Meriden Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 360 Broad Street, Ste 1, Meriden, Connecticut 06450
- CMS Provider Number
- 075295
- Inspections on file
- 32
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Meriden Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering and aggressive behavior was able to enter another resident's room and push them off the bed, and later pushed a roommate off the bed, resulting in both residents being found on the floor and one sustaining a subdural hematoma. Facility staff did not provide adequate supervision or protection, despite documented behavioral risks and care plan interventions.
A resident with a history of falls and multiple comorbidities was admitted and identified as a moderate fall risk, requiring extensive assistance and supervision. Despite this, no baseline care plan addressing fall risk was developed within 48 hours of admission, and the care plan was only created after the resident sustained an unwitnessed fall that led to pain and an emergency department evaluation.
A resident with dementia, hemiplegia, and high fall risk did not have floor mats placed on both sides of the bed as required by the care plan. Documentation and staff interviews confirmed the mats were not in place during a fall, despite care plan directives and facility policy requiring such interventions.
A resident with a history of falls and mobility issues was found on the floor after an unwitnessed fall and was left alone in their room while waiting for EMS to arrive. The facility lacked a policy specifying that staff should remain with the resident during this time, despite expectations from the DON that supervision should be provided.
A resident with a history of constipation and multiple sclerosis underwent a STAT abdominal x-ray that revealed critical findings, but nursing staff failed to promptly notify the physician or APRN of the results. Although the x-ray report was available in the EMR and faxed to the facility, staff did not access or act on the results for several hours, and the physician was not informed until the following morning, contrary to facility policy.
A resident with a history of multiple sclerosis and constipation underwent a follow-up KUB x-ray that revealed a critical finding suspicious for partial sigmoid volvulus. Despite the results being available in the EMR and faxed to the facility, staff did not access or review the results for over 12 hours, repeatedly documenting that results were pending. The lack of timely review and notification to the provider resulted in a delayed hospital transfer for the resident.
A resident was readmitted after a hospital stay and received Levemir insulin and oral anti-diabetic medications that were not ordered by the provider, due to inaccurate transcription and lack of verification of medication orders in the EMR. Nursing staff administered insulin without required blood glucose checks, and the resident's blood sugars were not monitored, resulting in severe hypoglycemia and a change in condition that was not promptly recognized or treated.
Annual performance appraisals were not completed for several nurse aides, with some not receiving an appraisal in over a year and one lacking any appraisal record. The HR Director had not initiated or completed appraisals and was unfamiliar with the process, and the facility could not provide a relevant policy.
A resident with multiple pressure ulcers, bowel incontinence, and high risk for further skin breakdown was admitted and assessed as dependent for ADLs and not oriented. The care plan created for this resident addressed only wounds and enhanced barrier precautions, omitting interventions for incontinence, pressure ulcer risk, and the active sacral wound, contrary to facility policy and assessment findings.
The facility failed to follow provider orders for two residents: one received Levemir insulin without required blood glucose checks, resulting in severe hypoglycemia and emergency transfer, while another did not receive a documented weekly skin assessment as ordered for pressure ulcer prevention. Nursing staff confirmed the lapses, and required documentation and protocols were not followed.
Following a resident-to-resident altercation involving two residents with dementia and anxiety disorders, the facility did not provide or document timely social services support or follow-up as required by policy. Despite care plans calling for investigation, psychiatric follow-up, and observation for mental distress, there was no evidence in the clinical record that social services met with or followed up with the residents involved in the days after the incident.
A resident with Alzheimer's, heart failure, and respiratory failure became unresponsive, and staff failed to perform a complete assessment or initiate emergency interventions such as CPR, use of the AED, or immediate oxygen administration, despite the resident's full code status. EMS found the resident with low oxygen saturation and initiated resuscitation upon arrival.
A resident with dementia and a history of wandering exited the memory care unit by observing and memorizing the door code, then unlocking the doors and leaving the building. Staff observed the resident at the lock pad but did not immediately redirect, allowing the resident to exit before intervention. The resident had refused a wander guard bracelet, and the facility's elopement prevention measures were not effectively implemented in this case.
The facility failed to complete Advance Directive forms for three residents upon admission, leading to discrepancies in their documented code statuses. One resident was initially documented as a full code but later expressed a wish to be DNR. Another resident was documented as a full code without a signed form, and a third resident also lacked a signed form despite being documented as a full code. Staff interviews revealed a failure to ensure the completion and proper documentation of Advance Directives.
