Havencare At Valerie Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrington, Connecticut.
- Location
- 1360 Torringford St, Torrington, Connecticut 06790
- CMS Provider Number
- 075332
- Inspections on file
- 37
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Havencare At Valerie Manor during CMS and state inspections, most recent first.
Three residents with pain and anxiety diagnoses had discontinued controlled medications (oxycodone and lorazepam) that went missing from narcotic lock boxes, along with the associated proof-of-use sheets. One resident with lumbar spine surgery and mood disorders had PRN oxycodone ordered and care planned for pain management, another resident with dementia had PRN oxycodone ordered and later discontinued, and a third resident with dementia and anxiety had PRN lorazepam ordered and discontinued. A drug audit revealed that multiple tablets of these discontinued medications, stored in the back of unit narcotic boxes for later destruction, could not be accounted for, and subsequent review showed that many nurses had access to the narcotic storage during the period between audits, with no staff member identified as responsible for the removal.
The facility failed to properly document, classify, and timely report an incident involving missing discontinued controlled medications belonging to three residents. An internal reportable event form noted that discontinued meds scheduled for destruction were missing but did not identify the affected residents or the specific drugs. Subsequent documentation showed that multiple tablets of Oxycodone and Lorazepam tied to these residents were unaccounted for, and disposition sheets were also missing. The event was reported to the State Agency 10 days after it was identified, was initially misclassified as a non-abuse event, and was not treated as potential misappropriation, despite facility policies requiring that alleged violations be reported promptly and that incident reports include the names of individuals involved and detailed event information.
The facility failed to maintain proper control and accountability of discontinued narcotic medications, resulting in missing Oxycodone and Lorazepam tablets for three residents with pain, dementia, and anxiety. Discontinued controlled drugs remained in unit narcotic lock boxes instead of being promptly removed to a secured nursing office lock box, and both the white proof-of-use sheets and matching medication packs went missing. An LPN’s narcotic audits did not include MAR review, discrepancies were adjusted to match proof-of-use sheets, and required dual nurse signatures for end-of-shift narcotic counts were missing on multiple dates. These actions and omissions violated the facility’s own controlled substance handling policy and led to unaccounted-for controlled substances.
Two cognitively impaired residents with a history of inappropriate sexual behaviors were allowed to spend time together in a common area with care plan restrictions limiting their contact to hand holding, as consented by their court-appointed conservators. Despite these restrictions, staff observed one resident with their chest exposed and the other in contact with the exposed area, constituting non-consensual sexual contact. Staff interviews confirmed awareness of the residents' relationship and care plan limitations, but inadequate supervision led to the incident, violating facility policy to protect residents from abuse.
Nursing staff administered medications as ordered but failed to document administration in the MAR at the time of delivery, instead recording doses hours later for multiple residents with complex medical needs. This practice was identified through an internal audit and confirmed by interviews, with facility leadership and policy requiring immediate documentation.
A resident with dementia and a history of falls suffered an unwitnessed fall resulting in bilateral femur fractures. Although the care plan was eventually updated to include a bolster mattress as a fall prevention measure, this intervention was not added or implemented until several days after the incident, indicating a delay in updating and executing care plan interventions following the injury.
A nurse aide verbally abused a resident with severe cognitive impairment by loudly confronting the resident in the dining room, using inappropriate language and aggressive gestures. Multiple staff witnessed the incident, and the aide admitted to making the statement out of frustration. The event caused the resident emotional distress and was substantiated as abuse according to facility policy.
Staff did not immediately report an incident where a resident with severe cognitive impairment was observed touching another resident inappropriately. An LPN initially reported only partial details, resulting in a delay of over 16 hours before the DON notified the State Agency, which was not in accordance with the facility's abuse reporting policy.
A resident with severe cognitive impairment and total dependence on staff for transfers sustained unexplained right foot fractures. The facility failed to conduct a thorough investigation, as required by its abuse policy, by not obtaining complete staff statements or documentation for several shifts prior to the injury, and could not provide evidence that all relevant staff were interviewed.
A resident with severe cognitive impairment and alcohol dependence was discharged home without adequate documentation, communication, or immediate support services in place. The facility did not ensure the responsible party was fully informed of the risks or that necessary discharge information was provided, resulting in the resident being hospitalized shortly after discharge.
A resident with severe cognitive impairment and multiple medical conditions was discharged from the facility with an inadequate plan, resulting in hospitalization within hours. Despite being medically cleared, the facility delayed readmission for eight days due to lack of a payer source and corporate approval, even though beds and staff were available. The resident was only readmitted after intervention from the LTC Ombudsman.
A resident with cognitive impairment and ongoing severe pain, as evidenced by daily pain reports and assessments, did not have a pain management care plan developed despite physician orders and facility policy requiring such interventions. The DON confirmed the absence of a care plan addressing the resident's pain.
A resident with multiple medical conditions was discharged home without proper medication reconciliation, resulting in the resident being sent home with medications belonging to other residents. Staff interviews confirmed that the required review and reconciliation process was not completed by the responsible LPN prior to discharge.
