Jerome Home
Inspection history, citations, penalties and survey trends for this long-term care facility in New Britain, Connecticut.
- Location
- 975 Corbin Avenue, New Britain, Connecticut 06052
- CMS Provider Number
- 075343
- Inspections on file
- 22
- Latest survey
- July 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Jerome Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was identified as high risk for falls upon admission, but the facility did not initiate a fall care plan or implement fall prevention interventions until after the resident suffered a significant fall injury requiring surgery. The care plan was only developed following the incident, contrary to facility policy.
Multiple residents reported that hot food was often served cold, and direct temperature checks confirmed that meals were below the required 135°F at the point of service. The Food Services Director acknowledged that food temperatures dropped during transport from the kitchen to the units, resulting in noncompliance with facility policy for hot food holding temperatures.
A resident with a history of psychosocial issues made a statement about trying to jump out the window, but the LPN did not notify supervisory staff, the social worker, or medical providers as required by policy. The required suicide precautions and psychiatric consult were delayed, and the care plan was not updated until after the incident was identified by surveyors.
A resident with severe cognitive impairment and multiple comorbidities was confined to their room and denied participation in activities after their roommate tested positive for RSV, despite having no symptoms or physician order for isolation. Staff physically blocked the resident from leaving the room, and leadership could not identify guidance supporting this practice for asymptomatic roommates. The resident experienced reduced engagement and increased napping, and the facility failed to recognize this as involuntary seclusion.
A resident with advanced dementia and significant care needs was found with an unexplained bruise on the forehead. Staff suspected the injury may have occurred during a mechanical lift transfer, but no one witnessed the event and the resident could not explain it. Facility documentation did not indicate that the injury was reported to the state agency, despite policy requiring immediate reporting of injuries of unknown source. Interviews with the DON and Administrator confirmed the reporting failure.
A resident with advanced dementia and significant care needs was found with an unexplained bruise on the forehead. The facility did not complete a thorough investigation or summary as required, failing to obtain statements from all staff involved and lacking documentation to determine the cause of the injury.
A resident admitted with a history of homicidal ideation and other medical conditions did not have psychosocial concerns or behaviors addressed in the baseline care plan within the required timeframe. Despite prior documentation of behavioral risks and a subsequent incident where the resident attempted to jump out a window, the care plan failed to include necessary interventions for psychosocial needs.
A resident with severe cognitive impairment and high fall risk did not have floor mats placed on both sides of the bed as ordered by the physician and outlined in the care plan. Observations found that only one mat was in place, with the other mat left folded against the wall. Staff interviews confirmed the mats were not consistently positioned after meals, and the DON acknowledged the requirement for both mats to be in place but could not explain the failure.
A resident with a history of mental health issues, including homicidal ideation and depression, was not promptly assessed or provided psychiatric services after making a statement about trying to jump out a window. Facility staff did not follow suicide precaution policies, including timely notification of supervisory staff and psychiatric services, or implementation of required safety checks.
A pharmacist did not identify or report missing behavioral monitoring and overdue AIMS assessments for a resident with dementia and other psychiatric diagnoses who was receiving an antipsychotic medication. Despite monthly medication regimen reviews and facility policy requiring regular monitoring, the pharmacist's reports failed to recommend necessary assessments or documentation.
Surveyors observed that large vents in two common areas contained significant dark-colored debris, indicating that regular cleaning by housekeeping staff, as required, had not been performed.
A resident with a history of mobility issues and osteoporosis fell and fractured their leg due to the failure of a nurse aide to use a gait belt during ambulation, as required by the facility's policy. The resident's care plan specified the use of a gait belt and walker, but the aide did not adhere to this, leading to the incident.
Failure to Initiate Fall Care Plan for High-Risk Resident
Penalty
Summary
A resident with a history of left artificial hip joint, type II diabetes, and Alzheimer's disease was admitted to the facility and identified as needing assistance with activities of daily living due to physical and mental impairments. The resident was assessed as a high risk for falls based on a fall risk assessment score of eighteen and had a documented fall in the month prior to admission. Despite these findings, the facility did not initiate a fall care plan or implement specific fall prevention interventions at the time of admission or upon identification of high fall risk. The lack of a fall care plan persisted until after the resident experienced a fall resulting in a right knee femur fracture, which required surgical repair. The care plan addressing fall risk and related interventions was only created following this incident. Facility documentation and interviews confirmed that the Director of Nursing was unaware that a fall risk care plan had not been implemented, despite facility policy requiring such a plan for residents identified as high risk for falls.
