New London Sub-acute And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterford, Connecticut.
- Location
- 90 Clark Lane, Waterford, Connecticut 06385
- CMS Provider Number
- 075158
- Inspections on file
- 22
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 18 (2 serious)
Citation history
Health deficiencies cited at New London Sub-acute And Nursing during CMS and state inspections, most recent first.
A resident with a history of falls, heart failure, anxiety, and moderately impaired cognition, but assessed as independent with transfers and wheelchair use, was allowed to use the bathroom and self-transfer. While transferring from a wheelchair to the toilet using a bathroom grab bar, the bar detached from the wall, causing the resident to fall to the floor. Initial assessment showed no visible injury, but the resident later developed chest pain, and imaging ordered by an APRN revealed multiple rib fractures. A NA reported finding the resident on the floor with the grab bar dislodged, and the Administrator stated that while monthly environmental rounds were conducted, they did not previously include checking the stability of grab bars.
Two residents were affected when the facility failed to maintain a safe and sanitary environment. A resident with a history of falls and limited mobility, who was allowed to self-transfer, used a bathroom grab bar that detached from the wall during a wheelchair-to-toilet transfer, resulting in a fall and later-confirmed rib fractures; facility environmental rounds did not include checking grab bar stability. Another dependent, severely cognitively impaired resident with CHF, prior UTIs, and pressure-ulcer risk was found to have a mattress emitting a strong urine odor beneath clean linens, despite reports from a visitor about urine smells and the absence of any mattress-cleaning schedule in facility checklists.
A resident’s representative reported multiple care complaints and concerns over an extended period to SW staff, the DSS, and the Administrator, initially without awareness of the formal grievance process and later via multiple emails due to uncertainty about using the grievance form. The Administrator, SW, and DSS each acknowledged receiving these complaints and either addressing them directly or forwarding them but did not treat them as formal grievances, did not enter them into the grievance log, did not document outcomes, and did not provide written resolutions to the representative. These actions did not follow the facility’s Resident Rights and Grievance policies, which require documentation of complaints, actions taken, and resolution, and a response to grievances.
A resident with COPD, CHF, severely impaired cognition, and oxygen dependence had physician orders for continuous oxygen at 0–4 L to maintain O2 saturation above 92%, with monitoring each shift and care plan directives to monitor oxygen and portable tank levels. Although the MAR showed continuous oxygen use and documented saturations, a visitor reported multiple occasions where the resident used empty portable tanks, and unused tanks were often empty. On one observation, the resident was found in bed with the nasal cannula off, the concentrator powered down, and tubing placed out of reach; staff, including a NA, an LPN, and the DON, all stated the oxygen should have been on and could not explain why it was off. The LPN documented that the resident’s O2 saturation was 90% before oxygen was reapplied, contrary to the physician’s order and facility policy requiring oxygen to be administered as ordered.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with advanced cancer and cognitive impairment missed multiple scheduled doses of morphine and lorazepam because the facility did not follow up with the pharmacy to clarify new orders or request refills before the supply was exhausted. The facility also failed to document that missed doses were reported to supervisors or the provider, resulting in lapses in pain and agitation management.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required.
Annual performance evaluations were not completed for two nurse aides as required by facility policy. One aide's evaluations for two consecutive years were missing, while another aide's annual review was overlooked and not documented. Errors in recordkeeping and staff transitions contributed to the failure to complete these evaluations, as confirmed by interviews with administration and HR.
The facility did not ensure that medications were administered as scheduled and failed to notify providers when medications were missed or administered late. Multiple residents experienced late or omitted medication administrations, and ongoing audits failed to identify these issues. The DON and Administrator were unaware of the continued deficiencies, despite being responsible for QAPI oversight.
A deficiency was cited when a resident's care plan did not include all necessary interventions, lacked measurable timetables, and failed to specify actions to address the resident's needs, as evidenced by incomplete documentation in the resident's records.
The facility did not maintain effective administrative oversight, resulting in repeated failures to ensure scheduled anxiety and narcotic pain medications were administered as ordered, timely medication refills and deliveries, and proper notification to providers of medication omissions. Significant medication errors persisted, and leadership interviews confirmed ongoing noncompliance and lack of oversight processes.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident experienced a significant medication error due to a failure in the medication administration process.
Physician orders for multiple residents were not reviewed or signed monthly as required, due to lack of awareness by facility leadership and the medical director, as well as unresolved access issues in the electronic medical record system. The facility did not have a policy specifying the frequency for physician order reviews, and the orders remained unsigned for at least two months.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes that affected the resident.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with dementia and a physician's order requiring supervision for ambulation and leave of absence was able to exit the facility unattended due to the front entrance door being left unlocked and unmonitored. Staff interviews revealed inconsistent practices regarding door security and front desk monitoring, which allowed the resident to leave the premises without staff knowledge, in violation of facility policy and the resident's care plan.
An LPN administered medications to 22 residents by memory after being unable to access the electronic MAR, without notifying supervisors or using alternative documentation for non-narcotic medications. This action bypassed established protocols for ensuring the 5 Rights of medication administration and resulted in Immediate Jeopardy.
An LPN administered morning medications to 22 residents by memory without access to the EMAR or any MAR documentation, failing to follow facility policy and without notifying supervisors. Additionally, a resident with heart failure and dementia experienced significant weight fluctuations without required reweighs or documentation, contrary to facility policy.
A resident with dementia and other health conditions alleged that an LPN pushed them onto a bed and took away their phone, causing distress and fear. The facility did not conduct a thorough investigation, failed to report the incident as required, and allowed the LPN to continue providing care to the resident even after the abuse was substantiated by surveyors. These failures led to an Immediate Jeopardy finding.
A resident with dementia alleged physical abuse by an LPN, including being pushed onto a bed and having their phone removed when calling for help, with the LPN continuing to provide care after the incident. The facility's investigation was incomplete, lacking documentation and interviews. In a separate event, two residents were involved in a physical altercation, with one striking the other in the face and the other pushing back. The facility failed to fully document and investigate these incidents, resulting in a deficiency for not protecting residents from abuse.
A resident with no cognitive impairment and multiple medical conditions was not invited to participate in care planning meetings, despite expressing a desire to attend. The social worker stated this was due to a conservator's request, but could not provide documentation to support this claim, and facility records did not show the resident was invited or declined to attend.
Several residents with complex medical needs experienced frequent shortages of clean towels and washcloths, resulting in missed or delayed showers and the use of makeshift materials for personal care. Staff and management were aware of the ongoing linen shortages but did not implement effective solutions, and the facility's policy lacked guidance for such situations. Additionally, a malfunctioning lock on a memory care unit's shower room door allowed unsupervised resident access, with lapses in staff monitoring and no policy provided for maintaining a secure environment.
Multiple residents with cognitive and medical impairments were placed on a secured memory care unit without documented clinical criteria, initial or ongoing assessments, physician orders, or evidence of resident or representative involvement in the placement decision. Staff confirmed there was no written policy or assessment process for admission to the secured unit, and residents could not independently exit the unit.
The facility failed to report multiple incidents of suspected resident-to-resident and staff-to-resident physical mistreatment to state protective services and the state agency as required. Despite documentation of physical altercations and allegations of abuse involving residents with cognitive impairments and behavioral issues, mandated notifications were not made in a timely manner, and staff interviews revealed a lack of understanding of reporting requirements.
Surveyors identified that the facility's medication error rate exceeded 5% due to repeated late administration of scheduled medications. Multiple residents, including those with complex medical conditions and varying cognitive statuses, received their morning medications well past the prescribed timeframe. Nursing staff reported ongoing difficulties in completing timely medication passes and had previously informed administration of these issues, but late administration persisted across several units.
Surveyors found that kitchen equipment had significant debris and residue buildup, opened and repackaged food items in storage were not properly labeled or dated, and a resident's reheated food was not checked with a thermometer as required. The Food Service Director confirmed that cleaning and labeling procedures were not consistently followed, and that staff reheated food without verifying temperatures per policy.
A review found that 31 employees had not received mandatory abuse and neglect training, despite facility policy requiring annual education for all staff. Additionally, the training provided was incomplete, lacking several federally required components such as screening, identification of abuse indicators, mandated reporting, and information on exploitation and restraints. Interviews confirmed that the Staff Development nurse and DON did not ensure the training matched facility policy or federal requirements.
The facility did not have a compliance and ethics program or policy, and staff were not provided with compliance and ethics training. Interviews confirmed that the existing Code of Conduct was not communicated to all staff and lacked key elements such as reporting procedures, identification of a compliance officer, and internal monitoring processes.
