Touchpoints At Chestnut
Inspection history, citations, penalties and survey trends for this long-term care facility in East Windsor, Connecticut.
- Location
- 171 Main St, East Windsor, Connecticut 06088
- CMS Provider Number
- 075436
- Inspections on file
- 27
- Latest survey
- August 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Touchpoints At Chestnut during CMS and state inspections, most recent first.
Two residents at high risk for skin breakdown did not have weekly skin assessments documented as required by facility policy. Despite care plans and risk assessments indicating the need for regular monitoring, there were significant gaps in the documentation of skin checks, which was confirmed by the DON during record review.
Multiple resident rooms were observed to have temperatures above 81°F, and several residents reported ongoing discomfort due to excessive heat over a period of weeks. Requests for portable air conditioners were not fulfilled in a timely manner, and the facility was unable to provide temperature logs for several days during a period of high outdoor temperatures. The Maintenance Director confirmed ongoing issues with the air conditioning system.
A resident with severe cognitive impairment and total dependence for care did not receive incontinence care or repositioning every two hours as required by the care plan and facility policy. Documentation and staff interviews confirmed that the resident was left saturated with urine for several hours, and care was not provided until a family member intervened. Facility policy mandates two-hour checks and care for incontinent residents unable to request assistance, which was not followed in this case.
Surveyors identified deficiencies in kitchen sanitation, food labeling, and monitoring practices, including unclean dry storage areas with debris and dead insects, improperly labeled and dated refrigerated food items, inadequate sanitizing solution levels, and dish machine rinse cycles not consistently reaching required temperatures. Documentation and verification of daily cleaning and temperature logs were frequently incomplete or missing, and staff could not provide clear explanations for these lapses.
The facility did not ensure nurse aides received or were properly tracked for the required 12 hours of annual education, including dementia care and abuse prevention. Education was delivered through self-directed poster boards and post tests, often completed in less time than credited, with answer keys available and no instructor present. There was no formal tracking of actual hours completed, and some nurse aides did not complete all required modules or have their competencies verified.
A resident with severe cognitive impairment was admitted without timely review and documentation of required admission paperwork, including resident rights, consent for treatment, and advance directives. The resident's representative did not review or sign these documents until about a month after admission, and the advance directive/code status consent was not signed until six months later, contrary to facility policy.
The facility did not consistently notify physicians or resident representatives when residents experienced significant changes, such as elevated blood glucose levels, returning from leave smelling of marijuana, or being found with smoking materials. In several cases, staff failed to follow physician orders and facility policy regarding notification and documentation, even when incidents were reported among staff or discussed in meetings. This lack of communication and documentation occurred despite clear expectations from the medical director and facility policies.
Two residents experienced failures in the timely reporting and investigation of abuse and neglect allegations. In one case, a resident alleged verbal abuse, including profanity and a racial slur, by a staff member during a smoking break, but the incident was not promptly reported to the state agency as required. In another case, a resident reported neglect after waiting several hours for incontinence care, but the concern was not properly documented or investigated, and key staff were unaware of the allegation. Facility policy requiring immediate reporting and investigation of such incidents was not followed.
A resident with significant care needs reported not receiving incontinence care for several hours after multiple requests for assistance. The facility did not conduct a thorough investigation, failed to document findings, and did not interview or remove involved staff as required by policy. Key staff were unaware of the incident, and the required investigative steps were not followed.
A resident with a new diagnosis of schizoaffective disorder did not receive a required PASARR rescreen after this change in mental health status. The facility's records and care plan reflected the updated diagnosis and use of psychotropic medications, but staff confirmed that only the original PASARR was on file and no new screening was completed as required.
A resident with significant care needs reported waiting five hours for incontinent care after a bowel movement, repeatedly calling for assistance without timely response. Despite the grievance being reported, no RN assessment was performed to check for injuries or complications, and key nursing staff were unaware of the incident. Required facility policy for assessment after a change in condition was not provided.
