Silver Springs Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 33 Roy St, Meriden, Connecticut 06450
- CMS Provider Number
- 075337
- Inspections on file
- 25
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Silver Springs Care Center during CMS and state inspections, most recent first.
The facility failed to protect two cognitively impaired residents with dementia, schizophrenia, and anxiety disorders from non-consensual sexual contact. One resident, wheelchair-bound and fully dependent for ADLs with severely impaired cognition, had a care plan noting a history of being the target of non-consensual sexual advances and calling for close observation as indicated. Another resident, also severely cognitively impaired but ambulatory, had a care plan addressing dementia-related memory and thinking problems. A staff member observed these two residents in an elevator, kissing, with one resident’s hand inside the other’s pants. Both residents were conserved and unable to consent to intimate touching, and the incident was determined by leadership to be inappropriate and sexual in nature, contrary to the facility’s abuse policy prohibiting non-consensual sexual contact.
The facility failed to thoroughly investigate a resident-to-resident sexual incident involving two cognitively impaired residents with dementia and psychiatric diagnoses. A recreation assistant observed the residents kissing in an elevator, with one resident’s hands inside the other’s pants, and reported the event to the DNS. Although the facility interviewed the witness and the involved residents, it did not obtain timely interviews or statements from other staff to determine how long the residents were unsupervised or where they had been prior to the incident, despite a policy requiring identification and interviewing of staff who might be witnesses and review of work schedules.
A resident with multiple chronic conditions experienced an unwitnessed fall from a wheelchair, resulting in facial injuries and a nasal fracture. Facility records showed that required neurological checks were not completed or documented as per policy before the resident was transferred to the hospital. Leadership confirmed the assessments should have been done, but documentation was missing for several required intervals.
A resident with severe dementia and agitation, known to wander, was physically pushed by a nurse aide after striking the aide while attempting to exit a secured unit. The push caused the resident to fall and hit their head, as confirmed by multiple staff interviews and video footage. The incident was initially reported as a fall, but later determined to be physical abuse in violation of facility policy.
A resident with severe dementia became physically aggressive while attempting to exit a secured unit and was pushed by a staff member, resulting in a fall and head injury. The incident was not accurately reported to the DON, and the true nature of the event was only discovered five days later through camera footage, leading to a delayed notification to the State Agency, in violation of facility policy requiring immediate reporting of suspected abuse.
A resident with severe dementia and agitation experienced a witnessed fall, after which no staff obtained or recorded vital signs as required by facility policy. The RN Supervisor later entered fabricated vital signs into the electronic transfer form to facilitate hospital transfer documentation. The DON confirmed awareness of the falsified documentation, and the facility's policy requiring assessment and documentation after a change in condition was not followed.
A resident with severe cognitive impairment and multiple health conditions did not receive timely incontinence care, and the resulting allegation of neglect was not promptly reported to the State Agency as required by facility policy. The incident was only reported after surveyor inquiry, and no investigation report was available.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely incontinence care, as reported by a nursing assistant. The concern was reported to a supervising RN, who attempted to notify nursing leadership, but there was no evidence that the required investigation was initiated or documented according to facility policy.
The facility did not ensure timely replacement of expired sink faucet filters in multiple resident rooms, as required by manufacturer guidelines, and failed to maintain records of filter changes. Staff interviews confirmed that filters were overdue for replacement despite a known infectious agent in the water and ongoing monitoring.
A resident receiving Methadone for opioid dependence did not receive a scheduled dose after six bottles of the medication went missing. The ADON placed the Methadone on a supervisor's desk instead of in the double-locked cabinet, and required counts and documentation were not performed by nursing supervisors during shift changes. The medication was not found, and the resident required alternative pain management and monitoring for withdrawal symptoms.
A resident receiving Methadone for opioid dependence missed a scheduled dose after the medication was improperly stored and not counted according to facility policy. The Methadone was left on a supervisor's desk instead of being placed in a double-locked cabinet, and no inventory count was performed by two nurses. As a result, the medication was missing at the time of administration, leading to withdrawal symptoms for the resident.
