Mary Wade Home, The Incorporated
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 118 Clinton Ave, New Haven, Connecticut 06513
- CMS Provider Number
- 075325
- Inspections on file
- 26
- Latest survey
- November 13, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Mary Wade Home, The Incorporated during CMS and state inspections, most recent first.
A resident with Alzheimer's and other cognitive impairments, who was dependent on staff for daily care, was verbally abused by a nurse aide who yelled at the resident during care. The aide's actions were witnessed by two nurses, and the behavior was loud enough to be heard by others. The resident's care plan required staff to use calm approaches and reapproach if care was refused, but these interventions were not followed, resulting in a substantiated incident of verbal abuse.
A resident with Alzheimer's and other conditions, who was dependent on staff for care, was subjected to verbal abuse by a nurse aide, as witnessed by two LPNs. Although the incident was substantiated through investigation, law enforcement was not notified as required by facility policy, since the abuse was not physical.
A resident with a history of depression and epilepsy, identified as an elopement risk and equipped with a wander guard, was able to leave the facility unsupervised after the security guard deactivated the wander guard alarm without intervening or notifying nursing staff. The resident crossed a street to visit a library and was later escorted back by staff, with no injuries reported. The incident was compounded by a lack of staff awareness of the resident's risk status and the absence of a specific wander guard policy.
Two residents who were dependent on staff for personal hygiene and incontinent of bowel and/or bladder did not receive incontinent care as required by their care plans. Documentation and staff interviews confirmed that, during a specific shift, both residents were left in soiled linens and briefs, with no record of care being provided as directed.
Two residents dependent on staff for toileting and personal hygiene did not receive required incontinent care during an overnight shift, as documented by care records and resident interviews. Both reported that a nurse aide failed to provide care or assist with repositioning, and the call bell was not accessible for one resident. Facility documentation confirmed the lack of care provided, in violation of established care plans and policies.
The facility did not provide a way for residents who were not at risk for elopement to independently open secured doors on two nursing units, requiring all residents to rely on staff for entry and exit. Despite many residents not being at risk, all were subject to locked-door restrictions, and the facility lacked policies and risk assessments for placement on secured units. An incident occurred where a resident became distressed after being unable to enter their unit without staff assistance.
The facility did not ensure that food was served at safe temperatures, as meal delivery carts lacked covers and warming systems, resulting in food being served below the required 135°F. Additionally, the dishwasher failed to reach the necessary hot water temperature of 160°F for proper sanitization, as confirmed by staff and equipment readings.
The facility did not complete or maintain required annual performance evaluations for four nurse aides, as confirmed by missing documentation in their personnel files and facility policy review. The DON was unaware of the missing evaluations, which were the responsibility of the previous DON.
Surveyors found that three opened multi-dose Tuberculin PPD vials in two medication rooms were not dated upon opening, contrary to facility policy requiring nurses to date vials and relabel them with a beyond-use date. Interviews with nursing staff and the pharmacist confirmed the expectation for dating and the importance of this practice for medication efficacy and test accuracy.
Residents were not provided with selective menus to make meal choices, resulting in repeated meals, lack of awareness about upcoming food, and delays in receiving alternative options. Dietary staff shortages contributed to the inability to assist residents with menu selection, despite facility policy requiring this option.
Surveyors found that oxygen tubing for several residents receiving oxygen therapy was frequently unlabeled, undated, and improperly stored, despite facility policy and provider orders requiring weekly changes, labeling, and storage in labeled bags. Nursing staff interviews confirmed responsibility for these tasks, but observations showed lapses in practice and inconsistencies in care plans, leading to a deficiency in the infection prevention and control program.
A resident with an indwelling urinary catheter was repeatedly observed without a privacy cover over the drainage bag, leaving urine visible from the hallway. Although a privacy cover was present, it was not used correctly, and staff interviews confirmed it should have concealed the bag to maintain dignity. The resident's care plan required the use of a privacy cover, but this intervention was not followed.
A resident with dementia and cognitive impairment was physically restrained by an LPN during medication administration after becoming agitated and resistant, with the LPN holding the resident's hands against their stomach. The incident was witnessed by a nursing assistant, and the facility's investigation was incomplete, lacking statements from all relevant staff and proper documentation.
A resident with cognitive impairment and behavioral issues was allegedly hit on the arm by an LPN during medication administration. The facility's investigation into the abuse allegation was incomplete, as not all staff present were interviewed and required documentation was missing, contrary to facility policy.
A resident with dementia and severe cognitive impairment was identified as being at risk for elopement, but the care plan did not address this risk despite assessments and facility policy requiring such interventions. The care plan focused on cognitive issues and confusion, omitting specific measures for elopement prevention.
