Parkville Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hartford, Connecticut.
- Location
- 5 Greenwood Street, Hartford, Connecticut 06106
- CMS Provider Number
- 075250
- Inspections on file
- 24
- Latest survey
- April 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Parkville Care Center during CMS and state inspections, most recent first.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failing to ensure that treatment and supports for daily living were delivered safely.
Surveyors found that food items were not consistently attractive, palatable, or served at appropriate temperatures. Waffles were served pale, floppy, and under temperature due to equipment limitations, and residents had previously reported issues with food being over or undercooked. Additional observations revealed visually unappealing and inconsistently textured fruit, as well as a lack of browning on main entrées, all contrary to facility policy.
Surveyors observed that dry goods, including powdered thickener and cornstarch, were left open or inadequately sealed in the kitchen, and a bag of rice was not properly closed. An open box of sugar free syrup was stored on its side, causing a bottle to leak onto the box and floor. In the freezer, two bags of taco meat were found without labels or dates. The Dietary Manager confirmed these items were not properly sealed or labeled, contrary to facility policy.
A resident on anticoagulant therapy with severe cognitive impairment was cut on the face by a disposable razor during shaving. The nurse aide reported the bleeding to an LPN, who did not assess the resident, document the incident, or review the medical record for anticoagulant use, citing being too busy. Facility policies required assessment and practitioner notification for bleeding in residents on anticoagulants, but these were not followed.
A resident with severe cognitive impairment and muscle contractures did not have a prescribed hand splint applied as ordered by the physician. Staff failed to document or verify splint use, and the electronic charting system did not include splint assignments, resulting in the resident not receiving the required care to maintain range of motion.
A resident with end stage renal disease and both an AV fistula and a Permcath for hemodialysis did not receive safe and appropriate care due to staff being unaware of the emergency kit's location and contents, lack of physician's orders for vital signs and access site monitoring, and missing documentation of required assessments. Facility policies did not address care for a Permcath, and the communication book and documentation for dialysis care were not maintained as required.
Emergency exits and an emergency response cart in a resident lounge were blocked by multiple wheelchairs and chairs that had been relocated due to construction in their usual storage area. A nurse and the administrator confirmed the obstructions and acknowledged that an alternative storage room was available, but the wheelchairs were not moved there, resulting in blocked emergency access and limited resident use of the lounge.
The facility did not consistently enforce its smoking policy, as observed by the presence of numerous cigarette butts scattered on the smoking patio, courtyard pathways, and gravel flower beds after a supervised smoking session. Staff interviews revealed confusion about smoking supervision and permitted areas, and the facility's policy requiring safe extinguishing of smoking materials was not consistently followed.
The facility did not ensure grievance forms were consistently available or accessible to all residents, including those using wheelchairs, and failed to respond to grievances in a timely manner. Residents reported that forms were not replenished and that staff had not explained the grievance process, with observations confirming the lack of accessible forms and delayed responses.
Two residents with significant medical conditions, one severely cognitively impaired and one cognitively intact but dependent on care, did not receive required quarterly statements for their personal funds managed by the facility. Interviews with the responsible party and a resident confirmed that statements had never been received, and the Business Office Manager could not provide evidence that statements were mailed or delivered, despite facility policy requiring quarterly distribution.
The facility did not hold required quarterly care planning meetings for three residents with complex medical needs, including those dependent for ADLs and requiring tube feedings. Documentation showed that after initial care conferences, no further quarterly meetings were held as required by facility policy, and staff interviews confirmed the lapse was due in part to staffing changes.
A resident with multiple behavioral and medical diagnoses was involved in an incident that led to a hospital transfer. Following this, an accusation was made that a nurse aide used abusive language in the presence of others. The DON investigated but did not report the allegation to the State Agency as required by facility policy.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Deficiency in Food Palatability, Appearance, and Temperature
Penalty
Summary
Surveyors observed that the facility failed to ensure food items were attractive, palatable, and served at an appetizing temperature. During observation of the dietary tray line, waffles were noted to be pale, floppy, and appeared uncooked, as the kitchen's toaster could not accommodate frozen items and thus did not brown the waffles. The Dietary Manager acknowledged these issues and was unable to achieve a higher serving temperature for the waffles, which were measured at 100°F, below the facility's policy requirement of 135°F for hot foods. Residents had previously voiced concerns about food being over or undercooked, with no changes made in response to their feedback. Further observations included a test tray where the main entrée of ham was pale and lacked browning, though it was at an appropriate temperature and tasted acceptable. The sweet potatoes were lumpy and left a lingering spicy aftertaste, while the green peas were soft but visually basic. The fruit, identified as canned pears, had a translucent appearance with accentuated dots and inconsistent texture, ranging from very soft to hard, making it difficult to chew for some residents. The Dietary Manager agreed that the pears' texture could be problematic and attributed the appearance to being packed in water. The facility's policy requires food to be served attractively and at palatable temperatures, which was not consistently met.
