Pierce Memorial Baptist Home, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Brooklyn, Connecticut.
- Location
- 44 Canterbury Road, Brooklyn, Connecticut 06234
- CMS Provider Number
- 075243
- Inspections on file
- 19
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pierce Memorial Baptist Home, Inc. during CMS and state inspections, most recent first.
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 dependent on staff for transfers and personal care, with a history of chronic osteomyelitis and mobility issues, experienced pain during a mechanical lift transfer for a shower. Despite repeatedly refusing to continue due to pain in a previously operated leg, staff proceeded with the transfer and shower, failing to honor the resident's right to refuse treatment as outlined in facility policy.
A resident dependent on staff for transfers was moved using a mechanical lift with a sling that was too small, contrary to care plan requirements. Staff experienced difficulty positioning the resident, causing pain to a previously operated leg, and the resident's leg struck a bedside table during the process. The sling was not properly supporting the resident, and a latch slipped during the return transfer, resulting in a near fall that required staff intervention. The DON confirmed the incorrect sling size and improper placement contributed to the incident.
A resident dependent on staff for transfers was improperly moved using a mechanical lift by two nurse aides, one of whom was in training. The aides used an incorrectly sized sling and did not follow proper procedures, resulting in pain and a near fall for the resident. The facility lacked a formal training protocol for mechanical lift use, and staff training was undocumented and informal, contrary to facility policy requiring trained caregivers and correct equipment.
A resident with a history of accusatory behaviors and multiple psychiatric and neurological diagnoses required two staff members for all care, as specified in their care plan. On one occasion, only one nurse aide provided care, contrary to the care plan and facility policy. The incident was reported after the resident alleged rough handling, and documentation confirmed the care plan was not followed.
A resident with dementia and aortic valve stenosis experienced respiratory issues and a low-grade fever, but the facility failed to notify the on-call provider as required. The LPN informed the RN supervisor, who did not contact the physician or APRN, contrary to the facility's policy.
A resident with dementia and aortic valve stenosis experienced respiratory distress and a fall, but the RN supervisor failed to conduct a timely assessment despite being notified by an LPN. The facility's policy requiring RN assessment for changes in condition was not followed.
The facility failed to properly label, date, and discard expired food items, and did not maintain cleanliness in food storage areas. Observations revealed expired and unlabeled food in the walk-in freezer and refrigerator, as well as sticky stains in the resident's nutritional refrigerator. The FSD and LPN acknowledged these issues, with the FSD responsible for ensuring outdated food was discarded.
A facility failed to develop comprehensive care plans for two residents. One resident on anticoagulant therapy lacked a care plan addressing side effects and monitoring, while another resident using heel floating boots for a foot wound had no documented care plan or order specifying their use. The facility's policies required timely updates to care plans, but these were not implemented, leading to deficiencies in meeting the residents' needs.
A facility failed to develop a comprehensive care plan for a resident identified as an elopement risk. Despite being placed with a wander guard, the resident was found outside alone multiple times, and the care plan did not reflect the elopement risk or the presence of the wander guard. Inconsistencies in monitoring and documentation contributed to the deficiency.
A resident with intact cognition and using a walker was found off the unit multiple times, despite being initially assessed as not at risk for wandering. The facility failed to consistently monitor the placement and functionality of the resident's wanderguard, leading to elopement incidents. Staff interviews revealed a lack of awareness and documentation regarding the resident's elopement attempts, contributing to the deficiency.
A facility failed to maintain sanitary care of nebulizer equipment for a resident with respiratory conditions. The nebulizer machine and components were found uncovered and undated, contrary to policy. Staff interviews revealed that equipment should be dated and stored properly, but records showed a lack of documentation for nebulizer care.
The facility failed to maintain complete hospice records for a resident with congestive heart failure, lacking essential documents like the Plan of Care and Certificate of Terminal Illness. Additionally, another resident's advanced directive consent form was missing from the medical record after a code status change to DNR/DNI. Interviews revealed a lack of clarity and adherence to policies regarding document filing and accessibility.
The facility failed to implement Enhanced Barrier Precautions for residents with MDROs and indwelling devices, despite knowing the deadline. A resident with a history of C-diff was not properly logged or cohorted, contrary to policy. The Infection Preventionist Nurse acknowledged oversight, and the DON expected proper review and cohorting.
A facility failed to review and revise the care plan for a high-risk resident after multiple falls. Despite the resident's history and the facility's policy, the care plan was not updated after falls on four separate occasions, leading to repeated incidents without new interventions.