A resident with cognitive and mood disorders was not provided with activities of interest, specifically music, as indicated in their MDS assessment. The Resident Care Plan and Care Card did not reflect the resident's interest in music, and the behavior monitoring form lacked documentation of music being offered. Observations showed minimal engagement in activities, and the Recreation Director, aware of the resident's interest, did not provide music during a brief visit.
The facility failed to securely store resident-identifiable information and medical records, with boxes containing sensitive data found in unlocked rooms and under fire suppression devices. The Administrator was aware of the storage issue, which arose after records were moved from sold outbuildings, but the method did not comply with the facility's policy to protect records from hazards.
The facility failed to maintain sanitary conditions in the laundry area, with clean hangers stored improperly with dirty laundry and laundered rags stored near damaged walls exposing insulation and debris. The Administrator acknowledged the need for improvement, and facility policy requires clean laundry to be covered for transport.
The facility failed to develop and implement comprehensive care plans for two residents. One resident, with cognitive impairments, had a care plan that did not include their interest in music, despite it being identified as important. Another resident with CHF was not monitored for symptoms as required by their care plan, and staff interviews revealed a lack of documentation and adherence to facility policy. These deficiencies highlight a lack of individualized care planning and monitoring for residents' specific needs.
The facility failed to conduct comprehensive assessments for two residents. A resident with Parkinson's disease did not receive a full neurological assessment after an unwitnessed fall with a head injury, as required by facility policy. In another case, a resident under hospice care was pronounced deceased by an RN who only noted the absence of a pulse, omitting other vital signs and assessments. Both incidents reflect a failure to adhere to the facility's policies for thorough assessments.
A resident was observed wearing a stained hospital gown and jeans due to the facility's failure to return personal laundry in a timely manner. The resident, who was cognitively intact and required partial assistance for dressing, expressed a preference for wearing their own street clothes. Interviews revealed that laundry was not collected as scheduled due to staff absence, resulting in the resident's laundry not being washed for an extended period.
The facility failed to provide the Notice of Medicare Non-coverage (NOMNC) form to two residents before their planned discharges, as required by policy. One resident with rhabdomyolysis, HIV, and hypertension, and another with spinal stenosis, hypertension, and hypothyroidism, were discharged without receiving the necessary NOMNC forms. The Administrator confirmed the oversight and noted the MDS Coordinator's responsibility in this process, but could not explain the failure to comply with the policy.
During an evening shift, three dependent residents with dementia and other serious conditions were not fed dinner or provided incontinent care by the assigned nurse aide, who was observed spending time at the nurses' station and leaving the facility without authorization. The residents' care needs, including feeding and hygiene, were not met until other staff were reassigned later in the shift, resulting in a delay of essential care.
Allegations that a nurse aide failed to provide care and meals to three dependent residents were not reported immediately to the Administrator or State Agency as required. The delay occurred despite facility policy mandating prompt reporting of suspected neglect, and involved multiple staff who did not escalate the issue in a timely manner.
An agency nurse aide began working without receiving the required orientation or education on facility policies, including the abuse and neglect policy, as mandated by facility procedures. Documentation and interviews confirmed that the orientation process was not completed prior to the aide's first shift, despite established policies assigning this responsibility to the Nursing Supervisor.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and protection for residents with severe cognitive impairment and known behavioral issues, resulting in multiple incidents of resident-to-resident physical altercations. One resident with diagnoses including dementia, schizoaffective disorder, and a brain lesion, and who was on hospice services, exhibited wandering and aggressive behaviors. Despite these known risks, this resident was able to enter another resident's room and push that resident off the bed, as well as later push a roommate off the bed, causing both residents to fall to the floor. Clinical records and facility documentation revealed that the resident responsible for the altercations had a history of severe cognitive impairment, required supervision for transfers and ambulation, and had documented wandering and behavioral issues. The care plan directed staff to be present on the unit during the evening shift to redirect wandering behaviors, but the resident was still able to access other residents' rooms and physically interact with them. In one incident, the resident pushed a roommate off the bed, resulting in both residents being found on the floor and requiring hospital evaluation. The resident who initiated the altercation was found to have a subacute right subdural hematoma with subfalcine herniation following the incident. Interviews with facility leadership confirmed that the resident with behavioral issues had no roommate until after the first incident, and that the roommate was assigned despite available beds on other units. The facility was unable to explain how the roommate was protected from harm, given the known history of aggressive behavior. Facility policy prohibits abuse by anyone, including other residents, but the actions taken were insufficient to prevent further incidents of mistreatment.