Two residents receiving oxygen therapy did not have their care plans updated to include required interventions such as administration details, equipment settings, and monitoring for complications. Nursing staff reported only updating interventions quarterly or after significant changes, and observations found unlabeled oxygen tubing in use. Facility policy required more timely and comprehensive care plan updates for oxygen therapy, which were not followed.
A resident with dementia and dysphagia, who had physician orders and care plans requiring 1:1 feeding assistance and supervision due to aspiration risk, was repeatedly observed eating alone without staff supervision. Staff were unaware of the resident's need for feeding assistance, and the resident was not included on the list of those requiring such care, resulting in a failure to follow prescribed aspiration precautions.
A resident with significant mobility and cognitive impairments, who was dependent on staff for bed mobility and hygiene, developed stage II pressure ulcers due to staff failing to follow the care plan for regular turning and repositioning and not ensuring the air mattress was functional. Staff did not consistently provide timely incontinence care or reposition the resident as required, and the care card lacked necessary interventions, leading to inadequate pressure ulcer prevention and care.
Two residents with cognitive impairments and identified elopement risks were able to leave the facility unsupervised due to failures in staff communication, lack of education on elopement risk, and incomplete implementation of care plans and elopement protocols. In both cases, staff were unaware of the residents' whereabouts until after the elopement occurred, and required documentation and reporting procedures were not followed.
Surveyors found that personal care items, including water pitchers and urinals, were not stored in a clean or sanitary manner for a resident with multiple health conditions, with items placed on the floor and overbed table. In a shared bathroom, two residents' personal care items and undergarments were left unlabeled and improperly stored. An LPN confirmed these practices did not meet facility expectations.
The facility did not ensure that an LPN and an RN completed and had documentation for required in-service training on Dementia, Communication, and Behavioral Health. Review of employee files and interviews with staff confirmed that the necessary training records were missing, and the facility lacked a qualified staff member on-site to conduct Dementia training, resulting in noncompliance with facility policy.
Required Communication in-service training was not documented for several direct care staff, including an LPN, an RN, and multiple nursing assistants. Facility staff could not provide evidence that this training was completed as required by policy, citing poor record-keeping by a previous staff development nurse.
The facility did not ensure that three nursing assistants received and had documentation of required Resident's Rights training upon hire and annually, as confirmed by review of employee files and facility policy. Interviews with the current Staff Development RN and DON indicated that the previous staff member responsible for training did not maintain proper records, resulting in missing documentation for these mandatory trainings.
The facility did not ensure that three nurse aides received and had documentation of required in-service training in areas such as Resident Rights, Dementia, Communication, Behavioral Health, and Infection Control. This deficiency was attributed to poor record-keeping by a previous staff member and the absence of a qualified staff trainer for Dementia care.
Three residents with varying medical conditions experienced verbal and physical abuse from a nurse aide, including rough handling, yelling, body-shaming, and dismissive comments. One resident was physically thrown into bed and tightly grabbed, while another was publicly criticized for their weight and incontinence. These actions were corroborated by another staff member and confirmed through interviews and facility documentation, demonstrating a failure to protect residents from abuse and uphold their rights.
Allegations of staff-to-resident abuse involving multiple residents were not reported to the administrator or authorities within the required two-hour window. Staff delayed escalation of concerns, and the accused aide continued working during the shift, contrary to facility policy. Fear of retaliation among staff and residents further hindered timely reporting and investigation.
A resident with dementia and major depressive disorder expressed self-harm intentions to an LPN, who reassured the resident and notified the ADNS. However, the physician was not informed, and there was no documentation of the resident being evaluated by a physician. The facility's policy requires timely notification of changes in condition, which was not followed in this case.
Failure to Prevent Verbal Abuse of Cognitively Impaired Resident
Penalty
Summary
A resident with Alzheimer's Disease, depression, and anxiety, who was dependent on staff for personal care and had altered cognition, was subjected to verbal abuse by a nurse aide. The resident's care plan required staff to use simple explanations, orientation guides, and to reapproach if the resident refused care. On the evening of the incident, a nurse aide was observed by a charge nurse aggressively gesturing and yelling at the resident while attempting to provide care. The charge nurse reported that the aide shouted phrases such as, "what's up with you? Don't be putting your hands on me, and you're not going to put your hands on me," after the resident became combative. Another LPN in the hallway also heard the aide yelling loudly at the resident, and both nurses confirmed the aide's behavior was extremely loud and could be heard by others. The incident was witnessed by two nurses, and the aide admitted to raising her voice in response to the resident's actions. The resident was known to resist care and could become combative, but staff were instructed to reapproach rather than escalate the situation. The facility's policies required staff to prevent abuse and treat residents with respect and dignity. The investigation substantiated that the nurse aide's actions constituted verbal abuse, as the aide failed to follow the care plan interventions and facility policies designed to protect residents from abuse.