A resident with a biliary drain did not receive the required twice-daily flushing of the biliary tube with normal saline as specified in the hospital discharge summary. Facility documentation and physician orders only addressed cleansing and dressing the drain site, omitting the flushing procedure needed to maintain tube patency.
A resident with multiple medical conditions reported daily headaches and received Acetaminophen with inconsistent relief, but the facility did not conduct required pain evaluations or develop a care plan for pain management, as confirmed by the DON.
A resident with dementia and severe cognitive impairment, who required assistance for ambulation, was improperly restrained in a wheelchair using a gait belt by staff, restricting movement without a physician order or assessment. Staff accounts conflicted regarding who directed the restraint, but it was confirmed that the gait belt was used to prevent the resident from standing, contrary to facility policy and the resident's care plan.
A resident with severe cognitive impairment was improperly restrained in a wheelchair using a gait belt by a nursing assistant, following an LPN's direction. Another staff member witnessed the event but did not report it immediately, and the facility delayed notifying the State Agency after learning of the incident, exceeding required reporting timeframes.
The facility improperly used Resident Council funds for activities and services that should have been covered by the facility's budget, including music entertainment, art classes, and the beauty salon license fee. Residents felt obligated to vote for these expenditures, and the Administrator was unaware of the misuse, lacking oversight and a policy for fund management.
The facility failed to complete required background checks and obtain professional references for six staff members, including NAs, LPNs, and RNs, before they began working. The HR department was responsible for these tasks but did not adhere to the facility's policies, resulting in incomplete employee files and a deficiency noted during the survey.
The facility failed to change and label oxygen tubing weekly for residents requiring respiratory care, as per its policy. Several residents, including those with chronic respiratory conditions, had tubing that was not changed on schedule, and staff were unaware of the policy requirements. Observations revealed inconsistencies in documentation and improper handling of oxygen equipment.
The facility failed to conduct required performance evaluations for several nursing assistants, as outlined in their employee handbook. The HR Director acknowledged the backlog, with some evaluations missing for multiple years. The Administrator was informed of the issue, which involved incomplete employee records and unrecognized staff performance.
The facility failed to notify medical personnel of critical changes in two residents' conditions. One resident with diabetes had multiple high blood sugar readings that were not reported to the physician, despite care plan requirements. Another resident refused a medication due to its taste, but the refusal was not communicated to the physician or documented. The facility lacked a policy on medication refusal.
A facility failed to monitor vital signs for a resident with chronic conditions as per physician's orders, missing 91 out of 135 shifts. Additionally, after a resident with dementia was struck on the head, the required neurological monitoring was not conducted, with only 1 out of 20 checks documented. These deficiencies were confirmed through record reviews and staff interviews, indicating non-compliance with care protocols.
A resident with multiple pressure injuries was not provided with proper air mattress care as the facility failed to adjust the mattress settings according to the resident's weight changes. Despite a physician's order and facility policy requiring specific settings, the air mattress was incorrectly set, contributing to inadequate pressure ulcer care.
A resident with a history of malnutrition experienced significant weight loss due to inconsistent weight monitoring and receiving burnt meals. Despite physician orders for weekly weight checks, the facility failed to document weights consistently. The resident's appetite was affected by the poor meal quality, confirmed by survey observations. Staff interviews revealed communication lapses and inadequate follow-up on weight monitoring and meal quality issues.
A resident with chronic respiratory issues was found with medication left on their bedside table, contrary to the facility's policy requiring nurses to ensure medications are taken immediately. Interviews confirmed that medications should not be left unattended, and the resident had not been evaluated for self-administration. This led to a deficiency in medication storage and administration.
The facility failed to provide palatable and presentable meals, as observed when cheese ravioli served to residents was blackened and hardened. The Dietary Director admitted the ravioli was overcooked and should not have been served. Additionally, the director did not inspect the meals before serving, and the facility lacked documentation of test tray monitoring.
Misappropriation of Discontinued Controlled Medications and Missing Narcotic Records
Penalty
Summary
Surveyors identified a deficiency related to misappropriation of resident property involving controlled medications for three residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. A second resident with dementia had an order for PRN oxycodone for moderate to severe pain, later discontinued, and was care planned as at risk for pain with interventions to administer pain medication as ordered. A third resident with dementia and anxiety had an order for PRN lorazepam for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that the second resident did not receive the ordered oxycodone. A facility reportable event documented that discontinued medications scheduled for destruction appeared to be missing, but initially did not identify which residents or which medications were involved. The incident was noted to have occurred in the afternoon, and the Medical Director and Consumer Protection were notified, but local law enforcement was not initially notified. Subsequent information identified that disposition sheets for controlled medications were missing and that the medications were last seen during a prior audit. The missing medications were quantified as 37 tablets of oxycodone 5 mg and 15 tablets of lorazepam 0.5 mg. Further facility documentation and interviews clarified that the missing controlled substances were discontinued medications belonging to the three residents: nine oxycodone tablets for the first resident, 28 oxycodone tablets for the second resident, and 15 lorazepam tablets for the third resident. The proof-of-use sheets and matching medication packs were missing from narcotic lock boxes on two different units, to which approximately 30 nurses had access during the period between two audits. The medications had been moved to the back of the narcotic lock boxes for later disposal, and the facility was unable to identify which nurse removed the medications or when they were removed. A memo from the Consumer Protection drug control division confirmed a significant loss of controlled substances, a procedural lapse in not segregating discontinued medications immediately, and the inability to reconcile inventory due to missing logs, while the medications were under the security of the narcotic lock boxes.
