Torrington Center For Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Torrington, Connecticut.
- Location
- 80 Fern Dr, Torrington, Connecticut 06790
- CMS Provider Number
- 075105
- Inspections on file
- 24
- Latest survey
- February 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Torrington Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident with multiple psychiatric diagnoses exhibited escalating agitation, aggression, and threatening behaviors over two days, including verbal and physical altercations and attempts to hit staff. Despite a physician's order for PRN trazodone and a care plan requiring monitoring and documentation of mood and behavior changes, the resident was not given the medication and the provider was not notified. Interviews confirmed that the expectation was for provider notification in such cases, but this did not occur, violating facility policy.
A resident with a history of psychiatric and behavioral disorders displayed escalating aggression and disruptive behaviors, which were documented by nursing staff but not reported to a provider or managed with as-needed medication. This culminated in the resident physically striking another resident in a common area, an incident witnessed by a speech therapist. The facility's investigation confirmed that physical abuse occurred and that required interventions to prevent such incidents were not implemented.
A resident with multiple psychiatric diagnoses and a history of aggressive and threatening behaviors did not have a comprehensive, individualized care plan to address these behaviors. Despite repeated incidents of verbal and physical aggression, staff interventions were not systematically documented or incorporated into a person-centered care plan, as confirmed by interviews with the MDS Coordinator and DON.
The facility failed to conduct timely interdisciplinary care plan meetings for several residents due to staffing issues, including the absence of a full-time social worker and a permanent MDS Coordinator. This led to delays in developing and updating comprehensive care plans, which should involve residents and their representatives.
The facility did not address the resident council's repeated requests for a social worker from April to July 2024. Despite using response forms to document concerns, no resolution was provided, and the social worker did not attend meetings. The Director of Recreation reported the issue to the Administrator, who failed to act. The part-time social worker was often unavailable, and the facility's policy for resolving issues was not followed.
The facility failed to maintain a homelike, safe, and sanitary environment in two shower rooms and the central unit's carpeted areas. Observations revealed cluttered shower rooms with various items, a black substance on the ceiling, and stained carpets. Staff interviews confirmed the issues, attributing them to limited storage space and informal environmental rounds. Additional maintenance problems included rusty pipes, a cracked light fixture, and ripped shower curtains.
The facility failed to provide adequate social services to residents requiring psychosocial support due to the absence of a full-time social worker. Several residents, including those with cardiac conditions, respiratory failure, and cerebral infarction, had not been evaluated or received necessary follow-up from social services. The lack of social service assessments and progress notes highlighted the facility's inability to meet residents' psychosocial needs.
The facility failed to properly document and complete its antibiotic surveillance tracking form as part of its antibiotic stewardship program. The Infection Preventionist could not produce the necessary documentation, and the Director of Nursing Services acknowledged that meeting minutes did not specify discussions on antibiotic stewardship. The facility's policy required regular reviews of antibiotic utilization and sensitivity patterns, but there was no evidence these were conducted or documented.
The facility failed to allocate appropriate time for the Infection Preventionist (IP) to perform their duties, as RN #2 was primarily scheduled as the RN Supervisor. Despite having completed the necessary training, RN #2 lacked designated hours for infection prevention tasks, often covering for call-outs or short staffing. The previous IP had a more focused schedule, but the current role combines IP, staff development, and RN Supervisor responsibilities without specified minimum hours for infection prevention.
A facility failed to document a resident's life support choices accurately, resulting in a discrepancy between the advance directive indicating DNR/DNI status and physician's orders showing full code. Staff interviews revealed that the inconsistency was not corrected, despite facility policy requiring accurate documentation of resident preferences.
A resident with Alzheimer's and dysphagia was administered crushed medications without a physician's order, including an extended-release medication, by an LPN. The facility's policy requires a provider order for medication administration, which was not followed. Interviews with staff confirmed the need for such orders and the risks of crushing extended-release medications.
A resident admitted with cardiac-related diagnoses did not have a timely discharge plan developed due to the absence of a full-time social worker. Despite the initial care plan identifying the need for discharge planning, no discussions or documentation occurred, and the resident reported no interaction with a social worker. Facility staff confirmed that discharge planning should start upon admission, but this was not done.
A resident with moderate cognitive impairment and health issues expressed dissatisfaction with the lack of weekend activities at the facility. The activities calendar showed only family visits on weekends, and the Director of Activities cited budget constraints as the reason for no weekend programming. The facility's policy requires activities seven days a week, which was not being met.
