and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to properly assess, care plan, and obtain necessary consents for residents residing on a secured dementia unit. Observations during the survey period revealed that the secured unit required a code for entry and exit, and only staff were observed using the code. The facility assessment did not include criteria or specific functions for the unit, and interviews with facility staff confirmed that there were no established criteria for placing residents on the secured unit. The decision to place residents was based on diagnoses or family requests, without a formal assessment process or physician's orders. The clinical records of thirty-eight residents on the secured unit did not show evidence of consent from responsible parties, physician's orders, or documentation that the secured unit was the least restrictive setting. Care plans did not reflect the residents' placement on the secured unit or agreement from residents or their responsible parties. Interviews with the facility's administration and staff confirmed the lack of criteria for placement and the absence of reassessments to ensure the appropriateness of the secured unit for residents.
Deficiency in Toenail Care for Resident with Paraplegia
Penalty
Summary
The facility failed to provide necessary services for maintaining good grooming and personal care for a resident with paraplegia, specifically related to toenail care. The resident, who had intact cognition and used a wheelchair, experienced pain due to long toenails. Observations revealed that the toenails were thickened, yellowed, brittle, and had grown over the ends of the toes. Despite regular visits from a podiatrist, the resident's toenails remained problematic, and the facility did not provide specific foot care beyond shower care. The podiatrist's notes indicated that the resident had fungal nails that were debrided, but anti-fungal treatment was not prescribed due to the resident's age and co-morbidities. The facility's foot care policy stated that residents should receive appropriate care to maintain foot health, and those with foot disorders should be referred to qualified professionals. However, the resident continued to experience issues with toenail care, as the podiatrist did not recall the resident and did not make a referral for oral anti-fungal medication. The facility's healthcare service agreement with the podiatry group required care and treatment in accordance with professional standards, yet the resident's toenail condition persisted, indicating a deficiency in the facility's adherence to its own policies and agreements.
Deficiency in Food Preparation and Serving Standards
Penalty
Summary
The facility failed to provide food that was prepared in a manner to conserve nutritive value and in a palatable manner for two residents. Resident #20, who has diagnoses including unspecified dementia, major depressive disorder, and diabetes insipidus, reported that the food lacked variety and flavor, with an overuse of pasta. The menu review showed frequent repetition of pasta dishes over several weeks. An observation and taste test of a lunch meal revealed issues such as undercooked pork, mushy zucchini, and a raw quiche crust. The food service manager confirmed the issues with the quiche and zucchini, attributing the latter to the use of frozen vegetables and a late delivery truck. Resident #39, with diagnoses including unspecified injury to the lumbar spinal cord and paraplegia, expressed dissatisfaction with the food choices and preparation, noting that the food was sometimes overcooked or undercooked. During an observation, Resident #39 was seen pushing away his lunch tray, indicating he did not consume the meal. A test tray observation confirmed the issues with the meal, including overcooked zucchini and undercooked quiche. The food service manager acknowledged the substitution of zucchini for broccoli due to a late delivery and confirmed the quiche was undercooked. The facility's policy on proper cooking temperatures was reviewed, highlighting the importance of maintaining food outside the danger zone to prevent bacterial growth. However, the policy did not account for maintaining the appropriate temperature during plating and transport. The dietician noted that consuming undercooked or raw foods could cause gastrointestinal symptoms and that overcooking could lead to a loss of nutritional value. The facility's failure to adhere to proper food preparation and serving standards resulted in unpalatable and potentially unsafe meals for the residents.