The facility failed to follow abuse prevention and reporting policies after two residents were involved in a physical altercation and another resident alleged mistreatment by an LPN. Key details were omitted from incident reports, investigations were incomplete or undocumented, and the accused LPN continued to provide care to the resident. Additionally, abuse prevention was not addressed in the facility's QAPI program.
A resident with dementia, CHF, and severe hearing loss did not have their care plan reviewed and revised quarterly as required. Due to an oversight, the resident was not scheduled for a care conference, and the MDS Coordinator failed to include the resident on the list for care plan updates, resulting in the care plan not being updated within the required timeframe.
A resident with severe cognitive impairment, incontinence, and limited mobility was not turned or repositioned every two hours as ordered by a physician, despite being at risk for pressure ulcers. Staff, including an RN, social worker, and nurse aides, entered the resident's room but did not reposition the resident over a nearly three-hour period. The responsible nurse aide was unaware of the repositioning requirement due to a lack of electronic charting prompts, and the LPN did not document any refusal of care. This failure to follow the care plan and physician's order resulted in a deficiency related to pressure ulcer prevention.
A resident with severe cognitive impairment and high fall risk was repeatedly observed seated in a wheelchair without the required pelvic positioning belt, despite physician orders and documented staff education. Nursing staff admitted to forgetting to apply the belt, and therapy staff confirmed its necessity for proper positioning and safety. Facility policies required adherence to such orders, but the belt was not consistently used as directed.
Two residents with dementia and high fall risk did not receive required supervision or assistive devices during ambulation and meals, as ordered by physicians and outlined in care plans. Staff were unaware of or did not follow orders for supervision and use of a walker, resulting in unsupervised ambulation and an unwitnessed fall during an unsupervised meal for one resident with dysphagia.
A resident with a history of pressure ulcer, CHF, and diuretic use did not receive adequate hydration, as daily fluid intake consistently fell below the established goal. Despite care plan interventions and facility policy requiring monitoring and assessment for dehydration, no dehydration assessment was completed during the period of low intake. Clinical staff did not effectively monitor or respond to the resident's hydration status, and lab results indicated potential dehydration.
A resident with severe cognitive impairment and respiratory conditions received continuous oxygen therapy for several days without a valid physician's order after the previous order expired. Nursing staff and supervisors were aware of the ongoing oxygen administration but did not ensure a current order was in place, contrary to facility policy.
A resident with end stage renal disease requiring dialysis did not have consistent communication and documentation between the dialysis center and facility, resulting in missing treatment records and unrecorded post-treatment weights. Additionally, staff failed to monitor and total the resident's daily fluid intake as ordered, leading to repeated exceedances of the prescribed fluid restriction. Facility staff were unaware of these lapses, and responsibilities for monitoring were unclear.
Nurse aides were unable to access essential resident care information in the EMR, requiring assistance from licensed staff despite prior training. This deficiency affected two residents with dementia and physical impairments, whose individualized care plans required specific interventions for mobility and feeding.
A resident receiving hemolytic treatments was sent with medication that was not properly packaged by the pharmacy and without an assessment for self-administration, contrary to facility policy. An LPN improperly secured narcotic keys by locking them in the medication cart, and required bimonthly narcotic audits were not conducted due to lack of staff training and oversight. The DON also failed to maintain proper records and storage for unused narcotics awaiting destruction, resulting in multiple breaches of medication management protocols.
A resident with severe dementia and Parkinson's disease, who required adaptive eating equipment and substantial assistance, was not consistently provided with the necessary utensils and cups during meals. Despite clear documentation on the meal ticket and care plan, staff were unaware of the resident's needs, and adaptive equipment was observed unused or missing during multiple meal observations.
Facility administration failed to provide timely oversight and reporting of an abuse allegation, did not ensure prompt investigation or removal of accused staff, and lacked documentation of administrative meetings and compliance policies. Additional deficiencies included untimely medication administration, improper narcotic storage, incomplete clinical records, inadequate staff training, insufficient linens, delayed care plan updates, and unsanitary kitchen conditions, resulting in immediate jeopardy and substandard care findings.
Surveyors identified multiple failures in infection prevention and control, including staff not wearing required PPE during high-contact care, delayed implementation of contact precautions for a resident with an active MDRO, improper hand hygiene during wound care, incorrect precaution signage for a resident with MRSA, and staff not following hand hygiene protocols before and after glove use.
The facility did not provide behavioral health education to staff as required by its own assessment, despite admitting residents with psychiatric and behavioral health needs. Only one in-service on personality disorders was documented, with low staff participation, and no additional evidence of regular behavioral health training or a related policy was provided.
The facility failed to maintain sufficient surety bond coverage for resident personal funds, as the Resident Trust Account regularly exceeded the $50,000 bond limit. Staff interviews and documentation review revealed that there was no regular monitoring of the adequacy of the surety bond, and the Administrator was unaware of the coverage shortfall. The facility was also unable to provide the Surety Bond Policy when requested.
Surveyors found that the facility failed to maintain accurate and complete documentation for two residents, including an abuse allegation and a fall incident. In both cases, records contained inaccuracies, missing information, and inconsistencies between staff accounts and official documentation, in violation of the facility's own charting policy.
The facility did not include the Infection Preventionist in its QAA committee meetings for six consecutive months due to staffing changes and a gap in hiring, with the Infection Preventionist only attending the most recent meeting. The facility's QAPI policy also failed to specify the federal requirement for this role to be part of the committee.
The facility did not provide required training to all staff on the Quality Assurance and Performance Improvement (QAPI) program or on how to report concerns, and the existing Code of Conduct policy was not communicated to all staff nor did it include QAPI components.
A resident with significant mobility and medical needs was injured on two occasions when staff failed to safely transfer them using a mechanical lift. In both incidents, the lift tipped during transfer, causing minor injuries. Staff interviews revealed uncertainty about proper lift use, including whether the correct equipment was used and a lack of awareness that pulling the lift pad could cause tipping. The facility's investigation did not identify the specific causes of the incidents, and staff did not recognize errors in their transfer technique.
A facility failed to ensure a resident's care plan addressed an actual skin impairment identified by an LPN. Despite a treatment being prescribed, the care plan only noted the potential for skin breakdown and did not include the existing wounds. The Director of Nursing confirmed the care plan should have included the skin impairment.
A resident with multiple diagnoses, including ESRD and diabetes, developed a skin impairment that was not assessed or evaluated by a higher-level licensed staff. Despite treatment orders being obtained, there was no documented assessment from 10/10/23 through 10/21/23. Interviews with staff revealed that the wound was not evaluated by a registered nurse or wound physician, and the facility's wound management policy was not provided.
Grab Bar Detachment Leads to Resident Fall and Rib Fractures
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards when a bathroom grab bar used for transfers dislodged from the wall while being used by a resident, resulting in a fall and subsequent rib fractures. The resident had diagnoses including a history of falls, heart failure, and anxiety, and a quarterly MDS showed moderately impaired cognition (BIMS score of 12) but independence with care, transfers, and wheelchair use. The resident’s care plan identified limited physical mobility and risk for falls, with interventions such as staff assistance with daily care as needed, provision of a urinal at night, call bell within reach, and use of non-skid socks. On the evening of the incident, the resident attempted to transfer from a wheelchair to the toilet using the bathroom grab bar, which dislodged from the wall, causing the resident to come down with knees on the floor between the wheelchair and toilet. Initial nursing documentation indicated no immediate injuries, marks, or bruises, and the resident reported no significant pain until several days later, when chest pain developed. A chest x-ray ordered by the APRN identified fractures of the left 5th to 7th ribs, and subsequent nursing notes documented pain management and use of an incentive spirometer. In interviews, the resident reported being permitted to use the bathroom and self-transfer independently, and described grasping the grab bar, its detachment from the wall, and falling with the head against the door before using the call bell for assistance. A nurse aide corroborated finding the resident on the knees on the floor with the grab bar on the floor. The Administrator reported that maintenance conducted monthly environmental rounds and assessed assigned resident rooms, but checking the stability of grab bars had not been part of those rounds prior to this incident.
