St Joseph's Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Trumbull, Connecticut.
- Location
- 6448 Main Street, Trumbull, Connecticut 06611
- CMS Provider Number
- 075001
- Inspections on file
- 25
- Latest survey
- March 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at St Joseph's Center during CMS and state inspections, most recent first.
The facility did not follow its water management plan to prevent Legionella growth, failing to conduct required water testing, maintenance, and notification to health authorities after multiple positive Legionella results. Key staff were unaware of their responsibilities, and expired or undocumented water filters were found throughout the building. Additionally, several residents with medical devices did not have Enhanced Barrier Precautions signage or PPE available, indicating lapses in infection control practices.
The facility did not ensure safe and comfortable room temperatures or properly maintain heating elements, as evidenced by rooms with old water leaks, accessible radiators with high surface temperatures, and ambient air temperatures reaching up to 87°F. Maintenance staff reported ongoing steam leaks, difficulty completing repairs, and challenges with vendor payments, while the Administrator confirmed boiler issues and lack of temperature regulation.
The facility did not consistently ensure accurate accounting and documentation of controlled medications, as evidenced by missing signatures on narcotic shift-to-shift sign-off sheets, unrecorded administration of a narcotic, and disorganized record-keeping. Staff interviews confirmed that required dual-nurse counts and reconciliations were not reliably performed, and facility policy for controlled substance management was not consistently followed.
Surveyors found that food items in various storage areas were not consistently labeled with open or discard dates, nor were expired items reliably removed. Some foods were incorrectly labeled using pre-printed stickers, and staff personal food was found in refrigerators designated for kitchen or resident use, contrary to facility policy. Interviews confirmed staff were aware of labeling and storage requirements, but these were not consistently followed.
Three residents with various medical and cognitive conditions were not offered or administered influenza and/or pneumococcal vaccines as required, and there was no documentation of vaccine consent or administration in their records. The Infection Preventionist confirmed the vaccines were not offered, despite facility policy mandating assessment and offering of these immunizations upon admission.
Two residents with cognitive impairments and multiple diagnoses were not offered or assessed for the COVID-19 booster vaccine, as required by facility policy. Review of immunization records and interviews with the Infection Preventionist confirmed that the booster was not offered, and no reason was provided for this omission.
The facility did not ensure that required consents and physician orders for advance directives and code status were obtained and documented for several residents, despite care plans and physician orders referencing these directives. Staff interviews confirmed that the process for completing and maintaining advance directive forms was not consistently followed, and audits of resident records were not performed as required by facility policy.
A resident with chronic respiratory failure and COPD was observed receiving continuous oxygen therapy at 3 liters per minute via nasal cannula without a physician's order in place. Nursing staff and the DNS confirmed that a physician's order specifying the method and rate of oxygen delivery is required for continuous use, but none was found in the resident's record, contrary to facility policy.
Expired medications, including several prescription drugs, were found in medication carts during surveyor observations. Despite facility policy and staff interviews confirming that nurses are responsible for removing expired or discontinued medications and placing them in designated bins for destruction or return, these medications remained in circulation. This failure to remove and properly store expired drugs resulted in noncompliance with accepted medication management standards.
The Administrator did not ensure a safe, homelike environment for residents, as room temperatures were not kept at comfortable and safe levels, the water management plan to prevent Legionella was not followed, and a positive Legionella test result was not reported to the state survey agency.
Two residents were involved in a physical altercation after one entered another's room uninvited and was struck, despite facility policies requiring supervision and intervention in such cases. In a separate incident, a resident's prescribed Oxycodone was found missing, with medication management protocols not followed and no narcotic requisition process in place at the time. These events reflect failures in abuse prevention and controlled substance management.
Following an altercation where one resident struck another after an uninvited entry into a room, the facility did not update care plans or aide instructions to ensure the two residents were kept apart or to provide guidance on redirecting wandering behaviors. Staff interviews revealed confusion about responsibility for care plan updates, and the required interventions to prevent further incidents were not documented or communicated.