The facility failed to document complete skin assessments for a resident with potential for impairment to skin integrity. Despite multiple falls and the presence of bruises and skin tears, the necessary assessments, including size, color, and description, were not conducted as required by the facility's policies. Additionally, unexplained puncture marks on the resident's leg were not documented or addressed.
A facility failed to consistently document a high-risk resident's location on observation sheets during every fifteen-minute monitoring. Despite interventions in the care plan, documentation gaps were found on multiple dates and shifts. The DON was unaware of these lapses and confirmed no policy for the monitoring protocol.
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.
Resident's Right to Refuse Treatment Not Honored During Painful Transfer
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's right to refuse treatment during a transfer and shower. The resident, who had diagnoses including chronic osteomyelitis, anxiety, and abnormal gait and mobility, was dependent on staff for transfers and personal care. According to clinical records and interviews, the resident initially agreed to a transfer using a mechanical lift for the purpose of showering, but began to refuse the transfer and shower after experiencing pain in the right leg, which had previously undergone surgery. Despite the resident's repeated requests to stop due to pain, staff continued with the transfer and proceeded with the shower. Documentation and interviews confirmed that one nurse aide continued the transfer process even after the resident expressed refusal and discomfort, while another aide was present and in training. The incident was reported by the resident and corroborated by facility documentation, which indicated that the resident's rights to refuse treatment were not upheld. The facility's own policies and the Residents' Rights documentation specify that residents have the right to request, refuse, and discontinue treatment, which was not followed in this instance.
Failure to Use Correct Mechanical Lift Sling Size During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to use the correct size mechanical lift sling during the transfer of a resident who was dependent on staff for all transfers due to limited physical mobility and a history of chronic osteomyelitis, anxiety, and abnormal gait. The resident's care plan required the use of a mechanical lift with two staff for all transfers, but documentation did not specify the appropriate sling size. During a transfer for a shower, nurse aides experienced difficulty positioning the resident, causing pain to the resident's right leg, which had previously undergone surgery. The resident expressed discomfort and attempted to refuse the transfer, but the transfer proceeded with continued difficulty. Interviews revealed that one nurse aide recognized the sling was too small but was overruled by another aide, who insisted on using the same size sling. During the transfer, the resident's leg was not properly supported, resulting in pain and the resident's leg hitting a bedside table. Upon returning from the shower, a latch on the sling slipped off the lift, causing the resident to begin to fall backward, though a staff member intervened to break the fall. The DON confirmed that the wrong sling size was used and that the sling was improperly placed, leading to inadequate support and pain for the resident.
Failure to Train Staff on Proper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that staff were properly trained in the use of mechanical lift transfers, resulting in an improper transfer of a resident who was dependent on staff for mobility. The resident, who had chronic osteomyelitis, anxiety, and abnormal gait and mobility, was care planned to require a mechanical lift with two staff for all transfers. On the day of the incident, two nurse aides, one of whom was in training, attempted to transfer the resident using a mechanical lift. The aides used a sling pad that was too small, and the pad was improperly placed, causing the resident's right leg to be unsupported and in pain. Despite the resident expressing discomfort and refusing the transfer, the aides continued, and during the process, the resident's leg was injured and a latch on the lift pad slipped, causing the resident to nearly fall. Interviews revealed that neither aide had previously transferred this resident, and the aide in training took over the transfer process, which was not appropriate. The DON confirmed that there was no formal training protocol for mechanical lift transfers in place at the facility, and that staff were expected to train each other without documentation or structured guidance. Facility policy required that only trained and qualified caregivers perform such transfers and that the proper size sling be used, but these requirements were not met in this instance.