The facility failed to ensure appropriate care and documentation for multiple residents, including not completing RN assessments after a feeding tube dislodgement, not obtaining or recording weights as ordered, not documenting or following up on refusals of care, and not assessing or notifying providers when a resident repeatedly returned from leave smelling of marijuana. Facility policies and physician orders were not followed, and required documentation was missing.
Two residents with cognitive and physical impairments were repeatedly observed using smoking materials, including vaping and marijuana, inside the facility. Staff failed to consistently report these incidents, and management did not ensure care plans were updated or that appropriate supervision and interventions were implemented. The facility did not follow its own policies for smoking assessments, care plan revisions, or notification of responsible parties and medical providers, resulting in ongoing safety hazards.
A resident with a history of epilepsy, gastrostomy, and dysphagia experienced significant, unaddressed weight loss after admission. Despite documented weight declines and recommendations for supplements, the facility failed to consistently monitor the resident's weight, update the care plan, or provide timely nutritional assessments. Inconsistent dietitian coverage and lack of follow-up contributed to the deficiency.
A resident with a history of alcohol dependence and anxiety disorder was admitted following hospitalization for alcohol withdrawal. The facility failed to assess the resident's smoking status upon admission and did not provide the substance abuse support services recommended by the Level II PASARR, such as group therapy and recovery support groups. During the stay, the resident was repeatedly found with marijuana and smoking paraphernalia, and staff confirmed that no substance abuse support programs were available.
The facility did not ensure timely action on pharmacy consultant recommendations for three residents, resulting in missed or delayed medication management interventions such as stop dates for anticoagulants, appropriate medication forms for tube administration, monitoring for side effects of antipsychotics, and completion of recommended laboratory tests. Staff interviews and record reviews confirmed that pharmacy recommendations were not consistently reviewed, signed, or acted upon by providers as required by facility policy.
Two residents with significant dental needs were not scheduled for recommended outside dental consultations and extractions due to unclear staff responsibilities and lack of training in the referral process, resulting in delays in receiving necessary dental care.
A resident with quadriplegia and full dependence on staff was not assisted out of bed for lunch as ordered by a physician. When the resident requested help, a nurse aide refused, responded disrespectfully, and instructed the resident to get out of bed independently, despite the resident's inability to do so. The incident was documented in the aide's personnel file and confirmed through staff interviews, highlighting a failure to treat the resident with dignity and respect.
A resident with dementia and behavioral disturbances was physically struck in the nose by another resident with a history of behavioral issues after a verbal exchange and accidental contact in a hallway. Despite care plans and staff presence, the altercation was not prevented, resulting in pain and distress for the affected resident.
Failure to Document Weekly Skin Assessments for At-Risk Residents
Penalty
Summary
The facility failed to ensure that weekly skin assessments were documented for two residents who were at risk for skin integrity issues. For one resident with a history of stroke, hemiplegia, incontinence, diabetes, and impaired mobility, the care plan required weekly skin checks and other interventions to prevent skin breakdown. However, there was no documentation of weekly skin observation tool assessments for this resident between February and late June, despite the resident being identified as very high risk for pressure sores on the Braden scale. The only documented skin assessments during this period were at the beginning and end of the timeframe, with a gap of several months in between. Similarly, another resident with chronic ulcer, osteomyelitis, and a history of stroke was also identified as at risk for skin breakdown, with care plan interventions including regular Braden/Norton assessments. For this resident, there was no documentation of weekly skin assessments between late April and mid-July, except for assessments at the start and end of the period. The Director of Nursing confirmed that she could not provide documentation of the required weekly skin assessments for either resident during the specified periods, despite facility policy directing that weekly head-to-toe skin checks be completed and documented.