Failure to Maintain Safe Grab Bars and Sanitary Mattress Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment for one resident and a sanitary sleeping environment for another. One resident with a history of falls, heart failure, anxiety, limited physical mobility, and moderately impaired cognition was care planned as being at risk for falls and was allowed to use the bathroom and self-transfer independently. While attempting to transfer from a wheelchair to the toilet using a bathroom grab bar, the grab bar detached from the wall, causing the resident to come down with knees on the floor and head against the door. The resident later reported chest pain, and a chest x-ray identified fractures of the left 5th to 7th ribs. Staff documentation and interviews confirmed that the grab bar was found dislodged on the floor and that prior to this incident, the facility’s monthly environmental rounds did not include checking grab bars for stability. The deficiency also includes the facility’s failure to ensure a sanitary sleeping environment for another resident with diagnoses including congestive heart failure, history of UTIs, and history of pressure ulcers, who was severely cognitively impaired, dependent for all care, and required a mechanical lift with two-person assistance. The resident’s care plan identified a self-care deficit and risk for skin breakdown, with interventions including regular repositioning, incontinence care, and use of barrier cream. A visitor reported that the resident’s mattress sometimes smelled of urine. During an observation with nursing staff, the resident was found incontinent of urine; while the brief did not have an odor, lifting the mattress sheet revealed a strong urine odor from the mattress. Interviews showed confusion among staff about responsibility for mattress cleaning, and facility documentation, including the Cleaning Checklist and Monthly Environmental Round Logs, did not identify a mattress cleaning schedule or checks of grab bar stability.
Failure to Log, Investigate, and Provide Written Resolution of Grievances
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to honor a resident representative’s right to voice grievances and receive a response. A resident representative (Person #1) reported multiple care complaints and concerns about Resident #2 over a prolonged period to Social Workers (SWs), the Director of Social Services (DSS), and the Administrator. Person #1 was not initially aware of the facility’s grievance process and, once informed that such a process existed, sent multiple emails regarding complaints and concerns because he/she did not know how to use the grievance form. Person #1 reported not receiving any written resolutions or being made aware of how the complaints and concerns were resolved and expressed dissatisfaction with the lack of follow-through. The Administrator acknowledged that Person #1 had reported care complaints and concerns and stated she addressed them immediately but did not treat them as grievances, did not ensure they were entered into the grievance log, and did not investigate them as required by the facility’s grievance policy. She also did not provide written follow-up to Person #1 regarding findings or resolutions. The SW similarly reported that although she addressed the complaints and concerns identified in email correspondence, she did not log them as grievances, did not document the outcomes, and did not follow the grievance policy. The DSS reported that Person #1 had sent multiple emails with complaints and concerns, which she either addressed or forwarded to the former Administrator, but she also did not log them as grievances, document outcomes, or follow the grievance policy. This was inconsistent with the facility’s Resident Rights Policy, which states residents have the right to have the facility respond to their grievances, and the Grievance Policy, which requires the SW to document the complaint, actions taken, and resolution in the grievance log.
Failure to Ensure Ordered Oxygen Therapy Was Provided
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with physician-ordered oxygen therapy actually received oxygen as ordered. The resident had COPD, CHF, a history of pressure ulcers, severely impaired cognition, was oxygen dependent, and dependent for all care. A physician’s order directed oxygen at 0–4 liters to maintain oxygen saturation above 92% and required oxygen saturation checks every shift. The resident’s care plan included interventions to administer medications as ordered, change oxygen and nebulizer tubing as ordered, monitor oxygen saturation as ordered, and check portable oxygen tank levels every three hours when in use. The MAR for January and February documented continuous oxygen administration and shift oxygen saturation readings. Despite these orders and documentation, interviews and observations showed that oxygen was not consistently provided as ordered. A visitor reported seeing the resident on multiple occasions using a portable oxygen tank that contained no oxygen and noted that unused portable tanks were often empty. During an observation, the resident was found in bed with the nasal cannula not in place, the oxygen concentrator powered off, and the oxygen tubing placed on top of a dresser out of the resident’s reach. Staff interviews revealed that a NA had fed the resident earlier and stated the oxygen was on at that time, and an LPN reported administering a nebulizer treatment earlier with oxygen in use and documented saturations of 95% and 98%. Both the NA and LPN stated they did not know why the oxygen was off and confirmed the oxygen should have been on, and the DON reported seeing the resident earlier with oxygen on and stated no one should have turned it off. When the LPN checked the resident’s oxygen saturation before reapplying oxygen, it was 90%, below the ordered threshold of above 92%. The facility’s policy stated oxygen is to be administered per physician’s orders.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Medication Administration Due to Inadequate Pharmacy Communication
Penalty
Summary
The facility failed to ensure timely follow-up with pharmacy services to fill new medication orders and refill standing orders before the supply was exhausted for a resident with multiple complex diagnoses, including ovarian cancer, schizoaffective disorder, and severe cognitive impairment. The resident, who was receiving hospice care, had physician orders for morphine sulfate ER and morphine sulfate oral solution for pain management. However, the morphine sulfate ER was not administered for several days after being ordered due to lack of availability, and the as-needed morphine solution was not given in its place. Documentation showed that the pharmacy had requested clarification on the order, but the facility did not respond promptly, resulting in missed doses. Additionally, the facility did not communicate with the pharmacy in a timely manner to ensure medication delivery before the supply was depleted. The resident also had a physician order for lorazepam intensol for agitation and pain, but missed multiple doses over several days due to the facility not requesting a refill in time and not requesting a STAT delivery when the supply ran out. Nurse documentation did not reflect that missed doses were reported to nursing supervisors or the provider as required by facility policy. Interviews with pharmacy representatives and the DON confirmed that the facility's lack of timely communication and follow-up led to the resident missing scheduled doses of both morphine and lorazepam.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes the failure to provide prompt notification to all required parties when significant events impacting the resident occurred.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for two of five nurse aides reviewed. One nurse aide, hired in July 2023, was due for annual performance reviews in 2024 and 2025, but no documentation of these evaluations was available or could be located. Another nurse aide, hired in April 2024, had a probationary evaluation completed in June 2024, but the required annual performance review for 2025 was not found in the personnel file and had not been completed. Interviews with the Administrator and Human Resources confirmed that annual evaluations are required on the month of hire for each nurse aide, but these evaluations were either overlooked, not completed, or incorrectly scheduled due to errors in recordkeeping and staff transitions. Review of facility policy confirmed the requirement for annual evaluations to assess performance, skills, and adherence to standards.
Failure to Ensure Timely Medication Administration and Provider Notification
Penalty
Summary
The facility failed to maintain compliance with previously cited deficiencies related to significant medication errors and failures in provider notification. During a complaint survey, it was found that three residents were not administered scheduled medications, and the provider was not notified of these missed administrations. Additionally, three residents received scheduled medications late, and again, the provider was not notified. Despite ongoing audits and QAPI meetings that reviewed survey results and claimed compliance improvement, documentation revealed continued late and omitted medication administrations during and after the Plan of Correction period. The Director of Nursing was unaware that late medication administrations were still occurring, as this information was not captured in the audits being conducted. The audits performed were random and did not identify ongoing issues with late and omitted medication administrations. The Administrator was unable to explain why the previous Plan of Correction was ineffective and acknowledged that the audits did not detect the continued deficiencies. The facility's QAPI policy assigned responsibility for monitoring the program to the Administrator and Director of Nursing, but the ongoing issues were not identified or addressed through their processes.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records, which did not contain comprehensive or measurable interventions to address the resident's assessed needs.
