Riverside Health Care Center, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in East Hartford, Connecticut.
- Location
- 745 Main St, East Hartford, Connecticut 06108
- CMS Provider Number
- 075257
- Inspections on file
- 31
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Riverside Health Care Center, Inc. during CMS and state inspections, most recent first.
Two residents with histories of anxiety and aggression engaged in a verbal altercation that escalated to a physical assault in a common area, resulting in one resident sustaining serious facial injuries and requiring hospital transfer. The incident was witnessed by others and occurred despite both residents being identified as having aggressive tendencies in their care plans.
A resident with dementia and a history of falls experienced increased mobility and exhibited wandering and agitation over several days. Despite these changes, staff did not timely reassess the resident's elopement risk, as required by facility policy. The resident subsequently eloped from the facility and was found outside without injury.
A resident with a history of psychiatric disorders and suicidal ideation expressed intent to self-harm and was hospitalized twice for evaluation. Despite these incidents, the care plan was not revised to include specific interventions for managing suicidal behaviors, and facility policy requiring care plan updates after such events was not followed.
A resident with a history of mental disorders and repeated suicidal ideation was not adequately protected from environmental hazards, as staff failed to promptly remove access to knives and other potentially harmful items despite multiple incidents of self-harm attempts and hospital transfers. The care plan was not timely updated to address these risks, and hazardous items remained accessible in the resident's environment.
A resident with a history of stroke, dysphagia, and cognitive impairment did not receive the required supervision during a meal, as specified in their care plan. Due to miscommunication and incorrect documentation on care cards, staff believed only setup assistance was needed, leading to the resident being left unsupervised and experiencing a choking episode that required emergency intervention.
A nurse failed to accurately transcribe a hospital discharge order for Quetiapine, resulting in a resident receiving the medication in the morning instead of at night as prescribed. The error was not caught during the required double-check process, and the resident, who had multiple neuropsychiatric diagnoses, was subsequently evaluated for somnolence related to medication timing.
A resident with diabetes and end stage renal disease experienced multiple episodes of low blood sugar, including critically low readings and the need for Glucagon administration. Despite physician orders and facility policy requiring provider notification in these situations, staff did not inform the provider of these events, and documentation of such notifications was absent.
A resident dependent on staff for toileting and transfers was left unattended on the toilet for over an hour after a nurse aide failed to inform other staff before leaving the unit. Other staff responded to the call light but did not assist or notify anyone, resulting in the resident not receiving timely hygiene and transfer assistance as required by their care plan.
Staff did not consistently follow physician orders and facility policy for treating and monitoring hypoglycemia in a resident with diabetes and end stage renal disease. After multiple low blood sugar readings, required rechecks and provider notifications were not documented, and a scheduled endocrinology follow-up was missed and not rescheduled.
A resident with multiple medical conditions who required two staff for transfers using a mechanical lift was transferred by only one nurse aide, despite physician orders and facility training materials specifying the need for two staff. The aide was aware of the requirement but did not seek assistance, and the incident was confirmed through documentation and interviews.
A resident with diabetes and end stage renal disease experienced multiple episodes of hypoglycemia, during which the facility failed to maintain accurate physician orders for Glucagon administration and did not document nursing actions, symptoms, or provider notifications as required by facility policy. Staff confirmed that nursing notes were missing for these events and could not explain the lack of documentation.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident following a verbal altercation. The incident involved two residents, both of whom had documented histories of anxiety and mood disorders, and were identified as having the potential for verbal aggression. Both residents were alert, oriented, and independently mobile in wheelchairs. Earlier in the day, a verbal altercation took place between the two residents on one of the facility's units. Later, in a common area near the front lobby, one resident approached the other and initiated a physical assault by punching the resident multiple times in the face. The assault was witnessed by other residents, who notified staff, prompting an in-house emergency response. The assaulted resident sustained significant injuries, including an open fracture of the nasal bone, hematoma of the nasal septum, periorbital hematoma, and an open fracture of the ethmoid bone, and was subsequently transferred to the hospital for treatment. Documentation and interviews confirmed that the physical altercation was preceded by a verbal dispute and that the facility's care plans had identified both residents as having aggressive tendencies. Despite these risk factors, the incident escalated to physical violence, resulting in harm to one resident. The facility's abuse policy states that residents have the right to be free from abuse, including abuse by other residents.
Failure to Timely Reassess Elopement Risk Following Change in Resident Condition
Penalty
Summary
The facility failed to timely reassess a resident's risk for elopement and wandering following significant changes in the resident's condition and mobility status. The resident, who had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and a history of falls, was initially assessed as non-ambulatory and not at risk for elopement. However, subsequent physical therapy assessments documented progressive improvement in ambulation, with the resident eventually able to walk up to 100 feet with minimal assistance. Despite these changes, the resident's elopement risk was not reassessed as required by facility policy. Over several days, nursing notes documented the resident exhibiting agitation, wandering within their room and into other residents' rooms, and difficulty with redirection. The resident was also involved in an incident with a roommate, which led to a temporary hospital transfer. Upon return, the resident continued to display wandering behaviors and increased mobility, but no updated elopement or wander risk assessment was completed during this period. The deficiency culminated when the resident eloped from the facility after being left unattended for a brief period. The resident was found outside the building and returned without injury. Review of facility documentation and interviews confirmed that a reassessment of elopement risk should have been conducted when the resident began exhibiting increased mobility, agitation, and wandering behaviors, but this was not done in a timely manner.