A resident prescribed Methadone for opioid dependence did not receive a scheduled dose because the medication was missing after being improperly stored and not counted upon arrival or during shift change. The ADON placed the Methadone on a supervisor's desk instead of in a double-locked cabinet, and staff failed to perform required counts and documentation, resulting in the loss of the controlled substance.
The facility did not ensure that the MAR accurately reflected the administration of Methadone for multiple residents with opioid dependence or abuse. For several days, there was no documentation in the EMR that Methadone was given as ordered, despite facility policy requiring immediate and accurate recordkeeping for controlled substances. Nursing leadership confirmed the documentation lapses and the responsibility of Nursing Supervisors to maintain accurate MARs.
The facility's Dietary Department had several deficiencies, including unclean conditions in the cold room due to sheetrock dust and debris, and improper food storage practices. Bags of cereal and orzo lacked expiration dates, and several food items in the refrigerator exceeded the 72-hour discard policy. Additionally, the kitchen wall had broken tiles with dust and debris present. The Director of Food Services acknowledged these issues, which were not in compliance with the facility's Food Storage policy.
A resident with GERD and other conditions received crushed Pantoprazole without an order, despite pharmacy recommendations to switch to Omeprazole capsules. The facility delayed implementing this change for 86 days, initially prescribing Omeprazole in tablet form instead of capsules. Staff interviews revealed no explanation for the delay, and the facility's policy for timely response to pharmacy reviews was not followed.
A facility failed to monitor a resident on long-term antibiotics per its stewardship policy. The resident, with multiple diagnoses including an infection due to a knee prosthesis, was prescribed Ciprofloxacin without an end date. Despite the care plan noting the need for monitoring, the LPN did not track the resident's ongoing antibiotic use, mistakenly documenting it as a one-time dose. This oversight was contrary to the facility's policy aimed at preventing resistant bacteria spread.
The facility failed to implement care plan interventions for two residents identified as fall risks. One resident's siderail pads were not in place as required, and another resident was left unattended on the bed edge despite a history of falls. Staff acknowledged the lapses, indicating a failure to follow the care plans designed to prevent injury.
A resident with muscle weakness and COPD required assistance with personal hygiene but was not shaved since admission, contrary to their grooming preference. The resident was told to wait for the hairdresser, leading to a delay in care. The facility's policy required nursing personnel to offer AM and PM care, including shaving, but this was not followed until after surveyor inquiry.
A facility failed to follow care plans and medication orders for residents with skin conditions, respiratory issues, and opioid dependence. A resident did not consistently receive ordered foot boots, another had incorrect bed positioning due to transcription errors, and three residents missed Methadone doses due to oversight in medication pick-up. Staff interviews revealed a lack of awareness and system issues contributing to these deficiencies.
A facility failed to conduct a baseline AIMS assessment for a resident on Risperdal, an antipsychotic medication. The resident, with dementia and PTSD, was severely cognitively impaired and dependent on staff. Facility policy required AIMS assessments every six months but did not include a baseline assessment upon admission. Despite a pharmacist's recommendation for a baseline assessment, it was not performed, as psychiatric services were expected to conduct it.
A resident with Parkinson's Disease and cognitive impairment experienced multiple falls without the responsible party being notified, contrary to the facility's policy. Despite having a care plan addressing fall risks, the facility failed to inform the responsible party of three specific falls, as confirmed by the ADN and DNS.