Failure to Develop Timely Baseline Care Plan for Fall Risk
Penalty
Summary
A deficiency occurred when the facility failed to develop a baseline admission care plan addressing a new resident's risk for falls within the first 48 hours of admission. The resident, who had a history of falls and multiple diagnoses including metabolic encephalopathy, osteoarthritis, osteomyelitis, low back pain, muscle weakness, and difficulty walking, was assessed as a moderate fall risk upon admission. The clinical record and facility documentation did not show that a baseline care plan was created to address this risk, despite the resident's need for extensive assistance with bed mobility and toileting, supervision for transfers, and use of assistive devices. The lack of a timely care plan persisted until after the resident experienced an unwitnessed fall, which resulted in complaints of pain and required evaluation in the emergency department. Interviews and record reviews confirmed that the expectation was for a baseline care plan to be in place for residents identified as at risk for falls, but this was not completed until after the incident occurred.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of falls, specifically neglecting to ensure that floor mats were placed on both sides of the bed as directed in the care plan. The resident, who had diagnoses including dementia, hemiplegia and hemiparesis following a stroke, muscle weakness, and difficulty walking, was identified as high risk for falls. The care plan included several interventions such as keeping the bed in a low position, using body pillows, and placing floor mats on each side of the bed. Despite these directives, documentation and staff interviews revealed that the floor mats were not in place at the time of a fall incident. On one occasion, the resident was found on the floor mat after a fall, but on a subsequent occasion, the resident was found on the floor without documentation that the mats were in place. The nurse's notes and incident reports failed to confirm the presence of the mats during the second fall, and staff interviews confirmed that the mats were not in place at that time. The DON acknowledged that it was staff responsibility to implement all care plan interventions and was not aware that the mats were missing during the incident investigation. Facility policies required comprehensive, person-centered care plans with measurable objectives and timely implementation, but these were not followed in this case.
Resident Left Unattended After Unwitnessed Fall
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, osteoarthritis, osteomyelitis, low back pain, muscle weakness, a history of falls, and difficulty walking, experienced an unwitnessed fall. The resident was found on the floor after sliding forward out of a wheelchair while attempting to reach the bathroom. The clinical record indicated the resident was at moderate risk for falls, required extensive assistance with bed mobility and toileting, and was unable to independently stand. Following the fall, the resident complained of bilateral hip and right shoulder pain, and the on-call Advanced Practice Registered Nurse directed that the resident be sent to the Emergency Department for evaluation. Facility documentation and the EMS report revealed that the resident was left alone on the floor in their room while awaiting EMS arrival. The facility did not have a policy in place at the time addressing whether staff should remain with a resident after a fall while waiting for EMS, although the Director of Nursing stated it was the expectation that staff would stay with the resident. The facility's unwitnessed falls policy directed that residents not be moved if a fracture or serious condition was suspected, but did not specify supervision requirements during the wait for EMS.
Failure to Timely Notify Physician of Critical X-ray Results
Penalty
Summary
The facility failed to ensure timely notification of a physician or APRN regarding critical x-ray results for a resident with multiple sclerosis, obstructive and reflux uropathy, and a history of constipation. The resident was identified as cognitively intact and at risk for constipation, with interventions in place to monitor and manage bowel function. On the day in question, the resident underwent a STAT abdominal x-ray due to loose stools, which revealed a severe colonic ileus and a suspicious finding for partial sigmoid volvulus. The radiology report, marked as critical, was available in the facility's EMR and faxed to the facility in the evening. Despite the critical nature of the findings, nursing documentation indicated that staff were unaware of the x-ray results for several hours after they became available. Nursing notes from the evening and overnight shifts repeatedly stated that results were pending, even though the report had been faxed and uploaded to the EMR. The radiology team attempted to notify the facility by phone and fax, eventually reaching a nurse supervisor in the early morning hours, but the physician was not notified until after the night shift ended. Interviews with nursing staff revealed that the process for checking and reviewing faxed results was inconsistent, with one RN supervisor stating she may have missed the report due to the high volume of paperwork. Another RN supervisor indicated she did not notify the physician because she had not received the printed report, despite being verbally informed of the results. The facility's policy required prompt notification of the physician for significant changes in a resident's condition, but this was not followed in this instance.
