Southport Center For Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Southport, Connecticut.
- Location
- 930 Mill Hill Terrace, Southport, Connecticut 06890
- CMS Provider Number
- 075200
- Inspections on file
- 24
- Latest survey
- July 31, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Southport Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
Two residents experienced delays in receiving necessary dental care due to failures in scheduling and communication among staff. One resident's broken tooth was not extracted for an extended period despite repeated recommendations, leading to infection and a fistula. Another resident did not have a needed oral surgeon consultation scheduled after referral, with no documentation of scheduling or refusal. These deficiencies occurred despite facility policies requiring timely coordination and documentation of ancillary services.
The facility failed to notify physicians and/or resident representatives in multiple cases, including when a resident left AMA, when a resident experienced significant blood sugar abnormalities, and when a dental provider identified a possible abscess. Required notifications and documentation were not completed by nursing staff, contrary to facility policy.
The facility did not ensure that the dishwasher's sanitizing solution was properly tested and maintained, resulting in inadequate sanitation of tableware. Dietary staff relied on temperature readings instead of using test strips to measure sanitizer concentration, and there was a lack of documented staff training on proper procedures. A mechanical issue also prevented the sanitizer from dispensing, and the facility could not provide a relevant sanitation policy.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of tracking or evaluating antibiotic administration among residents.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents did not receive comprehensive care plans addressing their specific needs: one with a hand contracture was not provided with documented interventions or goals, and another with schizoaffective disorder and PTSD did not have a care plan addressing management of disruptive behaviors. Staff were unaware of or unable to implement appropriate interventions, and facility policy requiring individualized, interdisciplinary care planning was not followed.
Multiple deficiencies were identified, including failure to address a resident's hand contracture in the care plan, lack of ongoing assessment and intervention for contractures, missed and undocumented skin checks and treatments for a resident with venous ulcers, improper medication self-administration without assessment, and lack of RN assessment or documentation following an elevated blood sugar in a diabetic resident. Staff interviews and observations confirmed that required care, monitoring, and documentation were not consistently provided according to physician orders and facility policy.
Two residents with pressure ulcers did not receive consistent weekly skin audits as required by facility policy, and documentation of these checks was missing for multiple weeks. Additionally, a low air loss mattress intended to prevent further skin breakdown was not set according to the physician's order, with staff failing to verify or document the correct settings and function each shift. Communication barriers and lack of care planning for resident behaviors further contributed to the deficiencies.
A resident did not receive appropriate care or services to maintain or improve ROM or mobility, and there was no documented medical reason for the decline.
Multiple residents with high risk for accidents, including those with substance abuse history and those requiring aspiration precautions, were not adequately supervised. One resident experienced two unresponsive episodes requiring Narcan after self-administering pain medication and taking a Methadone pill. Two other residents with dysphagia were left unsupervised during meals, did not receive required 1:1 feeding assistance, and consumed inappropriate food or liquids, resulting in repeated coughing episodes. Staff were unaware of or did not follow prescribed dietary and supervision orders.
Surveyors found that appropriate care was not provided for residents regarding continence management, catheter care, and UTI prevention, resulting in a deficiency.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A nurse aide did not receive the required 12 hours of annual in-service education or annual competency evaluations, as confirmed by documentation review and staff interviews. The staff development nurse lacked a tracking system for monitoring staff training, and education was provided only as time allowed, with limited assistance from other nursing leadership who were also managing multiple responsibilities.
The facility did not notify the State-designated authority when several residents received new mental health diagnoses, and failed to implement PASARR recommendations for a resident with a history of self-harm and violent behavior. Required crisis/safety plans were not included in care plans, and staff were unaware of PASARR directives, resulting in noncompliance with regulatory requirements.
A resident with a history of dental issues and other diagnoses did not have complete or readily accessible dental records in their clinical file after receiving services from a consulting dentist. The resident reported a tooth extraction and requested their dental records, but the facility did not follow up or ensure documentation was present as required by policy. Staff interviews confirmed the records were not immediately available until requested by surveyors.
A resident with advanced breast cancer was not followed up with their oncology office within the timeframe specified in hospital discharge instructions. Facility records and staff interviews confirmed that the required contact was not made, and there was no documentation to show that the follow-up occurred, despite facility policy requiring timely scheduling of such appointments.