Failure to Protect Cognitively Impaired Residents From Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect two residents from sexual abuse by not ensuring they were free from non-consensual sexual contact. Resident #1, admitted in December 2014, had vascular dementia, schizophrenia, anxiety disorder, severely impaired cognition with a BIMS score of 4, was dependent for personal hygiene, toileting, and bathing, and used a wheelchair. Resident #1’s care plan dated 12/22/25 documented a history of engaging in non-consensual sexual advances by others and directed that close observation levels be applied as indicated per policy. Resident #2, admitted in July 2008, had vascular dementia, schizophrenia, anxiety disorder, and severely impaired cognition with a BIMS score of 6, required set-up/clean-up assistance with personal, oral hygiene, and toileting, and ambulated independently. Resident #2’s care plan dated 1/27/26 identified dementia with memory, thinking, problem-solving, and language impairment, and directed staff not to attempt to correct statements the resident believed and to provide simple responses. On 2/9/26, a Recreation Assistant entered an elevator and observed Resident #1 sitting in a wheelchair kissing Resident #2, while Resident #2’s hand was inside Resident #1’s pants. When questioned by the Recreation Assistant, Resident #2 removed the hand from Resident #1’s pants and told the staff member to mind her business. The incident was reported to the Director of Nursing Services. The Director of Behavioral Health and Social Services later questioned Resident #2, who stated it was just a kiss. The DNS identified that both residents were conserved, unable to consent to intimate touching, and deemed the incident to be inappropriate and sexual in nature. The facility’s Abuse Policy in effect at the time stated that residents would not be subjected to abuse by anyone and defined sexual abuse to include non-consensual sexual contact of any type with a resident. Despite these policies and the known cognitive impairments and care plan directives, the residents were not adequately protected from non-consensual sexual contact, resulting in the abuse incident.
Failure to Thoroughly Investigate Resident-to-Resident Sexual Incident
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation following a resident-to-resident sexual incident. Resident #1, admitted in December 2014 with vascular dementia, schizophrenia, and anxiety disorder, had severely impaired cognition (BIMS score of 4), was dependent for personal hygiene, toileting, and bathing, and used a wheelchair. Resident #1’s care plan identified a history of engaging in non-consensual sexual advances by others, with interventions including close observation as indicated per policy. Resident #2, admitted in July 2008 with vascular dementia, schizophrenia, and anxiety disorder, also had severely impaired cognition (BIMS score of 6), required set-up/clean-up assistance for personal and oral hygiene and toileting, and ambulated independently. Resident #2’s care plan noted dementia-related memory and thinking problems, with interventions to avoid correcting the resident’s believed statements and to provide simple responses. On the date of the incident, a Recreation Assistant observed Resident #1 and Resident #2 kissing in an elevator, with Resident #2’s hands in Resident #1’s pants, and this was documented on a Reportable Event Form by the DNS. The facility’s investigation included interviews with the witness (Recreation Assistant) and both residents, but did not include interviews or statements from other staff to determine how long the residents had been unsupervised or their locations prior to the incident. Subsequent interviews with a NA assigned to Resident #2 and an LPN assigned to Resident #1 revealed each had last seen their assigned resident around early afternoon, but these interviews were not part of the original investigation. The DNS acknowledged that the investigation should have included staff interviews to establish a timeline and resident whereabouts, as required by the facility’s “Reportable Events-Reporting Allegations and Incidents; Investigation (CT)” policy, which directs identifying and interviewing staff who were potential witnesses and reviewing work schedules, with efforts to interview staff before the end of their shifts.
Failure to Complete Timely Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to complete timely neurological monitoring after an unwitnessed fall involving a resident with chronic obstructive pulmonary disease, morbid obesity, and heart failure. The resident, who was non-ambulatory and used a wheelchair, experienced a fall in the elevator after being pushed by another resident. The fall resulted in a nasal bone fracture and facial laceration, requiring hospital evaluation and treatment. Facility documentation, including the Neurological Check Sheet and nursing notes, lacked evidence that neurological assessments were performed as required by facility policy in the period following the fall and prior to the resident's transfer to the hospital. The facility's policies directed neurological checks at specific intervals after unwitnessed falls or suspected head injuries. However, the neurological assessment form was incomplete, with missing entries for vital signs, hand grasps, level of consciousness, pupil response, and nurse initials for the required time points. Interviews with facility leadership confirmed that neurological assessments should have been completed and documented, but no such documentation was available for the period before EMS arrival or for two of the required four-hour assessments. The failure to perform and document neurological checks was not in accordance with the facility's established protocols.
