Parkway Pavilion Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Enfield, Connecticut.
- Location
- 1157 Enfield Street, Enfield, Connecticut 06082
- CMS Provider Number
- 075195
- Inspections on file
- 31
- Latest survey
- November 28, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Parkway Pavilion Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and moderate cognitive impairment was able to leave the facility unsupervised and travel to a group home over a mile away. Staff failed to monitor the resident's whereabouts for over an hour, and no current physician order allowed the resident to be outside independently. Additionally, a timely wander assessment was not completed despite recent wandering behaviors being documented.
A resident with a history of falls, fractures, cognitive impairment, and incontinence experienced multiple falls with serious injuries due to the facility's failure to implement adequate supervision and fall interventions. Although the care plan included some fall prevention measures, it did not include a toileting schedule despite the resident's frequent need for toileting and use of diuretics. Staff reported that the resident often attempted to transfer independently and did not consistently call for help, leading to repeated falls and injuries.
A resident with major depressive disorder and impaired cognition, who had expressed worsening depressive symptoms and a desire to leave, exited the facility unescorted by following a visitor out. Staff did not recognize or communicate the resident's increased risk, and the resident was later found at the end of the driveway, visibly emotional and expressing suicidal ideation. The facility failed to identify the resident as at risk for elopement and did not provide adequate supervision to prevent the incident.
Two residents with severe cognitive impairment and behavioral issues were involved in repeated physical altercations after one, who was blind and prone to wandering, entered the other's room. Despite prior incidents and staff awareness of these behaviors, care plans were not updated with new interventions to prevent further altercations, resulting in physical abuse and minor injuries.
Two residents with severe cognitive impairment were involved in multiple behavioral incidents, including physical altercations and wandering into others' rooms. Despite ongoing behavioral issues and changes in condition, care plans were not updated with new interventions after these events, contrary to facility policy and documented staff awareness of the behaviors.
A resident's credit card was used without authorization by a nursing assistant while the resident was hospitalized. The unauthorized charges amounted to approximately $600. The nursing assistant was identified by the police, arrested, and subsequently terminated from employment for violating the facility's zero-tolerance policy on abuse and misappropriation of resident property.
Two residents with cognitive impairments were involved in a physical altercation, but their care plans were not updated as required by facility policy. Despite a history of altercations, the care plans remained unchanged after the incident, which was identified during a record review. RN confirmed the oversight but did not provide an explanation.
The facility failed to ensure annual in-servicing and competencies training for nursing staff, as well as annual performance evaluations. The Fear of Retaliation in-servicing for 2023 lacked training materials, and performance evaluations were incomplete for some nurse aides, LPNs, and RNs. Additionally, the facility could not provide evidence of nurse aide competencies in care provision, except for specific tasks like IV therapy and tracheostomy.
The facility failed to maintain cleanliness in the Dietary Department and Nourishment Rooms, with issues such as discolored ceilings, unlabeled and undated personal food items, and sticky floors. Interviews revealed confusion over cleaning responsibilities, contributing to the deficiencies.
The facility failed to ensure AED pads were not outdated, as observed by a Building and Fire Safety Investigator. Although the outdated pads were replaced, the DNS confirmed there was no process or documentation for checking expiration dates. The facility's policy required recording expiration dates and performing maintenance checks, but a copy of the AED manual was not provided.
The facility did not ensure nurse aides completed the required 12 hours of annual training. The DNS could not provide evidence of the training due to the departure of the Staff Development Nurse responsible for it, resulting in the inability to locate the necessary documentation.
The facility failed to ensure timely physician response to pharmacy recommendations for several residents, leading to deficiencies in medication management. Recommendations for discontinuing duplicate medications, conducting necessary bloodwork, and evaluating psychotropic medication use were not addressed promptly. The facility lacked a tracking system to ensure timely follow-up on pharmacy recommendations, resulting in significant delays in physician responses and implementation of necessary actions.
A facility failed to maintain a safe and homelike environment for a resident, as observed by surveyors. The resident's room had a chipped wall, detached floorboard, and a brown-like substance, which had been reported to staff but not addressed. The Director of Maintenance was unaware of the issue and did not participate in monthly Environmental Rounds, which failed to identify the problem.
A resident with a history of cognitive impairment and altercations verbally abused another resident, calling them 'stupid' while both were in their beds. The abused resident, who has anxiety and muscle weakness, felt hurt by the incident. Despite the known history of the abusive resident, the facility's interventions were limited, and staff interviews revealed a lack of consistent monitoring and documentation as required by facility policy.
Two residents reported improper incontinent care by a nurse aide, who was not immediately removed from the facility as required by policy. The aide was attending an in-service training and was only sent home after the training, despite allegations of abuse. The facility's policy mandates immediate suspension of staff involved in such allegations to prevent retaliation.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in documenting their medical conditions and care needs. A resident with schizophrenia was not coded for MI/ID despite a positive PASRR outcome. Another resident was incorrectly coded as discharged to a hospital instead of home. Additionally, a resident's oxygen use was not accurately reflected in the MDS. These errors were identified through record reviews and staff interviews.