Two residents with serious mental health diagnoses and positive Level II PASRR assessments were incorrectly coded on their MDS assessments as not having a serious mental illness or related condition. Staff interviews revealed errors in completing the PASRR section, confusion over responsibility, and missing documentation at the time of assessment.
Annual performance evaluations were not completed or documented for several nurse aides, despite facility policy requiring yearly appraisals. Staff interviews revealed that while some competency training was conducted through online modules and a skills fair, there was no verification or documentation for the previous year. Leadership and HR staff changes contributed to the lack of completed reviews.
Surveyors found that essential kitchen equipment, including a pot washer and a food warmer, was not maintained in safe and functional condition. Staff reported the pot washer had been broken for months and the food warmer door could not close properly, requiring makeshift solutions to keep it shut. Maintenance and administrative staff were either unaware of the issues or unable to arrange repairs due to vendor payment problems, resulting in noncompliance with the facility's equipment policy.
A resident with multiple health conditions did not receive wound care as ordered due to staff documentation errors and failure to reorder supplies. Despite physician orders for daily dressing changes, the resident's treatment was not performed for several days, leading to a deficiency in care.
Two residents did not receive dressing changes and wound care as ordered by physicians. One resident with a PICC line had a dressing that was not changed as scheduled, leading to a hospital transfer for evaluation. Another resident with a foot wound did not receive the prescribed daily dressing change, despite records indicating it was completed. Staff interviews revealed communication and procedural failures in both cases.
A resident with severe cognitive impairment and mobility issues fell during a transfer without a gait belt, contrary to facility policy. Two nursing assistants moved the resident without notifying the nurse, delaying the assessment of potential injuries. The charge nurse was informed later by a supervisor, highlighting a breach in protocol.
A facility failed to ensure accurate documentation and wound care for three residents. One resident with a PICC line had a dressing that was not changed as ordered, leading to a hospital transfer. Another resident did not receive wound care for a week due to supply issues and refusals, with inaccurate documentation. A third resident's wound care was not performed despite being documented as completed. These incidents reveal significant documentation inaccuracies and failures in following physician orders.
A resident with neurocognitive disorder and other conditions was found with multiple bruises and claimed to have been beaten. The facility failed to conduct a thorough investigation, lacking documentation of staff interviews and a summary of findings, as required by their Abuse Prohibition policy.
A facility failed to update the care plan for a resident with neurocognitive disorder and behavioral symptoms, leading to an injury of unknown origin. Despite increased agitation and combative behavior, the care plan lacked specific safety measures. Staff noted the resident's resistance to care and increased agitation, but the care plan was not revised accordingly.
Failure to Implement Water Management and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and follow its infection prevention and control program, specifically regarding its water management plan to prevent and mitigate the growth of Legionella species. Despite having a water management plan and contracts with two water management companies, the facility did not conduct regular water safety committee meetings, maintain water maintenance records, or perform required water sampling after a certain date. Multiple water samples collected from the facility's unused second floor showed positive results for Legionella species at levels significantly above the threshold outlined in the facility's own plan, but there was no evidence that required short-term control measures were implemented, nor was there documentation of notification to the local health department or state survey agency as required by policy. Key staff, including the Director of Maintenance, Administrator, and DNS, were unaware of the positive Legionella results and their responsibilities under the water management plan, and there was confusion regarding the roles of contracted water management companies versus facility staff in maintaining water safety. Further deficiencies were observed in the management of water filters throughout the facility. Several water filters installed on faucets and shower heads were found to be expired or lacked documentation of installation dates, which is necessary for ensuring timely replacement. The facility also failed to provide documentation of routine water maintenance tasks such as flushing, temperature checks, and filter changes, as required by their water management plan. Interviews with contracted water management providers confirmed that they were not notified of positive Legionella results and that the facility had ceased regular water sampling and maintenance activities. Additionally, the facility's infection preventionist was not informed of the positive Legionella findings, preventing appropriate clinical surveillance of residents for Legionella-related illnesses. The facility also failed to appropriately track and implement Enhanced Barrier Precautions (EBP) for residents with medical devices such as enteral feeding tubes, urinary catheters, and tracheostomies. Observations revealed that residents with these devices did not have EBP signage posted outside their rooms, and personal protective equipment (PPE) was not available for staff use. Staff interviews confirmed reliance on posted signage to identify precaution requirements, and the infection preventionist acknowledged that residents with such devices should have been placed on EBP with proper signage and PPE available. These failures in infection control practices and water management resulted in the finding of Immediate Jeopardy.