Resident Pushed by Staff Member Resulting in Fall and Injury
Penalty
Summary
A resident with severe dementia, agitation, mild cognitive impairment, and muscle weakness was involved in a physical altercation with a staff member, resulting in a fall. The resident had a BIMS score indicating severely impaired cognition and was known to wander, with care plan interventions directing staff to offer assistance and redirect the resident as needed. On the day of the incident, the resident was attempting to exit the memory care unit and became agitated, striking a nurse aide who was trying to enter the unit. In response, the nurse aide pushed the resident, causing the resident to fall and hit their head against the wall. Multiple staff members witnessed the event, and their accounts confirmed that the nurse aide used physical force after being struck by the resident. The incident was initially reported as a fall, with documentation indicating the resident lost balance after striking the staff member. However, subsequent interviews and review of camera footage revealed that the staff member had pushed the resident, which directly led to the fall and injury. The facility's abuse policy prohibits physical abuse and the use of corporal punishment, stating that residents must not be subjected to abuse by anyone, including staff. Despite this policy, the staff member's actions constituted physical abuse, as confirmed by witness statements and video evidence. The incident was not immediately reported as abuse, and the true nature of the event only came to light several days later upon review of surveillance footage.
Failure to Timely Report Suspected Abuse Following Resident Altercation
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify the Administrator and/or designee of a physical altercation between a staff member and a resident, resulting in a delayed report to the State Agency. The incident involved a resident with severe dementia, agitation, and mild cognitive impairment, who attempted to exit the memory care unit and became physically aggressive with a staff member. During the altercation, the staff member pushed the resident, causing the resident to fall and hit their head against the wall. The resident was subsequently transported to the emergency department for evaluation, but no acute behavioral issues were found upon return. Despite the seriousness of the incident, the initial reports from staff to the Director of Nursing (DON) did not accurately convey that the resident had been pushed by the staff member. The DON was informed that the resident had hit the staff member and then lost balance, leading to the fall. It was only five days later, after a review of camera footage prompted by another staff member, that it became clear the resident had been pushed. This delay in recognizing and reporting the incident as potential abuse resulted in the State Agency not being notified within the required two-hour timeframe. Facility policy mandates that all allegations or suspicions of abuse must be reported immediately to supervisors and the appropriate authorities, including the State Agency, within two hours if abuse is involved. In this case, the failure to communicate the true nature of the incident and to identify all witnesses led to a significant delay in reporting, contrary to facility policy and regulatory requirements.
Failure to Obtain and Accurately Document Vital Signs After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe dementia, agitation, and muscle weakness experienced a witnessed fall in the hallway. The resident was noted to be sitting on the floor with their head against the wall and was resistive to a skin check and range of motion assessment. Despite facility policy requiring assessment and documentation of vital signs following a fall, no staff—including nurse aides and the charge nurse—attempted to obtain or record the resident's vital signs after the incident. The resident was subsequently transferred to the emergency department for evaluation. When completing the required eInteract Transfer Form in the electronic health record, the RN Supervisor entered fabricated vital signs into the form several hours after the incident, as the system would not allow the form to be locked and printed without this information. The Director of Nursing confirmed awareness of the falsified documentation and stated that staff are prohibited from such actions. The facility's Change of Condition policy directs that assessment findings be documented and reported to the physician, but this was not followed in this case. A policy on Nursing Documentation was not available for review.
Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
An allegation of neglect involving a resident with multiple sclerosis, epilepsy, depression, anxiety, and severe cognitive impairment was not reported to the State Agency (SA) as required. The resident, who was dependent on staff for activities of daily living and had a care plan addressing communication difficulties and skin integrity risks, did not receive incontinence care until late in the 7 AM to 3 PM shift. A nursing assistant reported this delay in care to the RN supervisor at the end of the shift, and the supervisor submitted a written statement by sliding it under the office door of the Director of Nursing Services (DNS) or Assistant DNS (ADNS), but did not confirm receipt. The DNS later acknowledged awareness of the allegation but was unable to locate or provide an investigation report and confirmed that the concern should have been reported to the SA. The facility's abuse policy required immediate reporting and investigation of abuse or neglect allegations, including notification of the administrator and DNS or designee, and prompt reporting to appropriate authorities. The failure to report the allegation to the SA was only rectified after surveyor inquiry.