The facility failed to create comprehensive care plans for two residents with significant medical needs. One resident with a tracheostomy and using a non-mechanical ventilator did not have these needs reflected in their care plan. Another resident receiving hospice services lacked a documented hospice plan of care. These deficiencies were confirmed through record reviews and staff interviews.
A resident with CHF, cellulitis, and lymphedema had a care plan that was not updated to include daily weight monitoring and reporting of significant weight gain, as required by a physician's order. The facility's policy mandates care plan updates upon significant changes or readmissions, which was not followed, leading to the deficiency.
The facility failed to follow up on a resident's ENT appointment, did not consistently monitor another resident's weight as ordered, and lacked documentation for hospice evaluation for a third resident. These deficiencies involved issues with communication, documentation, and adherence to physician orders.
A facility failed to consistently change the bowel appliance for a resident with schizophrenia, Alzheimer's, dementia, and dysphagia, who was moderately cognitively impaired and used a colostomy. The resident reported that a nurse aide refused assistance and turned off the call bell without addressing needs. Records from mid-August to early September lacked documentation of appliance changes, and the DNS could not provide evidence of when it was last changed.
A resident with dysphagia, chronic kidney disease, and gastrointestinal hemorrhage experienced significant weight fluctuations, but the facility failed to re-weigh the resident within 24 hours as required by policy. Despite multiple weight changes exceeding 3 pounds, there was no documentation of re-weighing. Interviews revealed that the facility's practice involves nurse aides notifying nurses of weight changes, but a re-weigh did not occur, possibly due to agency staff being on duty.
The facility failed to provide adequate respiratory care and emergency preparedness for a resident with a tracheostomy and two residents requiring oxygen therapy. Supplies for a resident with a tracheostomy were unorganized, and no staff were trained for emergency tracheostomy replacement. Additionally, oxygen tubing for two residents was not dated and labeled as per facility policy.
A resident's psychosocial well-being was compromised when their missing wallet was not located in a timely manner. Despite being cognitively intact, the resident experienced stress and had to cancel credit cards and obtain new identification. The wallet was eventually found in a nursing supervisor's office closet, which staff had not initially searched, highlighting a lapse in the facility's search process.
A resident receiving hospice care for pancreatic cancer did not receive scheduled pain medications, including a fentanyl patch, due to unavailability. The nursing staff failed to obtain the medications from the emergency supply, and the facility lacked documentation of prescriptions being sent to the pharmacy. Interviews revealed a lack of recall and adherence to procedures for obtaining emergency medications.
A facility failed to limit PRN orders for psychotropic medication to 14 days for a resident with vascular dementia and other conditions. The resident was prescribed Lorazepam for anxiety/restlessness for 30 days without reassessment. Interviews with the APRN and Pharmacy Consultant confirmed the oversight, as the facility did not follow up on recommendations regarding the medication's duration.
The facility failed to ensure proper labeling and sanitary storage of medications. Observations revealed a soiled medication refrigerator with unlabeled food items and improperly stored items in medication carts, including expired reagents and unlabeled vials. Staff were unclear about cleaning responsibilities and proper storage procedures, contrary to facility policy.
The facility failed to properly dispose of garbage and refuse, with debris found around dumpsters, including a mattress with a brown substance, used gloves, and cigarette buds. Interviews revealed a lack of clarity on who was responsible for maintaining the area, with no existing policy in place. Some residents could independently access the grounds.
The facility did not conduct QAPI meetings quarterly or complete an annual PIP, as required. Interviews with the Administrator and staff revealed a lack of evidence for meetings from late 2023 to early 2024 and no PIP documentation for 2022-2024. The Administrator, not present during the deficiency period, could not explain the oversight.
A resident with Myotonic Muscular Dystrophy and acute respiratory failure required enhanced barrier precautions for tracheostomy care. An LPN failed to follow these precautions, as they were unaware of the resident's status, despite signage indicating the need. The facility lacked a specific policy for enhanced barrier precautions, leading to inadequate infection control practices.
A facility failed to ensure licensed staff were trained for emergency tracheostomy procedures for a resident with a tracheostomy tube and non-mechanical ventilator. The resident's care supplies were unorganized, and no care plan was in place for tracheostomy or AVAPS use. Staff interviews revealed no training had been provided for emergency tracheostomy replacement, leading to the resident's transfer to the emergency room.
Failure to Supervise and Timely Assess Resident for Wandering Risk
Penalty
Summary
The facility failed to provide adequate supervision and timely assessment to prevent a resident from leaving the premises without staff knowledge. A resident with diagnoses including Alzheimer's disease, schizoaffective disorder, and moderate cognitive impairment was last seen by staff and a visitor when going outside independently. The resident was not accounted for during lunch, and a search was initiated after staff realized the resident was missing. The resident was later found at a group home 1.2 miles away and returned to the facility without injury. There was no current physician order permitting the resident to sit outside independently, and staff were unaware of the resident's whereabouts for over an hour. Additionally, the facility did not complete a wander assessment in a timely manner. The last documented wander assessment for the resident was over 19 months prior, despite recent documentation of wandering behaviors by an APRN. Facility policy required supervision to prevent avoidable accidents, but staff failed to monitor the resident appropriately and did not reassess the resident's risk for wandering when new behaviors were identified.