Failure to Provide Timely Dental Services and Specialty Referrals
Penalty
Summary
The facility failed to provide or obtain timely dental services for two residents, resulting in unaddressed dental issues and progression of oral health problems. For one resident with a history of stroke and hemiplegia, repeated recommendations for extraction of a broken tooth (#18) were not acted upon over a period of 17 months. Despite multiple dental consultations, nursing notes, and provider recommendations indicating the need for extraction and referral to an oral surgeon, the necessary appointment was not scheduled. This inaction led to the development of a fistula and abscess at the site of the affected tooth. Interviews with staff revealed ongoing communication breakdowns and lack of follow-through in scheduling and documenting specialty dental care, despite the issue being previously identified and discussed among nursing leadership. Another resident, admitted with hypertension and peripheral vascular disease, was identified as needing an oral surgeon evaluation for removal of excess tissue and biopsy of a growth in the mouth. Although a referral was made following a dental assessment, there was no documentation that the appointment was scheduled or that the resident or representative refused the consultation. The resident reported that the dental appointment was never completed, and staff interviews confirmed that the required oral surgeon consultation had not been scheduled due to oversight and lack of communication between the scheduler and nursing staff. Facility policy required that ancillary services, including dental care, be provided or coordinated and that all services and outcomes be documented. The policy also directed that outside medical appointments be arranged, documented, and communicated effectively. However, the facility failed to ensure timely follow-up on dental recommendations, proper scheduling of specialty appointments, and adequate documentation of actions taken, resulting in prolonged resident discomfort and progression of dental conditions.
Failure to Notify Physician and Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify physicians and/or resident representatives as required in several situations involving three residents. In one case, a resident who was admitted with multiple diagnoses, including acute embolism, alcohol abuse, and pain, left the facility against medical advice (AMA). The clinical record did not contain a physician’s order for the AMA discharge, nor was there documentation that the physician was notified when the resident left. The nurse’s note also lacked documentation of the resident’s departure and the required notifications, despite facility policy mandating immediate physician notification and documentation in such cases. Another resident, with a history of traumatic brain injury and diabetes, experienced both hypoglycemic and hyperglycemic episodes. The facility failed to notify the resident’s representative of a hypoglycemic event that required intervention, and there was no documentation that the physician was notified of a subsequent blood sugar reading above 400. Interviews confirmed that the advanced practice registered nurse (APRN) was not notified of the elevated blood sugar, and the LPN involved could not recall or document the necessary notifications or follow-up actions. Facility policy required prompt notification and documentation of abnormal blood sugar levels and changes in condition, which was not followed. A third resident, with a history of stroke and hemiplegia, was found by a dental provider to have moderate inflammation and a possible abscess of a tooth root. The clinical record did not show that the physician was notified of this finding, and the nurse who received the dental consultation did not communicate the change in condition as required. Interviews with dental and medical staff confirmed that the physician was not made aware of the dental issue, despite facility policy requiring notification of providers and families for any change in a resident’s baseline condition.
Failure to Maintain and Monitor Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to ensure that the sanitizing solution in the dishwasher was tested and maintained at an adequate level according to manufacturer guidelines, resulting in tableware not being properly sanitized. Observations and documentation review revealed that while the kitchen service report previously showed satisfactory sanitizer concentration, a test run of the dishwasher later recorded a sanitizer level of 0-10 ppm, which is below the required 50-100 ppm range. Review of the dishwasher temperature log indicated that staff were recording only temperature readings from the dishwasher gauge and not using test strips to measure sanitizer concentration. Multiple dietary staff confirmed that they documented wash and rinse information based solely on temperature readings and did not use test strips as required. Further interviews revealed that the Food Service Director (FSD) was responsible for educating dietary staff on proper sanitation procedures but could not provide documentation of any prior training. One staff member misinterpreted the sanitizer test strip results, indicating a lack of understanding of the correct range. A dishwasher technician identified a mechanical issue that prevented the sanitizing solution from dispensing, which was subsequently fixed. Manufacturer guidelines confirmed that sanitizer levels should be maintained between 50-100 ppm, and the facility was unable to provide a policy for ensuring clean and sanitary plates and utensils.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating that the facility did not take necessary actions to ensure appropriate antibiotic stewardship.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Contracture and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, one with a contracture and another exhibiting disruptive behaviors. For the first resident, who was admitted with dementia, cerebral infarction, and adult failure to thrive, an admission observation identified a right-hand contracture. However, the care plan did not address this contracture, nor did it specify therapeutic or nursing interventions or functional goals. The Minimum Data Set (MDS) also failed to document the contracture, and the MDS Coordinator was unaware of its presence due to this omission. Facility policy requires individualized care plans for contractures, including specific interventions and goals, but this was not followed in this case. For the second resident, who had schizoaffective disorder and PTSD, the care plan included general interventions for anxiety and mood swings and instructions regarding smoking, but did not address the management of escalating or disruptive behaviors. An incident was observed where the resident became agitated and verbally aggressive after being denied a nicotine lozenge until after a shower. The assigned LPN did not implement any interventions to de-escalate the situation and was unable to articulate appropriate actions to address the resident's behavior. The nursing supervisor was not notified of the incident, and staff interviews revealed a lack of clarity regarding behavioral interventions for this resident. The facility's failure to develop and implement individualized, comprehensive care plans for both residents resulted in unmet needs related to contracture management and behavioral support. Staff were either unaware of the residents' specific conditions or unable to describe or implement appropriate interventions, contrary to facility policy and expectations for interdisciplinary care planning.