Failure to Properly Classify and Timely Report Missing Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to properly identify, document, classify, and timely report an allegation of misappropriation of controlled medications belonging to multiple residents. Resident #2 had diagnoses including lumbar spine fusion, bipolar disorder, and depression, with an order for PRN Oxycodone for pain and a care plan intervention to administer pain medication as ordered. Resident #3 had dementia with severe cognitive impairment, an order for PRN Oxycodone for pain that was later discontinued, and a care plan identifying risk for pain with an intervention to administer pain medication as ordered. Resident #4 had anxiety with severely impaired cognition, a care plan for anxiety with an intervention to administer anti-anxiety medication as ordered, and a PRN Lorazepam order that was later discontinued. A facility reportable event form dated 11/20/2025 identified that discontinued medications scheduled to be destroyed appeared to be missing, but the form did not identify which residents were affected or what specific medications were involved. Additional information later documented that disposition sheets for controlled medications were missing and that the medications were last seen during an audit, with missing quantities including 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility reportable event summary identified that a drug audit had found missing narcotics scheduled for collection as discontinued medications, specifying that 9 tablets of Oxycodone for Resident #2, 28 tablets of Oxycodone for Resident #3, and 15 tablets of Lorazepam for Resident #4 were missing. The facility’s incident report for the same event stated that discontinued medications scheduled to be destroyed appeared to be missing but again did not list any of the affected residents. The State Agency online portal showed that the reportable event was submitted on 11/20/2025 for an incident identified as occurring on 11/10/2025, resulting in a 10-day delay in reporting. The event was initially misclassified as a Class C (loss of heat/water/emergency systems or evacuation) before being changed to a Class B (abuse), and the DON reported that she did not classify the incident as misappropriation, instead selecting “other,” because the medications had been discontinued and should have been destroyed. Interviews with the DON and Corporate RN #1 confirmed that the medications and related documentation were identified as missing on 11/9/2025, that the State Agency was not notified of the resident names, and that they did not consider the situation a potential misappropriation despite facility policy defining misappropriation as the deliberate misplacement or use of a resident’s belongings without consent and requiring immediate reporting of alleged violations. The facility’s Accident and Incident Policy also required that incident reports include the names of individuals involved and a detailed description of the event and resident condition, which was not done in this case.
Failure to Control and Account for Discontinued Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate controls over narcotic medications, resulting in the misplacement and loss of controlled substances for multiple residents. One resident with lumbar spine fusion, bipolar disorder, and depression had an order for PRN Oxycodone for moderate to severe pain, with the care plan directing administration of pain medication as ordered. Another resident with dementia had a PRN Oxycodone order for pain, and a third resident with dementia and anxiety had a PRN Lorazepam order for anxiety, with the care plan directing administration of anti-anxiety medication as ordered. Review of the June MAR showed that one resident did not receive the ordered Oxycodone. A reportable event documented that discontinued medications scheduled for destruction were missing, but the initial form did not identify which residents or which medications were involved. Later information identified that disposition sheets for controlled medications were missing and that the medications were last seen during an audit. The missing medications were specified as 37 tablets of Oxycodone 5 mg and 15 tablets of Lorazepam 0.5 mg. A facility summary further detailed that a drug audit identified missing narcotics that had been discontinued and last observed weeks to months earlier, including nine Oxycodone tablets for one resident, 28 Oxycodone tablets for another resident, and 15 Lorazepam tablets for a third resident. The investigation did not identify the person responsible for the missing medications, and the last recorded medication disposal before the loss was more than a month earlier. Interviews and documentation showed that the white controlled substance disposition records and matching medication packs were missing from the unit narcotic books and lock boxes. The medications had been moved to the back of the narcotic lock boxes on the medication carts for future removal for destruction instead of being removed immediately to a secured lock box in the nursing office, as required. The RN involved stated she did not know why the narcotics were not removed when discontinued. An LPN who conducted narcotic audits reported that her audits did not include review of the MAR and that when discrepancies were found, she adjusted counts to match the white proof-of-use sheets. Audit records showed a discrepancy in one resident’s Oxycodone count and missing required dual nurse signatures for end-of-shift narcotic counts on multiple dates and shifts. The facility’s own policy required immediate documentation of controlled substances, shift-change counts by two licensed nurses, and timely return of discontinued controlled drugs to a double-locked cabinet in the nursing office, but these procedures were not consistently followed, leading to the misappropriation of narcotics.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident-to-resident incident involving inappropriate sexual contact. Two residents, both with severe cognitive impairment and court-appointed Conservators of Person (COP), were care planned to spend time together in the common area holding hands, as consented by their COPs. Both residents had a history of inappropriate sexual behaviors, and their care plans specifically prohibited intimate contact or being alone together in a room. Despite these interventions, staff observed one resident with their chest exposed and the other resident in contact with the exposed area in the common area. Staff interviews confirmed that the two residents were known to have a friendly relationship and often spent time together in the common area, holding hands as permitted. However, on the day of the incident, a nursing assistant witnessed inappropriate physical contact between the residents, which was not consented to by either the residents (due to their cognitive impairment) or their COP. The staff member intervened, and the resident involved became agitated and combative when redirected. Facility documentation and interviews with clinical staff, including the LPN, APRN, and Director of Nursing, confirmed awareness of the residents' cognitive limitations and the restrictions in place regarding their interactions. The facility's policy directed that residents be protected from abuse, including non-consensual sexual contact. Despite these policies and care plan interventions, the lack of adequate supervision allowed the incident to occur, resulting in a failure to protect the residents from abuse.