Failure to Provide Adequate Supervision and Fall Interventions for High-Risk Resident
Penalty
Summary
A resident with a history of falls, fractures, cognitive impairment, and functional incontinence was admitted to the facility and identified as being at moderate to high risk for falls. Despite this, the resident experienced multiple falls resulting in significant injuries, including rib and wrist fractures, as well as a left femur fracture. The care plan identified several risk factors and interventions, such as keeping the bed in a low position, providing moderate assistance, and ensuring the call bell was within reach. However, the care plan failed to implement a toileting schedule, even though the resident was frequently incontinent and required increased toileting due to diuretic use. Staff interviews and documentation revealed that the resident often attempted to transfer independently, especially to use the bathroom, and did not consistently call for assistance, leading to repeated falls. The facility's documentation and staff interviews indicated that, although the resident was placed on 15-minute safety checks after multiple falls, these checks were insufficient to prevent further incidents. Staff reported that the resident was impulsive, forgetful, and would get up quickly without waiting for help, even when staff were nearby or monitoring the resident. The resident was observed ambulating without staff assistance on several occasions, and staff acknowledged that the only way to ensure the resident did not get up alone would be to provide one-to-one monitoring, which was not consistently implemented. The care plan was updated after each fall, but the lack of a scheduled toileting program persisted despite ongoing evidence that the resident's attempts to toilet independently contributed to the falls. The facility's fall and fall risk policy required staff to identify and implement interventions specific to the resident's risks and to re-evaluate and change interventions if falls continued. Despite this policy, the resident continued to fall, and the interventions in place did not adequately address the resident's needs, particularly regarding toileting assistance. The failure to implement a toileting schedule and provide adequate supervision and interventions for a resident at high risk for falls resulted in repeated accidents and serious injuries.
Failure to Prevent Unescorted Exit of Resident with Depressive Symptoms
Penalty
Summary
A resident with a history of major depressive disorder, cerebral infarction, repeated falls, hemiplegia, and muscle weakness expressed worsening depressive symptoms related to being in the facility. The resident had a moderately impaired cognitive status, as indicated by a BIMS score of 8, and had previously verbalized feelings of hopelessness and a desire not to be in the facility. The care plan included interventions for suicidal ideation, such as social service visits, identifying triggers, and encouraging participation in activities, but did not identify the resident as at risk for elopement. Despite expressing increased depressive symptoms and a desire to leave the facility to the social worker, this information was not communicated to nursing staff or the provider. On the day of the incident, the resident was observed by staff fully dressed and wearing a coat in the lobby, which was unusual for them, but this was not recognized as a potential sign of intent to leave. Later, the resident exited the building unescorted by following a visitor out during a period when the front doors were temporarily unlocked, and was found in their wheelchair at the end of the driveway, visibly emotional and expressing suicidal ideation. Staff interviews revealed that the social worker did not report the resident's increased depressive symptoms because the resident had not explicitly stated an intent or plan to leave. The Director of Nursing Services was unaware of the resident's recent expressions of not wanting to be in the facility. The facility's policy required staff to identify residents at risk for unsafe wandering or elopement, but the resident was not identified as such prior to the incident, resulting in a failure to provide adequate supervision and prevent the resident from leaving the facility unescorted.
Failure to Update Care Plans After Resident-to-Resident Altercations
Penalty
Summary
The facility failed to protect a resident with a history of wandering and behavioral issues from physical abuse by not implementing effective interventions after repeated incidents. One resident, diagnosed with epilepsy, major depressive disorder, and dementia, had severely impaired cognition and was known to display physical and verbal aggression. This resident's care plan included general interventions such as medication administration, anticipating needs, and intervening to protect others, but did not address specific risks related to altercations with other residents who entered their room. Another resident, also with severe cognitive impairment, blindness, and a history of wandering into other residents' rooms, was involved in multiple incidents where they entered the first resident's room. Despite documentation of these behaviors and previous altercations, the care plan for the wandering resident was not updated with new interventions after these events. Staff interviews confirmed that the wandering behavior was longstanding and that redirection was the primary intervention used, but no additional measures were implemented following the incidents. On one occasion, the wandering resident entered the other resident's room, leading to a physical altercation in which both residents struck each other, resulting in minor injuries and hospital evaluations. Facility documentation and policy review indicated that care plans should be updated with new interventions following such incidents, but this was not done. The Director of Nursing confirmed that she would expect new interventions to be added if current ones were ineffective, but this did not occur, constituting a failure to protect residents from abuse.