Delayed Access to Critical X-ray Results for Resident with Bowel Complications
Penalty
Summary
Facility staff failed to access and act upon critical x-ray results in a timely manner for a resident with a history of multiple sclerosis, obstructive and reflux uropathy, and constipation. The resident was identified as cognitively intact and at risk for constipation, with care plan interventions to monitor for signs of constipation and administer medications as ordered. On one occasion, the resident received a bowel regimen and was ordered a KUB x-ray to rule out constipation and small bowel obstruction. The initial x-ray showed severe colonic ileus with moderate stool, but no obstruction. A follow-up KUB was ordered and performed, with results indicating a coffee bean shaped gas shadow suspicious for partial sigmoid volvulus, a critical finding. The results were available in the facility's EMR and faxed to the facility, but staff did not access or review the results for over 12 hours. Nursing notes repeatedly indicated that the results were still pending, despite the results being available in both the EMR and via fax. The resident was ultimately transferred to the hospital after the results were finally reviewed. Interviews with staff revealed that there was no consistent process for checking the fax machine or EMR for new results, and that the facility's systems did not provide alerts or confirmations for new critical findings. Staff reported high volumes of paperwork and lack of clear protocols for timely review of incoming results. The delay in accessing and acting upon the critical x-ray findings led to a significant delay in notifying the provider and transferring the resident for further care.
Failure to Prevent Significant Medication Error During Readmission
Penalty
Summary
A significant medication error occurred when a resident was readmitted to the facility following a hospital stay. During the readmission process, the responsible RN discontinued all previous medication orders in the electronic medical record (EMR) and then renewed all discontinued orders, including some that were not present on the hospital discharge documents and had been discontinued nearly a year prior. This included Levemir insulin, which was not ordered by the readmitting provider and was not listed as an active order on the hospital discharge summary. Additionally, oral anti-diabetic medications that were supposed to be stopped per the hospital discharge documents were also renewed and administered. Multiple nursing staff administered Levemir insulin to the resident over several days without obtaining required blood glucose checks prior to administration, as specified in the provider's order. The provider's order also directed that insulin should be held if blood sugar was less than 80, but this was not followed. The resident's blood sugars were not monitored from the time of readmission until the resident experienced a significant change in condition. When the resident became unresponsive and exhibited abnormal movements, staff failed to immediately check blood glucose, delaying identification of severe hypoglycemia. Interviews and documentation revealed that the medication transcription and verification process was not followed according to facility policy. The nurse practitioner did not review the active medication list in the EMR during post-readmission visits, and the third shift nurse did not verify the orders for accuracy. The facility's orientation materials for agency staff did not include clear procedures for medication reconciliation or order transcription during admission or readmission. As a result, the resident received medications that were not ordered, and critical monitoring steps were missed, leading to a hypoglycemic event requiring emergency intervention.
Removal Plan
- Ensure Resident #3 receives all medications according to provider order
- Educate all nursing staff on medication reconciliation and diabetes management
- Audit all residents prescribed insulin
- Audit all readmission orders
Failure to Complete Annual Performance Appraisals for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance appraisals for all nurse aides as required. Review of personnel files for five nurse aides revealed that four had not received a performance appraisal in over 16 months, and one had no record of any performance appraisal since their date of hire. The personnel files showed that the last documented appraisals for several nurse aides were dated more than a year ago, and one nurse aide's file lacked any appraisal documentation entirely. Interviews with the Director of Human Resources (HR), the Administrator, and the Director of Nursing Services (DNS) confirmed that annual performance appraisals were not conducted as expected. The HR Director, who had been in the role for five months, had not initiated or completed any appraisals during that time and was unfamiliar with the process. Additionally, the facility was unable to provide a policy regarding performance appraisals when requested.