Failure to Provide Care and Treatment According to Professional Standards
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for multiple residents, as evidenced by direct observations, record reviews, and staff interviews. For one resident with a right-hand contracture, the care plan did not address the contracture, and there was no documentation of ongoing assessment, monitoring, or specific nursing interventions for the contracture. Staff were unaware of any specific orders for the care of the contracture, and there was evidence of pain and skin issues, such as yellow crust between the contracted fingers, that were not reported or managed according to policy. The interdisciplinary approach required by facility policy was not implemented, and the contracture was not accurately reflected in the Minimum Data Set (MDS) assessments. Another resident with venous ulcers and lymphedema did not receive ace wraps to the lower extremities as ordered by the physician. Instead, the resident was observed multiple times with kerlix wraps and without the prescribed ace wraps, and the treatments were not completed before the resident was out of bed, as required. Additionally, weekly skin checks ordered by the physician were not consistently performed or documented, with only 3 out of 13 checks completed over a three-month period. Staff interviews confirmed that treatments and assessments were missed due to workload and lack of communication, and the facility's policies for implementing physician orders and documenting skin checks were not followed. A resident prescribed a Budesonide-Formoterol inhaler was found to have the inhaler at the bedside for self-administration without a completed self-administration assessment or a physician order permitting self-administration. The resident reported using the inhaler as needed without knowledge of the correct dosage or schedule, and the medication was not stored securely as required by policy. In another case, a resident with diabetes and a history of blood sugar fluctuations had an elevated blood sugar reading that was not followed by an RN assessment or proper documentation. The LPN involved could not recall if the appropriate notifications were made, and there was no evidence in the clinical record of follow-up or interventions as required by the facility's hyperglycemia management policy.
Failure to Complete and Document Weekly Skin Audits and Maintain Proper Air Mattress Settings
Penalty
Summary
The facility failed to ensure that weekly skin audits were completed and documented according to facility policy for two residents with pressure ulcers. For one resident with peripheral vascular disease, obesity, and diabetes, there was no physician's order for weekly skin checks until after surveyor inquiry, and the clinical record lacked documentation that weekly skin checks were being performed. Interviews with clinical staff confirmed that weekly skin checks were expected but not documented, and the facility's policy required these checks to be completed and recorded on shower days. The care plan for this resident also required weekly assessment of the pressure ulcer, but there was no evidence this was done. For another resident with spina bifida, hearing loss, and kidney disease, who had a stage 4 facility-acquired pressure ulcer, weekly body audits were inconsistently documented, with several weeks missing documentation over multiple months. The resident had a physician's order for a low air loss mattress set to a specific weight, but observations revealed the mattress was frequently set incorrectly, sometimes far above or below the resident's actual weight. The resident reported intermittent mattress function and communication barriers with staff, and staff interviews revealed that mattress settings were not always checked as required, with some staff signing off on checks without verifying the actual settings. Facility policies required that skin checks be completed and documented by nurses on shower days, and that air mattress settings be verified per physician's orders and checked every shift. However, documentation and staff interviews indicated these procedures were not consistently followed. There was also no documentation or care plan addressing the resident's reported habit of changing mattress settings, and staff were sometimes unaware of changes or malfunctions in the mattress equipment.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in ROM or mobility, except in cases where such decline was due to a documented medical reason. The report indicates that the necessary interventions to maintain or improve the resident's physical abilities were not implemented or followed, resulting in a deficiency.
Failure to Provide Adequate Supervision and Implement Aspiration Precautions
Penalty
Summary
The facility failed to provide adequate supervision and implement care planned interventions for multiple residents at risk for accidents, including those with a history of substance abuse and those requiring aspiration precautions. One resident with a known history of opioid abuse and a recent drug overdose was not sufficiently monitored, resulting in two separate incidents where the resident became unresponsive and required Narcan administration. Documentation revealed that the resident was able to save and self-administer multiple doses of pain medication, and also admitted to taking a Methadone pill provided by another resident. The care plan interventions were limited to offering substance abuse group attendance and support, without specific measures to prevent medication hoarding or unauthorized drug use. Another resident with hemiplegia, dysphagia, and dementia required 1:1 supervision with meals and strict aspiration precautions, as recommended by speech therapy and hospital discharge documentation. However, observations showed that this resident was left unsupervised during meals, both in their room and in the dining room, and was able to access and consume food and liquids without staff present. Staff interviews revealed confusion about the resident's dietary orders and supervision requirements, and the care plan did not reflect the most current speech therapy recommendations. The resident was observed coughing repeatedly during meals, a sign of aspiration risk, without immediate staff intervention. A third resident with a history of traumatic brain injury and dysphagia, who had transitioned from tube feeding to oral intake, was also not provided with the required 1:1 feeding assistance. Despite physician and speech therapy orders for ground solids, nectar thick liquids, and close supervision, the resident was observed eating unsupervised, taking large bites, and consuming thin liquids not consistent with their prescribed diet. Staff were not present to monitor or assist during meals, and the resident experienced coughing episodes indicative of aspiration risk. Facility policies on aspiration precautions and therapeutic diets were not consistently followed, and staff were not always aware of or implementing the required interventions.