Failure to Update Care Plans After Resident Altercations and Wandering
Penalty
Summary
The facility failed to revise and update care plans for two residents following significant behavioral incidents, including resident-to-resident altercations and wandering behaviors. For one resident with diagnoses of epilepsy, major depressive disorder, and dementia, the care plan was not updated after the resident was involved as the aggressor in a physical altercation with another resident. Despite new psychiatric evaluations and medication changes following the incident, the care plan did not reflect new or modified interventions to address the resident's aggressive behaviors. Another resident, also with dementia and additional psychiatric diagnoses, exhibited wandering behaviors and was involved in multiple incidents of entering other residents' rooms, which led to altercations. Nursing notes and staff interviews confirmed a pattern of wandering and difficulty redirecting the resident, yet the care plan was not updated with new interventions to address these behaviors. The resident's care plan continued to list general interventions without incorporating specific strategies to mitigate the risk of further incidents. Facility policies reviewed in the report directed that care plans should be revised when residents' conditions change or when current interventions are not effective. The interdisciplinary team was expected to update care plans in response to new behavioral episodes or when desired outcomes were not met. However, documentation and interviews revealed that care plans for both residents were not revised after the incidents, and new interventions were not implemented as required by facility policy.
Unauthorized Use of Resident's Credit Card by Staff
Penalty
Summary
The facility failed to protect a resident from the wrongful use of their belongings, specifically a credit card, which led to unauthorized charges. A resident with no cognitive impairment was hospitalized, and during their absence, their credit card was used for unauthorized transactions totaling approximately $600. The resident's family reported the fraudulent activity to the police, who identified a nursing assistant (NA) as the individual responsible for the charges. The NA claimed to have saved the card information on her phone after making a purchase for the resident at their request, which she then used for personal expenses. The facility's documentation and interviews revealed that the NA was arrested and charged with larceny. The facility's policies clearly state a zero tolerance for abuse or misappropriation of resident property, and the NA's actions were in direct violation of these policies. The incident was reported to the police, and the NA's employment was terminated following the identification of her involvement in the fraudulent activity.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the care plans for two residents following an incident of physical altercation. Resident #2, diagnosed with dementia, mood disorder, and psychotic disorder, was identified as severely cognitively impaired and ambulated independently with a rolling walker. Resident #3, with diagnoses including cognitive communication deficit, adjustment disorder, anxiety, and restlessness, was also severely cognitively impaired and independent with wheelchair mobility. On 10/21/2024, Resident #2 entered Resident #3's room, leading to Resident #3 physically shaking Resident #2. Although the residents were separated without injuries, the care plans for both residents were not updated to reflect this incident. The facility's policy requires that care plans be updated to incorporate identified problem areas and risk factors. Despite a history of altercations between the two residents, the care plans were not revised after the incident on 10/21/2024. Interviews with RN #1 confirmed that the care plans should have been updated, but no explanation was provided for the oversight. The failure to update the care plans was identified during a record review on 11/12/2024, 23 days after the incident, indicating a lapse in adhering to the facility's care plan policy.
Deficiency in Staff Training and Performance Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff completed required in-servicing and competencies training annually, as well as annual performance evaluations. During a review of facility documentation and staff interviews, it was found that the Fear of Retaliation in-servicing for 2023 was conducted without utilizing any training materials, although staff members reviewed and signed the facility policy. For 2024, documentation was provided using the Hand in Hand electronic media and signature sheets. Additionally, an interview with the HR Manager revealed that performance evaluations were not completed for one of three nurse aides and two of three LPNs, as well as two RNs, based on their hire dates ranging from 2005 to 2018. The HR Manager was unable to explain why these evaluations were not completed. Furthermore, the facility could not provide evidence of nurse aide competencies related to providing care, except for specific tasks such as IV therapy, tracheostomy, and changing a tracheostomy.
Deficiencies in Dietary and Nourishment Room Sanitation
Penalty
Summary
The facility failed to maintain the Dietary Department and Nourishment Rooms in a clean and sanitary manner, as observed during a tour conducted on September 4, 2024. In the kitchen, the ceiling was discolored with a grayish-brown substance hanging around the lights and ductwork. In the Central Nourishment Rooms, a resident's ice pack was found in the freezer, and there were discolored red and brown substances noted along the shelves and inside the doors. The East Wing Nourishment Rooms had brown substances on the refrigerator shelves and doors, and personal food items were found unlabeled, undated, and with freezer burn. Additionally, a bowl of cereal was left on the counter without a label or date. In the TCU Nourishment Rooms, a turkey sandwich was found in the refrigerator without a date, and packages of crackers were on the floor. The floor outside the refrigerators was sticky. Interviews with the Director of Housekeeping, Director of Dietary, and Dietary Manager revealed confusion over cleaning responsibilities, with the Dietary Department responsible for refrigerator cleaning and Housekeeping for the Nourishment Rooms. The Maintenance Director acknowledged the ceiling needed cleaning, but there was a lack of clarity on who was responsible for this task. The facility's policy required dietary staff to label and date items and clean spills, but these procedures were not followed, leading to the observed deficiencies.
