Ingraham Manor Rehab And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Connecticut.
- Location
- 400 N Main St, Bristol, Connecticut 06010
- CMS Provider Number
- 075329
- Inspections on file
- 25
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 43 (1 serious)
Citation history
Health deficiencies cited at Ingraham Manor Rehab And Nursing during CMS and state inspections, most recent first.
A resident admitted as Full Code with multiple medical conditions was found pulseless and not breathing by an LPN who did not know the resident’s code status, did not verify it in the EMR, and did not call a code blue or start CPR. The LPN instead left to notify another LPN and an RN. The RN arrived several minutes later, confirmed the resident had no respirations, and did not initiate CPR based on a belief that rigor mortis had set in, while another LPN also confirmed no pulse and noted no stiffness in the extremities but likewise did not begin resuscitation. Interviews with the MD and DNS confirmed that CPR and EMS activation should have been initiated for a Full Code resident found without pulse and respirations, and that residents are considered Full Code unless otherwise changed after admission.
A resident admitted with multiple medical conditions, including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, was documented as Full Code in the hospital discharge summary, admission assessment, and physician orders. During an early-morning blood glucose check, an LPN found the resident pulseless and not breathing but did not know the code status, could not access the EMR, and believed that was the only source for this information. The LPN performed a sternal rub, left to notify another LPN and an RN, and did not call a code blue or start CPR. An RN arrived several minutes later, found the resident without pulse or respirations, and pronounced the resident expired without initiating CPR, stating they believed rigor mortis had begun, despite later acknowledging CPR and EMS activation should have occurred and that facility practice was to follow the Full Code status on the hospital discharge documents. Administration reported there was no clear process to make advance directives for newly admitted residents readily identifiable in the paper chart during a transition from paper to EMR.
A resident admitted with multiple medical conditions and clearly documented as Full Code was found pulseless and not breathing by an LPN, who did not know or confirm the code status, did not call a code blue, did not initiate CPR, and did not activate EMS. A second LPN also assessed the resident, confirmed absence of pulse and respirations, noted no stiffness of extremities, and likewise did not start CPR or call a code. An RN arrived several minutes after notification, assessed the resident, determined the resident had expired, did not initiate CPR based on a belief that rigor mortis had set in, and pronounced death without a physician order authorizing RN pronouncement, despite facility policies and the physician’s expectation that CPR and EMS activation were required for a Full Code resident.
A resident with mobility difficulties and intact cognition, who required one-person assistance with a rolling walker for transfers, was assisted by staff without the prescribed walker. Instead, the resident was stood up holding onto a locked wheelchair, leading to a fall that resulted in fractures to the right arm and knee. Staff interviews and documentation confirmed that the wheelchair was improperly used as a support device, contrary to physician orders and facility policy.
A resident with severe cognitive impairment and a known history of wandering was able to leave their unit and access a stairwell without staff knowledge, despite care plan interventions requiring a wander guard device. The resident was found injured in the stairwell after passing through an alarmed, delayed-egress door, and sustained a hip fracture and lacerations. The failure to reinstate the wander guard order and provide adequate supervision led to the incident.
A resident with vascular dementia and a history of wandering was not properly assessed for elopement risk upon readmission, as key sections of the wander risk assessment were left incomplete, resulting in an inaccurately low risk score. Previous orders for a wander guard and related checks were not reinstated, and there was no documentation of new orders or consistent application of the device, despite the care plan identifying the resident as an elopement risk. Facility policy required these interventions for high-risk individuals, but they were not properly implemented or documented.
Failure to Initiate CPR and Activate EMS for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR and EMS activation, to a resident who was documented as Full Code. The resident had been admitted from the hospital with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, and the hospital discharge summary, nursing admission assessment, and physician’s orders all identified the resident as Full Code. Vital signs obtained after admission showed elevated blood pressure and a decreasing temporal temperature. Later, a progress note by an RN documented that the resident was found pulseless and without respirations and was pronounced expired, with subsequent notification of the resident representative and provider. When an LPN went to the resident’s room to obtain a blood glucose level, the LPN found the resident pulseless and without respirations. The LPN stated they did not know the resident’s code status and did not confirm it because their computer was not on, and indicated that the EMR was the only place they could find code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged the RN to report that the resident was pulseless and not breathing. The LPN acknowledged that they should have confirmed the code status, overhead paged a code blue, and initiated CPR. The RN reported arriving at the room approximately four to five minutes after being notified that the resident was not breathing, assessed the resident, and did not initiate CPR because they believed rigor mortis had already set in, despite acknowledging that CPR should have been started. Another LPN who checked the resident confirmed the absence of a pulse, noted the resident’s hands were folded with fingers intertwined, and reported that the resident’s arm and fingers were not stiff when moved to palpate a radial pulse, yet did not initiate CPR and later stated CPR, a code call, and EMS activation should have occurred. The physician interviewed stated that CPR and EMS activation should have been initiated once the resident was found pulseless and without respirations, and that EMS activation was required because there was no physician’s order authorizing an RN to pronounce death. The DNS stated that for a Full Code resident found without pulse and respirations, staff should call for help, announce a code blue over the intercom with room and location, and immediately start CPR, and that residents are considered Full Code unless otherwise decided after admission.