Failure to Investigate Alleged Neglect of Dependent Resident
Penalty
Summary
The facility failed to investigate an allegation of abuse/neglect for a resident with multiple complex medical conditions, including multiple sclerosis, epilepsy, depression, anxiety, and overactive bladder. The resident was severely cognitively impaired, dependent on staff for activities of daily living, and required frequent incontinence care. According to a nursing assistant's written statement, the resident did not receive incontinence care until late in the shift, and this concern was reported to the supervising RN at the end of the shift. The RN supervisor submitted the statement by sliding it under the office door of the Director of Nursing Services (DNS) or Assistant Director of Nursing Services (ADNS) but did not confirm receipt. The DNS later acknowledged awareness of the allegation but was unable to provide an investigation report and indicated that the ADNS, who was covering at the time, was unavailable. Facility policy required immediate reporting and prompt investigation of abuse allegations, including removal of the alleged abuser from resident care and initiation of an investigation within 24 hours. However, there was no evidence that an investigation was conducted or that the required procedures were followed after the allegation was reported.
Failure to Replace Expired Sink Faucet Filters for Infection Control
Penalty
Summary
The facility failed to follow infection prevention and control guidelines by not ensuring that resident room sink faucet filters were changed once expired. During a facility tour, it was observed that several resident room sink faucet filters were past their expiration dates, with some being 6 to 7 days overdue. Manufacturer instructions indicated that the filters should be used for a maximum of 31 days following initial connection. The Maintenance Director confirmed that he and the maintenance assistant were responsible for changing the filters, but was unaware that several filters were overdue for replacement. Additionally, the facility did not maintain records or logs of water filter changes, and the Maintenance Director stated that the Maintenance Assistant should have changed the filters during his absence. Interviews with the DNS and Corporate Clinical Director revealed that the building had a known infectious agent in the water, and the water was being monitored. They confirmed that the 31-day sink faucet filters in the affected rooms should have been changed when due. The lack of timely filter changes and absence of documentation contributed to the facility's failure to adhere to infection prevention and control protocols.
Failure to Secure and Account for Controlled Substance Results in Loss of Methadone
Penalty
Summary
The facility failed to ensure the proper storage and handling of a controlled medication, Methadone, prescribed to a resident with a history of opioid dependence and substance abuse. The resident was receiving medication-assisted therapy, and a physician's order directed a daily dose of Methadone. On one occasion, the Assistant Director of Nursing (ADON) picked up seven bottles of Methadone from a clinic, administered one dose to the resident, and placed the remaining six bottles on the supervisor's desk in a locked office, rather than in the designated double-locked cabinet. No medication count was performed with another supervisor at the time of receipt, and the chain of custody was not documented as required by facility policy. The following day, nursing staff discovered that the six bottles of Methadone were missing when attempting to administer the scheduled dose. There was no count of the Methadone during shift changes, and the medication was not found despite a search and investigation. Interviews with nursing supervisors and the ADON confirmed that the required procedures for controlled substance storage, counting, and documentation were not followed. The facility's policies specified that Methadone should be counted by two supervisors, documented on a chain of custody form, and stored in a double-locked cabinet, but these steps were not taken. As a result of these lapses, the resident missed a scheduled dose of Methadone and required alternative medication and monitoring for withdrawal symptoms. The facility's investigation confirmed that the Methadone was not properly secured or accounted for, and the medication was ultimately lost. The failure to follow established protocols for controlled substances led to the misappropriation of the resident's medication.