Failure to Timely Document Medication Administration in MAR
Penalty
Summary
The facility failed to ensure that clinical records accurately reflected the timing of medication administration for four residents reviewed. In each case, medications were administered according to physician orders, but documentation in the Medication Administration Record (MAR) was completed significantly after the actual administration time. This pattern was identified through an internal medication administration audit, which flagged late documentation for medications scheduled primarily around 9:00 A.M., with entries often made between 10:00 A.M. and 2:00 P.M. This issue affected approximately 80 residents across various units. For the residents involved, all had significant medical conditions such as dementia, failure to thrive, hypertension, diabetes, and behavioral disturbances. The MARs for these residents showed that medications, including supplements, psychotropics, and other daily treatments, were documented as being administered hours after the scheduled time. Interviews with nursing staff revealed that the delay in documentation was due to workload and the practice of signing off on the MAR after completing medication rounds for all assigned residents, rather than at the time of administration. Facility leadership, including the DON and regional nurse, confirmed that their expectation was for medications to be documented in the MAR at the time they are administered. The facility's own policy also required immediate documentation following administration. Despite the delayed documentation, there were no reports of negative outcomes or missed doses for the residents involved, as confirmed by the medical director and facility incident summaries.
Delayed Implementation of Fall Prevention Interventions After Resident Injury
Penalty
Summary
The facility failed to ensure timely implementation of care plan interventions following a resident's fall with injury. A resident with diagnoses including anxiety, dementia, history of falls, weakness, and insomnia, and with moderately impaired cognition, experienced an unwitnessed fall resulting in fractures to both femurs. Prior to the fall, the care plan identified the resident as at risk for falls and directed staff to place the call bell within reach and provide assistance with bed mobility. However, after the fall, the care plan was not promptly updated with new interventions to prevent further falls. Although pain management was added to the care plan after the incident, an intervention to use a bolster mattress was not included until two days after the fall, and the mattress itself was not applied until four days after the incident. Interviews with facility leadership confirmed that the care plan should have been updated and interventions implemented sooner, but no explanation was provided for the delay. The deficiency centers on the lack of timely care plan revision and delayed implementation of fall prevention measures following a significant injury event.
Verbal Abuse of Resident by Nurse Aide
Penalty
Summary
A deficiency occurred when a nurse aide (NA) verbally abused a resident with severe cognitive impairment, including dementia, depression, adjustment disorder, and anxiety. The resident required moderate assistance for personal hygiene and had a care plan directing staff to use a calm, gentle approach and avoid known triggers. On the morning of the incident, multiple staff members observed the NA approach the resident in the dining room, point her finger, and loudly state she would tell her supervisor to have the resident leave her "the hell alone." The NA admitted during the facility's investigation that she had become frustrated with the resident and intentionally made the statement in response to feeling targeted by the resident. Witnesses, including other nurse aides and a nursing supervisor, confirmed the NA's aggressive behavior and inappropriate language directed at the resident. The facility's policies defined such conduct as verbal and mental abuse, which is prohibited. The incident caused the resident initial emotional distress, although the resident did not recall the event later in the day. The facility's investigation substantiated the abuse based on staff interviews and documentation.
Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents with severe cognitive impairment. One resident, diagnosed with Wernicke's encephalopathy and mild cognitive impairment, was observed by an LPN with their hand on another resident's thigh and later with their hand resting against the other resident's upper chest area. Both residents had documented behavioral issues, including sexually inappropriate behavior and swearing at staff. The LPN separated the residents but did not immediately report the full extent of the incident, specifically that the hand was on the other resident's breast. The incident occurred during dinner and was documented in the nursing notes and a reportable event form. However, the State Agency was not notified until over 16 hours after the incident, contrary to the facility's policy requiring immediate reporting, but not later than two hours after an allegation of abuse. The delay in reporting was confirmed during an interview with the DON, who stated that the LPN initially reported only partial information about the incident, leading to the late notification to authorities.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an injury of unknown origin sustained by a resident with multiple complex medical conditions, including severe cognitive impairment, non-ambulatory status, and total dependence on staff for transfers and activities of daily living. The resident was found to have bruising and multiple fractures in the right foot, with no clear explanation for the injuries. The resident's care plan required two-person assistance and use of a mechanical lift for transfers, and the injury was discovered during a physician evaluation, which led to urgent imaging and hospital evaluation. Facility documentation indicated that a reenactment was performed to hypothesize possible causes, such as improper foot positioning during a mechanical lift transfer or entrapment with equipment attached to the bed. However, the facility was unable to produce a complete investigative record. Specifically, there was a lack of written staff statements and documentation covering five shifts within the 72-hour period prior to the identification of the injury, and it was unclear whether all relevant staff, including agency staff, were interviewed. The investigation did not provide information about the resident's care during several key shifts, and the responsible staff could not recall or explain why the investigation was incomplete. The facility's own Abuse Prohibition policy required that all allegations of abuse, including injuries of unknown origin, be thoroughly investigated, including interviewing all available witnesses and completing the investigation within five days. Despite this policy, the investigation into the resident's injury was not comprehensive, and the facility failed to meet its own standards for investigating potential abuse or neglect.
Failure to Ensure Safe and Documented Discharge for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that required discharge information was documented and communicated to the responsible party to ensure a safe and effective discharge for a resident with severe cognitive impairment and a history of alcohol dependence. The resident, who was admitted for short-term rehabilitation, had multiple diagnoses including metabolic encephalopathy, Wernicke's encephalopathy, brain atrophy, and severe cognitive impairment. The care plan indicated the resident would be discharged home after therapy, but the resident was assessed as needing 24-hour care and was noted to be disoriented, forgetful, and at risk for wandering and substance use. Despite these significant needs, the facility did not adequately document or communicate the resident's mental status, activities of daily living, or discharge instructions in the nursing discharge summary. The responsible party was not clearly informed of the risks associated with the resident returning home alone, nor was there evidence that the facility ensured immediate support or assistance would be available upon discharge. Interviews revealed that both the psychiatric APRN and the responsible party were not fully informed or involved in the discharge planning, and the responsible party expressed concerns about the resident's ability to safely return home, which were not addressed by the facility. The facility also failed to provide evidence that options for the resident to remain at the facility until additional services were available were explored or communicated. The discharge occurred without ensuring that the resident had a primary care physician or that home care services would be immediately available. As a result, the resident was discharged home alone, was later found wandering and confused, and was hospitalized approximately four hours after discharge. The facility's actions and lack of communication and documentation led to an unsafe discharge process.
Failure to Permit Timely Readmission After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, following an inadequate discharge plan that resulted in the resident being hospitalized shortly after discharge. The resident, who had multiple diagnoses including metabolic encephalopathy, alcohol dependence, brain atrophy, Wernicke's encephalopathy, adjustment disorder, anxiety, depression, diabetes, and hypothyroidism, was admitted for short-term rehabilitation with plans for discharge home. The care plan included discharge planning meetings and involvement of family, but documentation shows ongoing concerns about the resident's cognitive status, substance use, and lack of a long-term payer source. Despite these concerns, the facility proceeded with discharge, and the resident was found lost and disoriented on the street within hours, leading to hospital admission. Hospital documentation indicated that the resident was discharged from the facility to an unsafe situation, with the facility aware of the resident's cognitive impairment and risk factors. The hospital case manager attempted to coordinate the resident's return, but the facility initially refused readmission, citing the absence of a legal decision maker and a long-term payer source. The facility had available beds and staff to provide care, but required corporate approval for readmission due to payment concerns, resulting in delays. As a result, the resident remained in the hospital for an additional eight days after being medically cleared for return to the facility. The facility eventually readmitted the resident after intervention from the Long-Term Care Ombudsman and plans to apply for conservatorship. The facility's own policy indicated that priority admission should be granted to individuals discharged from the facility within fifteen days, but this was not followed in the resident's case.
Failure to Develop Pain Management Care Plan
Penalty
Summary
A resident with significant cognitive impairment and a history of a cervical vertebra fracture, as well as pain in the left ankle and foot, was admitted to the facility. The resident required extensive assistance with activities of daily living and had physician orders for Tramadol to manage severe pain. Documentation showed that the resident reported pain daily, and pain assessments indicated both non-verbal and verbal expressions of pain, with pain levels frequently rated as 6 out of 10. Despite these findings and the facility's policy requiring the development and implementation of pain management interventions, there was no evidence that a pain management care plan was created for this resident. The Director of Nursing confirmed during an interview and record review that a pain management care plan had not been developed to address the resident's ongoing pain.