Removal Plan
- Educate staff in all departments on the water management contingency plan
- Provide bottled water for consumption
- Offer non-rinse foam cleanser, cleanse spray, and disposable wipes to residents who require showers
- Tag all sinks with signage indicating not to use until water testing is completed
- Audit and change all expired Nephro filters and change them regularly for the shower filter and the ice machine based on the water contractor's recommendations
- Order and install Nephro filters, shower wand filters, and sink filters through the water contractor and use water once filters are installed
- Assess all residents for changes in condition and respiratory status and report findings to the Medical Director
- Notify families of the situation
- Order additional water for consumption
- Order water filters to be shipped to the facility
Failure to Maintain Safe Room Temperatures and Heating Elements
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents by not ensuring that room temperatures and heating elements were kept at comfortable and safe levels. Observations revealed multiple rooms with evidence of old water leaks, such as bubbled and peeling paint on walls, and accessible wall radiators with metal covers that reached up to three feet high. Some resident beds were placed directly against these radiators. Temperature readings taken in various rooms and hallways showed radiator surface temperatures ranging from 89 to 130 degrees Fahrenheit, with ambient air temperatures as high as 87 degrees Fahrenheit, even with windows open and fans running. These conditions were directly observed by surveyors during their inspection. Interviews with the Maintenance Director revealed that he was not fully familiar with all areas of the building and acknowledged ongoing issues with steam leaks from the boiler system. He also indicated that maintenance staff were overwhelmed with daily tasks and unable to address larger projects, partly due to outstanding debts to vendors and difficulties in obtaining corporate approval for repairs. The Administrator confirmed ongoing boiler issues, stating that one boiler had to be shut off to cool the building, and that there was no way to regulate the heat, resulting in excessively warm conditions throughout the facility.
Failure to Maintain Accurate Controlled Substance Accountability and Documentation
Penalty
Summary
The facility failed to maintain a consistent and accurate system for accounting for controlled medications, as evidenced by multiple missing signatures on narcotic shift-to-shift sign-off sheets across several medication carts. Observations revealed that, on various units, there were numerous instances where required signatures were absent, indicating that the mandated dual-nurse verification of narcotic counts at shift changes was not consistently performed. In one instance, a narcotic was administered but not signed out, and a signature was present for a shift change that had not yet occurred. These lapses were observed over several months, with missing signatures documented for December, January, and February on multiple medication carts. Interviews with nursing staff and administrative personnel confirmed that the process for narcotic reconciliation and record-keeping was not being reliably followed. The Assistant Director of Nursing Services (ADNS) acknowledged responsibility for conducting reconciliations but was unable to identify when the last facility-wide narcotic audit had been completed. The ADNS also described a disorganized system for managing drug disposition records, with multiple staff members having access to the records and inconsistent matching of documentation. The Director of Nursing Services (DNS) similarly could not specify when the last audit occurred and described recent changes to the record-keeping process, but gaps in compliance persisted. Facility policy requires that all Schedule II-IV controlled substances be counted at every shift change by two licensed nurses, with proper documentation of the count. Despite this, review of facility records showed repeated failures to obtain the necessary signatures and to maintain accurate, up-to-date records of controlled medication receipt, usage, and disposition. These deficiencies were corroborated by both direct observation and staff interviews, demonstrating a systemic breakdown in the facility's pharmaceutical services and controlled substance management.