Failure to Ensure Timely Medication Administration and Administrative Oversight
Penalty
Summary
The facility failed to administer its resources effectively and did not provide adequate administrative oversight to ensure staff compliance with medication administration and resident care. Specifically, the facility did not maintain compliance with a previously established plan of correction related to medication administration errors. There were repeated failures to ensure that scheduled anxiety and narcotic pain medications were administered as ordered, that medications were refilled before supplies were exhausted, and that medications were delivered to the facility in a timely manner. Additionally, the facility did not ensure that the Advanced Practice Registered Nurse (APRN) was notified of medication omissions, annual performance evaluations were completed as required, or that clinical records were complete and accurate. Survey findings revealed that significant medication errors persisted, including late administration of medications and lack of notification to nursing supervisors or providers when medications were missed or delayed. Interviews with facility leadership confirmed that, despite previous citations and corrective plans, the facility had not returned to compliance and lacked a process for effective administrative oversight to address these ongoing issues. The deficiencies were identified as immediate jeopardy and substandard care in the area of pharmacy services, specifically regarding residents being free of significant medication errors.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Ensure Timely Physician Review and Signature of Orders
Penalty
Summary
The facility failed to ensure that physician orders for all eleven residents reviewed were signed and reviewed monthly in accordance with facility practices. Clinical record reviews showed that for each resident, medical orders were not reviewed or signed for at least one or more months, specifically in May and June. Interviews with the Administrator and a regional RN confirmed that the medical director was responsible for this task, but they were unaware that the orders had not been signed for the specified months. The facility was also unable to provide a policy detailing the required frequency for physician order reviews. Further investigation revealed that the medical director was new to the facility and to long-term care, and had not been informed of the regulatory requirements for signing physician orders. The medical director reported being unable to sign orders electronically due to lack of access in the electronic medical record system, and as of the date of the interview, the issue had not been resolved and the orders remained unsigned. No alternative method for signing the orders had been implemented.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Secure Front Entrance Resulting in Unsupervised Resident Exit
Penalty
Summary
A deficiency occurred when a resident with diagnoses of dementia, depression, and convulsions, who had a physician's order to leave the facility only with a responsible party and required supervision for transfers and ambulation, was able to exit the facility unattended. The resident was last seen in the dining room and was later found off facility grounds in a nearby parking lot. The resident was able to ambulate independently but required assistance due to fall risk and impaired cognition, as documented in the care plan and confirmed by therapy staff. The investigation revealed that the front entrance door, which was supposed to be locked when the receptionist was not present, was found unlocked on the morning of the incident. Staff interviews indicated that the door was sometimes left unlocked for convenience, allowing staff and housekeepers to enter, and that there was not always someone monitoring the front desk. The receptionist, who arrived after the resident had already left, confirmed the door was unlocked upon arrival and had seen someone matching the resident's description walking outside. Facility policy required that residents not be unsupervised outside the facility, and staff were expected to monitor the front entrance. However, inconsistent practices regarding the locking and monitoring of the front door allowed the resident to leave the building without staff knowledge or supervision, contrary to the resident's care plan and physician's orders.
Medications Administered by Memory Without MAR Access
Penalty
Summary
A Licensed Practical Nurse (LPN) administered medications to 22 residents on a secured memory unit without access to the electronic Medication Administration Record (MAR) due to technical difficulties with the Point Click Care (PCC) system. The LPN was unable to log into the system from the start of her shift and attempted to use multiple computers without success. Despite being unable to access the MAR, the LPN proceeded to administer all scheduled medications by memory, without any written or electronic reference to the current medication orders, dosages, or administration times for each resident. The LPN did not notify a supervisor or the Assistant Director of Nursing (ADNS) about her inability to access the system, nor did she use any alternative documentation methods for non-narcotic medications during the medication pass. The residents affected had complex medical histories, including diagnoses such as dementia, diabetes, heart failure, Parkinson's disease, and other chronic conditions requiring multiple medications with specific administration instructions. The LPN relied solely on memory for medication administration, which did not ensure adherence to the 5 Rights of medication administration: right patient, right drug, right dose, right route, and right time. The only documentation maintained was for narcotic medications, as required by the facility's narcotic book, but all other medications were not documented at the time of administration. The LPN acknowledged that this practice was not appropriate and was against facility policy, which requires the use of the MAR and immediate notification of a supervisor if access issues occur. Facility leadership, including the ADNS and corporate regional nurse, confirmed that the LPN did not follow established protocols for medication administration and failed to communicate the access issue in a timely manner. The ADNS stated that the LPN should have contacted a supervisor or herself to resolve the access issue before proceeding with medication administration. The facility's policies and job descriptions require that all medication administration be documented and that the 5 Rights be followed to ensure resident safety. The failure to use the MAR and to document medication administration as required resulted in a deficiency that was identified as Immediate Jeopardy.
Immediate Jeopardy: Medications Administered Without MAR and Failure to Reweigh After Significant Weight Changes
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) administered morning medications to 22 residents in a secured memory unit without access to the electronic Medication Administration Record (EMAR) system. The LPN was unable to log into the EMAR system from the start of her shift and attempted to use multiple computers without success. Despite this, she proceeded to administer medications to all assigned residents by memory, without referencing the MAR or any alternative documentation to ensure the correct medications, dosages, times, or routes were followed. The LPN did not notify a supervisor or the Assistant Director of Nursing (ADNS) about her inability to access the EMAR, as required by facility policy, and failed to document the administration of non-narcotic medications by any means. Only narcotic medications were recorded, as they required a signature in a separate narcotic log. The LPN acknowledged that this practice was inappropriate and not in accordance with facility policy, which mandates the use of the MAR to ensure the five rights of medication administration. The deficiency was further compounded by the lack of communication and oversight. The ADNS and other supervisory staff were not informed of the EMAR access issue until after the medication pass was completed. Interviews with facility leadership confirmed that the LPN should have contacted a supervisor for assistance with EMAR access and that administering medications without the MAR was against policy. The facility's EMAR policy requires nurses to read physician orders, complete the five checks, administer medications as ordered, and document administration in the EMAR. However, the facility was unable to provide a policy specifically for MAR utilization when requested. Additionally, a separate deficiency was identified regarding the monitoring of resident weights for a resident with diagnoses including dementia, anxiety, heart failure, and chronic atrial fibrillation. The resident was to be weighed weekly, with significant weight changes requiring reweighs according to facility policy. However, there were multiple instances of significant weight fluctuations without evidence of reweighs or documentation of refusals. Nursing staff confirmed that reweighs should have occurred on several occasions when the resident experienced notable weight changes, but there was no documentation to support that these actions were taken.
Failure to Investigate and Remove Staff After Substantiated Abuse Allegation
Penalty
Summary
A resident with diagnoses including dementia, personality disorder, and hypertensive heart disease with heart failure, who was assessed as having no cognitive impairment, made an allegation of abuse against an LPN. The resident reported being pushed onto the bed by the LPN while alone in the room, having their phone taken away, and experiencing humiliation and fear as a result. The resident also stated that the LPN continued to provide care after the alleged incident, despite the resident's distress and ongoing fear. The facility failed to conduct a thorough investigation into the abuse allegation. The Director of Nursing (DNS) did not provide documentation of a comprehensive investigation, such as staff or resident interviews, staff statements, or a detailed timeline. The only documentation available was an undated, unsigned summary created after the fact, which lacked essential details and was based on the DNS's memory rather than contemporaneous records. The DNS relied on the resident's history of making accusations to dismiss the allegation and allowed the LPN to resume providing care to the resident. Additionally, the DNS did not report the incident to the State Agency as required by facility policy and state regulations. Despite being informed by surveyors that the abuse allegation had been substantiated, the facility allowed the LPN to continue working on the resident's unit and to have access to the resident. The LPN was not removed from the schedule until after further surveyor inquiry. The facility's own policies required immediate reporting and investigation of abuse allegations, as well as removal of implicated staff from resident care, but these procedures were not followed. The failures in investigation, reporting, and staff removal resulted in a finding of Immediate Jeopardy.
Failure to Protect Residents from Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to protect residents from abuse by both staff and other residents, as evidenced by multiple incidents involving three residents. One resident with dementia and a personality disorder, but no cognitive impairment, alleged that an LPN physically pushed them onto a bed and removed their phone when they called for help. The resident reported feeling humiliated and afraid, and the LPN continued to provide care to the resident after the incident. The facility's investigation into the allegation was inadequate, lacking documentation, staff and resident interviews, and failed to substantiate the claim despite the resident's consistent statements and the LPN's admission of providing care against the resident's will. In another incident, a resident with severe cognitive impairment was struck in the face by another resident with a history of unprovoked aggression. The altercation occurred in the hallway when the first resident attempted to prevent the second from pushing an item. The aggressive resident was immediately placed on 1:1 monitoring, and both residents were assessed for injuries. The care plans for both residents were updated to address the behaviors, but the incident documentation was incomplete, as it did not initially include that the first resident also pushed the second resident into a wall in response. The facility's abuse policy defines abuse as the willful infliction of injury or intimidation, and requires thorough investigation and documentation of all allegations. However, in both cases, the facility failed to conduct comprehensive investigations, did not collect or maintain necessary documentation, and did not ensure that staff or residents were protected from further abuse. The lack of timely and thorough investigation, as well as the failure to remove implicated staff from resident care, contributed to the deficiency.