Failure to Develop Comprehensive Care Plan for Resident with Pressure Ulcers and Incontinence
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with significant medical needs, including bowel incontinence and pressure ulcers. The resident was admitted with diagnoses such as pyelitis cystica and a sacral pressure ulcer, and was assessed as not oriented to person, place, time, or situation, and dependent on two or more staff for activities of daily living. Clinical assessments identified the resident as being at high risk for developing pressure ulcers, with existing unstageable pressure ulcers on both buttocks and an active gluteal cleft wound with 100% slough. The Minimum Data Set (MDS) also documented the resident's risk and presence of a stage three pressure ulcer. Despite these findings, the resident's care plan only addressed wounds and enhanced barrier precautions, such as signage and use of gloves and gowns, but did not include interventions for incontinence, pressure ulcer risk, or the active sacral wound. Facility policy requires that care plans incorporate all identified problem areas and risk factors, assign responsibility for care elements, and reflect current standards of practice. An interview with the Director of Nursing Services confirmed that the care plan should have addressed the resident's pressure injury risk, current wound, and incontinence, but these were omitted.
Failure to Follow Provider Orders for Insulin Administration and Weekly Skin Assessments
Penalty
Summary
The facility failed to follow provider orders and established protocols for two residents, resulting in deficiencies related to medication administration and skin assessments. For one resident with type 2 diabetes mellitus, Parkinson's disease, anxiety disorder, and depression, a physician's order specified that Levemir insulin should be held if blood sugar was less than 80. However, the medication was administered on multiple occasions without obtaining or documenting blood sugar levels as required. This resident subsequently experienced a significant change in condition, including unresponsiveness and involuntary movements, and was found by EMS to have a critically low blood sugar of 29. The resident was treated with dextrose and transported to the emergency department, where their condition improved. Interviews with nursing staff confirmed that insulin was administered without checking blood sugar, and documentation of blood glucose results was missing for the relevant period. Facility policy required verification of insulin orders and documentation of blood glucose results prior to administration, but these steps were not followed. The Director of Nursing Services acknowledged that blood sugar checks should have been performed and documented before administering insulin. For another resident admitted with osteomyelitis of the vertebra and a sacral wound, a physician's order directed weekly body audits (skin checks) on a specific day and shift. The resident was identified as high risk for pressure ulcers and had multiple pressure injuries. However, the medical record did not show that a weekly skin check was completed and documented for one week as ordered. The Director of Nursing Services confirmed that weekly skin assessments should be performed as ordered, but the facility did not have a preventative skin assessment policy, and no documentation was provided for the missed assessment.
Failure to Provide Timely Social Services Support After Resident Altercation
Penalty
Summary
The facility failed to provide timely social services support to residents involved in a resident-to-resident altercation. One resident with Alzheimer's disease, dementia with behavioral disturbances, anxiety disorder, and depression, who had severely impaired cognition, was involved in an incident where they struck another resident. The care plan for this resident included interventions such as investigation, reporting, psychiatric follow-up, and observation for mental distress, but review of social services notes revealed no documentation of social services involvement from the date of the incident through several days after. Another resident involved in the same altercation, who also had Alzheimer's disease, dementia, and anxiety disorder with moderately impaired cognition, was assessed after the incident and found to have no injuries. The care plan for this resident similarly called for investigation, reporting, psychiatric follow-up, and observation for mental distress. However, there was no documentation in the social services notes indicating that social services support was provided or that follow-up occurred in the days following the incident. Interviews with facility leadership and the social worker confirmed that the facility's policy requires the social worker to meet with all residents involved in abuse incidents as soon as possible and to follow up daily for 72 hours, documenting all encounters. The social worker acknowledged that documentation was lacking and could not confirm whether support was provided to one of the residents. The facility's policy also directs that social services provide written reports of findings to the Administrator and DON, but there was no evidence this was done.
Failure to Perform Complete Assessment and Emergency Response for Unresponsive Resident
Penalty
Summary
A deficiency occurred when facility staff failed to conduct a complete and accurate assessment of a resident who became unresponsive. The resident, who had diagnoses including Alzheimer's, heart failure, and respiratory failure, was care planned for alterations in respiratory status and congestive heart failure, with interventions to document changes in condition. On the night of the incident, the resident was found pale and not responding normally. The nursing supervisor assessed the resident, who became unresponsive for a few seconds. Despite the resident's full code status, the supervisor did not access the crash cart, use the AED, or initiate CPR. Oxygen was not immediately administered, and vital signs were not obtained before emergency services arrived. Emergency medical services found the resident with an oxygen saturation of 62% and provided oxygen via a non-rebreather mask. Upon further assessment, the resident was unresponsive with no palpable pulses or heart sounds, and CPR was initiated by EMS before transfer to the hospital. Facility policy required staff to assess and document vital signs, neurological status, and level of consciousness during acute changes in condition, but these steps were not fully carried out during the event. Interviews confirmed that the required emergency interventions and assessments were not performed prior to EMS arrival.