Failure to Timely Report Verbal Abuse Allegation to Law Enforcement
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of verbal abuse to law enforcement in a timely manner. The incident involved a resident with Alzheimer's Disease, depression, and anxiety, who was dependent on staff for personal care and had limited decision-making ability. On the evening in question, a nurse aide was witnessed by two LPNs screaming at the resident while assisting with bedtime care. The nurse aide denied the behavior but was removed from the facility pending investigation. The investigation, conducted by the Assistant Director of Nursing, substantiated the allegation of verbal abuse based on statements from the LPNs who heard the incident. Despite the facility's policy requiring notification of law enforcement within two hours of any abuse allegation, the facility did not notify law enforcement because the abuse was not physical. The facility's documentation and staff interviews confirmed that the event was limited to verbal abuse, and the nurse aide was subsequently barred from future employment at the facility. However, the failure to report the substantiated verbal abuse to law enforcement constituted a violation of the facility's own policy and regulatory requirements.
Failure to Prevent Elopement of Resident Identified as Wandering Risk
Penalty
Summary
A deficiency occurred when a resident, identified as an elopement risk with a history of major depression and epilepsy, was able to leave the facility without staff knowledge or intervention. The resident was assessed as alert and oriented, with a BIMS score of 14, and was independent in ambulation using a walker. Despite being under a voluntary court-appointed conservatorship and having interventions in place such as a wander guard and an elopement care plan, the resident was able to exit the facility and cross a street to access a library on another part of the campus. On the day of the incident, the resident exited through the front doors, triggering the wander guard alarm. The security guard at the front desk deactivated the alarm without interacting with the resident or notifying nursing staff, allowing the resident to leave the building. The security guard later stated he did not realize the alarm was triggered by this resident, as he was unaware of the resident's current status as a nursing home resident with a wander guard. The resident was later observed by an LPN returning from the assisted living facility across the street and was escorted back to the building by staff, with no injuries reported. Further review revealed that the facility did not have a specific wander guard policy, although their general policy on elopements and wandering residents directed that adequate supervision should be provided to prevent such incidents. The lack of staff awareness regarding the resident's elopement risk status and the improper response to the wander guard alarm directly contributed to the resident's unsupervised exit from the facility.
Failure to Provide Timely Incontinent Care as Directed by Care Plans
Penalty
Summary
The facility failed to provide incontinent care as documented in the care plans for two residents who were dependent on staff for personal hygiene and were incontinent of bowel and/or bladder. One resident, with neuromuscular dysfunction of the bladder and hemiplegia, was identified as always incontinent of bowel and dependent on staff for care. Documentation showed that on a specific day, there was no record of incontinent care being provided during the 7AM-3PM shift, despite care plans directing care every two hours. The resident was later found with soiled linens and evidence of inadequate care. Another resident, diagnosed with benign prostatic hyperplasia and also dependent on staff for personal hygiene, was always incontinent of urine and frequently incontinent of bowel. The care plan required incontinent care every two hours and as needed, but documentation for the 7AM-3PM shift was missing. This resident was also found with soaked pads, sheets, and briefs at the end of the shift. Staff interviews and facility documentation confirmed that the assigned nurse aide did not provide or document the required care during the shift in question.
Failure to Provide Required Incontinent Care and Neglect of Dependent Residents
Penalty
Summary
Two residents who were dependent on staff for toileting and personal hygiene did not receive the required incontinent care during an overnight shift. Both residents had care plans directing staff to provide incontinent care every two hours and as needed, to keep them clean and dry, and to ensure the call bell was within reach. Documentation and interviews revealed that a nurse aide failed to provide this care from the evening through the following morning, with no evidence of toileting hygiene being performed during the overnight hours. One resident, with diagnoses including peripheral neuropathy and morbid obesity, reported that after being put to bed in the evening, no staff entered the room to provide care or assist with toileting, and the call bell was not accessible. The resident was found soaked in the morning by the day shift staff. The other resident, with osteoarthritis and a history of recurrent urinary tract infections, similarly reported not receiving any care after a certain time in the evening, and that the nurse aide refused to assist with repositioning in bed, instructing the resident to do it independently despite their dependency. Facility documentation, including nurse notes and incident reports, corroborated the residents' accounts, and point of care records lacked evidence of overnight care being provided. The facility's policies require prevention of neglect and the provision of care as outlined in residents' care plans, but these were not followed during the incident in question.