Outdated AED Pads and Lack of Expiration Check Process
Penalty
Summary
The facility failed to ensure that the Automated Emergency Defibrillator (AED) equipment pads were not outdated. During an observation on September 5, 2024, it was noted by the Building and Fire Safety Investigator that the AED on the center unit had outdated pads, which were subsequently replaced by the facility. On September 10, 2024, an interview and observation with the Director of Nursing Services (DNS) confirmed that the AED on the center unit now had pads dated June 8, 2025, indicating that the outdated pads had been replaced. However, it was also revealed that the AED on the Transitional Care Unit (TCU) was new as of three months ago, with pads dated June 24, 2025. The DNS acknowledged that although any nurse could check the AED and pads for expiration dates, there was no established process or documentation for checking the expiration dates of the pads. The facility's policy and procedure for the Automatic External Defibrillator, Use and Care, required keeping a spare battery and adhesive pads in the case, recording the expiration date of the battery and pads on the maintenance tag or log, and storing it with the device. The policy also required checking the device and performing maintenance tasks as directed, including documenting checks, maintenance steps, and the date performed on the maintenance log, and storing the log with the device. A copy of the AED manual was requested but not provided.
Failure to Document Nurse Aide Training
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of annual training. During an interview with the Director of Nursing Services (DNS) on September 11, 2024, it was revealed that although nurse aide training had occurred, the Staff Development Nurse responsible for the training was no longer employed by the facility. Consequently, the DNS was unable to provide evidence of the completion of the required in-service training hours for 2024, as the training documentation could not be located.
Delayed Physician Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely physician response to pharmacy recommendations for several residents, leading to deficiencies in medication management. For Resident #6, the pharmacy recommended discontinuing a duplicate Acetaminophen order and conducting baseline and annual bloodwork for lipid monitoring due to statin use. However, the physician did not respond to these recommendations, resulting in a delay of over four months for the discontinuation of the duplicate medication and two months for the lipid monitoring. Resident #22 was prescribed Lorazepam as needed, but the pharmacy recommended evaluating the necessity of this psychotropic medication, as such orders should not exceed 14 days without documented rationale. The physician did not review or sign off on this recommendation, and the order was eventually discontinued over a month later without documented physician input. The facility lacked a tracking system to ensure timely follow-up on pharmacy recommendations, as confirmed by interviews with the Assistant Director of Nursing Services (ADNS). For Resident #65, a pharmacy recommendation to adjust the timing of Linzess administration was not addressed until after surveyor inquiry, despite being issued months earlier. Similarly, Resident #103 had multiple pharmacy recommendations regarding monitoring for side effects of medications, such as anticoagulants and diuretics, which were not acted upon in a timely manner. The facility's policy required action on recommendations within 30 days, but this was not consistently followed, as evidenced by the significant delays in physician responses and the lack of a systematic approach to track and verify the implementation of pharmacy recommendations.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a homelike, clean, and safe environment for a resident in the East South wing. During an initial facility tour, it was observed that the lower wall behind the resident's bed had a large area of chipped paint, a detached floorboard panel, and a brown-like substance on the wall and floor. The resident reported this condition to staff members but could not recall their names. The Director of Maintenance was unaware of the wall's condition and did not participate in the monthly Environmental Rounds. Although staff may have mentioned the wall needing repair, it was forgotten. The Environmental Round logs for several months did not identify the wall's need for repair, despite the facility's policy requiring monthly rounds with a Maintenance Representative.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving two residents. Resident #6, who has a history of psychosis, dementia, and depression, was identified as severely cognitively impaired and had a history of physical altercations with other residents. Despite these known issues, Resident #6 verbally abused Resident #110 by calling them 'stupid' while both were in their beds with the curtain open. Resident #110, who suffers from generalized muscle weakness and anxiety disorder, expressed feeling hurt by the verbal abuse. The incident was observed by a surveyor, and it was noted that Resident #6 had a history of altercations, yet the facility's interventions were limited to separating the residents and redirecting Resident #6. Interviews conducted with staff and residents revealed that Resident #6 did not recall the verbal altercation, and Resident #110 also did not recall any aggression. However, a Licensed Practical Nurse acknowledged Resident #6's past altercations and described typical interventions such as redirection with snacks or activities. An Advanced Practice Registered Nurse attributed Resident #6's behaviors to impulsiveness and frustration intolerance, but did not consider them an immediate danger. The facility's policy required close monitoring and documentation of residents involved in altercations, which was not adequately followed in this case, leading to the deficiency.