Failure to Properly Label, Date, and Store Food Items; Staff Personal Food in Resident Refrigerators
Penalty
Summary
Surveyors observed multiple instances where food items stored in the facility's refrigerators, freezers, kitchen, and dry storage areas were not properly labeled with open or discard dates, nor were they consistently removed once expired. Specific examples included an opened jug of salsa and a container of Dijon mustard in the reach-in refrigerator without open or discard dates, and a bag of Parmesan cheese in the produce refrigerator with no labeling. In the walk-in freezer, some items were labeled, but others, such as a dough-like item, lacked any identification or dates. Dry storage areas contained several opened packages of food, such as biscuit mix, cereals, noodles, and bread, all missing required labeling. Additionally, some items in the kitchen area were incorrectly labeled, and staff used pre-printed stickers with a standard 7-day expiration, which did not always align with actual product shelf life after opening. Interviews with dietary staff and the Director of Food Service revealed that staff were responsible for labeling and discarding food items according to facility policy and a food storage and retention guide. However, there was inconsistency in following these procedures, with some staff indicating they were not present on days when items needed to be discarded, and others acknowledging incorrect labeling practices. The Director of Food Service confirmed that staff were aware of their responsibilities and had assignment sheets outlining their duties, but acknowledged that items should have been labeled and discarded as per policy. Further observations identified that staff were storing personal food items in refrigerators designated for kitchen use and in resident unit refrigerators, despite facility policy prohibiting this practice. On multiple occasions, employee lunch bags were found in these refrigerators and were immediately removed when discovered. The facility's policies required all foods to be stored in covered containers, labeled and dated, and for storage areas to be organized and date-marked, but these standards were not consistently met during the survey.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that influenza and/or pneumococcal vaccines were offered to three of five sampled residents reviewed for immunizations. For one resident with diagnoses including seizures, hydrocephalus, and depression, clinical records and immunization documentation did not show that the influenza vaccine was offered or administered, despite the resident having intact cognition. Another resident with Parkinson's disease, bipolar disorder, and depression, and moderate cognitive impairment, was found to have neither the influenza nor pneumococcal vaccines up to date, with no evidence in the records that these vaccines were offered or administered. A third resident with paranoid schizophrenia, bipolar disorder, and intellectual disabilities, and severe cognitive impairment, also lacked documentation that the pneumococcal vaccine was offered or administered. Interviews with the Infection Preventionist confirmed that these residents were not offered the required vaccines, and no explanation could be provided for this omission. Facility policy required that all residents be offered influenza and pneumococcal vaccines upon admission and assessed for eligibility within 30 days, but this process was not followed for the affected residents, as evidenced by the lack of consents and administration records in their files.
Failure to Offer and Document COVID-19 Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccination was offered and/or assessed for two residents with cognitive impairments. One resident, admitted with diagnoses including Parkinson's disease, bipolar disorder, and depression, was identified on a quarterly MDS assessment as having moderate cognitive impairment and not being up to date with COVID-19 vaccination. Review of this resident's immunization records with the Infection Preventionist did not show evidence that the COVID-19 booster was offered. Another resident, admitted with diagnoses including paranoid schizophrenia, bipolar disorder, and intellectual disabilities, was identified on an admission MDS assessment as having severe cognitive impairment and also not being up to date with COVID-19 vaccination. Similarly, review of this resident's immunization records failed to show that the COVID-19 booster was offered. The Infection Preventionist confirmed during interview that the booster vaccines were not offered to these residents and could not provide a reason for this omission. Facility policy requires that all residents be offered the COVID-19 vaccine unless medically contraindicated or already immunized.