Failure to Allow Independent Egress for Residents Not at Elopement Risk
Penalty
Summary
The facility failed to ensure that residents who did not meet clinical criteria for residing on a locked unit were provided with a method to independently open secured doors. Observations across multiple days revealed that both nursing units had locked doors requiring a keypad code for entry and exit, and only staff were observed inputting the code for residents and visitors. Signage instructed individuals to call a phone number if staff were unavailable, and knocking on the door or window was discouraged. Review of facility records showed that a significant number of residents on both units were not at risk for elopement, yet were still subject to the same locked-door restrictions as those who were at risk. Interviews with staff and leadership confirmed that all residents, including those who were independent and cognitively intact, were not allowed to leave the units without staff accompaniment. The facility was unable to provide risk assessments or criteria for placement on secured units, and there was no policy available regarding secured/locked units or assessment for such placement. Additionally, the Director of Nursing Services acknowledged that there was no strategy in place to secure only those residents identified as elopement risks, resulting in all residents being restricted regardless of their assessed risk. An incident was observed where a resident was unable to enter their unit after exiting the elevator because they did not have the keypad code, leading to visible distress. Staff interviews indicated that residents on one unit were given the code, while those on the other were not, and there was no clear process for ensuring door security or tracking which residents were permitted to leave. The facility's elopement and wandering policy referenced the use of locks and alarms for residents at risk, but did not address the needs or rights of residents not at risk for elopement.
Failure to Maintain Safe Food and Dishwashing Temperatures
Penalty
Summary
The facility failed to ensure that food was served at safe temperatures and that dishwashing equipment met required sanitization standards. During observations of the tray line, it was noted that meal delivery carts lacked doors and did not use a pellet system to keep plates warm. As a result, test tray food temperatures for vegetables were recorded below the required 135 degrees Fahrenheit, with readings between 121.5 and 130.1 degrees Fahrenheit. Staff interviews confirmed that the carts had always been uncovered and that a pellet system had never been used for food transport within the facility. Facility policy indicated that food should be held at or above 135 degrees Fahrenheit to minimize the risk of foodborne illness, and appropriate transport equipment should be used to maintain safe temperatures. Additionally, the facility failed to maintain the dishwasher's hot water temperature at or above 160 degrees Fahrenheit, as required. Observations showed that the dishwasher's hot water temperatures ranged from 149 to 150 degrees Fahrenheit, which was below the standard indicated on the machine's label. The Dietary Manager confirmed that the wash temperature did not rise above 150 degrees Fahrenheit after several cycles. The facility's food safety best practices and manufacturer guidelines require minimum wash and rinse temperatures to ensure effective cleaning and sanitization of tableware.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete required annual performance evaluations for four nurse aides, as evidenced by the absence of these evaluations in their personnel files. Specifically, for four employees with varying hire dates, no documentation of annual performance evaluations was found, and the facility was unable to provide these records upon request. The Director of Nursing (DNS) confirmed during an interview that performance evaluations should be present in the personnel files and acknowledged that she was unaware the evaluations had not been completed. The DNS also stated that the previous DNS would have been responsible for these evaluations, as she had only recently assumed the role. A review of the facility's policy, dated July 2012, indicated that employees are to receive an evaluation after 90 days of service and then annually thereafter. The policy further specifies that evaluations are to be prepared by supervisors, reviewed by the administrator, and maintained in the employee's personnel file. Despite these requirements, the facility did not have the necessary documentation for the four nurse aides, resulting in noncompliance with their own policy and regulatory expectations.
Failure to Date Multi-Dose Tuberculin Vials Upon Opening
Penalty
Summary
Surveyors identified that in two medication storage rooms, three multi-dose vials of Tuberculin PPD were found opened and stored in the refrigerator without being dated. Specifically, two vials on the K1 unit and one vial on the K2 unit were observed to be partially used but lacked any indication of the date they were first opened. Facility policy requires that the nurse who opens a multi-use vial must date it at the time of opening, and this was confirmed in interviews with both a registered nurse and a licensed practical nurse. Additionally, the facility's policy states that multi-dose vials should be relabeled with a beyond-use date 28 days after opening, and the label should include the initials of the nurse who opened the vial. The pharmacist interviewed confirmed that multi-use vials are considered good for 28-30 days and should be dated upon opening to ensure efficacy and accuracy, particularly for the Mantoux test, which uses Tuberculin PPD. The facility's policy also requires unit managers to perform random checks of opened multi-dose vials for appropriate dating. Despite these policies, the failure to date the vials upon opening was observed during the survey, constituting a deficiency in medication labeling and storage practices.
Failure to Provide Selective Menus for Resident Meal Choices
Penalty
Summary
The facility failed to provide residents with a selective menu, preventing them from making meal selections according to their preferences, allergies, or intolerances. Multiple residents reported that they did not receive menus to choose their meals, were unaware of what food would be served until it arrived, and experienced repeated servings of the same foods. Residents also indicated that if they requested an alternative meal, it could take up to 30 minutes to receive it. These concerns were raised during interviews and Resident Council meetings, with several residents stating that their requests for selective menus had been ongoing and unaddressed. The Interim Dietary Manager confirmed that the lack of staff in the dietary department contributed to the inability to assist residents with filling out selective menus. Review of the facility's Selective Menus policy showed that residents should be offered the option to select their own menus, but this was not being implemented. Residents expressed dissatisfaction with the quality and variety of food, and some noted that staff had not reviewed menus with them for extended periods.