Failure to Secure and Account for Methadone Results in Missed Dose
Penalty
Summary
A deficiency occurred when a resident with a history of opioid dependence and currently receiving medication-assisted therapy with Methadone did not receive a scheduled dose due to improper storage and handling of the medication. The Assistant Director of Nursing (ADON) picked up seven bottles of Methadone from a clinic and, upon returning to the facility, administered one dose to the resident but placed the remaining bottles on the supervisor's desk in a locked office rather than in the designated double-locked cabinet. No medication count was conducted with a second nursing supervisor at the time of placement, and no count was performed during shift changes. As a result, when the next scheduled dose was to be administered, the Methadone could not be located, leading to a missed dose. The resident, who was alert and oriented, initially denied withdrawal symptoms but later reported moderate body aches, restlessness, anxiety, and irritableness, which were managed per physician orders. Facility policy required all controlled substances, including Methadone, to be stored in a locked cabinet with accurate inventory maintained and counted by two nursing supervisors. The failure to follow these procedures resulted in the omission of a critical medication dose and subsequent withdrawal symptoms for the resident.
Failure to Secure and Account for Methadone Upon Receipt and During Shift Change
Penalty
Summary
The facility failed to ensure that Methadone, a controlled substance prescribed to a resident for opioid dependence, was properly counted and securely stored according to facility policy and professional standards. Upon arrival from the Methadone clinic, the Assistant Director of Nursing (ADON) transported seven bottles of Methadone in a locked suitcase, administered one dose to the resident, and then placed the remaining six bottles on the supervisor's desk in the supervisor's office, rather than in the designated double-locked cabinet. No medication count was performed with a second nursing supervisor at the time the Methadone was brought into the facility, and the chain of custody was not documented as required by policy. During the subsequent shift change, the outgoing and incoming nursing supervisors did not conduct a count of the Methadone bottles, as mandated by facility policy. The next day, a nursing supervisor discovered that the Methadone was missing when attempting to administer the scheduled dose, and the omission was reported. Interviews with staff confirmed that the required counts and secure storage procedures were not followed, and the Methadone was not found after an internal investigation. The resident involved had a history of opioid dependence and was alert and oriented at the time of the incident. The omission of the Methadone dose was documented, and the resident was monitored for withdrawal symptoms, but denied experiencing any. Facility policies clearly required controlled substances to be counted upon receipt, documented, and stored in a double-locked cabinet, but these procedures were not followed in this instance.
Failure to Document Methadone Administration in MARs
Penalty
Summary
The facility failed to ensure that the Medication Administration Record (MAR) accurately reflected the administration of Methadone for seven of eight sampled residents with opioid dependence or abuse. Clinical record reviews and examination of the electronic medical record (EMR) for these residents revealed multiple instances where there was no documentation that Methadone was administered on various days throughout February 2025, despite active physician orders for daily dosing. The absence of documentation was noted for each resident on several specific dates, with some residents missing documentation for up to thirteen days in the month. Interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that facility policy requires each administered medication, especially controlled substances like Methadone, to be immediately documented in the EMR and on accountability records. Both the ADON and DON acknowledged that the MARs for the affected residents did not consistently show that Methadone was administered as ordered, and identified that Nursing Supervisors are responsible for ensuring the accuracy of these records. Facility policies reviewed also emphasized the necessity of accurate and immediate documentation following administration of controlled substances.
Deficiencies in Food Storage and Sanitation in Dietary Department
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in the Dietary Department, as observed during a tour. In the cold room, the floor was covered with a white, dusty, powdery material, identified as sheetrock dust and debris, with visible shoe prints throughout. An old green garden hose was also stored on the floor. The Director of Food Services acknowledged the issue, stating that the dust resulted from recent sheetrock replacement and that housekeeping services had been requested but not yet provided to clean the area. Additionally, in the dry storage room, bags of crisped rice cereal and orzo were found without expiration dates, and the original boxes with the manufacturer's expiration dates were missing. In the cold room walk-in refrigerator, several containers of food were found to be past the facility's policy of discarding prepared foods within 72 hours. Items such as chopped Salisbury steak, cranberry sauce, sliced turkey breast, cucumber salad, rice/orzo, chopped pineapple, and pancakes were all beyond the 72-hour limit. The Director of Food Services confirmed that the cook on duty was responsible for discarding food according to policy. Furthermore, the kitchen wall between the ice machine and the housekeeping closet had broken, cracked, and missing tiles, with the wall behind them dusty and crumbling, and debris on the floor. The facility's Food Storage policy mandates that all storage areas be clean and sanitary, and that ready-to-eat foods have expiration or use-by dates, which was not adhered to in this instance.