The facility failed to implement a neurologist's orders for a resident with tremors, continuing Primidone instead of starting Sinemet. Additionally, another resident with cellulitis did not receive proper documentation for a compression glove application, as per physician orders. The facility's policies for care coordination and documentation were not followed, leading to these deficiencies.
A resident with severe cognitive impairment and a history of falls was left unattended in the bathroom by a new nurse aide, resulting in a fall while attempting to transfer to an unlocked wheelchair. The resident's care plan required assistance with toileting, which was not followed, leading to the incident. Facility staff confirmed the resident's need for supervision, indicating a lapse in communication and training.
The facility failed to remove expired medications and improperly stored medications against manufacturer guidelines. An LPN was unsure of the storage requirements for Lorazepam, which was administered past its discard date. Morphine Sulfate was stored in a refrigerator instead of at room temperature, as required. The facility's policy mandates adherence to manufacturer specifications, which was not followed.
The facility failed to ensure proper hand hygiene by staff and did not conduct annual reviews of infection control policies. An LPN did not wash hands after glove removal and another did not perform hand hygiene between resident interactions. The infection control policy was not signed by the Infection Preventionist, and signature pages from previous years were missing.
The facility failed to notify the state Ombudsman's office of resident transfers and discharges, as required. A resident with acute respiratory failure and another with venous hypertension were transferred and discharged without proper notification. The Social Worker responsible for these reports had not sent them since late 2023, and the admissions person was not instructed to do so in their absence. This oversight occurred despite the facility's policy mandating such notifications.
The facility failed to complete timely comprehensive assessments for four residents, with delays ranging from 19 to 85 days. The delay was due to the absence of a full-time MDS coordinator, acknowledged by the LPN responsible for assessments and the DNS. The facility's policy requires adherence to federal and state submission timeframes, which was not met.
The facility failed to complete quarterly MDS assessments on time for 21 residents, with delays up to 72 days. This was due to staffing issues, including the absence of a full-time MDS coordinator and the MDS nurse being on maternity leave. An LPN acknowledged the delays, and the DNS confirmed the situation, leading to the hiring of an outside consultant to assist with the backlog.
A resident with schizoaffective disorder and muscle weakness was involved in two incidents of abuse by another resident with autism and severe cognitive impairment. The first incident involved physical assault, and the second involved pulling the resident's arm, causing a fall. Despite no physical injuries, the facility failed to prevent these incidents, highlighting a deficiency in protecting residents from mistreatment.
Failure to Notify Provider of Resident's Significant Behavioral Changes
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician regarding significant behavioral changes in a resident with multiple psychiatric diagnoses, including paranoid schizophrenia, antisocial personality disorder, conversion disorder with seizures, and severe anxiety. The resident had a physician's order for trazodone as needed for anxiety and a care plan that required monitoring and documentation of mood and behavior changes. Over a two-day period, nursing documentation showed the resident exhibited escalating behaviors such as agitation, anxiety, aggression, verbal and physical altercations, use of vulgar language, threats toward staff, and attempts to hit staff. Despite these documented behaviors, the resident was not administered the prescribed PRN trazodone, and the physician or psychiatric APRN was not notified of the changes. Interviews with the psychiatric APRN and the Director of Nursing confirmed that their expectation was to be notified of such behavioral changes, but this did not occur. The facility's policy required immediate notification of the provider and family when there is a significant change in a resident's physical, mental, or psychosocial status. The failure to notify the provider of the resident's significant behavioral changes and to administer the prescribed PRN medication constituted a violation of facility policy and regulatory requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with diagnoses including paranoid schizophrenia, antisocial personality disorder, conversion disorder, and dementia exhibited ongoing verbal and physical behavioral symptoms, such as aggression, vulgar language, threatening gestures, and attempts to hit staff. Nursing notes documented repeated incidents of disruptive and aggressive behavior over multiple shifts, including throwing staff belongings, using threatening language, and being verbally aggressive toward both staff and other residents. Despite these behaviors, the resident did not receive as-needed medication for anxiety, and there was no documentation that the physician was notified about the escalating behaviors as required by facility policy. On the morning of the incident, the resident attempted to access a closed therapy gym, became agitated, and engaged in a verbal and physical altercation with another resident. The aggressive resident struck the other resident on the shoulder with an open hand while yelling. The incident was witnessed by a speech therapist, who immediately separated the residents and notified nursing staff. The resident who was struck denied pain and had no noted injuries. Facility documentation and interviews confirmed that the aggressive behavior had been escalating prior to the incident, and that appropriate interventions, such as notifying the provider or administering as-needed medication, were not implemented. The facility's investigation substantiated that resident-to-resident physical abuse occurred, and the facility's abuse policy was not followed in preventing the incident.