Failure to Label, Date, and Store Oxygen Tubing per Policy
Penalty
Summary
Surveyors identified a deficiency in the facility's infection prevention and control program related to the management of oxygen therapy equipment for four residents with various diagnoses, including COPD, congestive heart failure, Alzheimer's disease, chronic kidney disease, and pneumonia. Facility policy and provider orders required weekly changing, labeling, and dating of oxygen tubing, as well as proper storage of tubing in labeled bags when not in use. However, multiple observations revealed that oxygen nasal cannulas were frequently found unlabeled, undated, and improperly stored, such as being left exposed on chairs, blankets, or near trash cans, rather than in labeled bags. Interviews with nursing staff, including LPNs and RNs, confirmed that it was the responsibility of the 11 PM to 7 AM shift to change, label, and date oxygen tubing weekly. Despite documentation in the treatment administration records indicating that tubing changes were performed as ordered, direct observations contradicted these records, showing that tubing was not consistently labeled or stored according to policy. Staff interviews further revealed a lack of awareness or lapses in following the labeling and storage procedures, with some staff unable to explain why tubing was not properly managed. Additionally, review of resident care plans showed that for some residents, interventions related to changing and labeling oxygen tubing were not included, despite provider orders and facility policy. This inconsistency between documented care, observed practice, and care planning contributed to the facility's failure to implement its infection prevention and control program as required for residents receiving oxygen therapy.
Failure to Maintain Resident Dignity with Catheter Drainage Bag Privacy
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed on multiple occasions lying in bed without a privacy cover over the catheter drainage bag, resulting in urine being visible from the hallway. The privacy cover, although present, was positioned above the drainage bag and not used to conceal it. This was observed on two consecutive days, and the issue was confirmed during interviews with a nursing assistant and the unit manager, both of whom acknowledged that the privacy cover should have been used to cover the drainage bag for dignity purposes. The resident involved had a history of osteoarthritis, neuromuscular dysfunction of the bladder, generalized muscle weakness, and cognitive communication deficit, and was dependent on staff for personal care. The resident's care plan included the use of a privacy cover for the catheter drainage bag as an intervention to maintain dignity. Despite this, staff failed to ensure the privacy cover was properly used, and facility leadership confirmed that the cover should have concealed the drainage bag. No facility policy regarding urinary catheter drainage bags or privacy covers was provided upon request.
Failure to Prevent Use of Physical Restraint During Medication Administration
Penalty
Summary
A resident with Alzheimer's disease, dementia with behavioral disturbances, and anxiety disorder, who was cognitively impaired and dependent for most activities of daily living, was involved in an incident where a staff member failed to keep the resident free from physical restraint. During an attempt to administer medications, the resident became resistant and scratched the LPN's arm. The LPN responded by placing her hands on top of the resident's hands and holding them against the resident's stomach. This action was observed by a nursing assistant, who also reported seeing the LPN hit the resident's arm. The LPN did not call for help or attempt to step away when the resident became agitated, and admitted that holding the resident's hands was a reaction to being scratched. The LPN also stated she had not received training on restraining residents. The facility's investigation into the incident was incomplete, as statements were not obtained from all staff present on the unit, and the Director of Nursing was unable to provide documentation of conflicting witness statements. The facility's policy prohibits abuse and requires thorough investigation and staff training, but these procedures were not fully followed in this case. The incident resulted in the resident being subjected to a physical restraint without medical necessity, in violation of regulatory requirements.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into an allegation of abuse involving a resident with Alzheimer's disease, dementia with behavioral disturbance, and anxiety disorder. The resident was cognitively impaired, dependent for mobility and toileting, and non-ambulatory. An incident was reported in which a nursing assistant alleged that an LPN hit the resident on the arm while administering medications. The LPN stated that the resident became combative and scratched her, and that she held the resident's hands against their stomach as a reaction. The LPN did not call for help or attempt to step away during the incident, and reported not having received training on restraining residents. The facility's investigation was incomplete, as the Director of Nursing Services (DNS) did not interview all staff members present on the unit at the time of the incident, nor did she interview other residents. The DNS also could not provide documentation of the conflicting statements that led to the determination that the allegation was unsubstantiated. The facility's policy required immediate and thorough investigation of abuse allegations, including interviewing all involved persons and witnesses, but this was not followed in this case.