Failure to Obtain and Document Advance Directive Consents and Code Status Orders
Penalty
Summary
The facility failed to ensure that consents were obtained and physician's orders were in place regarding residents' wishes for advance directives and code status decisions for four sampled residents. In each case, review of the clinical records, physical charts, and electronic health records did not identify a signed Resident/Patient Health Care Instructions form indicating the resident's or their representative's wishes for code status. This deficiency was observed despite the presence of physician orders and care plans that referenced code status or advance directives for these residents. For example, one resident with diagnoses including cerebral infarction and chronic respiratory failure was identified as cognitively intact and required significant assistance with activities of daily living. Although the care plan and physician's order indicated a full code status, there was no signed advance directive form in the chart or electronic record. Similar findings were noted for another resident with severe cognitive impairment and psychiatric diagnoses, as well as for a resident with multiple sclerosis and brain neoplasm, and another with peripheral vascular disease and dysphagia. In all cases, the required documentation of the resident's wishes regarding code status was missing from both the physical and electronic records. Interviews with facility staff, including the unit manager, DNS, social worker, and medical records staff, confirmed that the process for obtaining and maintaining advance directive documentation was not consistently followed. Staff acknowledged that the Resident/Patient Health Care Instructions form should be completed on admission and maintained in the chart or electronic record, but audits and reviews had not been performed as required. Facility policies also specified that advance directive discussions and documentation should occur on admission, quarterly, and with changes in condition, but these procedures were not adhered to for the residents reviewed.
Oxygen Therapy Administered Without Physician's Order
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure, hypoxia, heart failure, and COPD was observed receiving continuous oxygen therapy via nasal cannula at 3 liters per minute without a corresponding physician's order. The resident, who had severe cognitive impairment and required total assistance with activities of daily living, was care planned to receive oxygen per physician's order, with regular pulse oximetry and monitoring for shortness of breath. However, review of the clinical record and physician's orders revealed that no order for continuous oxygen use was present at the time of observation. Interviews with nursing staff and the Director of Nursing Services confirmed that continuous oxygen administration requires a physician's order specifying the delivery method and rate, and that such an order was not found for this resident. Facility policy also required verification of a physician's order prior to oxygen administration. The lack of a physician's order for ongoing oxygen therapy constituted a failure to provide safe and appropriate respiratory care as required.
Expired Medications Not Removed from Medication Carts
Penalty
Summary
Surveyors observed that expired medications, including Simvastatin, Lisinopril, Amlodipine Besylate, and Sertraline, were found in medication carts despite having passed their expiration dates. These medications were resident-specific and had current active orders, yet were not removed from circulation as required. Facility policy states that outdated or discontinued medications should be immediately removed from stock and disposed of according to established procedures, and that outdated medications should be stored in a secured area separate from active orders. Interviews with nursing staff and administration confirmed that the responsibility for removing expired or discontinued medications from the carts lies with the nurses, and that such medications should be placed in designated bins for destruction or return to the pharmacy. However, the presence of expired medications in the carts indicated that these procedures were not consistently followed, resulting in a failure to ensure proper medication storage and disposal in accordance with professional standards and facility policy.
Failure to Maintain Safe Environment and Report Legionella
Penalty
Summary
The facility failed to administer operations in a way that ensured effective and efficient use of resources, resulting in several deficiencies. Specifically, the Administrator did not ensure that residents had a safe and homelike environment, as room temperatures were not maintained at comfortable and safe levels. Additionally, the facility did not follow its water management plan to prevent and mitigate the growth of Legionella species in the water supply. Furthermore, a positive Legionella test result was not reported to the state survey agency as required. These findings were based on observations, review of clinical records, facility policies, facility documentation, and interviews.