Deficient Food Storage and Labeling Practices in Kitchen
Penalty
Summary
During an observation and interview in the facility's kitchen, several deficiencies in food storage practices were identified. Dry goods such as a bag of powdered thickener and a box of cornstarch were found left open or inadequately sealed, exposing them to air. A large bag of enriched rice was only loosely rolled to close it, and an open box of sugar free syrup was stored on its side, resulting in one bottle leaking syrup onto the cardboard box and the floor. Additionally, two bags of frozen taco meat were found in the freezer without any labels or dates to identify their contents. The Dietary Manager confirmed that these items were not properly sealed or labeled as required by facility policy, which mandates that all dry storage items be dated and opened food items be labeled to maintain an expiration or use by dating system.
Failure to Assess and Respond to Bleeding in Anticoagulated Resident
Penalty
Summary
A resident with diagnoses including vascular dementia, cerebral infarction, and long-term use of anticoagulants was identified as being at risk for bleeding, with care plan interventions requiring staff to report any bruising or bleeding. During an observation, the resident was found to have a cut on the face with a small amount of blood, which appeared to be caused by a disposable razor during shaving. The nurse aide responsible for the shaving reported the incident to the nurse and cleaned the area, but the nurse did not assess the resident or document the incident, citing being too busy. The nurse also did not review the resident's record to determine anticoagulant use, despite being informed of the bleeding. Facility policy required observation for signs of bleeding in residents on anticoagulants and prompt notification of the practitioner for such findings. Additionally, the policy on physician notification for change of condition required assessment and intervention for significant clinical symptoms. The nurse involved did not follow these policies, as she neither assessed the resident nor notified the practitioner, and was unaware of the resident's anticoagulant therapy. The incident was further confirmed through staff interviews and review of facility policies.
Failure to Follow Physician Orders for Splint Application
Penalty
Summary
A deficiency occurred when staff failed to follow physician's orders regarding the application of hand splints for a resident diagnosed with multiple muscle contractures and severe cognitive impairment. The physician's orders and care plan specified that a left-hand orthotic should be applied with bedtime care and removed with morning care, with skin checks before and after application. Observations revealed that the resident was not wearing the left-hand splint as ordered, and the splint was found in a bedside basket instead. Documentation and interviews indicated that nurse aides and charge nurses did not consistently document or verify the application of splints, and the electronic charting system did not include splint assignments for the resident or others. Further investigation showed that the nurse aide responsible for the resident did not indicate the need for splints in the assignment roster or electronic documentation, and the charge nurse's documentation for the overnight shift made no mention of the splint. Interviews with staff confirmed that the splint was not applied as ordered during the relevant shift, and the facility's policy required splints to be applied per physician orders. The lack of proper documentation and communication among staff led to the failure to ensure the resident received the prescribed care to maintain or improve range of motion.
Failure to Ensure Safe Dialysis Care and Monitoring for Resident with Multiple Access Sites
Penalty
Summary
Staff failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who had both a left arm arteriovenous (AV) fistula and a central venous catheter (Permcath) for hemodialysis. The facility did not ensure that staff knew the location or contents of the required emergency kit, as the kit was not clearly labeled, was inconsistently stored, and lacked essential items such as a clamp for the Permcath. During an observation, an LPN was unable to locate the emergency kit and was unsure how to manage bleeding from the Permcath, indicating a lack of preparedness for emergencies related to the resident's specialized treatment access. The facility also failed to obtain and implement physician's orders for critical monitoring tasks, including vital signs, weight monitoring, and evaluation of both access sites before and after dialysis treatments. There was no clear documentation or physician's order specifying the care and evaluation required for the two separate access sites, and the electronic records did not prompt staff to complete these tasks. Additionally, the facility did not maintain the specialized treatment communication book or document vital signs, weights, or access site evaluations as required by facility policy on days when the resident received dialysis. Facility policies reviewed did not address the care of a Permcath (central line) used for dialysis, nor did they provide guidance for emergency situations involving this type of access. The care plan for the resident included interventions for the Permcath, but these were not supported by physician's orders or clearance from the dialysis provider. The lack of clear policies, orders, and documentation led to gaps in care and monitoring for the resident receiving specialized dialysis treatment.
Obstruction of Emergency Exits and Emergency Cart in Resident Lounge
Penalty
Summary
Emergency exits and an emergency response cart in the Webster lounge, located behind the nurse's station, were found to be obstructed by 18 wheelchairs lined up in rows, as well as a standard chair and a charging electric wheelchair. These obstructions prevented easy access to both the emergency exits and the emergency response cart. The wheelchairs had been relocated to the lounge overnight due to ongoing construction in the room where they were previously stored. During an observation and interview, a registered nurse acknowledged that the wheelchairs should not be placed in front of the emergency exit or the emergency cart. The administrator confirmed that there was an alternative storage room available next to the conference room where the wheelchairs could have been stored. The administrator also stated that residents should have access to the lounge on their unit, indicating that the current arrangement impeded resident access and use of the lounge overnight.