Failure to Implement Comprehensive Care Plan for Resident with Behavioral Issues
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan with appropriate interventions for a resident exhibiting significant physical and verbal behaviors. The resident had a history of paranoid schizophrenia, antisocial personality disorder, conversion disorder, and unspecified dementia with severe anxiety. Despite multiple documented incidents of aggression, threats, and behavioral disturbances—including threats to staff, physical altercations, and gestures indicating harm—there was no individualized care plan addressing these behaviors. The care plan in place only referenced monitoring and documenting changes in mood and behavior, without specific, personalized interventions to manage the resident's ongoing behavioral issues. Clinical documentation revealed repeated episodes where the resident was verbally and physically aggressive towards staff and other residents, including making threats, using foul language, and engaging in altercations. Staff responses included placing the resident on one-to-one supervision, attempting redirection, and contacting emergency services when behaviors escalated. However, these interventions were not reflected in a comprehensive, person-centered care plan, and there was no evidence of systematic implementation or evaluation of behavioral management strategies tailored to the resident's needs. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing Services, confirmed the absence of a comprehensive care plan for the resident's behaviors. Both acknowledged that such a plan should have been in place and were unable to provide documentation or rationale for its omission. The facility's own policy requires the interdisciplinary team to develop and implement a person-centered care plan with measurable objectives for each resident, which was not followed in this case.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to ensure that interdisciplinary team (IDT) care plan meetings were held following comprehensive and quarterly assessments for nine sampled residents. These meetings are crucial for developing comprehensive care plans with the involvement of residents, their families, or responsible parties. The absence of these meetings was attributed to staffing issues, including the lack of a full-time social worker and a permanent MDS Coordinator, which led to a breakdown in scheduling and implementing resident care conferences. For Resident #26, the comprehensive care plan was not developed within the required timeframe due to the absence of a social worker and a newly appointed MDS Coordinator who had not yet organized the necessary meetings. Similarly, Resident #27's care plan did not reflect the resident's or representative's participation, and the care conference was delayed due to staff changes. Resident #32 had not attended a care conference since 2023, and the facility's records confirmed that no meetings were held following the required assessments. Other residents, such as Resident #43, #50, #61, #64, #69, and #376, also experienced similar issues with care plan meetings not being held as required. The facility's policies dictate that care plans should be developed and reviewed with resident participation, but due to the lack of a full-time social worker and consistent MDS Coordinator, these processes were not followed. This resulted in care plans not being updated or revised in a timely manner, impacting the residents' involvement in their care planning.
Failure to Address Resident Council's Request for Social Worker
Penalty
Summary
The facility failed to address the concerns of the resident council regarding the need for a social worker. Over several months, from April to July 2024, the resident council repeatedly expressed their desire to speak with a social worker during their meetings. Despite utilizing designated response forms to document and address resident council requests, there was no resolution or indication that a social worker attended any meetings to address these concerns. Interviews with residents revealed ongoing dissatisfaction due to the absence of a full-time social worker, despite being informed that the facility was attempting to hire someone for the position. The Director of Recreation, responsible for documenting the resident council minutes and distributing response forms, acknowledged the ongoing concern and had brought it to the Administrator's attention. However, the Administrator failed to address the issue effectively, as he could not recall if he had returned the response forms or notified the social worker. The social worker employed during part of this period worked only one day a week and was often at another facility, limiting her ability to address the residents' needs. The facility's policy required tracking and resolving issues through response forms, but this process was not followed, leading to unresolved resident concerns.