Failure to Involve Resident in Care Planning Meetings
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, hypertensive heart disease with heart failure, and osteoarthritis was not allowed to participate in the development and implementation of their person-centered plan of care. The resident was assessed as having no cognitive impairment and expressed a desire to attend Resident Care Conferences (RCCs), but was not invited to these meetings. Review of care plan documentation and RCC sign-in sheets over several months showed no evidence that the resident was invited, attended, or declined to attend the meetings. Interviews revealed that the social worker did not invite the resident to RCCs, citing a request from the resident's conservator, who allegedly did not want the resident to attend due to the resident's tendency to voice concerns during meetings. However, the social worker was unable to provide any documentation of this request from the conservator. Attempts to contact the conservator were unsuccessful, and facility policy required individualized care planning with resident participation.
Failure to Provide Adequate Linens and Maintain Secure Environment
Penalty
Summary
The facility failed to provide clean bed and bath linens in good condition and in sufficient quantity for resident care, as well as to ensure a safe and secure environment on a locked memory care unit. Multiple residents with significant medical conditions, including chronic obstructive pulmonary disease, heart failure, diabetes, dementia, and mobility impairments, reported frequent shortages of towels and washcloths. These shortages led to delays or missed showers, use of baby wipes purchased by residents, and staff resorting to cutting up blankets or using bed sheets and Chux pads for bathing and drying. Residents expressed feelings of indignity and dissatisfaction, with some too intimidated to complain to management. Staff interviews confirmed the recurring lack of linens, and the Director of Environmental Services and Administrator were aware of the issue but did not take timely action to resolve it, relying on scheduled laundry deliveries from a sister facility and lacking a contingency plan for shortages. Observations and interviews revealed that the facility's linen supply was insufficient for the census of 104 residents, with only 14 washcloths and 17 hand towels available for use across two shifts. The facility's linen stocking policy did not address procedures for handling shortages, and staff reported having to improvise with available materials. The Assistant Director of Nursing was also aware of the complaints and the use of makeshift washcloths, having notified the Administrator and Director of Environmental Services previously. Despite daily or near-daily laundry counts, the facility did not maintain an adequate supply to meet residents' needs. Additionally, on the secured memory care unit, the locking mechanism on the shower room door was found to be broken, allowing residents unsupervised access to the room. The Director of Maintenance and Administrator were unaware of the malfunction until it was brought to their attention during the survey. Although the Administrator initially assigned staff to monitor the area, there was a lapse in supervision, leaving the area unmonitored while the door remained unsecured. The facility was unable to provide a policy for ensuring a safe and secure environment on the memory care unit.
Failure to Document Criteria and Consent for Secured Memory Care Unit Placement
Penalty
Summary
Surveyors identified that for 11 residents placed on a secured memory care unit, the facility failed to establish and document clinical criteria for placement, did not perform or record initial assessments or periodic reassessments for continued placement, and did not obtain or document physician orders for such placement. The residents involved had diagnoses including dementia, Parkinson's disease, diabetes, congestive heart failure, schizophrenia, and other chronic conditions, with varying levels of cognitive impairment and functional dependence. Despite these complex needs, there was no evidence in the clinical records that justified their placement on the secured unit based on individualized assessments. Additionally, the facility did not document that residents or their representatives were involved in the decision-making process regarding placement on the secured memory care unit. There was no record of consent or notification provided to residents or their representatives about the placement or about their rights to independent egress. Observations during the survey confirmed that residents could not independently exit the secured unit, as the doors required a staff-entered code for entry and exit, and only staff were observed operating the keypad. Interviews with the Director of Nursing and a registered nurse revealed that there was no written policy or established criteria for admission to the secured memory care unit. The staff acknowledged the absence of initial or ongoing assessments for placement, lack of physician orders, and lack of documentation regarding resident or representative consent. The facility was unable to provide a policy for the secured memory care unit when requested by surveyors.
Failure to Timely Report Suspected Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure timely and appropriate reporting of suspected abuse, neglect, or theft, specifically regarding resident-to-resident and staff-to-resident physical mistreatment. Multiple incidents involving residents with cognitive impairments and behavioral issues were not reported to state protective services as required. In several cases, altercations between residents, including physical strikes, were documented in facility records, but there was no evidence that these incidents were reported to the appropriate state authorities. For example, one resident with dementia and a history of aggression struck other residents, and although the police and responsible parties were notified, protective services were not informed as mandated. Additionally, the facility did not report certain allegations of abuse to the state agency within the required timeframe. In one instance, a cognitively intact resident alleged that a staff member physically mistreated them during a transfer, and the incident was not reported to the state agency or protective services in a timely manner. Interviews with facility staff, including the social worker and the Director of Nursing Services (DNS), revealed a lack of understanding and compliance with mandatory reporting requirements. The DNS admitted to not submitting required reports due to oversight and misunderstanding of the reporting obligations. Facility policy required immediate reporting of suspected mistreatment, neglect, or abuse to the administrator or designee and notification of the state licensing and certification agency within two hours. However, the facility did not provide a policy for reporting to state protective services when requested. Connecticut state law mandates reporting suspected elder abuse to the Department of Social Services within 72 hours, but the facility failed to meet this requirement in multiple documented cases.
Medication Error Rate Exceeds Allowable Threshold Due to Late Administration
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5%, as required, with an observed error rate of 15.6%. Surveyors found that multiple residents did not receive their medications within the prescribed timeframe, with morning medications scheduled for 8:00 AM and 9:00 AM being administered significantly late, in some cases after 11:00 AM. These late administrations were directly observed by surveyors and confirmed through interviews with nursing staff, who reported ongoing difficulties in completing timely medication passes and had previously notified nursing administration of these issues. Specific residents affected included individuals with diagnoses such as paranoid schizophrenia, anxiety, glaucoma, hypertension, atrial fibrillation, heart failure, COPD, chronic kidney disease, and dementia. Many of these residents were cognitively intact, while others had varying degrees of cognitive impairment. Medications delayed included critical treatments such as antihypertensives, anticoagulants, antipsychotics, and insulin, with some doses being administered up to several hours past the allowed window. Facility documentation and direct observation confirmed the late administration of these medications across multiple units. Interviews with staff, including LPNs and advanced practice registered nurses, acknowledged the late medication passes and the challenges faced in adhering to scheduled administration times. The facility's own policy required medications to be given at the time ordered or within 60 minutes before or after the designated time, and to report medication errors immediately. Despite this, the survey identified a pattern of late medication administration affecting numerous residents, with staff indicating that administration delays were a known and ongoing issue.
Deficiencies in Kitchen Sanitation, Food Labeling, and Food Reheating Procedures
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's dietary department related to food safety and sanitation. During a tour of the kitchen, there was a heavy accumulation of debris and residue on the juice machine vent, stove, and oven doors. The Food Service Director (FSD) acknowledged that comprehensive cleaning of the juice machine was overdue and that documentation of the last cleaning could not be provided. The FSD also noted that the stove had not been cleaned after a spill over the weekend and that residue inside the oven doors could not be accessed by staff for cleaning. Facility policy required daily and monthly cleaning of kitchen equipment, but these procedures were not consistently followed. In the dry storage area, opened food items such as cake mix and pasta were found without required labeling or dating, and several unopened bags were removed from their original packaging without expiration dates. The FSD confirmed that all food items should be labeled with open and expiration dates per facility policy. Additionally, a nursing assistant reheated a resident's food in the nourishment room using a microwave but did not use a thermometer to verify the food reached the required temperature of 165°F, as no thermometer was present. The FSD confirmed that nursing staff were expected to use a thermometer to check food temperatures, in accordance with the facility's reheating policy.
Failure to Provide Comprehensive Abuse and Neglect Training to All Staff
Penalty
Summary
The facility failed to provide all staff with required abuse and neglect training, as evidenced by documentation showing that 31 employees, representing 19% of the workforce, had not received any abuse and neglect training since prior to 2024. Despite facility policy mandating annual in-service training for all staff, interviews with the Administrator, Staff Development nurse, and HR Director confirmed that these employees were still actively employed and had not been included in the mandatory training sessions. The Staff Development nurse, responsible for ensuring compliance with training requirements, was unable to explain the lapse and acknowledged the failure to implement the policy as directed. Additionally, the content of the abuse and neglect training provided to staff was found to be insufficient and not aligned with federal requirements or the facility's own policy. The training omitted key components such as screening for abuse, identification of abuse indicators, mandated reporting, misappropriation of resident property, exploitation, use of restraints, and recognition of staff burnout or stress. The Staff Development nurse admitted to not reviewing or updating the training materials and had only recently begun distributing the facility's abuse policy to staff, several months after being directed to do so. The DON confirmed that the training should be based on facility policy, which was not the case.