Failure to Serve Hot Foods at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that hot foods were served at appropriate temperatures for palatability, as evidenced by multiple resident interviews and direct temperature measurements. Several residents reported that their food was sometimes or often served cold, and one resident noted that the food did not taste good. The Food Services Director described the process for maintaining food temperature, which included taking and recording temperatures in the kitchen, using plate warmers, and covering plates with metal meal covers. A review of the temperature logs showed that temperatures met the food code standard when measured in the kitchen. However, during a test tray observation, food plated in the main dining room and delivered to a unit was found to be below the required temperature of 135 degrees Fahrenheit. Specifically, the internal temperatures of meatballs, spaghetti, and green beans ranged from 115 to 121.3 degrees Fahrenheit when measured upon delivery to residents. The Food Services Director acknowledged that the food temperatures were low due to the time taken for food to travel from the plating area to the unit. Facility policy required hot foods to be held at 135 degrees Fahrenheit or greater, which was not met at the point of service.
Failure to Notify Providers and Initiate Suicide Precautions After Resident's Suicidal Statement
Penalty
Summary
A deficiency occurred when the facility failed to notify the social worker, physician, and psychiatrist after a resident made a statement indicating suicidal ideation. The resident, who had a history of homicidal ideation, sepsis, chronic heart failure, and muscle weakness, was admitted following a hospital stay where psychosocial concerns had already been identified. Upon admission, the resident was noted to be cognitively intact but dependent on staff for many activities and had reported feeling down or hopeless in the two weeks prior. On one occasion, a nurse found the resident on the floor next to the bed, and the resident stated they were trying to jump out the window. Despite this statement, there was no documentation of further assessment by a charge nurse or notification of supervisory staff, social services, or medical providers as required by facility policy. The facility's policy required immediate notification and specific interventions, such as 15-minute checks or 1:1 observation, when a resident made suicidal statements. However, the LPN involved did not notify anyone, interpreting the resident's statement as a desire to go home rather than a suicidal intent. Interviews with staff confirmed that the required notifications and interventions were not initiated, and the psychiatric consult was not requested until three days after the incident. The social worker and APRN were not informed of the resident's statement, and the care plan addressing the behavior was only developed after surveyor inquiry.
Resident Confined to Room Without Symptoms or Physician Order Following Roommate's RSV Diagnosis
Penalty
Summary
A resident with severe cognitive impairment, ischemic cardiomyopathy, adjustment disorder, dementia, and stage 3 chronic kidney disease was placed on contact and droplet precautions after their roommate tested positive for RSV. Despite not exhibiting any symptoms of RSV and lacking a physician's order for isolation or testing, the resident was confined to their room. Observations showed the resident seated behind a privacy curtain, without access to engaging activities, and eating alone, while the roommate's television was playing. Facility staff, including nurse aides and LPNs, confirmed that the practice was to keep both the infected resident and their roommate on precautions, restricting the roommate from leaving the room even when asymptomatic. Staff physically blocked the resident from exiting the room and redirected them to remain seated behind the curtain. The recreation staff noted a decline in the resident's activity and increased napping, which was not reported to nursing or social services. The resident, who was typically active, was not allowed to participate in social or recreational activities during this period. Interviews with facility leadership, including the DON and infection control nurse, revealed that the policy was to confine all roommates of RSV-positive residents to their rooms, regardless of symptoms or mask compliance. The infection control nurse could not identify CDC guidance supporting this practice for asymptomatic roommates. The facility's policies required isolation to be the least restrictive possible and defined abuse to include unreasonable infliction of confinement. However, the resident was kept in their room without evidence of infection or a physician's order, and the facility failed to recognize this as involuntary seclusion.
Failure to Report Injury of Unknown Source to State Agency
Penalty
Summary
A resident with diagnoses including dementia, psychosis, restlessness, and agitation, who was severely cognitively impaired and dependent on staff for transfers and mobility, was found with a bruise on the forehead measuring 5.0 cm by 3.5 cm. The injury was discovered during a nurse's assessment, and there were no witnesses to the incident. The resident was unable to communicate how the injury occurred, and staff suspected it may have resulted from contact with the mechanical lift during a transfer, but this could not be confirmed. Documentation indicated that two staff had assisted with the transfer, but neither observed the injury occur or noticed any signs of injury immediately after the transfer. Facility documentation, including a Reportable Event Report and progress notes, classified the incident as not requiring reporting to the state agency, and the section indicating state agency notification was left blank. Interviews with the DON and Administrator confirmed that the injury was of unknown source and should have been reported to the state agency, as required by facility policy and regulations. The facility's policy defined an injury of unknown source as one not observed by any person or not explainable by the resident, and directed that such incidents be reported immediately to the state agency. Despite internal discussions and review of witness statements, there was no documentation or evidence to validate that the origin of the bruise was known or witnessed. The failure to report the injury of unknown source to the state agency constituted a deficiency, as the facility did not follow its own policy or regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown source.