Resident Elopement Due to Failure in Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with dementia, phobic anxiety, and mood disorder, who was identified as a wanderer and elopement risk, was able to exit the memory care unit through a locked door. The resident's care plan included interventions such as identifying wandering patterns, redirection, and providing structured activities. Despite these interventions, the resident was observed by staff at the lock pad, where the resident entered the door code, unlocked the doors, and exited the building. Staff interviews revealed that although the resident was seen at the lock pad, immediate redirection did not occur, and the resident was able to leave the facility before staff could intervene. Facility documentation indicated that the resident had memorized the door code, which is changed monthly or more often as needed, and the new code is verbally communicated to staff. The resident refused the placement of a wander guard bracelet and became agitated, leading to a hospital transfer for evaluation. The facility's elopement prevention policy required assessment and interventions for residents at risk of wandering or elopement, but in this instance, the resident was able to circumvent the locked door system and exit unsupervised.
Failure to Complete Advance Directive Forms for Residents
Penalty
Summary
The facility failed to complete Advance Directive forms for three residents upon admission, leading to discrepancies in their documented code statuses. Resident #1, diagnosed with chronic obstructive pulmonary disease, Erb's Paralysis, and hypertension, was initially documented as a full code in the Resident Care Plan and nurse practitioner notes. However, upon further communication, it was revealed that the resident's actual wish was to be a Do Not Resuscitate (DNR). The absence of a signed Advance Directive form led to a misrepresentation of the resident's wishes in the Electronic Medical Record (EMR). Similarly, Resident #41, with diagnoses including heart failure and neurogenic bladder, was documented as a full code without a signed Advance Directive form. The Medical Records Coordinator noted the resident was conserved, and the social worker needed to contact the conservator to obtain the form. Resident #46, suffering from a neurocognitive disorder and other conditions, also lacked a signed Advance Directive form, despite being documented as a full code. Interviews with staff revealed a failure to ensure the completion and proper documentation of Advance Directives, resulting in potential misalignment with the residents' actual wishes.
Failure to Provide Activities of Interest for Resident
Penalty
Summary
The facility failed to provide activities of interest for a resident diagnosed with mild cognitive impairment, anxiety disorder, and adjustment disorder with depressed mood. The resident's annual Minimum Data Set (MDS) assessment indicated an interest in listening to music, but this was not reflected in the Resident Care Plan (RCP) or the Resident Care Card. The RCP only noted a mood problem and included interventions such as reviewing the activity calendar and encouraging the resident to identify activities of choice. However, it did not specify the resident's interest in music or any other activities. Additionally, a physician's order required documentation of music or activity interventions on the behavior monitoring form, but the form did not indicate that music was offered. Observations and interviews revealed that the resident received minimal engagement in activities. The Recreation Participation Record showed limited participation in activities such as TV/movie/music and social events. During an observation, the resident was found lying in bed without any active stimulation, and a brief 1 to 1 visit by the Recreation Director did not include offering music, despite the director's awareness of the resident's interest. The Recreation Director, who had recently started working at the facility, acknowledged the oversight and noted that a radio should have been provided.
Insecure Storage of Resident Records
Penalty
Summary
The facility failed to ensure the secure storage of resident-identifiable information and medical records, as observed during a survey. In an unoccupied wing of the facility, several rooms were found to contain bankers boxes with resident medical records, including personally identifiable information such as names, dates of birth, medical record numbers, and diagnoses. These boxes were stored in unlocked rooms, with some located directly below fire suppression devices, which is against the facility's Records Retention Policy. Additionally, a dead mouse was found near the boxes in one of the rooms, indicating a potential pest hazard. The facility's Administrator acknowledged awareness of the storage situation, explaining that the records were moved from outbuildings, known as The Cottages, to the unoccupied rooms after the sale of The Cottages. Despite this awareness, the storage method did not comply with the facility's policy, which mandates that records be kept in a locked area free from hazards such as fire, flooding, and pests. The presence of controlled substance disposition records and other sensitive information in unsecured locations further highlights the deficiency in maintaining the security and integrity of resident records.