Failure to Follow Care Plan Requiring Two Staff During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of making accusatory statements against staff. The resident, who had diagnoses including transient ischemic attacks, mood disorder, and psychotic disorder with delusions, required assistance from two staff members for all care due to their behavioral history. The care plan and nurse aide care card both specified that two staff members should be present during care. However, on the date of the incident, one nurse aide provided care to the resident alone, contrary to the care plan directives. This failure was identified after the resident reported to a nurse that the aide was rough and had shoved them onto the toilet, nearly causing a fall. Documentation and interviews confirmed that the second aide was not present during the care, as required. The Director of Nursing acknowledged that the care plan was not followed, and the facility policy required staff to be informed of their responsibilities regarding care plan interventions. The incident was not substantiated as abuse, but it was determined that the care plan was not properly implemented.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure timely notification to the provider when a resident experienced a change in condition. The resident, who had diagnoses including dementia and aortic valve stenosis, was noted to have an audible wheeze and faint crackles in the lungs, along with a low-grade fever. Despite these symptoms, the RN supervisor and the physician or APRN were not notified of the change in condition as required by the facility's policy. The LPN on duty administered an inhaler and acetaminophen, raised the head of the bed, and encouraged fluids, but only notified the 11 PM to 7 AM supervisor about the resident's status. The RN supervisor acknowledged being informed of the resident's respiratory issues but did not notify the on-call provider, instead passing the information along in the morning report. The APRN confirmed that she was not aware of the resident's condition change and stated that such changes should be communicated to the on-call service provider rather than relying on a fax note. The facility's Change in Condition Policy mandates that the physician or NP be notified of any change in condition, which was not adhered to in this instance.
Failure to Conduct Timely RN Assessment for Change in Condition
Penalty
Summary
The facility failed to ensure a timely RN assessment for a resident who experienced a change in condition. The resident, diagnosed with dementia and aortic valve stenosis, had a moderate cognitive impairment and required assistance with activities of daily living (ADLs). On a specific date, the resident exhibited symptoms of respiratory distress, including audible wheezing and faint crackles in the lungs, and was administered an inhaler and acetaminophen by an LPN. Despite these interventions, the RN supervisor was not notified, and no RN assessment was conducted during the shift when the change in condition was identified. Further review revealed that the resident had shortness of breath and coarse lung sounds earlier in the day, and later experienced a fall, leading to a hospital transfer. Interviews with the LPN and RN supervisor confirmed that the RN was informed of the resident's condition but did not perform the necessary assessment. The facility's policy mandates that an RN must assess and document any change in a resident's condition, which was not adhered to in this case.
Deficiencies in Food Storage and Cleanliness
Penalty
Summary
The facility failed to ensure proper labeling, dating, and disposal of expired food items, as well as maintaining cleanliness in food storage areas. During an observation, several food items in the walk-in freezer were found to be stored in large zip lock plastic containers with expiration dates that had passed. The Food Service Director (FSD) acknowledged that expired food items should not be left in the freezer and that it was her responsibility to ensure outdated food was discarded. Additionally, in the walk-in refrigerator, there were items such as macaroni pasta and open beef base that were either unlabeled or past their expiration date. Further observations revealed issues in the resident's nutritional refrigerator and freezer, where opened juice boxes and ice cream were found without labels, and some ice cream was covered with freezer burn. The refrigerator and freezer also had multiple areas with sticky brown stains. Interviews with the LPN and FSD indicated that housekeeping and dietary staff were responsible for cleaning the resident's nutritional refrigerator, but neither could confirm when it was last cleaned. The facility's Food and Storage Supply Policy mandates that all food items be stored to prevent contamination and that expired or unlabeled food should be discarded.
Deficiencies in Care Planning for Anticoagulant Use and Pressure Relief Devices
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for Resident #3, who was on anticoagulant therapy for bilateral pulmonary embolism. Despite the resident's severe cognitive impairment and high-risk medication status, the care plan did not include necessary interventions such as monitoring for bleeding, unusual bruising, or changes in mental status. This oversight was acknowledged by the Assistant Director of Nursing Services (ADNS) and the MDS Coordinator, who admitted that the care plan should have been updated to address the side effects and monitoring requirements associated with anticoagulant use. For Resident #26, the facility did not develop a comprehensive care plan to address the use of heel floating boots, which were being used as a pressure-relieving device due to a new wound on the resident's foot. The resident, who had severe cognitive impairment and was non-ambulatory, wore the boots without a documented care plan or physician's order specifying their use, frequency, or skin integrity checks. The Charge Nurse and Wound Nurse both recognized the absence of a care plan and order, indicating that it was their responsibility to ensure these were in place. The facility's policies required the development of a comprehensive person-centered care plan within seven days after the completion of the comprehensive MDS assessment. However, in both cases, the care plans were not updated to reflect the residents' current needs and interventions, leading to deficiencies in the care provided. The lack of documentation and oversight in updating care plans contributed to the failure to meet the residents' medical and nursing needs effectively.