Failure to Prevent Resident-to-Resident Abuse and Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents from physical mistreatment and misappropriation of property, as evidenced by two separate incidents involving resident-to-resident abuse and missing controlled substances. In the first incident, a resident with severe cognitive impairment and behavioral symptoms entered another resident's room uninvited and was struck in the eye by the other resident, who admitted to the physical act after repeated requests for the first resident to leave were ignored. Documentation shows that the assaulted resident's account was inconsistent, but both residents and staff confirmed the physical altercation. The facility's abuse prohibition policy requires adequate supervision and intervention in cases of suspected resident-to-resident abuse, but the incident occurred despite these policies. In the second incident, a resident with chronic pain and a history of substance abuse was prescribed Oxycodone, a controlled substance. A blister pack containing 30 tablets of this medication was found missing during a shift change count. The report notes that the former Director of Nursing Services (DNS) had removed medication from the cart while orienting a new supervisor, and although one blister pack was returned, another remained unaccounted for. The current DNS and Administrator were unaware of the missing medication and indicated that a narcotic requisition process was not previously in place. Facility policy requires strict documentation and dual verification of controlled substances, which was not followed in this case. Both incidents demonstrate lapses in the facility's adherence to its own policies regarding abuse prevention and controlled substance management. The failure to provide adequate supervision and to maintain proper medication inventory controls resulted in residents being exposed to physical mistreatment and the misappropriation of property.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan following an altercation between two residents. One resident, with diagnoses including cerebral infarction, aphasia, hemiplegia, and delusional disorder, was identified as having severe cognitive impairment and disruptive behaviors such as yelling, using profanities, and refusing care. The care plan for this resident included interventions like establishing boundaries and providing verbal feedback, but did not address the risk of altercations with other residents or provide guidance on managing interactions with peers. An incident occurred in which this resident entered another resident's room and was struck in the eye by the second resident, who had diagnoses of hemiplegia, hemiparesis, diabetes, and peripheral vascular disease, but was cognitively intact. Documentation showed that the first resident was advised not to visit the second resident, and both residents expressed a desire to avoid each other. However, the care plans and nurse aide cards for both residents were not updated to reflect the need to keep them apart or to provide specific interventions for redirecting the first resident when wandering into other residents' rooms. Interviews with staff revealed a lack of awareness and clarity regarding restrictions between the two residents. Nursing staff and social work acknowledged the need to keep the residents separated but were unsure who was responsible for updating the care plans. The Director of Nursing confirmed that the altercation should have been included in both residents' care plans, with measures to ensure separation, but this was not done. The facility's abuse prohibition policy requires adequate supervision and identification of residents at risk for altercations, which was not fully implemented in this case.
Inaccurate Coding of PASRR Status on MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive assessments were accurately coded to reflect positive Level II PASRR assessments for two residents. One resident with diagnoses including bipolar disorder, anxiety disorder, and Parkinsonism had a Level II PASRR assessment indicating approval with no specialized services, but the significant change MDS assessment was incorrectly coded as 'no' to the question regarding serious mental illness or related conditions. Interviews with MDS coordinators and LPNs revealed that the PASRR section of the MDS was completed inaccurately, with staff acknowledging the error and indicating confusion over responsibility for completing the section. The PASRR information was supposed to be completed by the social worker, but was instead completed by an LPN who admitted to the mistake. Another resident with diagnoses of unspecified psychosis, anxiety disorder, and major depressive disorder also had a Level II PASRR evaluation with the same outcome, but the admission MDS assessment was similarly coded incorrectly. Staff interviews indicated that the PASRR was not available in the resident's record at the time of assessment, but the LPN recognized that the resident's diagnoses should have prompted a positive PASRR response. The facility did not provide a policy for the Resident Assessment Instrument, but staff stated that they follow the RAI manual guidelines when completing the MDS.