Failure to Revise Care Plan After Suicidal Ideation Incidents
Penalty
Summary
The facility failed to review and revise the care plan with appropriate interventions for a resident with a history of suicidal ideation and multiple psychiatric diagnoses, including paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. Despite physician orders to monitor behavioral occurrences every shift and an existing care plan that addressed general behavioral issues, the care plan did not specifically address the resident's suicidal ideations with intent or include personalized interventions following incidents where the resident expressed intent to self-harm. Notably, after the resident verbalized wanting to harm themselves with a weighted silverware knife and was subsequently transferred to the ER for psychiatric evaluation, there was no documented revision to the care plan upon their return from the hospital. Further, after additional episodes where the resident reported hearing voices instructing them to harm others and was again transferred for psychiatric evaluation, the clinical record still did not reflect any updates or new interventions in the care plan. Interviews with the Director of Nursing confirmed that the care plan was not revised after these incidents, and there was uncertainty about whether updates were necessary. Facility policy required episodic review and revision of the care plan, especially after hospital readmissions, but this was not followed in these instances.
Failure to Remove Environmental Hazards and Implement Safety Interventions for Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to remove environmental hazards and implement appropriate safety interventions for a resident with a history of mental disorders, including suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. The resident expressed suicidal ideation and intent on multiple occasions, resulting in four transfers to the emergency department over a 38-day period. Despite these incidents, the clinical record showed no timely revisions to the resident's care plan or mitigation of environmental risk factors, such as access to knives and other potentially harmful items. The resident was observed on several occasions with access to silverware, including butter knives, and was seen rubbing a knife against their wrist while expressing intent to self-harm. Staff interviews and documentation revealed that the resident was able to obtain knives from meal trays, and there was a lack of immediate action to restrict access to these items following repeated episodes of suicidal ideation and self-harm attempts. The facility's documentation did not reflect prompt updates to the care plan or consistent removal of environmental hazards, such as corded call lights and phone chargers, even after the resident's behaviors escalated. Multiple staff members, including nursing and medical personnel, indicated that access to knives and metal silverware did not pose a safety risk, despite the resident's documented history and visible evidence of self-harm. Observations confirmed that hazardous items remained accessible in the resident's environment after incidents of suicidal ideation and self-harm. The facility's failure to promptly identify and address these environmental risks contributed to repeated episodes of suicidal behavior and inadequate protection for the resident.
Failure to Provide Required Mealtime Supervision Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, dysphagia, aphasia, apraxia, epilepsy, and dementia did not receive the required supervision during mealtime as outlined in their care plan. The resident's care plan specified that all meals and fluid intake should occur under staff supervision due to swallowing difficulties. Despite this, the resident was left unsupervised during lunch, which resulted in a choking incident that required the Heimlich maneuver and emergency intervention. The resident had recently been discharged from speech therapy, which had reiterated the need for mealtime supervision due to swallowing safety concerns. However, the speech therapist did not verbally communicate the supervision requirement to the nursing staff, as the diet remained unchanged and the care plan already indicated supervision was needed. Nursing assistants and other staff members were unaware of the supervision requirement, as the resident's care card only indicated setup assistance for meals, not supervision. This miscommunication and lack of awareness led to the resident being left alone while eating. Interviews with staff revealed that the care plan interventions, including supervision with eating, were not correctly reflected on the quick-reference care cards used by nursing assistants. As a result, multiple staff members believed the resident only required setup assistance and not active supervision. This failure to ensure proper communication and implementation of the care plan directly contributed to the resident's choking incident.
Medication Order Transcription Error Resulting in Incorrect Administration Time
Penalty
Summary
A deficiency occurred when a nurse failed to accurately transcribe a physician's order from a hospital discharge summary into the resident's Medication Administration Record (MAR). The hospital discharge summary specified that Quetiapine 37.5 mg should be administered at night, but the nurse entered the order into the electronic medical record to be given at 9:00 AM. This error was not identified during the transcription process, despite facility policy requiring a double-check of the original order. As a result, the resident received Quetiapine in the morning on two consecutive days. The resident involved had multiple diagnoses, including Parkinson's Disease, vascular dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and multisystem degeneration of the autonomic nervous system. The resident's care plan included the use of psychotropic medications and required monitoring for side effects and effectiveness. The error was discovered after the resident was evaluated in the emergency department for somnolence, which was attributed to the timing and combination of medications. Interviews with facility staff confirmed that the transcription error occurred and was contrary to facility policy.