Failure to Implement Comprehensive Care Plan for Elopement Risk
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident identified as an elopement risk. The resident, admitted with diagnoses including heart failure and cognitive communication deficit, was found wandering on the first floor shortly after admission. A wander guard was placed on the resident's ankle, and an elopement risk assessment indicated the resident was at risk and required interventions. However, the comprehensive care plan did not reflect the resident's elopement risk or the presence of the wander guard. Despite physician orders to monitor the wander guard every shift, the Treatment Administration Record (TAR) showed inconsistencies in monitoring, and the wander guard was not always in place. The resident was found outside alone on multiple occasions, and the wander guard failed to alarm during one incident. Interviews with staff revealed a lack of documentation and communication regarding the resident's elopement risk and the need for a wander guard, contributing to the deficiency.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, identified as Resident #66, who was initially assessed as not at risk for wandering. Despite having intact cognition and using a walker for ambulation, the resident was found off the unit on multiple occasions. On one occasion, the resident was found outside alone, and it was noted that the wanderguard was not in place. On another occasion, the resident was found outside with a friend, and although the wanderguard was in place, it did not alarm when the resident left the unit. The facility's documentation revealed inconsistencies in monitoring the wanderguard's placement and functionality. The Treatment Administration Record (TAR) indicated that the wanderguard's battery function was checked nightly, but there was no documentation of checking its placement. Interviews with staff, including the DNS, highlighted a lack of awareness of the resident's elopement attempts and the absence of reportable event reports or investigations into how the resident exited the building. The facility's elopement policy required monitoring and documentation of the elopement bracelet every shift, which was not consistently followed, contributing to the deficiency.
Inadequate Sanitary Care of Nebulizer Equipment
Penalty
Summary
The facility failed to provide sanitary care of nebulizer equipment for a resident diagnosed with chronic obstructive pulmonary disease, obstructive sleep apnea, and anxiety. The resident had an order for Ipratropium-Albuterol inhalation solution to be used as needed for wheezing. During an observation, the nebulizer machine and its components, including the mouthpiece and medicine cup, were found lying uncovered on a windowsill without a date, contrary to the facility's policy. The resident was unable to recall the last time the nebulizer was used, indicating a lack of proper tracking and maintenance of the equipment. Interviews with the nursing staff revealed that the nebulizer equipment should have been dated and stored in a plastic bag to maintain infection control. The facility's policy required that nebulizer sets and tubing be changed weekly and documented accordingly. However, the Treatment Administration Record did not reflect any checks or care of the nebulizer equipment, indicating a lapse in following the established procedures for respiratory care. This oversight in maintaining and documenting the care of respiratory equipment led to the identified deficiency.
Incomplete Hospice and Advanced Directive Records
Penalty
Summary
The facility failed to maintain complete hospice records for Resident #2, who was receiving hospice care for conditions including congestive heart failure, asthma, and difficulty swallowing. The clinical record lacked essential hospice documentation such as the Interdisciplinary Team notes, Plan of Care, Certificate of Terminal Illness, and the Medicare/Medicaid Hospice Benefit Election form. Interviews with facility staff and the hospice manager revealed that the necessary hospice documents were not included in the resident's medical record, and there was a lack of clarity regarding the responsibility for ensuring these documents were filed appropriately. For Resident #55, who had diagnoses including dementia and type 2 diabetes mellitus, the facility failed to ensure that a signed copy of the advanced directives consent form was accessible in the resident's medical record. The resident's code status was changed from full interventions to Do Not Resuscitate (DNR)/Do Not Intubate (DNI), but the updated consent form was not found in the paper chart. Interviews with the Charge Nurse and the Assistant Director of Nursing Services (ADNS) indicated that the form might have been sent to the hospital in error, and there was a lack of adherence to the facility's policy requiring the updated form to be placed in the resident's chart. The deficiencies in both cases highlight a failure to adhere to professional standards for maintaining complete and accessible medical records. The facility's policies on medical records and advanced directives were not followed, resulting in incomplete documentation for residents receiving hospice care and those with updated advanced directives. These lapses were identified during a review of clinical records, facility policies, and interviews with staff and family members.