Failure to Develop and Implement Compliance and Ethics Program
Penalty
Summary
The facility failed to develop and implement a compliance and ethics program, as well as to provide staff with compliance and ethics training. Interviews with the Administrator and two Regional RNs revealed that there was no compliance and ethics program or policy in place, and that such training was not included in new hire orientation or annual training. Although a Code of Conduct policy existed, it was not communicated to all facility staff and did not include essential components such as identification of a compliance officer or committee, procedures for reporting ethical concerns, secure and confidential reporting mechanisms, internal monitoring and auditing, or processes for response and corrective action. The Director of Nursing Services was unavailable for interview, and the requested compliance and ethics policy was not provided.
Failure to Report, Investigate, and Prevent Abuse and Neglect
Penalty
Summary
The facility failed to properly implement and follow its abuse prevention, reporting, and investigation policies for multiple residents. In one incident, a resident with severe cognitive impairment and dementia was slapped by another resident with a history of unprovoked aggression. The altercation was observed by an LPN, but the written statement omitted key details, such as the retaliatory action by the first resident. The Director of Nursing Services (DNS) was unaware of the full extent of the incident due to incomplete reporting, and the required documentation and reporting procedures were not followed as outlined in facility policy. In another case, a cognitively intact resident with a history of making accusatory statements alleged that an LPN physically mistreated them during a transfer and removed their phone when they called for help. The DNS was aware of the allegation but failed to conduct or document a thorough investigation, as required by policy. The investigation lacked staff and resident interviews, written statements, and did not include an interview with the accused LPN. Despite the policy requiring removal of staff accused of abuse from resident care pending investigation, the LPN continued to have access to the resident for numerous shifts after the allegation, and the incident was not properly reported to the State Agency. Additionally, the facility did not integrate abuse prevention and response into its Quality Assurance and Performance Improvement (QAPI) program. The administrator and DNS confirmed that abuse was not included in QAPI meetings or staff training, and the QAPI plan did not address communication or coordination regarding abuse, neglect, or exploitation. This lack of integration further contributed to the facility's failure to ensure resident protection and compliance with regulatory requirements.
Failure to Review and Revise Resident Care Plan Quarterly
Penalty
Summary
A deficiency occurred when the facility failed to review and revise the Resident Care Plan (RCP) for a resident with diagnoses including dementia, congestive heart failure, and bilateral sensorineural hearing loss. The resident was identified as having severe cognitive impairment and required varying levels of assistance with daily activities. The RCP in effect addressed the resident's communication difficulties due to hearing loss, with interventions focused on discussing concerns with the resident and family and encouraging the resident to express thoughts. However, documentation showed that after a care conference was held, no subsequent resident care conferences were conducted as required. Interviews with facility staff revealed that quarterly resident care conferences are used to update care plans, but the resident in question was not scheduled for a conference in the required quarter due to an oversight. The MDS Coordinator, responsible for generating the list of residents needing care conferences, failed to include the resident on the list for the relevant period, and could not locate the list provided for scheduling. Facility policy requires quarterly care plan reviews and updates within seven days of the comprehensive MDS assessment, which was not met in this case.
Failure to Reposition Resident as Ordered, Leading to Pressure Ulcer Deficiency
Penalty
Summary
A deficiency occurred when staff failed to turn and reposition a resident with a physician's order for repositioning every two hours. The resident, who had diagnoses including dementia, generalized muscle weakness, and incontinence, was identified as being at risk for pressure ulcers and required maximum assistance for bed mobility. Despite a care plan and physician's order specifying the need for turning and repositioning every two hours, observations showed that the resident remained on their back for an extended period from 9:00 AM to 11:50 AM without being repositioned. Multiple staff members, including a registered nurse, social worker, and nurse aides, entered the room but did not reposition the resident during this time. Interviews revealed that the nurse aide responsible for the resident was unaware of the repositioning requirement, as the electronic charting system did not trigger a directive for this task. The nurse aide confirmed that the resident had not been turned or repositioned since the start of her shift at 7:00 AM. Additionally, the LPN on duty acknowledged the physician's order but had not attempted to reposition the resident and could not provide documentation of any refusal by the resident. The facility's policy required position changes every 2 to 3 hours for dependent residents, but this was not followed, resulting in a failure to provide appropriate pressure ulcer care.
Failure to Apply Pelvic Positioning Belt as Ordered
Penalty
Summary
A deficiency occurred when staff failed to consistently apply a pelvic positioning belt for a resident with Parkinson's disease, vascular dementia, and muscle weakness, as ordered by the physician. The resident was identified as severely cognitively impaired, non-ambulatory, and at high risk for falls, requiring assistance with transfers and proper positioning in a wheelchair. The care plan and therapy notes specified the need for a pelvic positioning belt to maintain body alignment, promote safety, and decrease the risk of skin breakdown. Despite clear orders and documented staff education on the use of the pelvic positioning belt, multiple observations revealed the resident seated in a wheelchair without the belt applied on several occasions. Nursing assistants and LPNs acknowledged responsibility for applying the belt but admitted to forgetting to do so after transferring the resident. Therapy staff and the Director of Nursing confirmed the necessity of the belt for the resident's safety and positioning, and that nursing staff were responsible for its application. Facility policies required adherence to physician orders and the provision of physical therapy services as prescribed. However, the pelvic positioning belt was not consistently applied as ordered, and a specific policy on wheelchair equipment or pelvic positioning belts was not provided upon request. This failure to follow physician orders and ensure proper use of assistive devices led to the identified deficiency.
Failure to Provide Required Supervision and Assistive Devices for High-Risk Residents
Penalty
Summary
The facility failed to ensure that residents at high risk for falls and with specific supervision and assistive device requirements received care in accordance with physician orders and care plans. One resident with dementia, muscle weakness, unsteadiness, and a history of falls was identified as a high fall risk and had orders for ambulation with supervision and a 2-wheeled walker. Despite these orders, the resident was repeatedly observed ambulating without staff supervision or the required assistive device. Nursing assistants and licensed staff were unaware of the resident's need for a walker and supervision, and the walker was found unused and stored in the resident's room. The facility's policy required staff to assist residents with walkers as indicated by physician orders, but this was not followed. Another resident with dementia, dysphagia, and muscle weakness, also identified as a fall risk, had orders for hand-held assistance with ambulation and 1:1 supervision during meals. This resident was observed ambulating independently in the hallway without staff assistance, and staff acknowledged being too busy to provide the required supervision. The care plan and physician orders specified the need for assistance, but staff failed to adhere to these requirements, resulting in the resident being left unsupervised. Additionally, the same resident with dysphagia was left alone in their room with a meal tray, despite orders and care plan interventions requiring 1:1 supervision during meals due to swallowing difficulties and risk of aspiration. The resident experienced an unwitnessed fall while unsupervised during breakfast. Staff involved were unaware of the resident's supervision needs and were unable to access care-specific information at the time. The facility's policies and updated mealtime guidelines were not followed, and staff failed to ensure the resident received the required supervision and assistance.
Failure to Ensure Adequate Hydration for Resident at Risk of Fluid Deficit
Penalty
Summary
The facility failed to provide adequate hydration to a resident with a history of pressure ulcer, neuromuscular bladder dysfunction, and congestive heart failure, who was also on diuretic therapy. The resident's fluid intake goal was established at 1400-1700 ml per 24 hours, as documented in both the dietary assessment and a physician's order. Despite this, a review of intake records over a 19-day period showed that the resident did not meet the fluid goal on any day, with daily intake ranging from 240cc to 1200cc. The care plan included interventions such as education on fluid intake, monitoring and documenting intake and output, and reporting signs of dehydration, but these interventions were not effectively implemented. Nursing documentation and interviews revealed that intake and output were recorded by nursing assistants and entered into the electronic health record by nurses, with the 3:00 PM to 11:00 PM nurse responsible for totaling the 24-hour intake and output. However, there was no evidence that a dehydration assessment was completed during the period of low intake, despite facility policy requiring evaluation for dehydration if fluid goals were not met for three consecutive days. Laboratory results during this period indicated elevated BUN/Creatinine levels, suggestive of potential dehydration, and the resident experienced increased confusion, urinary retention, and required a urinary catheter and antibiotics for a urinary tract infection. Interviews with clinical staff, including the APRN and dietician, confirmed that the resident's fluid needs were not met and that assessments for dehydration were not performed as required. The APRN relied on verbal reports rather than reviewing intake and output records, and the dietician stated that she would expect dehydration assessment and lab work if fluid goals were not consistently met. The facility's dehydration policy outlined the need for monitoring and assessment, but these steps were not followed, resulting in a failure to ensure the resident's hydration needs were addressed.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to ensure that a physician's order was in place for the administration of continuous oxygen to a resident with multiple respiratory and cardiac diagnoses, including pneumonitis, CHF, pleural effusion, and hypoxia. The resident, who was severely cognitively impaired and dependent for mobility and care, had a previous physician's order for oxygen therapy that expired on 3/10/25. Despite this, clinical documentation and direct observations confirmed that the resident continued to receive continuous oxygen from 3/11/25 to 3/18/25 without a valid physician's order. Multiple nursing notes and staff interviews acknowledged the ongoing administration of oxygen during this period, and staff were unable to provide a current order when asked. Facility policy required a physician's order for continuous oxygen administration, and both nursing staff and the DNS confirmed that such an order was necessary and should have been obtained. The lack of follow-through after the expiration of the previous order resulted in the resident receiving oxygen therapy without proper authorization. This deficiency was identified through review of the clinical record, staff interviews, and direct observation of the resident receiving oxygen without a current order.