Facility Fails to Maintain Homelike and Sanitary Environment
Penalty
Summary
The facility failed to provide a homelike, safe, and sanitary environment in two shower rooms on the central and middle units, as well as in the carpeted areas on the central unit. Observations revealed that two of the three shower rooms in the central shower area were cluttered with various items, including rolling shower chairs, IV poles, a utility cart, and a cardboard box. Additionally, a black substance was noted on the ceiling, and the shower curtain had holes. The third shower room also contained rolling shower chairs. The south wing hallway carpet had several dark brown stains of unknown origin. Interviews with a resident and staff members confirmed the cluttered state of the shower rooms and the presence of stains on the carpet, which were attributed to the lack of basins under shower chairs used by residents. The facility's environmental rounds were conducted informally, using a hot list rather than formal documentation, which led to the shower rooms not being identified as an issue. The Maintenance Director acknowledged that the shower rooms were used for storage due to limited space in the building, and the shower leaks were part of a planned remodel project. The Infection Preventionist did not list the shower room stalls as an issue during environmental rounds, as they had been in the same condition for approximately two years. The Environmental Round Policy of the facility mandates providing a safe, clean, and comfortable environment, but the facility failed to adhere to this policy in the shower rooms and hallway. Further observations of the central and middle unit shower rooms revealed additional issues, such as rusty pipes, a dirty glove on the floor, a cracked light fixture cover, and a burnt-out light bulb. The shower curtains were ripped, and there were numerous areas stained with rust and a brown substance. Interviews with staff confirmed the ongoing use of the shower rooms for storage and the lack of a homelike environment. The Administrator was aware of the maintenance issues and acknowledged the need for repairs, but the facility's limited storage space contributed to the continued use of the shower rooms for storing items.
Inadequate Social Services for Residents
Penalty
Summary
The facility failed to provide adequate social services to residents requiring psychosocial support, as evidenced by the lack of a full-time social worker and insufficient social service assessments and progress notes. Resident #26, admitted with multiple cardiac conditions, had not been seen by a social worker since admission, despite being at risk for psychosocial well-being issues. The facility's social worker, who worked only one day per week, confirmed that she had not evaluated Resident #26, and the clinical record lacked any social service documentation for nearly two months. Resident #35, with diagnoses including acute respiratory failure and morbid obesity, expressed dissatisfaction with the facility's care and follow-up, particularly regarding the Money Follows the Person program. The last social service entry for this resident was in January 2024, and there was no follow-up or documentation of the resident's status in the program, despite the care plan indicating the need for social work intervention for discharge planning. The social worker admitted that discharge planning should start at admission and be documented, but acknowledged the absence of notes for Resident #35 since January. Resident #69, admitted with cerebral infarction and psychosis, reported never having a care plan meeting or seeing a social worker since admission. The facility's records confirmed the lack of social worker evaluation or progress notes for this resident. Similarly, Resident #376, with diabetes and anxiety, had requested to see a social worker upon admission but had not been seen until after surveyor inquiry. The facility's administrator acknowledged the absence of a full-time social worker and the challenges in hiring one, which contributed to the deficiencies in providing necessary social services to the residents.
Deficiency in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to ensure the completion and proper documentation of its antibiotic surveillance tracking form as part of its antibiotic stewardship program. During a review, it was found that the Infection Preventionist (IP), who had been in the role since late May or early June 2024, was unable to produce the tracking/surveillance documentation when requested. Although the IP indicated that antibiotic stewardship was tracked monthly using McGeer's criteria, the actual stewardship book was not available for review. Additionally, the IP mentioned that labs were reviewed and checked off in the stewardship book, but these labs were not included in the book itself. Furthermore, the Director of Nursing Services (DNS) acknowledged that while antibiotic stewardship was discussed during Interdisciplinary Team meetings, the meeting minutes did not document the specifics of these discussions. The DNS was unable to locate the necessary antibiotic stewardship paperwork, except for a review from Trident Care covering the period from January 1, 2022, to December 31, 2022. The facility's policy on antibiotic stewardship required regular reviews of antibiotic utilization patterns and sensitivity patterns at committee meetings, but there was no evidence to confirm that these reviews were conducted or documented as required.