Failure to Reconcile Medications at Discharge
Penalty
Summary
A deficiency occurred when a resident with diagnoses including perforated gastric ulcer, peripheral vascular disease, and essential hypertension was discharged home without proper reconciliation of their medications. The resident, who was cognitively intact and required assistance with self-care and medication administration, was supposed to have their discharge medications reviewed and reconciled prior to leaving the facility. However, documentation revealed that the resident was discharged with medications belonging to two other residents, and the medication reconciliation process was not completed as required. Interviews with facility staff, including a social worker, the Director of Nurses, and an LPN, confirmed that the standard procedure is to review and reconcile medications with the resident or responsible party before discharge. The LPN responsible for the discharge admitted to not reconciling the medications, resulting in the resident receiving incorrect medications upon discharge.
Failure to Follow Hospital Discharge Orders for Biliary Tube Care
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including chronic obstructive pulmonary disease, malignant neoplasm of the pancreas, biliary tract disease, fatty liver, and chronic kidney disease, did not receive specialized treatment as ordered. The resident had a biliary drain following a hospital stay, with the hospital discharge summary specifying that the biliary tube should be flushed with 10cc normal saline twice daily to maintain patency. However, review of the facility's documentation and physician orders revealed that while there was an order to cleanse the drain site and apply a dressing, there was no order to flush the biliary tube as directed by the hospital discharge summary. Interviews with facility staff confirmed that the hospital's instructions regarding flushing the biliary tube were not followed.
Failure to Evaluate and Develop Pain Management Plan
Penalty
Summary
A resident was admitted with multiple diagnoses, including acute pulmonary edema, cellulitis, and pressure ulcers. Physician orders were in place for Acetaminophen 325 mg, 2 tablets every 6 hours as needed for pain. Initial assessments indicated the resident had no cognitive impairment and was not experiencing pain at admission. However, subsequent progress notes documented that the resident reported daily headaches with pain levels ranging from 1 to 7 on a 1-10 scale over several days, and Acetaminophen was administered daily with varying effectiveness, including a report of no effect on one occasion. Despite these ongoing reports of pain, the facility failed to conduct pain evaluations or develop a care plan to address pain management during the period when the resident was experiencing and reporting pain. The facility's pain management policy required a pain evaluation, physical evaluation, and physician notification when a new onset of pain was reported, as well as the development and implementation of both pharmacological and nonpharmacological interventions. An interview with the Director of Nurses confirmed that these steps were not taken during the relevant period.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
A resident with dementia and muscle weakness, who had severely impaired cognition and required assistance for ambulation and transfers, was subjected to the inappropriate use of a physical restraint. The resident's care plan specified one-person assistance for ambulation with a rolling walker and did not include any order or assessment for the use of a restraint or seat belt in the wheelchair. Despite this, a staff member used a gait belt to secure the resident to a wheelchair, restricting the resident's ability to stand or move freely. The incident occurred when two nursing assistants found the resident in a closet and placed the resident in a wheelchair in the common area. One nursing assistant, following the direction of an LPN according to her account, applied a gait belt around both the resident and the wheelchair, clipping it within the resident's reach. There was uncertainty among staff as to whether the resident could unclip the belt independently. Interviews revealed conflicting accounts regarding who directed the use of the gait belt, but it was confirmed that the gait belt was used to prevent the resident from standing, which was not in accordance with facility policy or the resident's care plan. Facility policies reviewed indicated that gait belts are to be used only for transfer and ambulation assistance, and that physical restraints require a specific physician order and assessment. The resident had not been assessed for restraint use, and there was no physician order for such an intervention. The use of the gait belt in this manner constituted a failure to ensure the resident was free from physical restraints, as required by both facility policy and resident rights.
Failure to Timely Report and Notify Authorities of Resident Restraint Incident
Penalty
Summary
Staff failed to report an alleged incident of mistreatment in a timely manner and did not notify the State Agency within the required timeframe after becoming aware of the allegation. A resident with dementia and severely impaired cognition, who required assistance for ambulation and transfers, was found to have been restrained in a wheelchair using a gait belt by a nursing assistant, following the direction of an LPN. The gait belt was used to restrict the resident's movement, which was not in accordance with facility policy on restraint use. Another nursing assistant witnessed the event but did not immediately report it, and the incident was not brought to the attention of facility leadership until several days later, after a non-nursing staff member reported a rumor about the event. The facility became aware of the incident on the morning of 12/9/2024 but did not notify the State Agency until over three hours later, exceeding the policy requirement to report violations of mistreatment immediately, but not later than two hours after the violation. Interviews with staff and review of facility documentation confirmed that the use of the gait belt as a restraint was inappropriate and that there was a delay in both internal and external reporting of the incident.