Failure to Enforce Smoking Policy and Proper Disposal of Smoking Materials
Penalty
Summary
The facility failed to consistently implement its smoking policy regarding the proper disposal of smoking materials. During a supervised smoking session, four residents participated, and four cigarette disposal containers were present. After the session, multiple cigarette butts were observed scattered on the concrete smoking patio, near the door, next to a disposal container, and along the remainder of the patio near the building. Additionally, over 50 cigarette butts were found on the pathways of the courtyard and in gravel flower beds next to the building, which contained green leafy plants and dried leaves. Staff interviews revealed uncertainty about why cigarette butts were scattered in these areas and inconsistent understanding of where residents were permitted to smoke, particularly regarding supervision and family visits. The Receptionist clarified that residents are not allowed to smoke with family in the courtyard unless on a leave of absence, and that visitors would not smoke in the courtyard due to video surveillance, although only the smoking patio was visible on the cameras. Housekeeping staff reported cleaning the patio daily and typically not finding many cigarette butts, but on this occasion, a significant number were present. The Administrator confirmed that the smoking patio should be cleaned daily and was unable to explain the presence of cigarette butts on the patio and in the gravel beds. Facility policy requires that smoking materials be extinguished safely, but observations indicated this was not consistently enforced.
Failure to Provide Accessible Grievance Forms and Timely Response to Resident Grievances
Penalty
Summary
The facility failed to promptly address residents' grievances and did not ensure that grievance forms were consistently available and accessible to all residents, including those who use wheelchairs. Minutes from a Residents Council meeting indicated that grievance forms were not replenished on resident units, and residents expressed that staff had not introduced themselves or explained the grievance process. During a subsequent Resident Council meeting, residents reported that grievances and recommendations were not responded to in a timely manner, and two residents confirmed that forms remained unavailable prior to the meeting. Observations on two units confirmed that grievance forms were not replenished and that information on how to fill out grievances was out of reach for wheelchair-bound residents. The facility's policy requires prompt efforts to resolve grievances within seven business days, but these procedures were not followed as observed and reported.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal funds accounts to two residents whose funds were managed by the facility. For one resident with chronic kidney disease, hypertensive heart disease with heart failure, depression, and dementia, who was severely cognitively impaired and dependent on staff for most activities of daily living, an interview with the responsible party revealed that they had never received a quarterly statement for the resident's personal funds and were unaware that such statements should have been provided. For another resident with chronic kidney disease, hypertensive heart disease with heart failure, peripheral vascular disease, and type 2 diabetes mellitus, who was cognitively intact but dependent on staff for care, the resident reported not having received any quarterly statements for personal funds since admission. The Business Office Manager, who was responsible for mailing and distributing the quarterly statements, was unable to provide evidence or verification that the statements had been mailed, printed, or delivered to the appropriate parties. Facility policy required that residents and responsible parties receive a quarterly accounting of their individual accounts, with statements to be sent at the end of each quarter. The deficiency was identified through review of clinical records, facility documentation, policy, and interviews.
Failure to Hold Required Quarterly Care Planning Meetings
Penalty
Summary
The facility failed to hold quarterly care planning meetings for three residents reviewed for care planning and restraints. For one resident with hypertensive heart disease, chronic kidney disease, and heart failure, the clinical record showed that the last documented care conferences were held in the previous year, with no further documentation for the current year. The resident, who was cognitively intact and dependent for personal hygiene and ADLs, reported not having been involved in a care planning meeting for a long time, though could not specify the exact timeframe. The care plan was revised, and a physician's order directed care as outlined in the plan, but required care conferences were not documented as held. For two other residents, one with gastrointestinal hemorrhage, dysphagia, and hemiplegia, and another with hereditary spastic paraplegia, depression, and dysphagia, similar deficiencies were observed. Both residents were dependent for all personal care and ADLs, and required tube feedings with monthly dietician evaluations. Their records showed that after initial care conferences, no further quarterly care conferences were documented for the current year. Interviews with facility staff confirmed that care conferences should be held quarterly after the MDS is completed, and a change in social workers may have contributed to the missed meetings. Facility policy required care conferences at least quarterly, but this was not followed for the residents reviewed.
Failure to Report Alleged Staff-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse to the State Agency as required by policy. A resident with diagnoses including cerebral palsy, anxiety, depression, and disruptive mood disorder was involved in an incident where they became verbally and physically aggressive, resulting in a transfer to the hospital. Subsequently, a report was received alleging that a nurse aide had used unprofessional and abusive language in the hallway, witnessed by several residents, visitors, and staff. Despite this, the facility did not submit a Reportable Event to the state agency. The Director of Nursing (DON) became aware of the alleged verbal abuse several weeks after the incident and conducted an internal investigation, collecting statements. The DON determined the allegation could not be substantiated and, as a result, did not report the incident to the State Agency, contrary to the facility's abuse policy, which requires all allegations of abuse to be reported promptly and thoroughly investigated.
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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