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels for residents, as evidenced by observations of three resident rooms with temperatures exceeding 81 degrees Fahrenheit. Specifically, rooms were recorded at 82 and 83 degrees, and multiple residents reported that their rooms had been uncomfortably hot for two to three weeks. Residents expressed dissatisfaction with the temperature, with one resident stating they had requested a portable air conditioner from the Maintenance Director but had not yet received one. The Director of Maintenance confirmed ongoing issues with the air conditioning and chiller systems and acknowledged that requests for portable air conditioners were being prioritized. Additionally, the facility was unable to provide temperature logs for a four-day period during which outdoor temperatures ranged from 86 to 91 degrees Fahrenheit. Interviews with several residents confirmed persistent discomfort due to the heat, and the Maintenance Director verified that the temperature control issues had been ongoing. The lack of temperature documentation and unresolved maintenance concerns contributed to the deficiency in providing a safe, comfortable, and homelike environment for residents.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
A resident with a history of stroke, left-sided hemiplegia, dysphagia, epilepsy, diabetes, and severe cognitive impairment was admitted with total dependence for activities of daily living and was always incontinent of bowel and bladder. The care plan and physician's orders required incontinence care and repositioning every two hours to maintain skin integrity and assist with wound healing. On the date in question, documentation and interviews revealed that the resident was not provided incontinence care or repositioned as required between 4:00 PM and 7:00 PM. The resident's family member discovered the resident saturated with urine at 7:00 PM, and facility records failed to show incontinence care provided between 12:21 PM and 10:19 PM that day. Staff interviews confirmed that the resident was checked at 4:00 PM and not again until the family member raised concerns at 7:00 PM. The nurse aide responsible did not return to the resident's room after the initial check, and the nurse confirmed the resident was wet when assessed. Facility policy and the Director of Nursing Services both indicated that incontinent residents unable to request care should be checked and changed every two hours, which was not done in this instance. The lack of timely incontinence care and repositioning was not in accordance with the resident's care plan and facility policy.
Deficiencies in Kitchen Sanitation, Food Labeling, and Monitoring Practices
Penalty
Summary
The facility failed to maintain the kitchen's dry storage areas in a clean and sanitary condition, as evidenced by observations of debris, dead insects, dried pasta, and powdery substances scattered throughout the storage rooms and under shelving. Multiple mouse and insect glue traps were present, and cleaning schedules did not specifically assign or document regular cleaning of these areas. The Dietary Director and staff were unable to provide documentation or clear explanations regarding the cleaning assignments or verification of completed cleaning tasks for these areas. Additionally, the facility did not ensure that previously opened refrigerated items were properly labeled and dated. Packages of meat and bags of what appeared to be raw chicken were found in the walk-in refrigerator without clear identification or date markings. The Dietary Director was unable to confirm the contents or the dates when the items were prepared or opened, and there was confusion regarding the labeling system in use. This lack of proper labeling and dating of perishable food items is contrary to facility policy and food safety standards. The facility also failed to maintain appropriate sanitizing solution levels and dish machine rinse temperatures. Testing of the sanitizing solution in the pot sink and sanitizing bucket revealed levels below the required 200 PPM, and the test strips used were found to be expired. The high temperature dish machine did not consistently reach the required rinse temperature of 180°F, with multiple documented instances of substandard temperatures and missing temperature logs. Daily monitoring sheets for sanitizer levels, dish machine temperatures, and food temperatures were frequently incomplete or missing, and staff did not consistently initial or verify these logs as required by facility policy.