Inadequate Time Allocation for Infection Preventionist Duties
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), RN #2, had appropriate time to fulfill their infection prevention and control duties. The Facility Assessment for 2023 identified RN #2 as holding the dual role of Infection Preventionist and Staff Development, but the facility's monthly schedules from May to September 2024 showed that RN #2 was primarily scheduled as the RN Supervisor. Interviews with the Director of Nursing Services (DNS) and RN #2 revealed that RN #2 did not have designated hours for infection prevention tasks and was often required to cover for call-outs or short staffing, limiting their ability to focus on infection prevention responsibilities. The DNS acknowledged that the previous IP/staff development person worked 32 hours as the IP and 8 hours in staff development, without the additional responsibility of being an RN Supervisor. The current arrangement, as identified by the corporate entities, combined the roles of IP, staff development, and RN Supervisor, with no federal minimum hours specified for the IP role. Despite RN #2 having completed the necessary training for the Infection Preventionist position, the lack of dedicated time for infection prevention duties was a significant issue, as RN #2 was predominantly scheduled as the RN Supervisor.
Failure to Document Resident's Life Support Choices Accurately
Penalty
Summary
The facility failed to accurately document a resident's life support choices, leading to a discrepancy between the resident's advance directive and the physician's orders. The resident, who was admitted with diagnoses including metabolic encephalopathy, dementia, and pneumonia, had an advance directive form signed by their representative and physician indicating a do not resuscitate (DNR) and do not intubate (DNI) status. However, the physician's orders from the time of admission through several months later indicated a full code status, which contradicted the advance directive. Interviews with facility staff revealed that the inconsistency was not identified or corrected in a timely manner. RN #3 acknowledged that the advance directive form and the physician's order were not congruent and indicated that it was the responsibility of the charge nurse or nursing supervisor to update the orders when the advance directive form was completed. The Director of Nursing Services (DNS) also expected that any change in code status should be updated in the resident's clinical record by the charge nurse or RN supervisor. The facility's policy on advance directives emphasized that resident preferences should always be respected and documented accurately in the medical chart and electronic medical record.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to ensure that an extended-release medication was not crushed and that a physician's order was in place to administer crushed medications to a resident. Resident #59, who had diagnoses including Alzheimer's disease, dysphagia, and anxiety, was observed during medication administration. The resident's care plan included aspiration precautions, but there was no physician's order to crush medications. During the observation, an LPN crushed several medications, including Metoprolol Succinate, an extended-release medication, and mixed them with pudding for administration. The LPN acknowledged that there was no physician's order to crush the medications and that extended-release medications should not be crushed. Interviews with the RN Supervisor, DNS, and Pharmacist confirmed that medications should be administered whole unless there is a specific order to crush them. The pharmacist highlighted that crushing extended-release medications like Metoprolol Succinate could alter their intended effects. The facility's Medication Administration policy requires a provider order for medication administration, including the right route, which was not followed in this instance. The deficiency was identified through the observation of the medication administration process and subsequent interviews with facility staff.
Failure to Develop Timely Discharge Plan for Resident
Penalty
Summary
The facility failed to develop a timely discharge plan for a resident admitted with multiple cardiac-related diagnoses, including pericardial effusion and hypertensive heart disease with heart failure. The initial care plan identified the need for discharge planning and social service evaluation, but the social service progress notes from admission until late August did not document any discussion of the discharge plan with the resident. The resident, who required extensive assistance for daily activities and had a discharge plan in place according to the admission MDS assessment, reported not having interacted with a social worker or participated in the discharge planning process. Interviews with facility staff revealed that the social worker is responsible for initiating discharge planning upon admission, which should involve meeting with the resident within 72 hours to discuss their discharge plan. However, the covering social worker confirmed that no discharge planning had been documented for the resident. The Director of Nursing Services acknowledged that discharge planning should start upon admission and be documented in the progress notes or care plan, but this was not done due to the absence of a full-time social worker.
Lack of Weekend Recreation Activities for Resident
Penalty
Summary
The facility failed to provide weekend recreation activities for a resident with moderate cognitive impairment and multiple health conditions, including cerebral infarction due to embolism, ischemic cardiomyopathy, and adjustment disorder with depressed mood. The resident expressed dissatisfaction with the lack of activities on weekends, noting that they sometimes prefer in-room activities but also enjoy group activities. The resident reported that weekends were particularly boring due to the absence of recreation staff and lack of visitors. The facility's activities calendar for August showed that the only activities scheduled for weekends were family visits. The Director of Activities confirmed that there was no weekend programming due to budgetary constraints. Before the COVID pandemic, the facility had more recreation staff, but post-pandemic, staffing was reduced, and the Director of Activities had additional responsibilities beyond recreation. Despite discussions with the Administrator and facility owner about the need for more staff and hours, budget limitations prevented any changes. The facility's policy requires activities to be scheduled seven days a week to support residents' physical, mental, and psychosocial well-being, which was not being met.