Failure to Develop Comprehensive Care Plan for Resident at Risk of Elopement
Penalty
Summary
The facility failed to develop a comprehensive Resident Care Plan (RCP) for a resident identified as being at risk for elopement. The resident, admitted in May 2024, had diagnoses including dementia, hypertension, and depression. An Elopement Risk assessment indicated the resident was at risk for elopement and required precautions. The annual Minimum Data Set (MDS) assessment documented severe cognitive impairment, fluctuating behaviors, and the ability to ambulate independently. Despite these findings, the RCP did not address the resident's elopement risk, instead focusing on altered cognition, confusion, and forgetfulness, with interventions such as providing a daily routine and monitoring cognitive changes. A provider progress note further described the resident as alert but disoriented, with poor safety awareness and a tendency to ambulate around the unit. Facility policy requires that residents at risk for elopement receive adequate supervision and care in accordance with a person-centered care plan, including systematic monitoring and management of elopement risk. The facility's Comprehensive Care Plans policy also mandates the inclusion of measurable objectives and timeframes to address all identified needs. The omission of elopement risk from the resident's care plan represents a failure to meet these requirements.
Failure to Update Care Plans for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to revise and update the Resident Care Plans (RCPs) for two residents receiving oxygen therapy, as required by facility policy. For one resident with Alzheimer's disease, COPD, and diabetes, the RCP did not include specific interventions for the administration of continuous or intermittent oxygen, such as the flow rate, type of delivery system, procedures for changing and labeling nasal cannula tubing, or monitoring for complications related to oxygen use. Despite provider orders specifying oxygen administration and tubing changes, these interventions were not reflected in the care plan. Interviews with nursing staff revealed a lack of awareness regarding the resident's oxygen orders and a practice of only updating interventions quarterly or upon significant change, rather than promptly after new orders or assessments. Similarly, another resident with pneumonia, dysphagia, and chronic kidney disease had an RCP that omitted necessary interventions for oxygen therapy, including details on administration, equipment settings, and monitoring for complications. Observations showed the use of unlabeled oxygen tubing, and staff interviews confirmed that care plan interventions were not updated in a timely manner. Facility policy required that care plans for residents on oxygen therapy include specific interventions based on assessments and provider orders, but this was not consistently implemented for the residents reviewed.
Failure to Provide Required Supervision During Meals for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, respiratory failure with hypoxia, and dysphagia did not receive the required supervision during meals as ordered by the physician and outlined in the care plan. The resident had multiple physician orders and therapy notes specifying the need for supervision and 1:1 feeding assistance due to aspiration risk, including after a recent episode of aspiration pneumonia. Despite these orders, the resident was observed eating alone in both the dining room and in bed, without staff present to provide supervision or assistance. Documentation and interviews revealed that the resident was not included on the facility's list of individuals requiring feeding assistance, and staff were unaware of the specific feeding supervision needs. Nursing assistants relied on the resident care cards (RCCs) for guidance but did not consistently review them, leading to a lack of awareness about the resident's requirements. The care plan and RCC both indicated the need for 1:1 feeding assistance and aspiration precautions, but these interventions were not implemented during observed meals. Therapy and nursing staff confirmed that the resident required supervision to manage swallowing difficulties and to prevent further aspiration events. The facility's aspiration precautions protocol required staff to monitor residents for signs of difficulty during meals and to intervene as needed, but this protocol was not followed for the resident in question. As a result, the resident was left unsupervised during meals, contrary to physician orders and established care plans.
Failure to Follow Pressure Ulcer Prevention Plan and Inadequate Pressure Ulcer Care
Penalty
Summary
A resident with multiple medical conditions, including neuromuscular dysfunction, generalized muscle weakness, and cognitive impairment, was identified as being at risk for skin breakdown and pressure ulcers. The resident was dependent on staff for bed mobility, transfers, and personal hygiene, and had an indwelling catheter with a history of bowel incontinence. The care plan included the use of an air mattress and required turning and repositioning every two hours to prevent pressure ulcers. However, the resident care card did not include the turning and repositioning intervention, and staff did not consistently implement or document this requirement. Observations and interviews revealed that the air mattress was left unplugged and nonfunctional after incontinence care, and staff failed to check its operation before leaving the resident's bedside. The resident reported discomfort and inability to feel the mattress functioning. Additionally, the resident experienced significant delays in receiving incontinence care, sometimes waiting up to four hours, and was not repositioned after care was provided. Staff interviews indicated a misunderstanding of the resident's need for regular turning and repositioning, as some believed it was only necessary for bed-bound residents, despite documentation and assessments showing the resident was dependent on staff for bed mobility. Further review showed that the care plan intervention for turning and repositioning every two hours was not added to the resident care card, and no physician's order was obtained for this intervention. As a result, staff did not routinely turn and reposition the resident, contributing to the development and worsening of stage II pressure ulcers on the resident's buttocks. Facility policy required turning and repositioning for residents at risk of pressure injuries, but this was not followed in the resident's care.
