Trinity Hill Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hartford, Connecticut.
- Location
- 151 Hillside Ave, Hartford, Connecticut 06106
- CMS Provider Number
- 075268
- Inspections on file
- 31
- Latest survey
- May 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Trinity Hill Care Center during CMS and state inspections, most recent first.
A resident with a history of aggressive behavior and moderate cognitive impairment was involved in multiple physical altercations with other residents, including an incident where another resident with severe cognitive impairment was struck in the face, resulting in a laceration and a subdural hematoma requiring hospitalization and surgery. Despite documented behavioral risks and prior incidents, the facility did not provide adequate supervision or effective interventions to prevent the altercation, and did not substantiate the event as abuse according to its own policy.
A resident with atrial fibrillation, severe cognitive impairment, and a pacemaker was admitted while receiving Eliquis and Plavix, but the facility failed to develop a care plan addressing the risk of bleeding associated with these anticoagulants, as required by policy. Staff acknowledged the omission, attributing it to a change in the electronic medical record system and oversight.
A resident with a history of aggressive behaviors and moderate cognitive impairment was not adequately supervised, leading to a physical altercation with another resident who had severe cognitive impairment and was on anticoagulant therapy. The incident, which was unwitnessed by staff, resulted in a serious head injury and hospitalization for the injured resident. The aggressive resident's monitoring had been discontinued prior to the event, despite a documented pattern of similar incidents.
Two residents with psychiatric and cognitive conditions did not have their physician orders reviewed or renewed within the required 60-day timeframe, with a lapse of 127 days between signatures. Facility leadership and the Medical Director confirmed the orders were not signed as scheduled, and no policy on medical visits was provided for review.
A resident with severe cognitive impairment and mobility dependence was physically abused by another resident with a history of aggression and psychiatric diagnoses. The aggressor, who had previously refused medications and had prior altercations, slapped the victim in the hallway, resulting in facial redness. The incident was witnessed by staff and a non-staff member, and the facility failed to prevent the abuse as required by policy.
The facility failed to document and address grievances from the resident council regarding staff not folding clothing, cellphone usage during care, and residents' choice of bedtime. Despite a resolution to educate staff, the issue of cellphone usage persisted, indicating inadequate follow-through. Interviews revealed a lack of communication and awareness among staff responsible for addressing these concerns.
The facility failed to protect residents from abuse, as evidenced by multiple incidents of resident-to-resident altercations. One resident with dementia and schizophrenia was injured when another resident threw a chair, while another resident with vascular dementia was hit in the face. A third incident involved a resident being physically assaulted by another, resulting in pain and scratches. Despite policies prohibiting abuse, these events highlight the facility's failure to maintain a safe environment.
The facility failed to update care plans for residents involved in altercations, including a resident with dementia who was injured by another resident, and another resident with a history of altercations. Additionally, a newly admitted resident did not have an interdisciplinary care plan meeting. Interviews revealed a lack of clarity in responsibilities for updating care plans.
A facility failed to ensure pharmacy recommendations were reviewed by the provider and documented in a resident's clinical chart. The resident, with a history of traumatic brain injury and anxiety disorder, had missing pharmacy reviews and lab results in their chart. The facility lacked a clear policy for processing pharmacy recommendations, leading to unsigned recommendations and unaddressed lab tests. Interviews revealed the facility was revising its process for handling these recommendations.
A resident with multiple fractures and total dependence for oral hygiene did not receive necessary dental services despite complaints of pain and physician orders for evaluation. The process for scheduling dental appointments was not followed, resulting in the resident not being seen by a dentist or hygienist. This highlights a deficiency in the facility's management of physician orders.
The facility did not conduct the required annual water management plan meeting, as revealed by a review of the Water Management Plan and safety committee meeting minutes. The Director of Maintenance admitted to losing track of time, resulting in the meeting not being held. The administration confirmed the oversight, and the facility's policy requiring annual updates to environmental assessments was not followed.
A resident with diagnoses including osteomyelitis and major depressive disorder elected a DNR status, which was documented in the Advance Directives/Code Status Consent form. However, the physician's order incorrectly indicated a full code status. The error was identified by an LPN, and APRN acknowledged the mistake, noting that the order should have reflected the resident's DNR status.
A facility failed to obtain necessary consents from a resident's conservator upon admission. The resident, with psychiatric and neurological diagnoses, was admitted without completing required forms or contacting the conservator. Staff interviews revealed a lack of adherence to the facility's admission policy, which mandates obtaining conservator signatures for admission paperwork.