Inappropriate Use of Resident Council Funds
Penalty
Summary
The facility failed to ensure that Resident Council funds were utilized appropriately, as evidenced by the improper use of these funds for activities and services that should have been covered by the facility's budget. Interviews with residents revealed that they felt obligated to vote in favor of using Resident Council funds for music, entertainment, and art classes, as these activities were not provided by the facility. The Administrator confirmed that the facility allocates a monthly budget for the recreation department, which includes art supplies and entertainment, but the Director of Recreation indicated that the budget was insufficient, leading to the use of Resident Council funds. The review of bank statements showed that these funds were used to pay for music entertainment and art classes, despite the facility's responsibility to cover these costs. Additionally, the Resident Council funds were used to pay for the annual licensure fee for the beauty salon chair, a cost that should have been borne by the facility. The Administrator was unaware of these expenditures and acknowledged that the facility should have covered the beauty salon license fee. The lack of oversight and a facility policy for managing Resident Council funds contributed to the inappropriate use of these funds, as the Administrator had not reviewed how the funds were being dispersed.
Failure to Complete Background Checks and References
Penalty
Summary
The facility failed to ensure that required references and background checks were completed prior to hiring six staff members, including nursing assistants, LPNs, and RNs. The Director of Human Resources (HR) was responsible for completing these checks and obtaining two professional references for each employee before they started working. However, upon review, it was found that the personnel files for all six employees lacked the necessary background check/eligibility forms and, in some cases, the required professional references. This oversight allowed these employees to begin working at the facility without the proper screening. The facility's Abuse Prohibition Policy mandates the screening of personnel for a history of abuse, which includes conducting criminal background checks and obtaining at least two reference checks. These requirements were not met, as evidenced by the incomplete employee files. The HR New Hire Checklist also specifies that pre-offer paperwork should include completed and signed references and fingerprinting information. Despite these policies, the HR department did not adhere to the procedures, resulting in the deficiency noted during the survey.
Failure to Change and Label Oxygen Tubing as Per Policy
Penalty
Summary
The facility failed to adhere to its policy regarding the timely changing and labeling of oxygen tubing for residents requiring respiratory care. Resident #7, who was dependent on supplemental oxygen due to chronic respiratory failure and COPD, had oxygen tubing that was not changed weekly as per the physician's order and facility policy. The tubing was observed to be dated several weeks prior, and the responsible LPN was unaware of the policy requirements. Resident #16, with diagnoses including acute and chronic respiratory failure and COPD, also had issues with the timely changing of oxygen tubing. The tubing was labeled with a date that did not align with the facility's policy of weekly changes, and the resident could not recall when it was last changed. Documentation inconsistencies were noted in the treatment administration record, which did not match the observed dates on the tubing. Resident #20 and Resident #81 also experienced similar deficiencies. Resident #20's oxygen tubing was found on the floor, unlabeled, and not discarded as required by the facility's policy. Resident #81's tubing was not changed according to the weekly schedule, and the responsible LPN was unaware of why the task was overlooked. These observations indicate a systemic issue with adherence to the facility's policy on oxygen tubing maintenance.
Failure to Conduct Required Performance Evaluations for Nursing Assistants
Penalty
Summary
The facility failed to conduct performance evaluations for nursing assistants as required by their employee handbook and internal policies. The Director of Human Resources (HR) acknowledged that it was her responsibility to ensure all employee files were complete, including performance evaluations at 6 months and annually for employees hired before June 2023, and at 3 months and annually for those hired after. However, upon review, it was found that several nursing assistants had missing evaluations. For instance, one nursing assistant hired in 2022 lacked both the 6-month and annual evaluations due in 2023, while another hired in 2005 had not had an evaluation since 2019. Similar lapses were noted for other nursing assistants, with some not having evaluations for multiple years. The HR Director admitted awareness of the backlog in evaluations and mentioned a new Director of Nursing Services (DNS) at the facility. The Administrator, upon being informed of the issue, acknowledged the deficiency and discussed it with HR. The employee handbook, updated in June 2023, specifies that the first 90 days of employment is an introductory period during which performance should be reviewed, followed by annual evaluations. Despite these guidelines, the facility did not adhere to its own policies, resulting in incomplete employee records and unrecognized staff performance.
Failure to Notify Medical Personnel of Critical Changes
Penalty
Summary
The facility failed to notify the appropriate medical personnel and responsible parties regarding significant changes in the condition of two residents. For one resident with type 2 diabetes and end-stage renal disease, the facility did not inform the physician or APRN of blood glucose readings that exceeded the ordered parameters on multiple occasions. Despite having a care plan that required such notifications, the nursing staff did not document any communication with the physician/APRN about these elevated blood sugar levels, which were recorded on four separate dates. In another case, a resident with diabetes and mild cognitive impairment refused a prescribed medication due to its taste, but the facility did not notify the physician or document the refusal in the progress notes. The resident explicitly requested that the physician be informed of the refusal, yet there was no record of such communication. The facility also failed to provide a policy regarding the refusal of medications when requested.