Incomplete Investigation of Injury of Unknown Source
Penalty
Summary
The facility failed to ensure a complete investigation and summary were completed for a resident with an injury of unknown source. A resident with diagnoses including dementia, psychosis, restlessness, and agitation, who was severely cognitively impaired and dependent on staff for transfers and mobility, was found with a significant bruise on the forehead. The injury was unwitnessed, and the resident was unable to communicate how it occurred. Although staff suspected the mechanical lift may have been involved during a transfer, the nurse aide who assisted with the transfer did not observe any injury at the time and did not witness the resident's head being struck. The Director of Nursing Services (DNS) obtained some staff statements but did not collect a statement from the second nurse aide involved in the transfer. Additionally, the DNS did not complete a summary of the investigation, mistakenly believing the cause of the bruise was known and witnessed, despite a lack of documentation or statements to support this. The facility's policy required a thorough investigation and documentation for injuries of unknown source, but this was not completed as directed.
Failure to Address Psychosocial Needs in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission that addressed a resident's psychosocial and behavioral needs, specifically homicidal ideation documented prior to admission. The resident was admitted with diagnoses including homicidal ideation, sepsis, heart failure, and muscle weakness. Hospital records indicated the resident had made comments about homicidal ideation, and the hospital had taken precautions by withholding potentially dangerous items. Despite this, the facility's baseline care plan, created three days after admission, did not include any psychosocial concerns or behaviors, and psychiatry services at the facility were not updated regarding the resident's prior psychosocial behavior. A nursing note several days after admission documented an incident where the resident was found on the floor next to the bed, stating an attempt to jump out the window. The baseline care plan policy required a resident-centered plan within 48 hours of admission, including necessary healthcare information. However, the resident's care plan did not reflect the known psychosocial risks, and staff interviews confirmed that the baseline care plan should have addressed these issues but did not, as the resident had no prior behavioral incidents during a previous admission.
Failure to Consistently Place Fall Mats as Ordered for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that floor mats were in place on both sides of the bed for a resident with dementia, hypotension, and mobility abnormalities, who was assessed as high risk for falls. The resident's care plan and physician's order specifically directed that floor mats be placed on both the left and right sides of the bed every shift. Despite these orders, observations on multiple occasions found that only one floor mat was in place, with the other mat folded and leaning against the wall. The resident was bedfast and required extensive assistance for transfers and bed mobility, and was dependent with toileting. Interviews with nurse aides and an LPN confirmed that the floor mat was not consistently placed on the window side of the bed after meals, as required. The nurse aide referenced the need to check the care card on the computer, as it was not posted in the resident's room, and acknowledged the oversight. The LPN also recognized the failure to ensure both mats were in place. The Director of Nursing Services confirmed that both nurses and nurse aides were responsible for mat placement but could not explain why the intervention was not implemented as ordered. Facility policy required that fall prevention interventions be implemented according to assessed risk, but this was not followed in this case.
Failure to Provide Timely Psychiatric Intervention and Follow Suicide Precaution Policy
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed psychosocial behaviors and had a history of mental health concerns, including homicidal ideation and depression. Upon admission, the resident had documented psychiatric issues from the hospital, including emotional distress and statements about self-harm, which led to a referral for psychiatric services. Despite this, psychiatric services at the facility were not promptly notified or updated regarding the resident's psychosocial behavior, and the resident was not seen by psychiatry in a timely manner. A significant event occurred when the resident was found on the floor next to their bed and stated they were trying to jump out the window. The nursing note documenting this incident did not include further assessment by a charge nurse or documentation that supervisory staff, social services, or medical providers were notified. The responsible LPN did not interpret the statement as suicidal and therefore did not follow facility policy, which required 15-minute checks, close observation, and notification of appropriate staff for suicidal statements. Interviews with facility staff confirmed that the required procedures for managing suicidal statements were not followed. The nursing supervisor, social worker, and advanced practice registered nurse were not notified of the resident's statement, and psychiatric services were not engaged until several days after the incident. Facility policies required immediate assessment, notification, and safety interventions for residents expressing suicidal ideation, but these steps were not taken in this case.