A resident admitted with a PICC line did not have their admission orders verified, leading to improper documentation and care. The facility failed to follow its policy on physician orders transcription and central line catheter protocol, resulting in unverified medication administration and inadequate catheter care. Staff interviews revealed poor communication and responsibility for verifying orders.
A resident with chronic health issues was observed using oxygen therapy without a physician's order documented in their medical records. The resident's care plan included oxygen use, but the quarterly assessment did not reflect this. An LPN confirmed the need for an order, but it was missing from the MAR and TAR, contrary to facility policy.
A resident with severe pain from a gunshot wound did not receive timely pain medication due to a nurse's inaction. Despite multiple requests and notifications from a nursing assistant, the nurse did not administer the medication, resulting in the resident experiencing prolonged pain and a fall. Facility policies on medication administration and pain management were not followed.
A resident with anxiety disorder was unable to access Lorazepam PRN due to the facility's failure to ensure emergency medication availability and proper controlled substance management. The resident became agitated and injured themselves. The facility's system for managing controlled substances was inadequate, with unsecured records and improper audit procedures.
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and accessibility. A resident with alcohol-induced dementia did not have complete documentation of required checks. Another resident's admission paperwork was incomplete, lacking conservator consent. Additionally, pharmacy recommendations and lab results were missing from a third resident's chart, indicating lapses in record-keeping and adherence to facility policies.
The facility failed to label and date food items appropriately, as observed during a kitchen tour. Five brown bags in the refrigerator lacked identifiable information, and four large bins contained undated or expired food items. The Food Service Director confirmed that these items should have been labeled and dated according to facility policy.
The facility failed to maintain a complete and accurate medical record for a resident with a substance abuse disorder. The resident's refusals to attend the Recovery Program groups were not documented, despite directives in the Resident Care Plan and confirmation from the Director of Social Work, the Director of Nursing, and the Clinical Director.
Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect residents from abuse and did not provide adequate supervision to prevent a resident-to-resident altercation resulting in injury. One resident with a history of aggressive behaviors and moderate cognitive impairment had multiple prior incidents of physical altercations with other residents, including hitting and slapping, which were documented in the clinical record. The care plan for this resident included interventions such as every 15-minute checks, psychiatric and social services follow-up, and specific behavioral interventions, but these measures did not prevent further incidents. On a specific occasion, a resident with severe cognitive impairment and dependent on staff for bathroom use was struck in the face by the resident with a history of aggression. The incident was unwitnessed by staff, and the injured resident sustained a significant laceration to the temporal area, which resulted in active bleeding. The injured resident was subsequently diagnosed with a hyperacute subdural hematoma and required hospitalization, including a craniotomy and further neurological intervention. The facility's documentation indicated that the aggressive act was not substantiated as abuse due to a lack of willful intent, despite the physical evidence and medical opinion linking the injury to the altercation. The facility's abuse policy defined physical abuse as including hitting and slapping, and directed that residents should not be subjected to abuse by anyone, including other residents. Despite this, the facility did not substantiate the incident as abuse and failed to implement effective supervision or interventions to prevent the altercation and resulting injury. The monitoring interventions for the aggressive resident were discontinued prior to the incident, and the facility did not identify or implement additional interventions following the altercation that led to the severe injury.
Failure to Develop Care Plan for Anticoagulant Use and Bleeding Risk
Penalty
Summary
A deficiency was identified when a resident with atrial fibrillation, severe cognitive impairment, and a pacemaker was admitted to the facility while receiving anticoagulant medications, specifically Eliquis and Plavix. Physician orders directed the administration of these medications for atrial fibrillation, and the resident's quarterly MDS assessment confirmed ongoing use of anticoagulants. Despite these factors, the facility failed to develop a comprehensive care plan addressing the use of Eliquis and Plavix and the associated risk of bleeding for this resident. Record review and staff interviews revealed that there was no care plan in place for the risk of bleeding related to anticoagulant use, as required by facility policy. The Director of Nursing and the MDS Coordinator both acknowledged that a care plan should have been created but was not, citing a change in the electronic medical record system and oversight as contributing factors. The facility's care plan policy mandates the development of a person-centered plan of care within seven days of completing the MDS and CAA's, but this was not followed in this case.