Failure to Prevent Elopement Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for two residents identified as being at risk. One resident, admitted with diagnoses including alcohol and opiate use disorder, cognitive impairment, major depressive disorder, and diabetes, was assessed as an elopement risk and had a physician's order for a wander guard. Despite these interventions, the resident was able to leave the facility premises after returning from a medical appointment. The nursing assistant escorting the resident was not informed of the elopement risk and left the resident unattended outside the facility to seek help, during which time the resident crossed a busy intersection and continued to a liquor store. The staff member reported not receiving any education or information about the resident's risk prior to the appointment, and the facility did not provide elopement drills or education to other staff following the incident. Another resident, with diagnoses including dementia, hypertension, and depression, was also identified as an elopement risk. This resident, who was severely cognitively impaired and had a history of confusion and wandering, exited the unit through a stairwell door and left the building unaccompanied. The resident re-entered the facility through the front door and was returned to the unit by a security guard. Staff were unaware that the resident was missing until the security guard brought the resident back, and there was no clear record of how long the resident was off the unit. The care plan and care card for this resident did not initially identify the elopement risk, and the resident's photo was not included in the elopement book as required by facility policy. Interviews with staff revealed a lack of communication and education regarding residents' elopement risks. Staff responsible for escorting residents to appointments were not always informed of the risks, and there was confusion about the procedures for reporting and investigating elopement incidents. The facility's policies required reporting and investigation of such incidents, as well as the maintenance of elopement books with photos of at-risk residents, but these procedures were not consistently followed.
Failure to Maintain Sanitary Storage of Personal Care Items
Penalty
Summary
Surveyors observed that personal care items were not stored in a clean and sanitary manner for multiple residents. For one resident with diabetes, anxiety, and chronic kidney disease, water pitchers were repeatedly found on the floor next to the bed, and a urinal containing urine was placed on the overbed table near meal trays. The resident reported having no other place to keep the water pitchers except on the floor. There was no documentation in the clinical record of care refusal or infection prevention education provided to the resident regarding the placement of water pitchers or urinal storage. Additionally, in a shared bathroom used by two residents, personal care items were found unlabeled on top of the toilet tank, and undergarments were observed in an unlabeled basin on the floor beneath the toilet tank. These items remained unlabeled and improperly stored during multiple observations. An LPN confirmed that personal care items in shared bathrooms should be labeled and kept at the resident's bedside, not in the bathroom. The facility did not provide a policy on the storage of personal care items when requested.
Failure to Complete and Document Required Staff Training
Penalty
Summary
The facility failed to ensure that required employee training and in-service education were completed and properly documented for two nursing staff members. Review of employee files for an LPN and an RN revealed that there was no documentation of completed in-service training on Dementia, Communication, and Behavioral Health from the previous year to the present. Despite requests, the facility was unable to provide evidence that these mandatory trainings had been completed for either staff member. The staff development nurse and the Director of Nursing both confirmed that the documentation was missing and attributed the lapse to the previous staff development nurse's failure to maintain adequate records. Further review indicated that the facility did not have a staff member trained to conduct Dementia training on-site, as the only qualified individual worked in another building. Facility policy requires that all staff complete the necessary in-service trainings upon hire and annually, but the required documentation was not found in the employee files. The policy also states that the training program should be maintained effectively for all employees, but the lack of current training records for the LPN and RN demonstrated noncompliance with this requirement.
Failure to Document Required Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that required Communication in-service training was completed and documented for all direct care staff members reviewed. Specifically, the employee files for five staff members, including licensed nurses and nursing assistants, did not contain evidence that the mandated Communication training had been provided from the time of hire through the present. Despite requests, facility staff were unable to produce documentation confirming completion of this training for any of the five employees. The absence of this documentation was noted for both newly hired and long-term staff, with gaps identified for multiple years in some cases. Interviews with the current Staff Development RN and the Director of Nursing revealed that the lack of documentation was attributed to the previous staff development nurse's failure to maintain adequate records. Both confirmed that, according to facility policy, Communication in-service training is required upon hire and annually for all staff. However, the necessary records were not available for review, and the current staff were unable to verify that the training had been completed as required.
Failure to Document and Complete Required Resident's Rights Training for Staff
Penalty
Summary
The facility failed to ensure that required Resident's Rights training and in-service education was completed and documented for three nursing assistants. Review of employee files for these staff members showed that, despite their active employment during the review period, there was no documentation of Resident's Rights training upon hire or as part of annual in-service requirements. The facility was unable to provide evidence that these trainings had been completed, even after requests for documentation. Interviews with the current Staff Development RN and the Director of Nursing revealed that the prior Staff Development nurse did not maintain adequate records of completed trainings. Both acknowledged that it was facility policy for staff to complete Resident's Rights training upon hire and annually, but the necessary documentation was missing from the employee files. Review of facility policy confirmed the requirement for an effective training program, including annual in-service training for all employees.