Failure to Immediately Remove Alleged Abuser
Penalty
Summary
The facility failed to protect residents from abuse by not immediately removing an alleged staff member from the facility as per their policy. Resident #89, who has diagnoses including polyneuropathy, chronic pain, Type 2 diabetes mellitus, and anxiety disorder, reported that Nurse Aide (NA) #5 did not provide proper incontinent care and mishandled personal items. Despite the report being made at 1:00 PM, NA #5 was not immediately removed from the facility, as they were attending an in-service training and were only sent home after the training concluded. The facility's policy requires immediate suspension of staff involved in allegations to prevent retaliation, which was not adhered to in this case. Similarly, Resident #106, who has multiple diagnoses including Multiple Sclerosis and morbid obesity, reported that NA #5 applied two briefs without providing proper incontinent care, causing discomfort and pain. The resident also mentioned that this was a recurring issue with the aide. The Director of Nursing Services (DNS) confirmed that NA #5 was in the facility for an in-service training before being notified of the allegations, and acknowledged that the facility's abuse policy was not followed as the aide should have been removed immediately pending investigation.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment coding for three residents, leading to deficiencies in the documentation of their medical conditions and care needs. Resident #74, diagnosed with schizophrenia and unspecified intellectual disabilities, was not accurately coded on the MDS to reflect a diagnosis of mental illness/intellectual disability (MI/ID) despite having a positive Preadmission Screening and Resident Review (PASRR) Level II outcome. This oversight was acknowledged by the social worker responsible for the coding. Similarly, Resident #121, who was admitted with atrial fibrillation and hypertension, was incorrectly coded as discharged to an acute hospital when the resident was actually discharged home with family. This error was identified by the registered nurse responsible for discharge coding. Additionally, Resident #79, with diagnoses including heart failure and anxiety, was not accurately coded for oxygen use on the MDS, despite having a care plan that included interventions for non-compliance with oxygen use. The licensed practical nurse responsible for the coding acknowledged the error, which was later corrected. These inaccuracies in MDS coding were identified through clinical record reviews and staff interviews, highlighting a failure in the facility's assessment processes.
Deficiencies in Care Planning for Respiratory and Hospice Needs
Penalty
Summary
The facility failed to ensure that the care plan for a resident with respiratory needs was comprehensive and reflective of the resident's requirements. The resident, diagnosed with a muscle disorder, acute respiratory failure with hypoxia, and obstructive sleep apnea, had a tracheostomy and used a non-mechanical ventilator (AVAPS). Despite these significant medical needs, the care plan did not initially include interventions for tracheostomy care or the use of the AVAPS. This oversight was identified during a review of the clinical records and confirmed through interviews with the Assistant Director of Nursing Services and the MDS Nurse, who acknowledged that the tracheostomy and AVAPS care had been overlooked in the care plan. Additionally, the facility did not develop a comprehensive care plan for a resident receiving hospice services. The resident, who had diagnoses of emphysema, chronic obstructive pulmonary disease, and dementia, was identified as severely cognitively impaired and required extensive assistance with daily activities. Although a physician's order directed hospice services to evaluate and admit the resident, there was no hospice plan of care documented in the resident's records. This deficiency was confirmed through an interview with the Director of Nursing Services, who could not locate any hospice plan of care or records of care conferences.
Failure to Update Care Plan for CHF Monitoring
Penalty
Summary
The facility failed to update and revise the care plan for a resident with a history of Congestive Heart Failure (CHF), cellulitis, and lymphedema. The resident was admitted to the facility and later readmitted after a hospital stay. A physician's order required daily weight monitoring for CHF, with instructions to notify the physician if there was a significant weight gain. However, the care plan did not include these directives, which are crucial for managing the resident's CHF. During an interview, a registered nurse acknowledged that the care plan lacked the necessary reference for daily weight monitoring and reporting weight gain as part of CHF management. The facility's policy mandates that care plans be reviewed and updated when there is a significant change in a resident's condition, upon readmission from a hospital stay, and at least quarterly. The failure to update the care plan as required by the facility's policy led to the deficiency identified in the report.
Deficiencies in Resident Care and Follow-Up
Penalty
Summary
The facility failed to follow up on a resident's Ear, Nose, and Throat (ENT) appointment as per the physician's order. The resident, who had chronic kidney disease, COPD, and unspecified hearing loss, was experiencing ear pain due to wax buildup. Despite being cognitively intact and having reported the pain multiple times, the resident was told to wait for a specialist evaluation. The Licensed Practical Nurse (LPN) attempted to contact the ENT office once but did not follow up or notify the nursing supervisor. The appointment was only scheduled after a surveyor inquiry, and the facility did not provide a policy for facilitating community specialty service referrals. Another resident with congestive heart failure and lymphedema had a physician's order for daily weight monitoring, which was not consistently followed. The resident required two people to obtain weight using a mechanical lift, and weights were not documented on several occasions. The nursing supervisor was unaware of the missed weights, and staff shortages contributed to the issue. The facility's policy required documentation if a weight was refused or not obtained, but this was not adhered to. A third resident, diagnosed with emphysema, COPD, and dementia, did not have a care plan for hospice services despite a physician's order for hospice evaluation. The nurse contacted the hospice vendor as directed by the medical doctor, but there was no documentation of the hospice evaluation in the clinical record. The Director of Nursing Services (DNS) could not explain the absence of hospice documentation.
Failure to Consistently Change Bowel Appliance for Resident
Penalty
Summary
The facility failed to consistently change the bowel appliance for a resident diagnosed with schizophrenia, Alzheimer's disease, dementia, and dysphagia, who was identified as moderately cognitively impaired. The resident utilized a colostomy and required assistance with activities of daily living (ADL), receiving physical therapy five times a week and occupational therapy four times a week. On one occasion, the resident reported to a nurse that a nurse aide refused to assist with the bowel appliance and turned off the call bell without addressing the resident's needs. A review of the Treatment Administration Records (TAR) and Medication Administration Record (MAR) from August 15, 2024, to September 10, 2024, showed no documentation of when the resident's bowel appliance was changed. Additionally, the nurse's notes during this period also failed to record any changes to the bowel appliance. The Director of Nursing Services (DNS) could not provide evidence of when the appliance was last changed, leading to the deficiency being identified.