Deficient Continence and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not provided in these areas, indicating lapses in the facility's practices for maintaining continence care, catheter hygiene, and UTI prevention. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Provide Required Annual In-Service Education and Competency Evaluations for Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide received the required 12 hours of annual in-service education and annual competency evaluations. Documentation review for the years 2023, 2024, and 2025 did not show evidence that education and competency assessments were completed for a nurse aide who began employment in December 2022. Interviews with staff revealed that the staff development and infection control nurse, who was responsible for tracking and providing education, did not have a system in place to monitor which staff members needed updated training or competencies. Education was provided as time allowed, and there was reliance on sign-in sheets and competency packets without a comprehensive tracking mechanism. Additional interviews indicated that the assistant director of nursing provided some help with in-services and competencies but was also responsible for multiple other roles, limiting her availability. The director of nursing was not aware of any issues related to in-service education and stated that staff should receive required education and competencies after hire and annually. The facility's own assessment tool specified that annual in-servicing, training, and competencies would be provided, and that the staff development nurse was responsible for maintaining these records, but this was not consistently implemented.
Failure to Notify State Authority and Implement PASARR Recommendations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to comply with requirements for the Pre-Admission Screening and Resident Review (PASARR) process for several residents with mental health diagnoses. For three residents, the facility did not notify the State-designated authority when new mental health diagnoses were identified. Specifically, one resident was diagnosed with major depressive disorder, recurrent, but this was not reported to the State authority as required. Another resident received a new diagnosis of schizoaffective disorder, bipolar type, which was also not communicated to the State. A third resident was diagnosed with schizoaffective disorder, but the facility did not update the State-designated authority with this information. Additionally, for a resident with a history of schizoaffective disorder, bipolar disorder, attempted self-harm, and violent behaviors, the facility did not incorporate PASARR recommendations into the care plan. The PASARR had recommended a crisis/safety plan due to the resident's history, but the care plan lacked this intervention. Interviews and record reviews confirmed that the required crisis/safety plan was not present in the clinical record, and staff were unaware of the PASARR recommendations for this resident. The facility's own PASARR policy requires notification of the State-designated authority when a resident receives a new mental health diagnosis or shows signs of mental illness not previously identified. Despite this, the responsible staff did not conduct audits to ensure compliance, and new diagnoses were not consistently reported or incorporated into care plans as required. These failures were identified through review of clinical records, facility documentation, and staff interviews.
Failure to Maintain Complete and Accessible Dental Records
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident who was reviewed for dental services. The resident, who had diagnoses including partial loss of teeth, anxiety, and obesity, was care planned to attend appointments without an escort and to receive education about appointment status. Despite the resident's report of a dental extraction performed by the facility's Consultant Dentist and subsequent complaints of pain and requests for dental records, the clinical record did not contain documentation of dental care and services provided by the consulting dental group for a significant period. The resident also reported that after the extraction, they began receiving dental care from a community dentist and had requested their dental records from the facility without follow-up. Upon surveyor inquiry, dental records from the Consultant Dentist were obtained and made accessible, revealing details of the extraction and subsequent dental complaints. Interviews with facility staff indicated a lack of awareness regarding the resident's request for dental records and confirmed that the dental records from the consulting provider were not immediately available in the resident's clinical record as required by facility policy. The facility's policy directs that all ancillary services, including dental, must be documented in the resident's medical record, specifying the type of service and outcome.
Failure to Follow Up with Oncology Office Post-Discharge
Penalty
Summary
Staff failed to follow hospital discharge instructions for a resident with a diagnosis of Stage 4 left breast cancer. The discharge summary and nursing admission note both directed that the resident's oncology office be contacted within two weeks post-discharge. However, record review did not show any evidence that this follow-up contact was made within the specified timeframe. Interviews with the oncology office RN, the Director of Nursing Services (DNS), and the Administrator confirmed that the oncology office did not receive a call from the facility, and facility leadership could not locate documentation of any such contact. The facility's own policy required the admitting RN to review discharge instructions and schedule necessary follow-up appointments in a timely manner, but this was not done for the resident in question.
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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