Inadequate Sanitary Conditions in Laundry Area
Penalty
Summary
The facility failed to maintain sanitary conditions in the laundry area, as observed during a tour with various staff members. In the soiled laundry area, a dirty laundry bin was found containing a bag of dirty, personal resident laundry. Clean hangers were improperly stored, hanging from the edge of the dirty bin and placed under and next to the bag of dirty laundry. Additional clean hangers were stored on top of a dirty item receptacle. A laundry aide confirmed that these hangers were considered clean and ready for use, while an RN acknowledged that clean items should not be stored with dirty items. In the clean laundry area, a bin filled with laundered rags designated for kitchen use was stored inappropriately. The bin was placed touching a wall with several broken and open areas of sheetrock, including a large crack and a fist-sized hole. There were also larger areas of missing sheetrock exposing insulation, dust, debris, and dirt. A window along this wall was covered with plastic secured by duct tape, which also served as a dryer vent. The Administrator noted that the area could use improvement. According to the facility's policy, all clean laundry must be covered for transport back to the facility, and resident clothing should be folded or pressed and hung in the clean laundry area for transfer to residents' rooms.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive individualized care plan for Resident #7, who was admitted with mild cognitive impairment, anxiety disorder, and adjustment disorder with depressed mood. The resident's Minimum Data Set (MDS) assessment identified listening to music as an activity of importance, yet the Resident Care Plan (RCP) did not include a person-centered, comprehensive problem with interventions related to the resident's preferred activities. Interviews with the Recreation Director and the MDS Coordinator revealed that no activity assessments had been completed to identify the resident's leisure interests, and the care plan was not comprehensive or individualized as it did not include music as an interest. For Resident #24, who had diagnoses including congestive heart failure (CHF), the facility failed to implement the Resident Care Plan to monitor the resident for CHF. The care plan included interventions to check breath sounds and monitor for signs or symptoms of CHF, but the physician's orders did not include monitoring for these symptoms. Observations identified edema in the resident's right hand, and interviews with facility staff revealed a lack of monitoring or assessments for CHF. The facility policy required monitoring of residents with CHF, but there was no documentation of such monitoring for Resident #24.
Failure to Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to complete a neurological assessment for a resident who experienced an unwitnessed fall with a head injury. Resident #20, diagnosed with Parkinson's disease, diabetes mellitus, and hypertension, was identified as being at risk for falls. Despite the facility's policy requiring neurological checks following such incidents, the records showed that only vital signs were taken, and the necessary neurological assessments, including pupillary reaction, hand grasps, and level of consciousness, were not documented. Interviews with the Director of Nurses and an LPN confirmed the oversight, but no explanation was provided for the incomplete assessments. In a separate incident, the facility did not perform a comprehensive assessment at the time of pronouncement of death for Resident #54, who had chronic obstructive pulmonary disease, hyperlipidemia, and dementia. The resident was under hospice care with a DNR/RNP order. When RN #3 pronounced the resident deceased, the assessment was limited to noting the absence of a pulse, without including other vital signs or assessments such as lung sounds and pupillary reaction, as required by the facility's policy. The RN admitted to being unaware of the complete assessment requirements, and the Administrator could not explain the omission. Both incidents highlight a failure to adhere to the facility's policies for conducting thorough assessments in critical situations. The lack of complete neurological checks for Resident #20 and the incomplete death pronouncement assessment for Resident #54 indicate a gap in following professional standards of practice, as outlined in the facility's policies.
Failure to Return Personal Laundry Timely
Penalty
Summary
The facility failed to ensure the timely return of personal laundry for a resident, leading to a deficiency in maintaining the resident's dignity. The resident, who was cognitively intact and required partial assistance for dressing, was observed wearing a hospital gown with stains and jeans, as their personal clothing had not been returned from the laundry. The resident expressed a preference for wearing their own street clothes and reported that staff had not prioritized retrieving their clothing. Interviews revealed that the laundry for the resident's floor was scheduled weekly, and due to staff absence, the resident's laundry was not collected on the designated day. Consequently, the resident's laundry had not been washed since December 30, 2024, and was not scheduled to be done until January 13, 2025. This delay in laundry service resulted in the resident being unable to maintain a dignified appearance, as outlined in the facility's policy to provide an adequate supply of clean personal clothing for each resident at all times.