Removal Plan
- Audited all resident charts to confirm code status was active in the electronic medical record (EMR).
- Educated all nursing staff on Response to Unresponsive Residents and Code Status, CPR, and conducted a Mock Code followed by a code debrief on all shifts.
- Performed a Code Procedure Checklist (competency evaluation) for all licensed staff.
- Conducted code blue mock drills.
- Scheduled the corrective action plan for QAPI review.
Failure to Ensure Readily Accessible Code Status Resulted in No Emergency Response for Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s advance directives/code status were readily accessible to staff during an emergency, resulting in no emergency response being initiated for a resident documented as Full Code. The resident was admitted from the hospital with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease, and the hospital discharge summary, nursing admission assessment, and physician’s orders all identified the resident as Full Code. When an LPN entered the resident’s room early in the morning to obtain a blood glucose level, the resident was found pulseless and without respirations. The LPN did not know the resident’s code status, could not access the EMR because the computer was not on, and believed the EMR was the only place to confirm code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged an RN, but did not call a code blue or initiate CPR. When the RN arrived approximately four to five minutes after being notified, the RN assessed the resident, determined the resident was pulseless and not breathing, and pronounced the resident expired without initiating CPR, stating that they believed rigor mortis had already set in. The RN later acknowledged that CPR should have been initiated, that a code should have been called, and that EMS should have been activated, and confirmed that facility practice was to follow the hospital discharge documents, which indicated the resident was Full Code. Another LPN also stated that facility practice was to follow the hospital discharge summary for advance directives but was unaware that this resident was Full Code. Facility administration reported the facility was transitioning from paper charts to an EMR system and did not have a process to ensure advance directives for newly admitted residents were readily identifiable in the paper chart; such directives could be located within hospital documents or physician order sections, but administration could not say how long it would take to find them during an emergency. The facility’s own policy stated that adults have the right to control decisions related to their medical care and that advance directives are legally recognized written declarations specifying a person’s wishes for future care.
Failure to Initiate CPR and Improper RN Pronouncement for a Full Code Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary emergency services, including CPR and EMS activation, for a resident who was documented as Full Code, and the pronouncement of death by an RN without a physician order authorizing RN pronouncement. The resident had been discharged from the hospital with a documented Full Code status and was admitted to the facility with diagnoses including Type II diabetes, acute kidney injury, and atherosclerotic heart disease. On admission, the nursing assessment confirmed the resident was oriented and Full Code, and physician orders also reflected Full Code status. Vital signs obtained during the night showed a blood pressure of 168/70 with a temperature of 98°F, and later a blood pressure of 137/44 with a temperature of 95°F. In the early morning, an LPN went to the resident’s room to obtain a blood glucose level and found the resident pulseless and without respirations. The LPN did not know the resident’s code status, did not confirm it because the computer was not on, and identified the EMR as the only place to find code status. The LPN performed a sternal rub with no response, then left the room, asked another LPN to check on the resident, and paged the RN to report that the resident was pulseless and not breathing. The LPN did not call a code blue, did not initiate CPR, and did not activate EMS, later acknowledging that he/she should have confirmed the code status, called a code blue, and started CPR. The second LPN, after being informed the resident had expired, assessed the resident, found no pulse, noted no stiffness of extremities or fingers, and also did not initiate CPR, later stating that CPR, a code call, and EMS activation should have occurred once the resident was found without pulse and respirations. The RN responded approximately four to five minutes after being notified that the resident was not breathing, assessed the resident by auscultating lungs and heart, evaluating the eyes, and checking for blood pressure, and determined the resident had expired. The RN did not initiate CPR, stating the belief that rigor mortis had already set in, and contacted the Administrator to report the resident’s death. A subsequent progress note documented the resident as pulseless, without respirations, and pronounced expired, and later that the provider was notified and an order received to release remains to the funeral home. The facility’s Director of Nursing stated that for a Full Code resident found without pulse and respirations, staff should call for help, overhead page a code blue three times with room and location, and immediately initiate CPR, and confirmed that a physician’s order is required for RN pronouncement of death. The facility’s policies required CPR to be performed on appropriate residents by CPR-certified staff and specified that RN pronouncement of death is only permitted when the attending physician has documented an anticipated death and authorized RN pronouncement in writing, conditions that were not met in this case. The attending physician stated that CPR and EMS activation should have been initiated once the resident was found pulseless and apneic, and that EMS activation was required because there was no physician order authorizing RN pronouncement.