Failure to Notify Provider of Repeated Hypoglycemic Episodes
Penalty
Summary
The facility failed to notify the resident's provider in a timely manner when a resident with diabetes and end stage renal disease experienced multiple episodes of low blood sugar. Despite physician orders requiring notification if blood sugar was less than 70 or greater than 400, and further instructions to notify the provider if hypoglycemia persisted or if Glucagon was administered, there was no documentation that the provider was informed of several hypoglycemic events. These events included blood sugar readings as low as 42 mg/dl, repeated administration of Glucose Gel and Glucagon Emergency Injection Kit, and persistent low blood sugar levels over several days. Interviews with facility staff confirmed that the provider should have been notified during these episodes, especially when blood sugar was critically low or when Glucagon was required. However, the provider was not informed of these incidents, and staff were unable to explain the lack of notification. Facility policy also directed staff to notify the provider under these circumstances, but this was not followed, resulting in a failure to communicate significant changes in the resident's condition as required.
Resident Left Unattended on Toilet Due to Staff Failure to Communicate and Assist
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration, who was alert and oriented but dependent on staff for activities of daily living and required two staff for toilet transfers, was left on the toilet for an extended period. The resident's care plan specified the need for assistance with toileting and transfers using a Sara lift. On the day of the incident, a nurse aide placed the resident on the toilet and left the room to assist another resident, then left the unit for lunch without notifying any staff that the resident was still on the toilet. Video footage confirmed that the resident remained unattended for approximately one hour and fifteen minutes, during which time other staff entered the room in response to the call light but did not assist or notify anyone about the resident's situation. The incident was reported by the resident to a family member, who then contacted the facility. Interviews confirmed that the resident had asked staff for help during the period but did not receive assistance. The facility's policy defines neglect as the failure to provide necessary goods and services, and the actions of the staff in this case resulted in the resident not receiving timely toileting hygiene and transfer assistance as required by their care plan.
Failure to Timely Respond to Hypoglycemia and Missed Endocrinology Follow-Up
Penalty
Summary
Staff failed to act in a timely manner on multiple low blood sugar test results for a resident with diabetes, IGG4-related disease, and end stage renal disease. The resident's care plan and physician orders required blood sugar checks before meals and at bedtime, with instructions to notify the provider if blood sugar was less than 70 or greater than 400, and to administer glucose gel or glucagon as needed. Despite these orders and facility policy, documentation showed repeated instances where the resident's blood sugar was below 70, and after initial interventions, staff did not consistently recheck blood sugar within the required timeframe or document further actions as directed by protocol. In several cases, blood sugar remained low after treatment, but there was no evidence of additional interventions or provider notification as required. Facility policy specified that after treating hypoglycemia, blood sugar should be rechecked in 15 minutes, and if still low, treatment should be repeated. If glucagon was administered, blood sugar was to be rechecked every 15 minutes until stable, and the provider notified if hypoglycemia persisted after three interventions, if blood sugar was critically low, or if glucagon was used. Interviews with facility staff confirmed that these steps were not always followed, and staff could not explain the lack of timely rechecks or provider notifications. Documentation also failed to show that the resident's blood sugar was monitored according to policy after several hypoglycemic episodes, including instances where blood sugar was critically low. Additionally, the resident was scheduled for regular endocrinology follow-up appointments, but a key appointment was cancelled due to a scheduling conflict and was not rescheduled by the facility. This resulted in a missed endocrinology evaluation for a resident with a known history of low blood sugars, contrary to the recommended follow-up interval. Interviews confirmed that the appointment should have been rebooked, but there was no evidence this occurred.
Failure to Follow Two-Person Transfer Protocol with Mechanical Lift
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration, who required two staff members for transfers using a mechanical lift, was transferred by only one nurse aide. The resident's care plan and physician's order both specified that two staff members were required for transfers with the Sara lift. Documentation and interviews confirmed that the nurse aide was aware of this requirement but proceeded to transfer the resident alone. The facility's Sit to Stand Lift Competency form also directed staff to use two people for such transfers, and the Assistant Director of Nursing confirmed that this protocol was not followed. The incident was identified after the resident reported being left on the toilet for an extended period, and subsequent investigation revealed the improper transfer procedure. There was no facility policy on the use of the Sara lift, but staff training materials clearly required two staff for these transfers.
Failure to Accurately Document and Manage Hypoglycemia Episodes
Penalty
Summary
The facility failed to ensure accurate and complete medical record documentation and physician orders for a resident with diabetes and end stage renal disease who experienced multiple episodes of hypoglycemia. Specifically, the physician order for Glucagon was incorrectly written to indicate administration for blood sugars over 70, rather than under 70, which was confirmed as an error by both the APRN and ADNS. Additionally, the clinical record lacked complete and accurate documentation of nursing actions, including the absence of nursing notes detailing interventions, resident symptoms, provider notifications, and responses to treatment following several low blood sugar events. Review of the Medication Administration Record revealed multiple instances where the resident had blood glucose levels below 70 and received Glucose Gel or Glucagon, but there was no corresponding nursing documentation of the events or follow-up actions. The facility's own Diabetes Management Protocol required documentation of all hypoglycemic episodes, including symptoms, interventions, provider notification, and resident response, but this was not followed. Interviews with facility staff confirmed that nursing notes should have been written for each episode, but they were not, and no explanation was provided for this omission.
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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