Failure to Provide Adequate Supervision for Resident with Aggressive Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent accident hazards for a resident with a known history of aggressive behaviors toward others. The resident, who had diagnoses including anxiety and schizophrenia and demonstrated moderate cognitive impairment, had a documented pattern of resident-to-resident altercations. The care plan for this resident included interventions such as every 15-minute checks, medication administration, and staff intervention when agitation escalated. Despite these interventions, the resident was involved in multiple incidents of physical aggression toward other residents, with care plan updates following each event. Monitoring was discontinued by psychiatry shortly before the most recent incident. Another resident, who had severe cognitive impairment, required assistance with mobility and communication, and was on anticoagulant therapy, became the victim of an unwitnessed physical altercation. This resident was struck in the face by the aggressive resident, resulting in a laceration and subsequent hospital admission for a subdural hematoma. The incident was not witnessed by staff, and the facility's documentation indicated that the aggressive resident's monitoring had been discontinued prior to the event. The injured resident required intensive medical intervention, including a craniotomy and embolization, and remained hospitalized at the time of the survey. Interviews and record reviews confirmed that the aggressive resident admitted to hitting others in the past and in this incident. The facility's investigation did not substantiate abuse, citing lack of willful intent, but did not address whether adequate supervision was provided to prevent the injury. The facility's policy on close observation identified risk factors for harm, including impulsivity and impaired judgment, which were present in the aggressive resident. The deficiency centers on the facility's failure to maintain adequate supervision and implement effective interventions to prevent resident-to-resident altercations and resulting injuries.
Failure to Ensure Timely Physician Review and Order Renewal
Penalty
Summary
The facility failed to ensure that two residents with significant psychiatric and cognitive diagnoses received timely physician reviews and order renewals as required. For both residents, clinical record review showed that physician orders were not signed or renewed for a period of 127 days, despite the facility's 60-day schedule for such reviews. The residents had care plans addressing their mental health and behavioral needs, and both were identified as having moderate cognitive impairment. Documentation revealed that the last physician orders were signed in early November, with no further signatures until early March of the following year. Interviews with the Director of Nursing Services (DNS) and the Medical Director confirmed that the required physician order reviews and signatures were not completed within the mandated timeframe. The DNS was unable to provide documentation or an explanation for the lapse, and the Medical Director acknowledged being behind in signing orders, noting a transition to electronic signatures during the period in question. The facility was also unable to provide a policy regarding medical visits when requested by the surveyor.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A resident with vascular dementia and schizophrenia, who was severely cognitively impaired and dependent for wheelchair mobility, was physically abused by another resident diagnosed with dementia, paranoid schizophrenia, and schizoaffective disorder. The incident occurred when the second resident, who had a history of physical aggression and prior altercations, approached the first resident in the hallway and slapped the left side of their face. This act was witnessed by a non-staff member and a nursing assistant, with the latter observing the aggressor slap the victim a second time. The victim was found with facial redness as a result of the incident. Prior to the event, the aggressive resident had refused medications and was on a waitlist for in-patient psychiatric evaluation, with ongoing psychiatric follow-up and 15-minute checks in place. Despite a documented history of similar altercations, the facility failed to prevent the physical abuse, as required by their abuse policy, which prohibits residents from being subjected to abuse by anyone, including other residents. The facility's documentation and staff interviews confirmed the physical contact and the resident's history of aggression, but did not consider the contact willful.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately document and address grievances raised by the resident council, as evidenced by the review of resident council minutes and interviews with staff. From May to September 2024, residents expressed concerns about staff not properly folding or hanging cleaned clothing, staff using cellphones while providing care, and residents not being able to choose when to be put back to bed. Although the facility documented a resolution in June 2024 to provide staff education on these issues, the concern about cellphone usage was raised again in August 2024, indicating that the issue was not fully resolved. Interviews with the Recreation Director, Staff Development Nurse, and former Director of Nursing Services revealed a lack of communication and follow-through on staff education regarding the concerns raised. The Staff Development Nurse was unaware of the need for education on these issues, and the former Director of Nursing Services could not recall whether she communicated the need for staff education to the Staff Development Nurse. The facility's policy requires department heads to address issues raised at resident council meetings, but the documentation and follow-up on these concerns were insufficient, leading to repeated grievances.