Failure to Implement Physician Orders and Document Care
Penalty
Summary
The facility failed to implement a neurologist's orders for a resident with chronic obstructive pulmonary disease, Type 2 diabetes mellitus, dementia, and a skin-picking disorder. The neurologist had recommended discontinuing Primidone due to its lack of therapeutic benefit and starting Sinemet for persistent tremors. However, the facility continued administering Primidone and did not initiate Sinemet as ordered. Interviews with the neurology consultant and nursing staff revealed that the responsibility for updating medication orders was not clearly executed, leading to the oversight. Another deficiency involved a resident with pneumonia, dementia, and seborrheic dermatitis, who was prescribed a compression glove for cellulitis and dependent edema. The facility failed to document the application and removal of the compression glove as per the physician's orders. The Medication Administration Records and Treatment Administration Records did not reflect the necessary documentation, and the resident's skin condition was not consistently assessed for signs of infection. The facility's policies for MD consults and skin and wound management were not adhered to, resulting in lapses in care coordination and documentation. The Director of Nursing Services acknowledged the errors in entering orders into the system, which led to the tasks not being prompted for the nursing staff. This lack of documentation and follow-up on physician orders contributed to the deficiencies identified during the survey.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident during toileting, resulting in a fall. The resident, who had diagnoses including Alzheimer's disease, schizoaffective disorder, spinal stenosis, and delusional disorder, was identified as being at risk for falls due to a decline in functional mobility. The resident's care plan included interventions such as encouraging the resident to sit at the nurses' station, checking wheelchair brakes, instructing on proper use, and providing assistance with toileting. Despite these interventions, the resident was left unattended in the bathroom by a new nurse aide, leading to an unwitnessed fall while attempting to transfer to an unlocked wheelchair. The resident's fall risk assessment and annual MDS assessment indicated severe cognitive impairment and a need for extensive assistance with toilet transfers and total assistance with toileting hygiene. The incident occurred when the resident was left alone in the bathroom, contrary to the care plan and facility fall prevention policy. Interviews with facility staff, including an LPN, the Rehabilitation Manager, and the Director of Nursing Services, confirmed that the resident required assistance and should not have been left alone. The nurse aide involved was unaware of the resident's need for supervision, highlighting a lapse in communication and training.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that expired medications were not in use and were removed from the medication cart, and also failed to store medications according to the manufacturer's recommendations. During an observation of the South unit's medication cart, an opened bottle of Lorazepam Intensol concentrate was found with an opened date of 7/19/24, which should have been discarded by 8/18/24. However, it was still being administered to a resident nine days past the discard date. The LPN responsible was unsure of the storage requirements for the medication once opened, and the pharmacist confirmed that the medication should be stored at room temperature for no more than 30 days after opening. Additionally, the facility improperly stored Morphine Sulfate Oral Concentrate in a refrigerator, contrary to the manufacturer's instructions to store it at room temperature. The LPN was unaware of the correct storage requirements, and the pharmacist noted that incorrect storage could affect the medication's integrity and potency. The facility's Medication Storage policy requires medications to be stored according to the manufacturer's specifications, which was not adhered to in these instances.