Failure to Provide and Track Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to provide and accurately track the required 12 hours of annual education for nurse aides, including essential topics such as dementia care and abuse prevention. Interviews with the ADNS and RN responsible for staff education revealed that the annual mandatory education was delivered primarily through poster boards and post tests in the staff break room, with no formal tracking system for the actual hours completed by each nurse aide. The staff development nurse and the corporate regional educator both acknowledged that they did not monitor the actual time spent on education modules, instead assigning predetermined credit hours regardless of the time staff actually spent on the material. Multiple nurse aides reported that the mandatory education and dementia training took significantly less time than the hours credited, often completing the material in 15 to 60 minutes. The education was self-directed, with answer keys available for copying, and there was no instructor present to answer questions or verify understanding. Some nurse aides did not complete all required modules, and there was no observation or verification of competency for skills, as staff simply signed off on forms themselves. The corporate COO confirmed awareness of issues with the staff education and competency process during the year in question. A review of the facility assessment indicated that the facility's staffing plan required nurse aide competency in areas such as dementia management and abuse prevention, with training to be completed during orientation and annually. However, the facility was unable to provide a policy for mandatory staff education or documentation verifying that nurse aides received the full 12 hours of required education. The lack of a structured, monitored education program and insufficient documentation led to the deficiency.
Failure to Provide Timely Notice of Rights and Secure Admission Consents
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed of their rights, rules, and responsibilities upon admission. Specifically, the clinical record did not show that the required admission paperwork—including the bed hold policy, contraband policy, consent for treatment, advance directive/code status consent, smoking policy, resident rights, influenza vaccination consent and education, and the facility admission agreement—was reviewed with the resident representative at the time of admission. Additionally, there was no documentation of a signed advance directives/code status consent form at admission. The resident in question was admitted with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, and had severely impaired cognition, requiring moderate assistance with activities of daily living. The resident was hospitalized for alcohol withdrawal prior to admission and was initially identified as full code regarding resuscitation status. However, the care plan and physician orders regarding code status were inconsistent and not supported by timely, signed documentation from the resident or their representative. Interviews with facility staff revealed that the social worker was responsible for reviewing administrative paperwork, while the RN supervisor was responsible for clinical paperwork. The social worker acknowledged that, due to the resident's cognitive impairment, paperwork was reviewed with the resident's representative, but this did not occur until approximately one month after admission. Furthermore, the signed documents were not placed in the resident's paper chart or uploaded to the electronic record. The advance directive/code status consent form was not signed until six months after admission, contrary to facility policy requiring this to be completed upon admission.
Failure to Notify Physician and Resident Representatives of Significant Changes and Incidents
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in resident status and incidents as required by policy and physician orders. For one resident with diabetes, there were multiple documented instances where blood glucose readings exceeded the threshold set by the physician's order, which required immediate physician notification. Despite this, nursing staff did not notify the physician or document such notifications in the clinical record, even though the physician expected to be informed to provide additional insulin coverage. Interviews with nursing staff confirmed that notifications were not made, and the Director of Nursing Services (DNS) stated that her expectation was for staff to follow the physician's order and document all notifications. For another resident with chronic kidney disease who frequently left the facility for dialysis and with family, staff repeatedly noted the resident returned smelling of marijuana. Although this was reported among staff and discussed in meetings, there was no documentation of physician notification, assessment, or notification to the dialysis center, as required by facility policy. The physician was not made aware of these ongoing issues, despite his expectation to be notified due to potential drug interactions with prescribed medications. The facility also lacked documentation of smoking assessments, education, or agreements for this resident, contrary to its own smoking policy. A third resident with a history of substance use and impaired cognition was involved in multiple incidents of suspected smoking and possession of smoking paraphernalia within the facility. Documentation showed that room searches were conducted and smoking materials were found, but there was a lack of evidence that the physician or the resident's representative was notified in most cases. The facility's own policies required such notifications and documentation, but interviews with staff and review of records confirmed these steps were not consistently followed. The only documented notification to the resident's representative occurred after a policy violation that led to discussions of discharge planning.