Pharmacist Failed to Identify Missing Behavioral Monitoring and AIMS Assessments for Antipsychotic Use
Penalty
Summary
A deficiency occurred when the facility's consulting pharmacist failed to identify and report irregularities in the medication regimen review for a resident receiving an antipsychotic medication. The resident, who had diagnoses including dementia, adjustment disorder with depressed mood, and anxiety disorder, was severely cognitively impaired and dependent on staff for several activities of daily living. The resident's care plan and physician's orders indicated ongoing use of Risperidone, an antipsychotic, and required behavioral monitoring and regular AIMS (Abnormal Involuntary Movement Scale) assessments every six months. However, behavioral monitoring was not documented on the Medication Administration Record (MAR) after a certain date, and no AIMS assessment was completed for over 14 months, despite the continued administration of the antipsychotic medication. The consulting pharmacist conducted monthly medication regimen reviews but did not recommend the completion of overdue AIMS assessments or the resumption of behavioral monitoring, even though these omissions were evident in the clinical record and psychiatric progress notes. Facility policy required adherence to CMS guidelines and current practice standards, including maintaining consultant pharmacist reports and ensuring appropriate pharmaceutical care. Despite these requirements, the pharmacist's consultation reports failed to address the lack of behavioral monitoring and overdue AIMS assessments, contributing to the deficiency.
Failure to Maintain Clean Vents in Common Areas
Penalty
Summary
During observations of two common areas, surveyors identified that large vents located in the North and East units were not maintained in a clean condition. The vents, each measuring approximately 2.5 feet by 5.0 feet, were found to have a significant amount of dark-colored debris within the slats and inside the vents. Interviews with the Director of Facilities confirmed that housekeeping staff were responsible for cleaning the vents and that the vents were supposed to be vacuumed weekly, but this cleaning had not occurred as required.
Failure to Use Gait Belt Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to utilize a gait belt when assisting Resident #1, who required staff assistance for ambulation, resulting in a fall and subsequent fractures. Resident #1 had a history of acute respiratory failure, weakness, difficulty walking, osteoporosis, and generalized osteoarthritis. The resident's care plan specified the use of a gait belt and a two-wheeled walker for ambulation with staff assistance. However, on the day of the incident, the nurse aide did not use a gait belt while assisting the resident from the bathroom to the bed, leading to the resident leaning to the left and being lowered to the floor, resulting in a left leg fracture. The facility's policy mandates the use of gait belts for all resident transfers and ambulation requiring assistance, which the nurse aide had acknowledged understanding. Despite this, the nurse aide did not adhere to the policy, contributing to the resident's fall. The Director of Nursing confirmed the policy requirement and the failure to use the gait belt during the incident. The facility's fall prevention policy also emphasizes the use of gait belts, underscoring the deficiency in following established safety protocols.
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 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 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 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 significant cardiac and respiratory diagnoses experienced respiratory symptoms and wheezing that prompted multiple APRN evaluations and orders, including a chest x-ray and IV Lasix. Staff notes later documented hypoxia, oxygen administration, and stat orders for labs and a chest x-ray on the day the resident died from heart failure related to sick sinus syndrome and COPD. However, the clinical record lacked documentation of an earlier chest x-ray order, any reason it was not performed, and respiratory assessments prior to the acute decline, despite staff recalling prior wheezing. Leadership acknowledged that nursing staff should have documented the change in condition and related assessments in accordance with the facility’s documentation policy.
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.
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 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 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 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 Document Respiratory Change in Condition and Ordered Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with multiple cardiac and respiratory diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease. The resident’s care plan directed staff to administer medications as ordered and monitor for abnormal breath sounds, difficulty breathing, and signs of heart failure. An APRN evaluated the resident due to respiratory symptoms and increased wheezing and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from that period did not contain an order for the chest x-ray, nor any documentation explaining why the x-ray was not performed. Subsequently, the APRN again evaluated the resident at nursing’s request for a change in respiratory condition and documented that there were no signs of dyspnea, CHF, or glycemic issues, and that the resident was not in apparent distress. Later, the APRN documented another visit for increased respiratory distress, during which Lasix 40 mg IV was administered and a stat chest x-ray was ordered. Nursing notes documented that 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 ordered stat labs, a stat chest x-ray, and continuation of oxygen. The resident’s death was later pronounced the same day, with the death certificate listing heart failure due to sick sinus syndrome and COPD as the primary cause of death. Record review showed no documentation of the chest x-ray order on the earlier date, no documentation for the reason the chest x-ray was not performed, and no documentation of respiratory-related assessments prior to the later date, despite staff recalling episodes of wheezing and respiratory concerns in the week prior. The APRN confirmed she had ordered a chest x-ray and discussed the plan with a nurse but could not recall which staff member or why the order was not entered or carried out, and could not locate documentation explaining the omission. The ADON and the President of Clinical Services stated that nursing staff should have documented the change in condition and related assessments when the APRN was asked to see the resident for respiratory changes, and that the facility failed to follow its Documentation Policy requiring complete, accurate, and timely documentation by the end of the shift in which assessments or care occurred.
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.
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