Failure to Ensure Communication and Monitoring for Dialysis and Fluid Restriction
Penalty
Summary
The facility failed to ensure appropriate communication and documentation between the dialysis treatment center and the facility for a resident with end stage renal disease who was dependent on dialysis. Physician orders required the resident to attend dialysis three times per week, with staff responsible for recording post-treatment weights from the dialysis center's communication book. However, documentation from the dialysis center was missing for several treatment dates, and there was no evidence that staff contacted the center to obtain the required information. Interviews revealed that the communication book was not always sent or returned with the resident, and staff could not explain the missing documentation or why follow-up was not conducted as per facility practice and agreements. Additionally, the facility failed to comply with physician orders regarding fluid restriction and intake monitoring for the same resident. Orders specified a daily fluid restriction and required nursing staff to document intake and output every shift, with the 3:00 PM to 11:00 PM shift responsible for totaling the 24-hour intake. Review of records showed that the resident's fluid intake exceeded the prescribed limit on multiple occasions, and the required 24-hour totals were not consistently calculated or communicated. Interviews with nursing staff and supervisors indicated a lack of awareness of the resident's fluid overages and confusion regarding responsibility for monitoring and totaling intake. The facility's own policies and care plans outlined the need for accurate documentation and communication regarding both dialysis treatment and fluid management. Despite these directives, there were repeated failures to obtain and record necessary information from the dialysis center and to monitor and report fluid intake as ordered. These lapses resulted in the facility's inability to follow physician orders and ensure safe, appropriate care for the resident requiring dialysis and fluid restriction.
Failure of Nursing Staff to Demonstrate EMR Competency for Resident Care
Penalty
Summary
Nursing staff, specifically nurse aides, failed to demonstrate competency in accessing and utilizing the electronic medical record (EMR) system to obtain resident-specific care information. In two separate instances, nurse aides were unable to retrieve essential care details for residents with significant cognitive and physical impairments, including information on ambulation status, supervision levels, and mealtime guidelines. In both cases, the nurse aides had to rely on licensed nursing staff to access the EMR and provide the necessary information, despite having previously received training on the system. The residents involved had complex care needs, including dementia, muscle weakness, unsteadiness, a history of falls, and dysphagia. Their care plans required staff to follow specific interventions for mobility, supervision, and feeding. The inability of nurse aides to independently access the EMR resulted in a failure to ensure that care was provided according to each resident's individualized plan. Interviews with supervisory staff confirmed that nurse aides were expected to have the competency to access this information, and the lack of a provided policy on EMR training was noted.
Deficiencies in Pharmaceutical Services and Controlled Substance Management
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident receiving hemolytic treatments. Specifically, a resident with end stage renal disease and anemia, who required hemolytic treatment three times a week, was sent to treatment with hydralazine medication that was not properly packaged by the pharmacy. Instead, an LPN removed the medication from the resident’s blister card, placed it in a clear plastic pouch, labeled it by hand, and sent it in the communication binder. The medication was not in pharmacy-provided Leave of Absence (LOA) packaging, and there was no way for the treatment center staff to verify the medication. Additionally, the facility did not assess the resident for self-administration of medication, despite the treatment center’s policy that only self-administered medications could be taken during treatment. The APRN and DON were unaware of these practices, and the facility’s own policies required pharmacy-labeled medications and self-administration assessments, which were not followed. Further deficiencies were observed in the handling and security of narcotic medications. During an observation, an LPN was found to have locked narcotic keys inside the medication cart, rather than keeping them on her person as required by facility policy. The DON confirmed that narcotic keys should always be kept separately and in the possession of the nurse on duty, not locked in the cart. This practice was not being followed, indicating a lapse in controlled substance security protocols. The facility also failed to conduct required bimonthly narcotic audits. The ADNS was not performing these audits and was unaware it was her responsibility, as she had not been instructed or educated by the DON. The DON also had not completed any bimonthly audits since starting in the position. Additionally, the DON stored unused narcotics for destruction in a double-locked cabinet but did not maintain a log of these medications after receiving them from the units. The Controlled Substance Disposition Record was kept wrapped around the medication blister pack, contrary to policy requirements. These actions demonstrate multiple failures in the facility’s medication management and controlled substance accountability processes.
Failure to Provide Adaptive Eating Equipment as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's disease, severe dementia, and adult failure to thrive was not provided with adaptive eating equipment as specified in their care plan and meal ticket. The resident was identified as severely cognitively impaired and required substantial to maximum assistance with eating, as well as adaptive equipment such as a built-up spork, lip plate, and handled cup with a straw. Despite these documented needs, observations revealed that the adaptive equipment was not consistently provided during meals. On one occasion, the required sippy cup was missing and the built-up spork was left unused on the delivery cart. Staff assisting the resident were unaware of the need for adaptive equipment, even though it was clearly indicated on the meal ticket. Family members reported that the resident did not always have access to drinks and silverware, and staff appeared unaware of the resident's needs when concerns were raised. The Food Service Director confirmed that adaptive equipment was labeled and placed on the silverware carts, with the expectation that nursing assistants would distribute it as needed. However, repeated observations showed the resident without the necessary adaptive equipment during meals, and staff interviews indicated a lack of awareness regarding the resident's requirements.
Administrative Oversight Failures Result in Multiple Deficiencies and Immediate Jeopardy
Penalty
Summary
Facility administration failed to ensure timely and effective oversight of staff and resident care, resulting in multiple deficiencies. The Administrator was aware of an allegation of staff-to-resident abuse but did not notify the State Agency in a timely manner, and a summary of the event was only created over two months later. The Administrator also failed to provide adequate oversight to ensure the reporting of the abuse allegation and did not follow the facility's policy for reporting such incidents. Additionally, there was no documentation of regular meetings between the Administrator and the Director of Nursing Services (DNS), and the facility lacked an ethics or compliance policy. Issues related to resident abuse were not discussed in Quality Assurance and Performance Improvement meetings. Further deficiencies included failure to investigate allegations of abuse promptly and thoroughly, failure to remove staff accused of abuse from the schedule in a timely manner, and failure to provide an environment free from involuntary seclusion. The facility also did not ensure timely administration of medications, proper storage and auditing of narcotics, completeness and accuracy of clinical records, adequate staff training, sufficient clean linens for residents, timely review and updating of care plans with resident participation, and maintenance of kitchen sanitation and emergency food supplies. These failures led to findings of immediate jeopardy and substandard care in the areas of abuse prevention, quality of care, and training requirements.
Deficiencies in Infection Control and PPE Compliance
Penalty
Summary
Multiple deficiencies in infection prevention and control were identified through observations, record reviews, and staff interviews. In one instance, staff providing incontinent care to a resident on Enhanced Barrier Precautions (EBP) wore gloves but failed to wear gowns as required. The staff were not aware that the resident was on EBP, despite signage and indicators being present, and attributed their lack of compliance to the location of the precaution cart. The facility's policy required gowns and gloves for high-contact care activities, but this was not followed. Another deficiency involved a resident with a positive laboratory result for an active Multi-Drug Resistant Organism (MDRO). The facility failed to promptly change the resident's precautions from EBP to contact precautions after receiving the positive result. There was a delay of three days before the appropriate precautions were implemented, as staff did not identify the MDRO result in a timely manner. Additionally, during a wound care procedure for this resident, staff failed to perform hand hygiene between glove changes, contrary to facility policy. Further deficiencies were observed with other residents, including failure to post correct precaution signage for a resident with an active MRSA infection, leading to staff entering the room without appropriate PPE. In another case, staff did not perform hand hygiene before donning PPE or after removing gloves, and one staff member was observed walking in the hallway with gloves, removing and reapplying them without hand hygiene. These actions were inconsistent with the facility's infection control, hand hygiene, and MDRO policies.