Inadequate Hand Hygiene and Policy Review Lapses
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff, as observed in multiple instances. On one occasion, an LPN performed hand hygiene, donned gloves, and obtained a blood glucose level from a resident. However, after removing her gloves, she failed to wash her hands before discarding the used lancet in the corridor, which she held in her ungloved hand. Another LPN was observed not performing hand hygiene after leaving a resident's room and before preparing medications for another resident. This LPN also failed to perform hand hygiene after assisting a resident who had slipped to the floor and before returning to medication preparation. Additionally, the facility's infection prevention and control policies were not reviewed and signed annually as required. The Infection Control Policy Manual was last reviewed and signed by the Administrator, Director of Nursing, and Medical Director in January 2024, but not by the Infection Preventionist, who had not been employed since February 2024. The facility was unable to provide signature pages from 2023 or 2022, indicating a lapse in the annual review process.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide the required notification of resident transfers and discharges to the state Ombudsman's office for two residents. Resident #35, who had diagnoses including acute respiratory failure, chronic osteomyelitis, and morbid obesity, was hospitalized from May 8 to May 14, 2024, but the facility could not provide the Ombudsman's notice of transfers and/or discharges report for May 2024. The Administrator revealed that the Social Worker, responsible for sending these reports, had not done so since December 2023. The Social Worker, who was shared with another facility and worked limited hours, confirmed she was not making the Ombudsman notifications. Similarly, Resident #73, with diagnoses including venous hypertension, type 2 diabetes, and atrial fibrillation, was discharged home against medical advice on May 24, 2024. The facility's documentation showed that the last report sent to the Ombudsman was in November 2023, despite numerous discharges and transfers occurring in the subsequent months. The Administrator acknowledged the lapse in reporting and noted that the admissions person was not instructed to send the reports in the absence of a full-time Social Worker. The facility's policy requires notification to the Ombudsman for all transfers and discharges, which was not adhered to in these cases.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to complete yearly comprehensive assessments for four residents, as required by federal and state regulations. Resident #30's annual Minimum Data Set (MDS) assessment was due by June 3, 2024, but was not completed until August 27, 2024, making it 85 days late. Similarly, Resident #35's assessment was due by August 8, 2024, but was also not completed by August 27, 2024, resulting in a 19-day delay. Resident #47's assessment was due by June 14, 2024, and was 74 days late, while Resident #376's admission MDS assessment was due by July 26, 2024, and was 31 days late. The delay in completing these assessments was attributed to the facility not having a full-time MDS coordinator at the time. The LPN responsible for MDS assessments began her role on July 15, 2024, and acknowledged the lateness of the assessments. The Director of Nursing Services (DNS) was also aware of the delays. The facility's policy mandates that resident assessments be conducted and submitted within the prescribed timeframes, which was not adhered to in these cases.
Delayed MDS Assessments Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for 21 out of 27 sampled residents. The assessments were significantly delayed, with some being overdue by as much as 72 days. This deficiency was identified through clinical record reviews, facility policy reviews, and interviews. The MDS assessments are required to be completed within 14 days of the assessment reference date, as per the Resident Assessment Instrument 3.0 user manual and the facility's MDS policy. The delay in completing the MDS assessments was attributed to staffing issues within the facility. Specifically, the Licensed Practical Nurse (LPN) responsible for MDS coordination acknowledged the delays and cited the absence of a full-time MDS coordinator prior to her taking the position on July 15, 2024. Additionally, the Director of Nursing Services (DNS) confirmed that the MDS nurse was on maternity leave, which contributed to the backlog of assessments. An outside consultant was hired to assist with completing the overdue assessments. The residents affected by the delayed assessments included those with assessments due in June and July 2024. The facility's failure to adhere to the required timelines for MDS assessments indicates a lapse in maintaining compliance with federal and state submission timeframes. This deficiency highlights the importance of having adequate staffing and resources to ensure timely completion of resident assessments, which are crucial for maintaining the quality of care in long-term care facilities.
Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to protect a resident from mistreatment, as evidenced by two incidents of resident-to-resident abuse involving Resident #1 and Resident #2. Resident #1, who was alert and oriented with a history of schizoaffective disorder/bipolar and muscle weakness, was independent for transfers and mobility with a walker. Resident #2, who had autism, Parkinson's disease, schizoaffective disorder/bipolar, depression, and anxiety, was severely cognitively impaired and required assistance for mobility. The first incident occurred when Resident #2 approached Resident #1 and punched them in the stomach, hit their leg, and grabbed their walker. This incident was witnessed by staff, and Resident #2 was placed on one-to-one supervision and sent to the hospital for evaluation. A second incident occurred two days later when Resident #1 alleged that Resident #2 pulled their arm, causing them to fall to the floor. Again, the residents were separated, and Resident #2 was sent to the hospital for evaluation. Interviews with staff and facility documentation revealed that Resident #1 had been calling Resident #2 names prior to the incidents, indicating inappropriate interactions between the two residents. Despite these incidents, Resident #1 did not sustain any physical injuries, and Resident #2 was noted to have increased impulsivity. The facility's policies on resident abuse and resident rights emphasize the importance of ensuring residents are free from abuse. However, the facility's failure to prevent these incidents of resident-to-resident abuse highlights a deficiency in protecting residents from mistreatment. The facility's documentation and interviews with staff indicate that the interactions between the two residents were not adequately managed, leading to the physical altercations.
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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