Failure to Provide and Document Required In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that required in-service training and education were completed and documented for three nurse aides. Specifically, for two recently hired nurse aides, there was no documentation in their employee files to show that they had received mandatory training in areas such as Resident Rights, Dementia, Communication, and Behavioral Health from the date of hire to the present. For a third nurse aide, who had been employed since 2021, there was no documentation of annual in-service training in Resident Rights, Dementia, Infection Control, Communication, and Behavioral Health for the most recent years reviewed. Despite requests, the facility was unable to provide evidence that these trainings had been completed for any of the three nurse aides. Interviews with the Staff Development RN and the Director of Nursing revealed that the lack of documentation was due to poor record-keeping by the previous Staff Development nurse. Additionally, the facility did not have a staff member trained to conduct Dementia training on-site, as the only qualified individual worked in another building. Facility policy requires that staff complete the necessary in-service trainings upon hire and annually, but the required documentation was not available for the nurse aides in question.
Failure to Prevent Staff-to-Resident Abuse and Verbal Mistreatment
Penalty
Summary
The facility failed to protect three residents from verbal and physical abuse by a nurse aide. One resident, who had diagnoses including Parkinson's, depression, diabetes, and dementia, required moderate assistance with daily living and was unable to make decisions regarding daily tasks. This resident reported that the nurse aide was rough during care, yelled frequently, and on one occasion, picked the resident up from behind and threw them into bed, causing fear. The resident also described the aide grabbing their arm tightly and yelling at them to get into bed. Another resident, with chronic obstructive pulmonary disease, muscle weakness, and depression, was dependent on staff for daily living activities and had no memory deficits. This resident reported that the same nurse aide often yelled, complained about her job, made rude comments about the resident's weight, and criticized them in front of others. The resident avoided calling for help when this aide was working and described an incident where the aide was dismissive and critical after an episode of incontinence, as well as witnessing the aide push and tightly grab another resident's arm. A third resident, diagnosed with diabetes, chronic kidney disease, and dementia but independent in daily living, reported being yelled at by the nurse aide regarding hearing and the need for hearing aids. Another staff member corroborated these accounts, stating they witnessed the aide yelling at a resident, pushing their head back, and making body-shaming comments to residents. Facility documentation and interviews confirmed that the aide's actions violated facility policies on abuse, neglect, and resident rights.
Failure to Timely Report and Respond to Alleged Abuse
Penalty
Summary
The facility failed to report allegations of staff-to-resident verbal and physical abuse to the Administrator and/or designee within the required two-hour timeframe, as outlined in facility policy. On 11/24/24, three separate incidents involving a nurse aide and three residents occurred during the 3-11PM shift. A nurse, who wished to remain anonymous, reported concerns about the nurse aide's conduct to the DON the following day, rather than immediately. The DON confirmed that another nurse aide had initially reported concerns to the nurse on the day of the incidents, but the nurse did not escalate the matter or remove the alleged perpetrator from duty, allowing the aide to continue working that shift. Interviews revealed that staff and residents were hesitant to provide information due to fear of retaliation from the accused nurse aide. Review of the facility's Abuse, Neglect, and Exploitation policy indicated that any suspicion of abuse or neglect requires immediate investigation and reporting to the administrator, state agency, adult protective services, and law enforcement within two hours. The facility did not adhere to this policy, as the allegations were not reported in the required timeframe and the alleged victims were not immediately protected.
Failure to Notify Physician of Resident's Self-Harm Verbalization
Penalty
Summary
The facility failed to ensure timely notification of a physician or APRN after a resident expressed self-harm intentions. The resident, diagnosed with dementia and major depressive disorder, had a history of suicidal ideation. On the date in question, the resident expressed feelings of depression and asked an LPN if she had anything to kill themselves with. The LPN reassured the resident and offered a social services visit, which was declined. The LPN notified the ADNS, who was the acting RN Supervisor, but there was no documentation that the physician was informed of the resident's self-harm verbalization. Interviews revealed that the LPN was unaware if the resident was placed on one-to-one supervision or if the physician was notified. The DON later communicated with the ADNS, who confirmed she was not informed of the incident. The facility's policy requires licensed nurses to notify an attending physician and responsible party of a change in condition within 24 hours, which includes changes in mental status or behavior. However, there was no evidence that the resident was evaluated by a physician or that the 24-hour report sheet was reviewed by the DON.
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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