Failure to Timely Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse involving a resident with a history of hemiplegia, hemiparesis, and depression. During a supervised smoking break, the resident alleged that a nurse aide used profanity and a racial slur towards them. The resident reported the incident to the administrator, but the administrator did not immediately recognize or act upon the allegation of verbal abuse. The charge nurse was informed by the resident that the aide had used a racial slur, but did not escalate the report to the RN Supervisor as required, choosing instead to wait for the resident to calm down before seeking further details. The administrator only became fully aware of the specific allegation the following day, at which point the state agency was notified and an investigation was initiated, outside the required reporting timeframe. In a separate incident, another resident with chronic osteomyelitis and a diaphragmatic hernia reported a concern of neglect after waiting several hours for incontinence care. The resident filed a grievance stating that they called for assistance multiple times over a five-hour period before receiving care. The social worker documented the grievance and reported it to nursing and administration, but the Director of Nursing Services (DNS) was unaware of the concern and could not locate documentation of an investigation. The administrator, upon learning of the allegation, spoke with the resident and the assigned aide, but determined that the information did not require reporting to the state agency, despite facility policy requiring immediate reporting of all allegations of mistreatment. Both incidents demonstrate failures in the facility's process for reporting and investigating allegations of abuse and neglect. The facility's own policy requires that all allegations of abuse, neglect, exploitation, or mistreatment be reported to the state agency immediately, but in both cases, the required notifications and investigations were either delayed or not completed according to policy. Documentation was incomplete or missing, and key staff members were not always aware of the allegations or the required procedures for handling them.
Failure to Investigate Allegation of Neglect
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate an allegation of neglect involving a resident with chronic osteomyelitis and a diaphragmatic hernia. The resident, who required assistance with activities of daily living and was incontinent, reported calling for help after a bowel movement and not receiving assistance for five hours, despite multiple requests. The resident's grievance was documented, but the investigation process was incomplete. Key facility staff, including the Director of Nursing Services (DNS), social worker, and administrator, were responsible for investigating such allegations. However, the DNS was unaware of the incident, and the administrator could not provide documentation of a completed investigation, including staff or resident statements or a summary of findings. The administrator also could not identify the staff involved or explain why the DNS was not included in the investigation. Staff members who worked during the incident were not interviewed as part of the investigation, nor were they removed from the schedule pending the outcome, as required by facility policy. Interviews with staff assigned to the resident on the day of the incident revealed that they were not informed of the allegation, were not asked to provide statements, and did not receive any education related to the event. The facility's policy required immediate reporting and thorough investigation of all allegations of neglect, including removal of the alleged abuser from resident care, but these steps were not followed. Attempts to interview additional staff involved were unsuccessful.
Failure to Complete PASARR Rescreen After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Pre-admission Screening and Resident Review (PASARR) rescreen was completed for a resident following a new diagnosis of schizoaffective disorder. The resident had an initial Level 2 PASARR evaluation that determined they met the criteria for nursing home level-of-care but did not require specialized mental health services, and no further evaluations were required unless there was a change in condition related to mental illness. Despite the resident later being diagnosed with schizoaffective disorder, this significant change in mental health status was not reported or followed up with a new PASARR screening as required by facility policy and federal/state procedures. Review of the clinical record showed that the resident's primary diagnosis was updated to schizoaffective disorder, and the care plan included interventions for multiple mental health conditions, including the use of psychotropic medications. However, the annual MDS did not identify a serious mental illness or intellectual disability as a Level II PASARR condition. Interviews with facility staff confirmed that the only PASARR on file was the original one, and that a new Level 1 and potentially Level 2 PASARR should have been completed after the new diagnosis. The lack of timely PASARR rescreening following the change in mental health diagnosis constituted the deficiency.
Failure to Conduct RN Assessment After Reported Delay in Incontinent Care
Penalty
Summary
A resident with chronic osteomyelitis, a diaphragmatic hernia, and urinary incontinence reported waiting five hours for incontinent care after a bowel movement. The resident, who required assistance with transfers and perineal care, called for help multiple times over a five-hour period, but staff did not respond until much later. The incident was documented in a grievance report, and the resident was cognitively intact at the time. The baseline care plan and physician's orders indicated the resident's need for significant assistance with mobility and toileting. Despite the resident's report of delayed care, there was no evidence that an RN assessment was conducted to evaluate for potential injuries or complications resulting from the delay. The Director of Nursing Services (DNS) was not aware of the allegation, and the LPN on duty was not informed of the untimely care concern. Facility policy for assessment following a change of condition was requested but not provided. The failure to conduct an RN assessment after the reported delay in care constituted a lapse in meeting professional standards of quality.