Failure to Re-Weigh Resident After Significant Weight Change
Penalty
Summary
The facility failed to adhere to its policy of re-weighing a resident within 24 hours of a significant weight change. Resident #65, who has diagnoses including dysphagia, chronic kidney disease, and gastrointestinal hemorrhage, experienced multiple weight fluctuations. The resident's weight changed by more than 3 pounds on several occasions, specifically between 7/5/24 and 7/12/24, and again between 7/31/24 and 8/7/24. Despite these fluctuations, there was no documentation or evidence that the resident was re-weighed within the required 24-hour period as per the facility's policy. Interviews with the Registered Dietician and the Director of Nursing Services (DNS) revealed that the facility's practice involves nurse aides notifying nurses of weight changes, who then document these in the medical record software. The DNS acknowledged that a re-weigh should have occurred on 7/13/24 following a significant weight loss of 23.8 pounds but was unsure why it did not happen, suggesting that agency staff might have been on duty at the time. The facility's Weight Measurement Policy, dated 8/17/18, mandates that weights with a 3-pound gain or loss be verified within 24 hours, which was not followed in this case.
Deficiencies in Respiratory Care and Emergency Preparedness
Penalty
Summary
The facility failed to ensure that supplies were readily available for a resident with specific respiratory needs in the event of an emergency. Resident #72, who has a tracheostomy and uses a non-mechanical ventilator, did not have a care plan in place for tracheostomy or ventilator use and care. During an observation, it was noted that the resident's care supplies were unorganized, making it difficult to locate necessary items quickly in an emergency. Additionally, no licensed staff had been trained to replace a tracheostomy in an emergency, and the facility lacked the necessary smaller size tracheostomy tube for emergencies. The facility also failed to ensure that oxygen tubing for two residents was dated and labeled according to facility practice. Resident #79, who has heart failure and other conditions, was observed with an unlabeled oxygen cannula on the floor. The staff responsible for labeling and dating the tubing could not explain why it was not done. Similarly, Resident #112, who has respiratory failure and other conditions, was found using oxygen tubing that was not changed and labeled as required by the physician's orders. These deficiencies highlight a lack of organization and adherence to facility policies regarding respiratory care. The absence of a care plan for Resident #72's tracheostomy and ventilator use, along with the failure to date and label oxygen tubing for Residents #79 and #112, indicates a significant oversight in ensuring proper respiratory care and emergency preparedness.
Failure to Timely Locate Resident's Missing Property
Penalty
Summary
The facility failed to promote the psychosocial well-being of a resident by not locating the resident's missing property in a timely manner. The resident, who was cognitively intact and required supervision for bed mobility, reported that their wallet was missing and believed it might have been left with a family member. Despite this, the wallet was later found in a closet in the nursing supervisor's office, a location that staff did not initially search. The Director of Nursing Services (DNS) indicated that staff did not expect the wallet to be there, and it was revealed that no staff had searched the nursing supervisor's closet during the investigation. The resident expressed feeling overwhelmed and stressed due to the incident, which led to the cancellation of all credit cards and the need to obtain new identification. The expectation, as stated by a registered nurse, was that staff should have searched the nursing office as a potential storage place for residents' items. This oversight in the search process contributed to the resident's distress and the delay in resolving the issue.
Failure to Provide Pain Medication for Hospice Resident
Penalty
Summary
The facility failed to provide routine and emergency pain medication for a resident receiving end-of-life hospice services. The resident, diagnosed with pancreatic cancer and diabetes mellitus type II, was admitted from home and was initially alert, oriented, and independent in self-care, with no reported pain. The medication orders included acetaminophen, morphine sulfate, and a fentanyl patch for pain management. However, the facility did not ensure the availability of these medications, particularly the fentanyl patch, which was due to be changed but was not administered due to unavailability. The nursing staff, including an LPN and RN supervisors, were aware of the medication orders but failed to obtain the necessary medications from the emergency controlled medications box when they were not available from the pharmacy. The Director of Nursing Services, who was not employed at the time of the incident, confirmed that the medications were never received from the pharmacy and expected the staff to use the emergency supply. The Medical Director also indicated that prescriptions for controlled drugs should be filled and expected the resident to receive all medications as ordered. Interviews with the nursing staff revealed a lack of recall regarding the incident, but they acknowledged the procedure to follow when medications are unavailable, which includes checking the emergency supply and contacting the pharmacy. The facility's policy required medications to be administered only upon written order, but there was no policy provided for the availability and use of emergency controlled medications. The pharmacy confirmed that no prescriptions for the required medications were sent during the resident's stay.