Failure to Provide NOMNC Forms Before Discharge
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-coverage (NOMNC) form to two residents prior to their planned discharges, as required by facility policy. Resident #306, who was diagnosed with rhabdomyolysis, human immunodeficiency virus disease, and hypertension, was discharged home on 8/16/24. Although a nurse's note indicated that the resident's family member was informed of all discharge instructions, the clinical record did not show that a NOMNC notice was provided. Similarly, Resident #307, with diagnoses of spinal stenosis, hypertension, and hypothyroidism, was discharged home on 11/29/24, but their clinical record also lacked evidence of a NOMNC notice. An interview with the facility's Administrator revealed that the MDS Coordinator was responsible for ensuring that all residents receive a NOMNC form before a planned discharge. However, the Administrator acknowledged that both residents should have received the form and did not, and was unable to explain why the forms were not provided according to facility policy. The facility's NOMNC policy specifies that the Resident Care Coordinator must issue the NOMNC to every resident in person at least two calendar days prior to discharge, or document the means of delivery if not done in person. The MDS Coordinator was unavailable for interview to provide further insight into the oversight.
Failure to Provide Timely Feeding and Incontinent Care to Dependent Residents
Penalty
Summary
Three residents with significant cognitive and physical impairments, including dementia, epilepsy, adult failure to thrive, and chronic obstructive pulmonary disease, were dependent on staff for activities of daily living such as eating and incontinent care. Care plans for these residents required staff assistance with eating, toileting hygiene, and repositioning, as well as prompt pericare after episodes of incontinence. On the evening shift in question, the assigned nurse aide failed to provide these essential care services, resulting in the residents not being fed dinner and not receiving necessary incontinent care during the shift. The deficiency was identified when staff reported to the Nursing Supervisor that the assigned nurse aide was not attending to residents, instead spending time at the nurse's station and leaving the facility for an extended period without authorization. Upon investigation, it was found that the aide had not provided care or meals to the assigned residents. When another aide was later assigned to one of the residents, the resident was found in bed in a fetal position with dried feces, indicating a prolonged period without care. Documentation and interviews confirmed that the residents did not experience immediate ill effects, but there was a clear delay in the provision of required care. The facility's own policy prohibits abuse and neglect, yet the actions and inactions of the assigned nurse aide on the evening shift resulted in neglect of the residents' basic needs. The incident was reported to facility management, and the residents were eventually reassigned to other staff who provided the necessary care, but only after a significant delay during which the residents' care needs were not met as required by their care plans.
Failure to Timely Report Allegations of Neglect
Penalty
Summary
The facility failed to ensure that allegations of neglect involving three residents were reported immediately to the Administrator and/or designee and to the State Agency within the required two-hour timeframe after the allegations were identified. The residents involved had significant cognitive and physical impairments, including dementia, epilepsy, incontinence, and dependence on staff for activities of daily living such as eating and toileting. The care plans for these residents required staff assistance with eating, turning, repositioning, and incontinent care after each episode. On a specific evening shift, staff alleged that a nurse aide did not provide care or feed dinner to three residents assigned to her. The 3-11PM Nursing Supervisor first received a complaint from another nurse aide at 5:00 PM and subsequently observed that the nurse aide in question was absent from the unit for a period of time. The supervisor confirmed with the charge nurse that the aide had not been performing her duties and had left the facility without authorization. The supervisor contacted the aide, who returned to the facility, but the supervisor did not immediately report the allegations to the covering DON or Administrator. The Staff Development Coordinator, who was acting as the DON, was informed of the allegations just before 9:00 PM and immediately notified the Administrator. However, the State Agency was not notified until the following day at 11:45 AM. Facility policy required immediate reporting of suspected abuse or neglect to the DON or Administrator, but this protocol was not followed, resulting in a delay in both internal and external notifications regarding the allegations of neglect.
Failure to Provide Required Orientation to Agency Nurse Aide
Penalty
Summary
A nurse aide employed by an outside agency began working at the facility without receiving the required orientation and education as outlined in the facility's policy. Review of facility documentation confirmed that the agency nurse aide was not provided with orientation or training prior to starting her first shift. During an interview, the nurse aide stated that she did not receive any information or education on facility policies, including the abuse and neglect policy, before beginning her shift. Further review and interview with the DON revealed that the facility had established policies and procedures mandating orientation and education for all agency staff before their initial shift, including review of the abuse and neglect policy. However, documentation showed that this process was not followed for the agency nurse aide, and the DON was unable to explain why the orientation and education were not provided. The responsibility for conducting the orientation was assigned to the Nursing Supervisor, but the required steps were not completed.
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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