Failure to Implement Enhanced Barrier Precautions and Proper Cohorting
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents who required them, particularly those with a history of Multidrug Resistant Organisms (MDROs) and those with indwelling medical devices. During a tour, it was identified that residents needing EBP were not placed under such precautions. The Infection Preventionist Nurse (RN #4) acknowledged that EBP was not currently implemented and that the facility was in the initial phase of formulating a policy and identifying residents who would need EBP. Despite knowing the implementation deadline was April 1, 2024, RN #4 faced pushback from management due to concerns about resident dignity and costs. The facility's MDRO log failed to include all necessary residents, such as Resident #55, who had a history of Clostridium difficile (C-diff) upon admission. This resident was co-horted with an individual without a C-diff diagnosis or history, which was not in line with the facility's infection control policy. RN #4 admitted to an oversight in not identifying Resident #55's C-diff history, which should have been reflected in the MDRO list. The Director of Nursing (DON) expected the infection control nurse to review such diagnoses upon admission and cohort residents accordingly. The facility's policy required maintaining a history log of residents diagnosed with infections like C-diff, MRSA, and VRE, to determine appropriate roommate assignments and monitor infection signs. However, the policy was not followed, as evidenced by the failure to log Resident #55's C-diff history. The DON confirmed that the infection control nurse should have entered this information into the history log and considered it when determining room assignments.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of falls after multiple incidents of falling. The resident, diagnosed with aphasia, anxiety, and a history of falls, was identified as high risk for falls. Despite this, the care plan was not updated after falls on four separate occasions. The resident's care plan included interventions such as ensuring the call light was within reach, prompt response to requests for assistance, encouraging the resident to be in common areas for supervision, and regular toileting and checks. However, these interventions were not reviewed or revised after each fall to determine new strategies to prevent further incidents. The Director of Nursing (DON) and the Minimum Data Set Coordinator acknowledged that the care plan was not reviewed and revised after each fall. The facility's policy required the comprehensive care plan to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, including measurable objectives and time frames to meet the resident's needs. Despite this policy, the care plan for the resident was not updated after falls on 7/24, 7/30, 8/3, and 8/8/23, leading to repeated incidents without new interventions being implemented.
Failure to Document Complete Skin Assessments
Penalty
Summary
The facility failed to document a complete assessment for Resident #1, who had potential for impairment to skin integrity. Resident #1 had diagnoses including aphasia, anxiety, and a history of falls, and was identified as high risk for falls. The admission nursing assessment noted scattered bruising on the abdomen and bilateral arms, but the clinical record lacked documentation of a complete assessment, including size, color, and exact location of the discolorations, to establish a baseline for further evaluation. Additionally, after Resident #1 sustained falls on multiple occasions, the facility failed to document complete assessments of the resulting bruises and skin tears, including a bruise to the left wrist and lower lip, and a skin tear to the left upper extremity. These assessments were necessary to monitor improvement or decline of the discolorations and were not conducted as required by the facility's policies. Furthermore, on 8/8/23, a series of puncture marks were noticed on Resident #1's right leg, but no one could provide an explanation for how these marks were acquired. The weekly evaluation of alteration in skin integrity did not document these puncture marks, and the regular nurse aide did not notice them while caring for Resident #1. The Director of Nursing was unaware of the puncture marks and stated that the Registered Nurse was responsible for completing skin assessments, including documenting the location, size, and description of any skin alterations. The facility's policies directed licensed nurses to document non-pressure skin conditions and complete weekly skin evaluations for all bruises, skin tears, and abrasions until resolved, which was not adhered to in this case.
Failure to Consistently Document Resident Monitoring
Penalty
Summary
The facility failed to consistently document the location of a resident on the resident observation sheets while on every fifteen-minute monitoring. Resident #1, who had diagnoses including aphasia, anxiety, and a history of falls, was identified as high risk for falls. Despite being placed on every fifteen-minute monitoring after a fall incident, the facility's documentation from 7/22/23 through 8/17/23 showed gaps in monitoring on multiple dates and shifts. The nurse's notes and resident observation sheets revealed that the required monitoring was not consistently documented on 8/1, 8/4, 8/5, 8/8, 8/10, 8/14, and 8/15/23 during various shifts. The Director of Nursing (DON) was unaware of these documentation lapses and confirmed that there was no policy regarding every fifteen-minute monitoring. Resident #1's care plan included several interventions to mitigate fall risks, such as ensuring the call light was within reach, prompt responses to assistance requests, encouraging the resident to be in common areas for supervision, and every two-hour toileting while awake. Despite these measures, the facility's failure to consistently document the resident's location during the fifteen-minute checks indicates a lapse in adherence to the care plan and monitoring protocols. This deficiency highlights a significant gap in the facility's ability to safeguard resident-identifiable information and maintain accurate medical records in accordance with accepted professional standards.
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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