Failure to Provide Care and Documentation per Orders and Standards
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and professional standards for multiple residents. For one resident with a history of epilepsy, gastrostomy, and dysphagia, the facility did not complete or document an RN assessment after the dislodgement of a feeding tube, nor did they notify the provider on the day of the incident. There was also a lack of documentation regarding the resident’s removal or self-discontinuation of the G-tube, and weights were not consistently obtained or recorded as ordered by the physician. The clinical record showed significant gaps in weight monitoring, and weights provided by therapy staff were not entered into the resident’s clinical record. Interviews confirmed that staff did not document or communicate key events, and the facility’s own policies on weight monitoring and documentation were not followed. Another resident with congestive heart failure and severe protein calorie malnutrition had a physician’s order for daily weights, which were not consistently obtained or documented on numerous days over several months. When the resident refused weights, there was no documentation of education, re-approach, or notification to the physician or APRN, despite repeated refusals. The care plan did not address refusals of care, and interviews with staff and leadership confirmed that documentation and follow-up were inconsistent or absent. The facility’s policies and guidelines for inotrope therapy, which emphasize the importance of daily weights, were not adhered to in this case. A third resident, with chronic kidney disease and a history of returning from leave of absence or dialysis smelling of marijuana, did not receive care in accordance with professional standards. There was no documentation of assessments upon return, notification to the physician or dialysis center, or education provided to the resident regarding the impact of drug use. The facility also failed to maintain required documentation such as a smoking agreement or smoking assessment, and did not document room searches or the retrieval of smoking materials. Interviews revealed that staff were aware of the issue but did not consistently document or communicate it, and the facility’s smoking policy requirements were not met.
Failure to Prevent and Address Unauthorized Smoking and Substance Use
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with a history of tobacco and substance use. One resident, with hemiplegia, hemiparesis, and depression, was repeatedly observed by staff vaping in their room and bathroom, in violation of the facility's smoking policy. Despite these observations, there was a lack of consistent reporting to management, and the Director of Nursing Services (DNS) was not made aware of the incidents. The care plan for this resident did not initially address the ongoing unauthorized use of smoking materials, and staff interviews revealed that management was aware of the behavior but did not take effective action. Another resident, with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, was involved in multiple incidents of smoking and possession of smoking paraphernalia within the facility. Documentation showed that this resident was found with marijuana, a lighter, and a smoking pipe on several occasions, and was observed smoking in both their room and a facility bathroom. The facility failed to notify the resident's physician or conservator after these incidents, did not revise the care plan to address the repeated policy violations, and did not consistently document or implement increased supervision or other interventions. Staff interviews indicated that the issue of residents smoking, including marijuana use, was ongoing and that reporting and follow-up were inconsistent or lacking. Facility policy required smoking assessments upon admission and after significant changes, as well as care plan updates and supervision for residents with smoking risks. However, the facility did not adhere to these requirements, as evidenced by the lack of smoking assessments, care plan revisions, and documentation of interventions following repeated incidents. The facility also failed to consistently notify responsible parties and medical providers, and did not maintain adequate records of investigations or actions taken in response to the observed hazards, resulting in a failure to protect residents from accident hazards related to unauthorized smoking and substance use.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor and address the nutritional status and weight of a resident with a history of epilepsy, gastrostomy, and dysphagia, who was dependent on staff for care and had a G-tube for enteral nutrition. Upon admission, the resident weighed 173.6 lbs, but within a week, a significant weight loss of 9.4 lbs (5.4%) was documented. The dietitian recommended nutritional supplements and an appetite stimulant, but there was no evidence that the stimulant was started, and no follow-up weights or nutritional assessments were performed in the subsequent weeks. After a hospitalization and readmission, the resident's weight continued to decline, with a further loss of 21 lbs (12.1%) since admission. Despite this, there were no documented weights or nutritional assessments for the entire month following readmission, and the care plan was not revised to address the ongoing weight loss. Interviews revealed that the facility lacked consistent, in-person dietitian coverage, with periods of only remote coverage and uncertainty among staff about who was responsible for nutritional oversight. Staff also reported that diet slips and diet change forms were not being signed off by a dietitian for newly admitted residents. Facility policy required weights to be obtained on admission and monthly, with additional monitoring and interventions for significant weight changes. However, the resident did not receive the required monitoring or timely interventions after multiple episodes of significant weight loss. Interviews with staff and the resident confirmed that weight monitoring was inconsistent, and the lack of dietitian presence contributed to the failure to reassess and update the nutritional care plan as required.