Failure to Provide Behavioral Health Training to Staff
Penalty
Summary
The facility failed to provide behavioral health education to staff as identified in its annual facility assessment. The assessment indicated that the facility admits residents with psychiatric and mood disorders, including psychosis, impaired cognition, depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, and behavioral disturbances. It also stated that Nursing Assistants were to receive education on managing combative care and behavioral disturbances. However, a review of in-service calendars from March 2024 through March 2025 did not show any scheduled behavioral health training by the facility or its psychiatry services group. Further review found only one documented behavioral health in-service, focused on personality disorders, with attendance by 19 staff members out of 164 employees, resulting in a compliance rate of 11.5%. No additional in-service sign-in sheets for behavioral health education were provided. Interviews with the Administrator and Staff Development nurse confirmed that behavioral health education was expected to be provided regularly, but they could not produce evidence of such training beyond the single session. Additionally, the facility was unable to provide a policy for behavioral health when requested.
Inadequate Surety Bond Coverage for Resident Trust Accounts
Penalty
Summary
The facility failed to ensure adequate coverage for resident personal funds deposited in the Resident Trust Account (RTA). Review of the RTA balances over several months revealed that the account regularly held amounts ranging from approximately $62,879 to $149,270.15. However, the facility's surety bond only provided coverage for $50,000 during this period. This discrepancy was identified during an interview and review of documentation with Business Office staff, which showed that the RTA balance consistently exceeded the surety bond coverage limit. Further investigation revealed that the facility did not have a process in place to regularly monitor whether the surety bond coverage was sufficient for the RTA balances. The Administrator was unaware that the RTA frequently exceeded the $50,000 coverage and could not identify who was responsible for monitoring the adequacy of the surety bond. Additionally, the facility was unable to provide a copy of the Surety Bond Policy upon request.
Failure to Maintain Accurate and Complete Resident Documentation
Penalty
Summary
Surveyors identified deficiencies in the facility's documentation practices for two residents, both involving inaccurate or incomplete records of significant events. For one resident with dementia and heart failure, an allegation of abuse was not properly documented or investigated. The Director of Nursing Services (DNS) failed to produce timely investigation documentation and instead provided an undated and unsigned summary created much later, which contained multiple inaccuracies regarding the resident's admission date, age, cognitive status, and diagnosis. Additionally, there were no progress notes or assessments in the electronic medical record related to the alleged abuse incident, and the reportable event form submitted contained incorrect information about the event type, resident's age, admission date, and the presence of injury or distress. For another resident with severe cognitive impairment and mobility issues, documentation of a fall incident was inconsistent and inaccurate. The DNS's late entry progress note described events that did not align with the accounts of the nurse aide and registered nurse involved. The note incorrectly stated that the resident was lowered to the ground with a gait belt and that the DNS was present for the assessment, while both staff members confirmed that no gait belt was used and the DNS was not present. The nurse aide also reported that the DNS did not interview her regarding the incident, and the incident report was completed on paper and handed to another nurse. These discrepancies resulted in the medical record failing to accurately reflect the resident's experience during the incident. The facility's own Charting and Documentation policy requires that documentation be objective, complete, and accurate, and that all treatments, services, and incidents involving residents be properly recorded. In both cases, the facility failed to meet these standards, as evidenced by inaccurate, incomplete, and delayed documentation of significant resident events, including an abuse allegation and a fall with potential injury.
Infection Preventionist Not Included in QAA Committee Meetings
Penalty
Summary
The facility failed to include the Infection Preventionist as a required member in its Quality Assessment and Assurance (QAA) committee meetings, as mandated by federal guidelines. Documentation and interviews revealed that although the facility held monthly QAPI/QAA meetings from July 2024 through January 2025, the Infection Preventionist only attended the January 2025 meeting and was absent from the previous six meetings. The absence was attributed to staffing issues, including the resignation of the prior Infection Preventionist in August 2024 and a delay in hiring a replacement. Additionally, the facility's QAPI policy did not specify the federal requirement for the Infection Preventionist to be a committee member.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory training to all staff on its Quality Assurance and Performance Improvement (QAPI) program, as well as on how to communicate concerns, problems, or opportunities for improvement. During interviews with the Administrator and two Regional Registered Nurses, it was identified that while a Code of Conduct policy existed, it was not communicated to the entire staff. Additionally, the facility was unable to provide the requested policy documentation, and the Code of Conduct policy did not include the essential components related to the use of a QAPI program. The Director of Nursing Services was unavailable for interview, and no further information was provided regarding staff awareness or training on QAPI.
Failure to Ensure Safe Mechanical Lift Transfers Resulting in Resident Injuries
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was safely transferred using a mechanical lift, resulting in minor injuries on two separate occasions. The resident involved had significant medical conditions, including morbid obesity, chronic pain, muscle weakness, and difficulty walking, and required assistance with transfers as documented in the care plan and physician orders. Despite these documented needs, the resident experienced two incidents where the mechanical lift tipped during transfer, causing injury. In the first incident, staff were transferring the resident with a Hoyer lift when the lift began to tip as the resident was being lowered into a chair. Staff were unable to stabilize the lift due to the resident's weight, resulting in both the resident and the lift falling to the floor. The resident sustained a scrape to the right great toe and reported pain, and was subsequently sent to the emergency department for evaluation. Interviews and documentation revealed uncertainty among staff about whether the correct bariatric lift was used, and there was a lack of clarity regarding the presence of environmental hazards or proper use of the lift's features. In the second incident, three staff members were transferring the same resident with a bariatric Hoyer lift when the lift tipped, causing the bar to strike the resident's face and chest, resulting in an abrasion and bruising. Staff interviews indicated that they pulled the resident by the Hoyer pad to position them over the chair, as they had difficulty maneuvering the lift using only the handlebar. Some staff were unaware that pulling the pad could cause the lift to tip, and there was a general lack of understanding about the correct procedures for using the lift safely. The facility's investigation did not identify the specific cause of the tipping, and staff were unable to recognize errors in their transfer technique.
Failure to Address Skin Impairment in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident with multiple diagnoses, including end-stage renal disease, sepsis, diabetes mellitus, heart failure, and a history of cellulitis, addressed an actual skin impairment. On 10/10/23, a Licensed Practical Nurse (LPN) identified four soft scabbed areas on the resident's left shin, which were swollen and red. Despite the Advanced Practice Registered Nurse (APRN) prescribing a treatment for the wounds, the care plan dated 10/19/23 did not include this skin impairment, only noting the potential for skin breakdown due to fragile skin, incontinence, and anticoagulant therapy. The care plan directed staff to inspect the skin daily and provide treatments according to physician orders but failed to specifically address the existing wounds identified earlier in the month. The deficiency was confirmed during an interview with the Director of Nursing (DNS) on 11/21/23, who acknowledged that the care plan should have included the skin impairment identified on 10/10/23. The facility's policy for care plans mandates that an interdisciplinary care plan be developed to achieve and maintain optimal status, including the resident's needs, realistic goals, and the care and services required to meet those goals. The care plan should address physical, cognitive, and psycho-social problems on an individualized basis, which was not done in this case, leading to the deficiency.
Failure to Assess and Evaluate Resident's Skin Impairment
Penalty
Summary
The facility failed to ensure a wound assessment or evaluation was completed for a resident who developed a skin impairment. Resident #1, diagnosed with end stage renal disease, sepsis, diabetes mellitus, heart failure, and a history of cellulitis, was admitted without skin lesions. However, on 10/10/23, LPN #1 identified four soft scabbed areas on Resident #1's left shin, which were swollen and red. Although treatment orders were obtained, there was no documented assessment or evaluation of the newly identified skin impairment from 10/10/23 through 10/21/23. Interviews with facility staff revealed that the wound was not assessed by a registered nurse or the wound physician. LPN #1 reported the change to the APRN, DNS, and RN #1, but the area was never evaluated by a higher-level licensed staff. The DNS and APRN both indicated that they would have expected the wound to be assessed and monitored, but this did not occur. The facility's wound management policy was requested but not provided.
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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