Pest Infestation in Resident Rooms and Kitchen Storage
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of fruit flies in several resident rooms and the hallway of the Northeast wing. Observations revealed fruit flies in rooms 15, 18, and 20, with significant infestations noted on overbed tables, side tables, and beds. The presence of food items, such as cups of orange juice and sandwiches, contributed to the infestation. Despite previous pest control treatments, the issue persisted, indicating inadequate pest management and sanitation practices. In addition to the fruit fly issue, the facility's kitchen food storage area showed signs of rodent infestation. Observations identified chewed markings and fecal droppings on emergency food supplies, including cans of diced peaches, carrots, and corned beef hash. The flooring beneath the storage racks was also coated with fecal droppings. Interviews with the Food Service Manager and review of pest control invoices revealed that the facility had a history of rodent issues, with treatments conducted twice monthly. However, the presence of droppings indicated that these measures were insufficient. Interviews with facility staff, including the Administrator and DNS, highlighted a lack of awareness and documentation regarding pest control efforts. The Administrator admitted to changing pest control companies due to unsatisfactory results, while the DNS mentioned that treatments for fruit flies were conducted outside, as the chemicals could not be used indoors. The facility's failure to effectively address pest issues in both resident areas and food storage environments demonstrates a significant deficiency in maintaining a sanitary and safe environment for residents.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident, identified as Resident #33, during morning hygiene care. Resident #33, who has diagnoses including unspecified dementia, a history of traumatic brain injury, and Asperger's syndrome, was observed in a vulnerable state with the door to their room open, exposing their naked body to the hallway. The resident, who has moderately impaired cognition and requires assistance with daily activities, was subjected to undignified treatment by a nursing assistant (NA#1). NA#1 responded to the resident's repeated comments about a smell with a disrespectful and inappropriate remark, which was repeated multiple times. This interaction was witnessed by a surveyor, prompting NA#1 to close the door belatedly. Interviews with staff, including NA#1, LPN#1, and RN#1, confirmed that the resident's privacy should have been maintained by closing the door or drawing the curtain during care. NA#1 acknowledged the failure to provide privacy and admitted that the comment made to the resident was inappropriate. LPN#1 identified the incident as verbal abuse and emphasized the importance of reporting such behavior immediately. The facility's policy on dignity, which mandates respectful communication and the protection of resident privacy, was not adhered to in this instance.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy for Resident #33 during personal care, as observed by a surveyor. Resident #33, who has diagnoses including unspecified dementia, a history of traumatic brain injury, and Asperger's syndrome, was observed receiving morning hygiene care with the door open, exposing the resident's naked body to the hallway. The care plan for Resident #33, which includes interventions for privacy during care, was not followed. NA#1, who was providing the care, responded inappropriately to the resident's repeated comments about a smell, using the resident's first name in a frustrated manner. It was only after noticing the surveyor that NA#1 closed the door. Interviews with NA#1, LPN#1, and RN#1 confirmed that privacy should have been maintained by closing the door or drawing the curtain during care. The facility's policy on Quality of Life Dignity, revised in 2009, directs staff to promote and protect resident privacy during personal care and treatment procedures. The failure to adhere to these policies and procedures resulted in a deficiency related to the privacy and dignity of Resident #33.
Failure to Monitor and Assess Changes in Residents' Conditions
Penalty
Summary
The facility failed to consistently monitor and assess two residents for changes in their health conditions, leading to deficiencies in care. Resident #16, who had multiple co-morbidities including chronic anemia, cirrhosis of the liver, and heart failure, experienced an acute onset of nausea and vomiting. Despite orders for close monitoring and assessments, the facility's nursing staff did not document complete assessments or notify the attending physician of significant changes in the resident's condition, such as altered mental status, shortness of breath, and labored breathing. The resident's condition worsened, leading to an emergency transfer to the hospital, where the resident later expired. Resident #43, diagnosed with congestive heart failure, diabetes, and dementia, experienced a significant weight gain of 35.1 pounds over a short period. The facility failed to reassess the resident or notify the physician of this significant change, which could indicate fluid overload due to CHF. The weight gain was not addressed until much later, despite the potential for contributing to the resident's lower leg edema. Interviews with facility staff, including LPNs, RNs, and the APRN, revealed a lack of communication and failure to follow protocols for monitoring and reporting changes in residents' conditions. The facility's policy required prompt notification of changes to the attending physician and detailed assessments by nursing staff, which were not adhered to in these cases. The deficiencies highlight a failure in the facility's processes for managing residents' health changes effectively.