Failure to Monitor Vital Signs and Neurological Status
Penalty
Summary
The facility failed to adhere to physician's orders for Resident #63, who was admitted with chronic obstructive pulmonary disease, end-stage renal disease, and congestive heart failure. The care plan required monitoring of vital signs every shift, but records from March 1 to April 22 showed that vital signs were not taken for 91 out of 135 shifts. Interviews with the LPN and DNS confirmed the inconsistency in monitoring, and the facility's policy mandates that vital signs be monitored and reported if abnormal. For Resident #94, who has Alzheimer's disease and dementia, the facility did not conduct neurological monitoring as per policy after an incident where the resident was struck on the head by another resident. The policy required frequent neurological checks following a head injury, but only 1 out of 20 required checks were documented. The DNS was unaware of the lapse in monitoring, and the facility's policy outlines specific intervals for neurological assessments following head injuries. Both deficiencies highlight a failure to follow established protocols for monitoring residents' health conditions, as evidenced by the lack of documentation and adherence to physician's orders and facility policies. These lapses were identified through clinical record reviews and staff interviews, indicating a need for improved compliance with care standards.
Failure to Properly Utilize Air Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper utilization of an air mattress for a resident with multiple pressure injuries. The resident, who was admitted with severe malnutrition and several pressure injuries, had a physician's order for a specialty air mattress with specific settings to be checked every shift. However, observations revealed that the air mattress pump was set incorrectly at 10/65 lbs instead of the prescribed 10/105 lbs, which was supposed to correspond to the resident's weight. This discrepancy was confirmed by a regional nurse, who noted that the settings and physician's order were incorrect and should have been adjusted according to the resident's weight changes. The facility's policy on alternating pressure air mattresses required verification of physician orders and settings according to manufacturer guidelines. Despite this, the Director of Nursing Services (DNS) indicated that the air mattress was set based on physician orders, and it was the responsibility of the nursing staff to monitor the functioning and pressure settings every shift. The wound nurse was specifically responsible for ensuring the air mattress was set according to the resident's weight. This failure to adhere to the correct settings and policy guidelines contributed to the deficiency in providing appropriate pressure ulcer care for the resident.
Failure in Weight Monitoring and Meal Quality
Penalty
Summary
The facility failed to ensure proper weight monitoring and nutritional care for a resident with a history of weight loss and malnutrition. The resident was admitted with diagnoses including mild protein calorie malnutrition, weakness, and dementia, and was supposed to have their weight monitored weekly as per physician's orders. However, the clinical records showed a lack of consistent weight documentation, with a significant weight loss of 10 lbs. occurring between 2/26 and 3/4, which was not promptly addressed. The dietician's notes confirmed the weight loss and recommended increased nutritional supplements, but the facility did not consistently follow through with the required weekly weight checks. The resident reported receiving burnt meals, which affected their appetite and contributed to the weight loss. Observations by the survey team confirmed that meals served to the resident were often overcooked, with test trays showing blackened and hardened food. Despite the resident's complaints and the dietician's recommendations, the facility did not adequately address the issue of meal quality, which was a contributing factor to the resident's nutritional decline. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's weight monitoring and meal quality. The LPN responsible for recording the resident's weight failed to ensure a re-weight was conducted after noting a discrepancy, and the DNS was unaware of the burnt meals issue. The facility's policy required weights to be documented weekly, but this was not consistently done, leading to a failure in monitoring the resident's nutritional status effectively.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored appropriately for a resident who was admitted with chronic respiratory failure and chronic obstructive pulmonary disease. A physician's order directed the administration of Acetaminophen for pain, and the resident was last given the medication for a pain rating of 8/10. However, a medication cup containing two white tablets was observed on the resident's bedside table, which the resident indicated had been there for about a week. This indicates that the medication was not administered according to the facility's policy, which requires the nurse to remain at the bedside until the medication is taken. Interviews with nursing staff confirmed that medications should not be left at the bedside and that the nurse is expected to ensure the resident takes the medication before leaving. The facility's policies on oral medication administration and self-administration of medications were not followed, as the resident had not been evaluated for the ability to self-administer medications safely. The failure to adhere to these policies led to the deficiency observed during the survey.
Failure to Provide Palatable and Presentable Meals
Penalty
Summary
The facility failed to ensure that residents were provided with palatable and presentable meals, as observed during a survey. On one of the nursing units, test trays of cheese ravioli with tomato sauce were found to be blackened and hardened, indicating that the meals were not prepared to a satisfactory standard. During the meal service on the Skyview unit, the ravioli on the steam table was observed to be charred and blackened, with the tomato sauce appearing dry, cracked, and discolored. Out of 22 meals served, 11 were returned and exchanged for alternatives, highlighting the unacceptability of the meal quality. The Dietary Director admitted that the ravioli had been overcooked due to being left in the oven too long and acknowledged that the meals should not have been served to residents. The director also failed to inspect the test trays before providing them to the survey team and did not observe the meals prepared for residents before they were served. Additionally, the facility did not provide documentation related to test tray monitoring, which was supposed to be conducted three times weekly to ensure proper food quality and appearance.
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.