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for three nurse aides, as required by facility policy. Review of the employee files for these nurse aides showed that none contained an annual performance evaluation for the years 2023 or 2024, despite their long-term employment. Interviews with the Staff Development nurse revealed that while competencies were reportedly completed quarterly through a web-based education platform and an annual skills fair was planned, there was no verification of when the skills fair occurred in 2024 or where documentation of completed competencies was kept for that year. Further interviews with the Administrator and Director of Nursing Services (DNS) indicated that performance reviews for 2024 were neither completed nor located, and the reason for this lapse was unclear. The process for annual reviews involved notifications from Human Resources to the Administrator and unit managers, who were responsible for completing the reviews. However, disruptions in leadership and HR staff absences contributed to the failure to conduct and document the required annual performance appraisals, as outlined in the facility's policy.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe and functional condition. During a kitchen tour, surveyors observed that the pot washer was not operational and the food warmer door could not close properly, being held shut by a door stopper. The Director of Food Service confirmed that the pot washer had been broken for months and the food warmer door had not closed properly due to a faulty gasket for an extended period. Staff reported using alternative methods, such as a 3-bay sink and dishwasher for pots and using a cart or door stopper to keep the food warmer door closed. The Director of Maintenance, who started working at the facility in November 2024, stated he became aware of the broken equipment about two weeks prior to the interview and was attempting to arrange repairs, but outstanding debts to vendors hindered timely service. The Administrator, also new to the facility as of November 2024, was not aware of the broken equipment and explained that repairs requiring outside vendors need corporate approval. The facility's equipment policy requires all food service equipment to be clean, sanitary, and in proper working order, which was not met in this instance.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care to a resident, identified as Resident #2, in accordance with physician orders, leading to a deficiency in care. Resident #2, who had a diagnosis of gangrene, type 2 diabetes, chronic kidney disease, and peripheral vascular disease, was supposed to receive daily wound care for a deep tissue injury and multiple ulcers. The physician's order required the left heel to be cleansed and a foam dressing applied every evening shift. However, the Treatment Administration Record (TAR) indicated that the wound treatment was not performed from September 24 to September 30, 2024, despite documentation suggesting otherwise. The deficiency was further compounded by staff actions and inactions. LPN #6 documented that the dressing was changed on September 28 and 29, but later admitted that the resident refused the treatment on those days and failed to update the records accordingly. Additionally, LPN #4 did not perform the dressing changes from September 25 to 27 and on September 30 due to a lack of calcium alginate, which was not reordered or reported to a supervisor. Interviews with staff confirmed that the treatments were not provided as ordered, and the facility's policy on neglect was not adhered to, as the necessary goods and services to prevent harm were not provided to the resident.
Failure to Provide Dressing Changes and Wound Care as Ordered
Penalty
Summary
The facility failed to provide dressing changes and wound care in accordance with physician orders for two residents. Resident #1, diagnosed with osteomyelitis, diabetes mellitus, and methicillin-resistant staphylococcus aureus, had a physician order to change the intravenous (IV) catheter site dressing every seven days. Despite the Medication Administration Record (MAR) indicating the dressing was changed, it was found on 9/28/2024 that the dressing had not been changed since 9/18/2024. The dressing was reinforced with tape, had dry blood underneath, and the insertion site was obscured. The resident was transferred to the hospital for evaluation, where the dressing was changed, and no signs of infection were noted. Interviews revealed that LPN #1 did not change the dressing as ordered and did not receive assistance from the supervisor, who was unaware of the request. Resident #3, with diagnoses including venous insufficiency and Parkinson's, had a physician order for daily wound care on the left dorsal foot. The Treatment Administration Record (TAR) indicated the treatment was completed on 9/30/2024, but the dressing was dated 9/29/2024, revealing the treatment was not performed. LPN #3 admitted to not completing the dressing change but signed off as if it was done and reported the task to the next shift. LPN #4 confirmed receiving the report but did not agree to perform the dressing change. The Director of Nursing Services (DNS) confirmed the dressing should have been changed as per the physician's order.