Failure to Use Prescribed Assistive Device During Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to provide safe assistance during a transfer for a resident with diagnoses of difficulty walking and osteoarthritis. The resident, who had intact cognition and required assistance of one staff member with a rolling walker for transfers per physician order, was being assisted by a nursing assistant who did not use the prescribed walker. Instead, the resident was stood up facing the front of a wheelchair, holding onto its arms while the wheelchair was locked. During this process, the resident's knee buckled, causing a fall to the floor. As a result of the fall, the resident sustained a fractured right humerus and a fractured right patella, requiring transfer to the hospital for evaluation and treatment. Facility documentation and staff interviews confirmed that the wheelchair was used as a support device during the transfer, contrary to both physician orders and facility fall prevention policy, which directed the use of appropriate assistive devices such as a walker, grab bar, or railing. The incident demonstrated a failure to ensure adequate supervision and use of proper assistive devices to prevent accidents.
Failure to Prevent Wandering Resident from Accessing Stairwell Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and a high risk for wandering was able to leave their unit without staff knowledge, resulting in a fall with injury in a stairwell. The resident had a history of agitation, combative behavior, and was previously identified as a high elopement risk, with interventions including the use of a wander guard device. Upon readmission to the facility after a hospital stay, the order for the wander guard was not reinstated, despite the care plan indicating the need for such an intervention. The resident continued to display wandering behaviors after readmission, as documented in nursing progress notes. The care plan directed staff to ensure the resident wore a wander guard and to check its placement and function, but this was not implemented. The resident was last seen by nursing staff at the nursing station and was found approximately 20 minutes later by housekeeping staff on the landing of a stairwell, having accessed an egress door equipped with a delayed-egress mechanism and alarm. The alarm system was designed to alert staff when the door was opened, but the resident was able to enter the stairwell and fall without staff intervention. Interviews with facility leadership and staff did not clarify how the resident was able to access the stairwell unnoticed, despite known wandering behaviors and the presence of an alarm system. The resident sustained a right hip fracture and lacerations, requiring transfer to the hospital. The failure to reinstate the wander guard order and to provide adequate supervision and monitoring for a resident at high risk for wandering directly contributed to the incident.
Failure to Complete Wander Assessment and Implement Wander Guard Orders for High-Risk Resident
Penalty
Summary
The facility failed to accurately complete a wander risk assessment and to ensure appropriate interventions and orders were in place for a resident with a known history of wandering and elopement risk. The resident, who had diagnoses including vascular dementia and anxiety disorder, was initially assessed as high risk for wandering prior to a hospital transfer. Upon readmission, the wander risk assessment was incomplete, with key sections left blank, resulting in an inaccurately low risk score. According to the facility's own assessment directions, the missing sections should have been completed and would have indicated a high risk for wandering. Additionally, after the resident's transfer to the hospital, all previous physician orders, including those for the use of a wander guard and checks for its placement and function, were discontinued. Upon readmission, although the care plan identified the resident as an elopement risk and included interventions such as the use of a wander guard, there was no documentation that a new physician order for the wander guard was obtained or that checks for placement and function were ordered or documented. The DON confirmed that the assessment was incomplete and that staff should have entered new orders for the wander guard but could not provide documentation that this was done. Facility policy required that residents identified as high risk for wandering have a wander guard applied, but the lack of a complete assessment and missing physician orders meant that this intervention was not properly implemented or documented. The deficiency was identified through review of clinical records, facility documentation, and staff interviews, which confirmed the failures in assessment completion, order initiation, and adherence to the plan of care for a resident at risk for wandering.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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