Failure to Implement PASARR Recommendations for Substance Abuse Support
Penalty
Summary
A deficiency occurred when the facility failed to implement Level II PASARR recommendations for a resident with a diagnosed substance abuse disorder. The resident was admitted with a history of alcohol dependence, anxiety disorder, and repeated falls, and had recently been hospitalized for alcohol withdrawal. Upon admission, the resident's smoking status was not assessed, and subsequent clinical records did not document any smoking assessments. Despite a physician's order for supervised smoking and care plan interventions for safety risk evaluations, the admission MDS did not identify current tobacco use, and there was no evidence that the recommended substance abuse support services were provided. The Level II PASARR identified that the resident required specific services, including participation in a support group for substance abuse recovery (such as Alcoholics Anonymous), group therapy with a trained therapist, and the appointment of a guardian conservator for health and safety decisions. While the care plan acknowledged these recommendations, the facility did not offer group counseling or substance abuse support programs. Interviews with facility staff confirmed that the recommended services were not available, and there was no documentation of the resident receiving these supports. During the resident's stay, multiple incidents occurred involving the possession and use of marijuana and smoking paraphernalia, as well as violations of the facility's smoking and safety policies. Room searches revealed marijuana, a smoking pipe, and a pocketknife in the resident's possession. Despite these findings and the clear recommendations from the PASARR, the facility did not provide the required substance abuse support services, contributing to ongoing behavioral and safety concerns.
Failure to Act on Pharmacy Consultant Recommendations for Medication Management
Penalty
Summary
The facility failed to ensure that physicians or advanced practice registered nurses (APRNs) acted upon pharmacy consultant recommendations in a timely manner for three residents reviewed for unnecessary medications. For one resident with multiple complex diagnoses, including diabetes, stroke, epilepsy, and gastrostomy, the pharmacy consultant made several recommendations over multiple months regarding medication management, such as adding stop dates for anticoagulants, switching medication forms for easier administration via feeding tube, and monitoring for side effects. Despite these recommendations, there was no documentation that the physician or APRN responded to or acted upon them within the expected timeframe, as required by facility policy. Interviews with facility staff confirmed that the process for following up on pharmacy recommendations was inconsistent, with forms not always being reviewed, signed, or returned by the responsible providers. Another resident with a history of stroke, diabetes, and heart failure was started on an antipsychotic medication, and the pharmacy consultant recommended baseline and ongoing monitoring for side effects, as well as laboratory testing for lipid profiles. The clinical record review revealed that these recommendations were not completed, and the forms were not signed or dated by the provider. Interviews with nursing and pharmacy staff confirmed that the recommendations were not reviewed or acted upon, and the required monitoring and laboratory tests were not documented in the resident's record. A third resident with bipolar disorder and hyperlipidemia was receiving an antipsychotic medication, and the pharmacy consultant recommended ordering a lipid profile and HbA1C due to the risk of diabetes and dyslipidemia. Although the prescriber agreed with the recommendations, only the HbA1C was completed, and there was no documentation that the lipid profile was ordered or completed. Facility staff interviews indicated that the process for ensuring completion of pharmacy recommendations was not consistently followed, resulting in missed or delayed actions on important medication management recommendations.