Failure to Follow Transfer Protocols and Notify Nurse After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was transferred in accordance with facility policy and was not moved off the floor prior to the completion of an assessment. Resident #4, who had a diagnosis of muscle weakness, abnormalities of gait and mobility, and cognitive communication deficit, required maximal assistance with transfers. The facility's incident report indicated that two nursing assistants moved Resident #4 after a fall without notifying the nurse, which was against the facility's policy. The nursing note documented that Resident #4 had a fall with no changes in mental status but sustained skin tears. An interview with one of the nursing assistants involved revealed that Resident #4 lost balance during a transfer to the toilet, and the assistant guided the resident to the floor without using a gait belt. The assistant admitted to not notifying the charge nurse immediately after the fall. The charge nurse was later informed by a supervisor about the resident's condition. The Director of Nursing Services confirmed that the nursing assistant should have notified the nurse before moving the resident and should have used a gait belt for the transfer, as per the facility's Safe Resident Handling/Transfer Equipment policy.
Inaccurate Documentation and Wound Care Deficiencies
Penalty
Summary
The facility failed to ensure accurate and complete documentation of wound care for three residents, leading to deficiencies in care. Resident #1, diagnosed with osteomyelitis, diabetes mellitus, and methicillin-resistant staphylococcus aureus, had a PICC line dressing that was not changed as ordered. Despite documentation indicating the dressing was changed, it was found to be dated incorrectly, with dry blood underneath, and the resident was transferred to the hospital for evaluation. The LPN responsible admitted to not changing the dressing and inaccurately documenting the procedure. Resident #2, with diagnoses including gangrene and diabetes, did not receive wound care treatments as ordered for a week. The Treatment Administration Record (TAR) was signed to indicate treatments were completed, but an incident report revealed the dressing was not changed due to a lack of supplies and resident refusals. The LPN involved failed to document the refusals and did not notify the supervisor about the unavailability of necessary supplies. Resident #3, who had venous insufficiency and Parkinson's, was supposed to receive daily wound care for a foot wound. However, the TAR was signed to indicate the treatment was completed, but an investigation found the dressing was not changed as documented. The LPN responsible admitted to not performing the treatment and inaccurately signing off on the TAR. These incidents highlight significant documentation inaccuracies and failures in following physician orders for wound care.
Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident diagnosed with neurocognitive disorder with Lewy bodies, anxiety disorder, insomnia, anemia, and hallucinations. The resident was dependent on assistance for daily living tasks and was at risk of skin breakdown. On a specific date, a nurse's note identified new injuries, including bruises on the shoulder, bicep, shin, and knee, as well as a red mark on the neck. The resident claimed to have been beaten up, prompting the facility to call the police and order an x-ray. However, the investigation lacked documentation of staff interviews and a summary of findings regarding possible causes. The facility's policy on Abuse Prohibition required thorough documentation and reporting of investigation results to the state agency, which was not adhered to in this case. The administrator was unable to locate all components of the investigation, including staff statements and a summary of findings, and could not reach the former Director of Nursing who conducted the investigation. This lack of documentation and follow-through on the investigation process led to the deficiency noted in the report.
Failure to Update Care Plan for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to review and revise the care plan for a resident who exhibited behavioral symptoms, such as kicking and combativeness, leading to an injury of unknown origin. The resident, diagnosed with neurocognitive disorder with Lewy bodies, anxiety disorder, insomnia, anemia, and hallucinations, was dependent on assistance for daily living tasks and was at risk for skin breakdown. Despite these conditions, the care plan did not include specific safety measures to address the resident's increased agitation and behavioral symptoms. The resident's care plan, dated 11/10/23, included interventions for personal care, monitoring cognitive status, and providing psychiatric services as needed. However, it lacked documentation of review and revision to address the resident's increased agitation. Psychiatric evaluation on 10/27/23 noted increased behaviors, and a nurse's note on 11/14/23 reported new injuries and increased agitation over the past 10 to 20 days. Interviews with nursing staff confirmed the resident's combative behavior and resistance to care, yet the care plan was not updated to reflect these changes.
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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