Failure to Implement Pharmacy Recommendations for Medication Administration
Penalty
Summary
The facility failed to follow pharmacy recommendations for a resident diagnosed with gastroesophageal reflux disease (GERD), Wernicke's encephalopathy, and anxiety. The resident was receiving crushed medications without an order, including Pantoprazole, which is enteric-coated and should not be crushed. The pharmacy recommended switching from Pantoprazole to Omeprazole capsules, which can be opened and administered with applesauce, but this change was not implemented until 86 days later. During this period, the resident continued to receive Pantoprazole inappropriately, and when Omeprazole was finally ordered, it was initially prescribed in tablet form instead of the recommended capsule form. Interviews with facility staff revealed that the Director of Nursing Services was responsible for addressing pharmacy recommendations, but there was no explanation for the delay in implementing the recommended changes. The facility's policy required a response to the Drug Regimen Review within 7 to 14 days, yet the recommendations were not acted upon within this timeframe. The Regional Director Pharmacist confirmed that the delayed release form of Omeprazole is more effective when administered as a capsule, and crushing the tablet could lead to less effective acid suppression and increased gastrointestinal symptoms.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to monitor a resident on long-term antibiotics according to its antibiotic stewardship policy. Resident #112, who had diagnoses including hemiparesis, hemiplegia, infection due to a knee prosthesis, and epileptic seizures, was prescribed Ciprofloxacin 500 mg twice daily without an end date. The resident's care plan noted the infection and antibiotic treatment, with instructions to follow the facility's policy for tracking infections. However, the Infection Preventionist, an LPN, did not have Resident #112 on the antibiotic monitoring list, mistakenly documenting the resident as having received only a one-time dose in October 2024. Upon further inquiry, it was revealed that Resident #112 had been on suppressive antibiotic therapy since April 2024, but the LPN was unaware of the ongoing antibiotic use. This oversight was contrary to the facility's antibiotic stewardship policy, which aims to promote improved antibiotic use and prevent the spread of resistant bacteria. The deficiency was identified during an interview and record review, highlighting the lack of proper monitoring and documentation for Resident #112's antibiotic regimen.
Failure to Implement Care Plan Interventions for Fall Risk Residents
Penalty
Summary
The facility failed to implement the care plan interventions for Resident #12, who was identified as a fall risk due to a history of falls. Despite the care plan specifying the use of padded siderails, observations over several days revealed that the siderail pads were not in place while the resident was in bed. The pads were found on the floor and on dressers in the room, rather than covering the siderails as intended. Nurse aide #7 confirmed that it was the responsibility of the night shift to place the siderail pads, but if they were missing, it was her responsibility to ensure they were in place. The absence of siderail pads during the surveyor's observations indicated a failure to follow the care plan, potentially exposing Resident #12 to injury. For Resident #121, the facility also failed to adhere to the care plan interventions related to fall prevention. The resident, who had a history of falls and required substantial assistance with transfers, was observed sitting unattended on the edge of the bed, contrary to the care plan's directive. Nurse aide #1 acknowledged leaving the resident unattended to provide care to another resident, and the Director of OT/PT, along with the Regional Director of PT, also left the resident unattended despite being aware of the fall risk interventions. This repeated oversight demonstrated a lack of adherence to the care plan, which was designed to prevent falls and ensure the resident's safety.