Failure to Implement Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to implement pharmacy review recommendations for two residents, leading to deficiencies in medication management. For one resident with diagnoses including GERD, bipolar disorder, and COPD, the pharmacist recommended clarifying the frequency of a PRN Miralax order on multiple occasions. Despite the APRN agreeing to the recommendation, the order was not updated in the resident's medical record, and the facility's policy requiring action within 30 days was not followed. Interviews revealed communication issues between the pharmacy consultant, DNS, ADNS, and APRN, contributing to the oversight. Another resident with diagnoses of unspecified dementia, psychosis, and Asperger's syndrome was prescribed Seroquel, which can cause orthostatic hypotension. The pharmacist recommended monitoring orthostatic blood pressures, and the physician agreed to this recommendation. However, the facility failed to implement the order, as no orthostatic blood pressures were recorded in the resident's medical record. Similar communication lapses were noted, with the APRN and DNS not ensuring the recommendation was acted upon. The facility's policy on Medication Regimen Review and Reporting requires that recommendations be communicated to the DNS or designee and acted upon within 30 days. However, the facility did not adhere to this policy, resulting in unaddressed pharmacy recommendations for both residents. The lack of follow-through on these recommendations highlights a breakdown in the facility's processes for managing medication regimens and ensuring resident safety.
Medication Administration Error Due to Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an incident involving a resident with diagnoses including hypertension, depression, repeated falls, and anxiety. The resident was severely cognitively impaired and required assistance with personal hygiene, bed mobility, transfers, and supervision with eating. On a specific date, an LPN prepared and administered medications to the resident by crushing and mixing them in applesauce, despite pharmacy directions indicating that the medications should not be crushed. The medications included Aspirin enteric coated (EC), Bupropion Hydrochloride (HCl) extended release (ER), and Metoprolol Succinate ER, all of which have specific release mechanisms that are compromised when crushed. The LPN, who was not the regular nurse for the unit, admitted to not fully reading the medication administration record and instructions, leading to the error. The RN Nursing Supervisor confirmed that the administration orders should have been followed. The Pharmacy Consultant explained the potential effects of crushing these medications, such as faster release and potential irritation. The facility's total medication error rate was reported to be 12%, and the facility's policy required medications to be administered according to orders, with staff verifying the right resident, medication, dose, time, and method before administration.
Incomplete Medical Records for Resident
Penalty
Summary
The facility failed to ensure that medical records for a resident were readily accessible and complete, as required by professional standards. The resident in question had diagnoses including gastro-esophageal reflux disease (GERD), bipolar disorder, and chronic obstructive pulmonary disease (COPD). The facility's deficiency was identified during a clinical record review, which revealed that signed copies of pharmacist recommendations from December 2023 to February 2024 were missing from the resident's medical records. These recommendations were supposed to be part of the resident's medical chart, but they were not filed appropriately, as confirmed by interviews with the Director of Nursing Services (DNS) and the Assistant Director of Nursing Services (ADNS). The facility's policy on medication monitoring and regimen review required that findings be communicated to the director of nursing or designee and documented in the resident's chart. However, the process was not followed correctly, as the recommendations were found outside the medical chart and not filed under the pharmacy tab as expected. Interviews with the former DNS and medical records personnel revealed a lack of clarity and consistency in the handling and filing of these documents, contributing to the incomplete medical records for the resident.
Failure to Prevent Resident Altercations
Penalty
Summary
The facility failed to protect two residents from mistreatment, resulting in a deficiency related to abuse prevention. Resident #1, who had diagnoses including dementia and behavioral disorders, was known to exhibit behaviors such as wandering and intruding into others' spaces. Despite being identified as an elopement risk and having a history of altercations, the facility did not effectively prevent Resident #1 from entering Resident #2's room, leading to a confrontation. Resident #2, who had moderate cognitive impairment and a potential for mood disorders, was found in a physical altercation with Resident #1, which was not prevented by the facility's interventions. On two separate occasions, Resident #1 entered Resident #2's room, leading to incidents of yelling and physical altercations. The first incident occurred when Resident #1 was found next to Resident #2's bed, causing Resident #2 to yell for Resident #1 to leave. Although a Velcro cloth stop sign was placed across Resident #2's doorway as a deterrent, it was not documented as being in place during a subsequent incident. During the second incident, both residents were observed punching each other, resulting in red marks on their faces, indicating a failure to maintain a safe environment. The facility's documentation and interviews revealed that the interventions to prevent Resident #1 from entering Resident #2's room were not consistently implemented. Despite the known behaviors of Resident #1 and the previous altercations, the Velcro cloth stop sign was not in place during the second incident, allowing Resident #1 to enter the room and engage in a physical altercation with Resident #2. This oversight contributed to the deficiency in ensuring residents were free from mistreatment and abuse.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