Failure to Schedule and Follow Up on Dental Referrals
Penalty
Summary
The facility failed to follow through on recommendations for outside dental consultations for two residents who required specialized dental care. One resident, with a history of multiple sclerosis, paraplegia, and cardiomegaly, was fully dependent on staff for oral hygiene and had documented dental issues including tooth decay and mobile teeth. Despite a dental provider's note indicating the need for an outside dental appointment for specific teeth, the resident was not scheduled for the recommended consultation for several months. Interviews revealed that the staff responsible for scheduling such appointments was unclear about their responsibilities and had not received adequate training on the referral process, resulting in the delay. Another resident, diagnosed with type 2 diabetes, reduced mobility, and requiring a mechanically altered diet, was identified as having significant dental issues, including cavities and broken teeth. The dental provider recommended referral to an oral surgeon for extractions prior to denture fabrication. However, the resident was not scheduled for the necessary dental extractions, and staff interviews indicated confusion and lack of clarity regarding the process for scheduling follow-up appointments. The staff member responsible for appointments had only recently taken on this role and had not been fully trained, contributing to the oversight. Facility policy required assistance with making appointments and arranging transportation for medical and professional services, including dental care. Despite this, the lack of clear procedures and staff training led to failures in ensuring timely dental services for the residents, as recommended by consulting dental providers.
Failure to Honor Resident Dignity and Physician Orders During Transfer Request
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, contracture of the left hand, and chronic pain syndrome, who was fully dependent on staff for all activities of daily living and required transfer via a Hoyer lift, was not assisted out of bed for lunch as per physician's orders. The resident requested assistance from a nurse aide to be transferred to a wheelchair before lunch, but the aide refused, stating she was busy and instructed the resident to get out of bed independently, despite the resident's inability to do so due to their medical condition. The resident reported this interaction to a registered nurse supervisor, and documentation confirmed that the aide responded in a rude and disrespectful manner, failed to follow the physician's order, and was insubordinate to the supervising nurse. The clinical record did not document the negative interaction, but the aide's personnel file included a corrective action record for the incident, noting the refusal to assist the resident and the disrespectful communication. The aide had a history of multiple disciplinary actions related to care issues. Interviews with facility staff confirmed awareness of the incident and the expectation that all residents be treated with dignity and respect. The facility's policy directs that residents have the right to be treated with consideration, respect, and full recognition of their dignity and individuality.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with dementia, epilepsy, anxiety disorder, and depressive disorder was involved in a physical altercation with another resident who had a history of behavioral problems, including being inconsiderate to roommates and intentionally disturbing others. The incident occurred when the first resident was waiting at the nurse's medication cart and accidentally touched the second resident, who was attempting to pass by in a wheelchair. The second resident responded by shouting and then physically striking the first resident in the nose. The facility's documentation indicated that both residents had care plans addressing their behavioral issues, with interventions such as monitoring behaviors, documenting observed incidents, and intervening to protect the rights and safety of others. Despite these interventions, the altercation occurred, resulting in the first resident experiencing pain and discomfort, though no visible trauma was noted upon assessment. Staff present at the scene attempted to intervene but were unable to prevent the physical contact, and one staff member was injured while separating the residents. Interviews with the involved resident and staff confirmed the sequence of events, with the resident expressing feelings of embarrassment and fear following the incident. The facility's abuse policy prohibits abuse, neglect, and mistreatment by anyone, including other residents. The report documents that the facility failed to protect the resident from physical abuse by another resident with a known history of 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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