Failure to Timely Accommodate Resident's Grooming Request
Penalty
Summary
The facility failed to accommodate a resident's grooming request in a timely manner, leading to a deficiency in providing care and assistance for activities of daily living. Resident #125, who was diagnosed with general muscle weakness and chronic obstructive pulmonary disease, required substantial assistance for personal hygiene. The resident expressed a preference for choosing grooming options and was independent in decision-making. However, upon observation and interview, it was found that the resident had not been shaved since admission and was told to wait for the hairdresser, who was only available on Wednesdays. This delay in grooming was not documented as a refusal of care in the nursing progress notes. The facility's policy directed that nursing personnel should offer AM and PM care, including shaving according to personal preference. Despite this, the resident was left with a beard approximately 3 inches long, which was against their usual grooming preference. The LPN confirmed that nurse aides were responsible for shaving, and the resident was eventually shaved after surveyor inquiry. The resident was under the impression that they had to pay for shaving, which contributed to the delay in receiving the necessary personal care.
Deficiencies in Care Plan Adherence and Medication Management
Penalty
Summary
The facility failed to adhere to a physician's order for Resident #12, who was diagnosed with dementia, muscle weakness, and reduced mobility, among other conditions. The resident was at risk for skin integrity issues and was ordered to wear bilateral soft multi-podus boots at all times, except during care. However, observations revealed that the boots were often not applied, as they were found on the floor or dresser instead of on the resident's feet. Staff interviews indicated that the resident frequently removed the boots, and there was a lack of consistent application as per the care plan. For Resident #18, who had severe cognitive impairment and chronic respiratory conditions, the facility failed to transcribe a physician's order for bed positioning to prevent shortness of breath. Observations showed that the resident's bed was often in a flat position, contrary to the order to keep the head elevated. Interviews with staff revealed a lack of awareness of the positioning needs, and the order was not reflected on the NA Care Card, which was supposed to guide care. The issue was attributed to a transition to a new electronic health record system, which led to transcription errors. Additionally, the facility failed to ensure the availability of Methadone for three residents with opioid dependence. Residents #35, #118, and #129 missed their Methadone doses due to an oversight in picking up the medication from the clinic. The Assistant Director of Nursing was responsible for obtaining the Methadone but lacked a formal tracking system for pick-up dates, leading to missed doses. The Medication Error Reports confirmed the oversight, and interviews with staff highlighted the absence of a structured process for managing Methadone pick-ups.
Failure to Conduct Baseline AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct a baseline Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving an antipsychotic medication, Risperdal. The resident, who had diagnoses including dementia, anxiety, and PTSD, was identified as severely cognitively impaired and dependent on staff for personal hygiene. The facility's policy required AIMS assessments every six months but did not include conducting a baseline assessment upon admission. Despite a recommendation from the pharmacist for a baseline AIMS assessment to monitor for involuntary movements, the facility did not perform this assessment upon the resident's admission. Interviews with facility staff, including a social worker and a registered nurse, revealed that the responsibility for conducting AIMS assessments was assigned to psychiatric services, which had not yet performed the assessment. The facility's policy and procedures did not mandate a baseline AIMS assessment on admission, and the psychiatric provider had not yet seen the resident. The pharmacist's recommendation for a baseline AIMS assessment was not immediately acted upon, as the psychiatric provider was expected to conduct the assessment. This oversight led to a deficiency in monitoring the resident for potential side effects of the antipsychotic medication.
Failure to Notify Responsible Party After Resident Falls
Penalty
Summary
The facility failed to notify the responsible party of a resident after multiple falls, which is a violation of their own Fall Management Policy. The resident in question, who has diagnoses including Parkinson's Disease, cognitive impairment, and a fluency disorder, experienced twelve falls over the course of the year. Despite the facility's policy requiring notification of the resident's physician and family or responsible party in the event of a fall, the responsible party was not informed of three specific falls that occurred on 4/2/24, 6/2/24, and 10/11/24, all of which resulted in no injury. The resident's care plan, dated 8/28/23, acknowledged a history of falls with injury and included interventions such as education on call bell usage and ensuring the resident was not left unattended while sitting on the side of the bed. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the oversight in notifying the responsible party and could not provide a reason for the failure. The resident was noted to be cognitively intact, with unclear speech, requiring substantial assistance with transfers, and reliant on a motorized wheelchair.
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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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