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to adhere to the regulatory requirement of limiting PRN orders for psychotropic medications to 14 days unless reassessed and justified for continued use. This deficiency was identified in the case of a resident diagnosed with vascular dementia, hyperlipidemia, and type 2 diabetes mellitus, who was cognitively impaired and dependent on staff for daily activities. The resident's care plan included the use of anti-anxiety medication for restlessness, with a physician's order to administer Lorazepam as needed for 30 days. However, the facility did not reassess the need for this medication within the 14-day period as required. Interviews with the APRN and Pharmacy Consultant confirmed the oversight, noting that the facility did not follow up on the pharmacy's recommendations regarding the medication's duration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled appropriately and stored in a clean and sanitary environment. During an observation of the East Medication Room, the medication refrigerator was found to be visibly soiled with brown, flaky residue and sticky pink residue, making it difficult to open one of the drawers. The refrigerator also contained unlabeled vanilla ice cream cups and frozen water bottles, which were not supposed to be stored there. The LPN present was unaware of the residue's origin or duration and indicated that housekeeping was responsible for cleaning the room but not the refrigerator. The nursing supervisor confirmed that the refrigerator should be clean and that food should not be stored in the medication room. Additionally, the medication carts were found to contain items that were improperly stored. One cart had nail clippers, an expired COVID-19 antigen reagent bottle, and aerosol air fresheners, which were not supposed to be there. Another cart contained a multidose vial of Lidocaine without a top cover, resident label, or date of opening. The LPNs involved were unsure of the proper storage procedures for these items. The facility's policy stated that medications should be stored separately from food and that nursing staff were responsible for maintaining a clean and sanitary environment, but these guidelines were not followed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed by surveyors. During an inspection, numerous debris were found alongside the dumpsters and facility, including a discarded mattress with a brown substance, used gloves, cigarette buds, plastic cups, bags, and bottles. Interviews with the Dietary Director, Maintenance Director, and Environmental Director revealed a lack of clarity regarding responsibility for maintaining the area around the dumpsters. The Dietary Director admitted the area was not well kept and was unsure who was responsible for its maintenance. Similarly, the Maintenance Director confirmed the dumpsters were emptied twice a week but was also unsure of who was responsible for the area. An RN stated that all staff were responsible for picking up around the dumpsters, but there was no existing policy. The DNS noted that some residents could independently access the grounds outside.
Failure to Conduct QAPI Meetings and Annual PIP
Penalty
Summary
The facility failed to ensure that Quality Assurance and Performance Improvement (QAPI) meetings were conducted at least quarterly, and that a Performance Improvement Plan (PIP) was completed annually. During an interview with the Administrator, the Director of Nursing Services (DNS), and a registered nurse, it was revealed that there was no evidence of QAPI meetings from October 2023 through February 15, 2024. Additionally, there was no documentation of a PIP being performed in 2022, 2023, or 2024. The Administrator, who was not present at the facility during the time of the deficiency, could not provide an explanation for the oversight. The facility's policy on QAPI indicated that prioritizing identified quality issues and determining which would become a focus of PIPs is a crucial step in the process.
Failure to Implement Enhanced Barrier Precautions for Tracheostomy Care
Penalty
Summary
The staff at the facility failed to implement appropriate infection control techniques for a resident requiring tracheostomy care. The resident, who was diagnosed with Myotonic Muscular Dystrophy, acute respiratory failure, and muscle weakness, was identified as cognitively intact and required maximum assistance for daily activities. A physician's order directed that tracheostomy care be provided twice daily, and the resident's care plan specified the use of enhanced barrier precautions, including wearing a gown and gloves during care. However, during an observation of tracheostomy care, an LPN did not initially follow these precautions, as they were unaware of the resident's status requiring enhanced barrier precautions. The LPN gathered supplies and began the procedure without wearing a gown, only using gloves. Upon intervention by a surveyor, the LPN was informed of the enhanced barrier precautions sign outside the resident's room, which they had not noticed. The LPN then contacted a supervisor to confirm the resident's status. An interview with another RN revealed that the facility had a system of signage to indicate which residents required enhanced barrier precautions, but the LPN did not adhere to this system. Additionally, the facility failed to provide a specific policy for enhanced barrier precautions, only offering generic information that did not adequately guide staff in infection control practices for residents requiring tracheostomy care.
Lack of Emergency Tracheostomy Training and Supplies
Penalty
Summary
The facility failed to ensure that licensed staff were adequately trained to provide emergency procedures for a resident requiring specialized respiratory care. Resident #72, who had a tracheostomy tube and utilized a non-mechanical ventilator, did not have a care plan in place for tracheostomy or AVAPS use and care. The resident's diagnosis included a muscle disorder with generalized muscle weakness, acute respiratory failure with hypoxia, and obstructive sleep apnea. Despite physician orders for tracheostomy care, the facility did not have organized supplies readily available for emergencies, and staff were not trained to replace a tracheostomy in an emergency. During an observation and interview, it was noted that the resident's care supplies were unorganized, making it difficult to locate necessary items in an emergency. An Ambu bag was attached to the resident's wheelchair, but spare tracheostomy tubes were difficult to find. Interviews with staff revealed that no licensed staff had been trained to replace a tracheostomy in an emergency, and the facility's policy required a tracheostomy tube of the same size and one size smaller to be kept at the bedside. The lack of training and organization of supplies led to the decision to transfer the resident to the emergency room until the situation could be rectified.
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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