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations. Resident #30, diagnosed with dementia, anxiety, and schizophrenia, was involved in an altercation with Resident #32, who has alcohol-induced dementia and anxiety disorder. Resident #32 threw a chair at Resident #30, resulting in a skin tear and pain. Despite interventions in place to manage behaviors, the facility did not prevent the incident, indicating a failure to ensure residents were free from abuse. Another incident involved Resident #31, who has vascular dementia and major depressive disorder, being hit in the face by Resident #32. Although Resident #31 did not sustain visible injuries, the altercation highlights the facility's inability to prevent aggressive interactions between residents. The facility's investigation did not substantiate the incident as abuse, citing the residents' confusion, but the event still reflects a deficiency in protecting residents from harm. A third incident involved Resident #112, who has vascular dementia and anxiety disorder, physically assaulting Resident #31. Resident #112 slapped, punched, and kicked Resident #31, who complained of pain and had visible scratches. Despite the facility's policy prohibiting abuse, these incidents demonstrate a failure to maintain a safe environment for residents, as evidenced by repeated aggressive interactions and inadequate supervision or intervention to prevent such occurrences.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to ensure that the care plans for three residents were reviewed and revised following incidents of resident-to-resident altercations. Resident #30, who had diagnoses including dementia, anxiety, and schizophrenia, was involved in an altercation where another resident threw a chair, resulting in a skin tear. Despite this incident, Resident #30's care plan was not updated to reflect the altercation or the interventions put in place to support and protect the resident. Interviews with the Director of Nursing Services (DNS) and social workers revealed a lack of clarity and responsibility in updating the care plan. Resident #31, diagnosed with vascular dementia and major depressive disorder, was struck on the head by another resident while seated in a wheelchair. Although the incident was documented, Resident #31's care plan was not updated to include the altercation or any interventions to ensure the resident's safety. The DNS and social workers acknowledged the oversight and identified that the care plan should have included specific interventions to address the incident. Resident #32, with a history of alcohol-induced dementia and anxiety disorder, was involved in multiple altercations with other residents. Despite these incidents, Resident #32's care plan did not reflect the altercations or the interventions implemented, such as room changes and psychiatric evaluations. Additionally, Resident #59, who was admitted with diagnoses including major depressive disorder and schizoaffective disorder, did not have an interdisciplinary care plan meeting conducted after admission, and there was no documentation of the resident or their conservator being involved in the care planning process.
Failure to Review and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed by the provider and included in the resident's clinical chart. This deficiency was identified during a review of the clinical record, facility policy/procedures, and interviews concerning a resident with diagnoses including traumatic brain injury, vascular dementia, and anxiety disorder. The resident's care plan indicated participation in a Behavioral Health Program and monitoring for psychotropic medication side effects. However, the facility did not have an established policy and procedure for processing pharmacy recommendations. The pharmacy progress notes indicated that drug regimen reviews were completed on several occasions, with recommendations made to the provider. However, the clinical chart failed to include these pharmacy reviews and recommendations, as well as lab results for the resident. Interviews with the Director of Nursing Services (DNS) and Regional Clinical Director revealed that the recommendations were not all present in the charts, and the facility was in the process of revising the process for handling pharmacy recommendations. The process involved emailing recommendations to the DNS and Assistant Director of Nursing Services (ADNS), who would then print, copy, and provide them to the Advanced Practice Registered Nurse (APRN) for review and signature. Despite this process, some recommendations were not signed by the provider, and lab results were missing from the chart. The APRN acknowledged that drug regimen reviews were placed in her inbox and addressed, sometimes with verbal orders or written on the Physician Order sheets. However, the APRN was only notified of certain drug regimen reviews on the day of the interview and subsequently placed orders for necessary tests. The facility's policy for chart order and retention guidelines required that pharmacy recommendations be included in the resident's chart for the current year, but the facility did not provide a policy for processing these reviews.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with multiple fractures and required total dependence for oral hygiene, received necessary dental services. The resident was identified as having obvious or likely cavities or broken teeth upon admission. Despite complaints of dental pain and orders for a dental evaluation and chlorhexidine mouthwash, there was no documentation of the resident being seen by a dentist or hygienist. The process for scheduling dental appointments involved the nurse who noted the physician's order contacting the unit secretary, who would then arrange the appointment. However, the unit secretary reported not receiving any requests for a dental referral for the resident. Interviews with staff, including the APRN and LPNs, revealed a breakdown in communication and follow-up, resulting in the resident not receiving the necessary dental care. The facility's policy required dental evaluations to be performed by qualified professionals, but the resident was not seen by the dentist or hygienist during their visits to the facility. The failure to ensure the resident received dental services as ordered highlights a deficiency in the facility's process for managing and following through on physician orders.
Failure to Conduct Annual Water Management Plan Meeting
Penalty
Summary
The facility failed to conduct an annual water management plan meeting as required by their policy. The review of the facility's Water Management Plan for 2023 to 2024, conducted with the Director of Maintenance, revealed that the meeting to review the updated and revised plan was not held. The safety committee meeting minutes indicated that the water management meeting was scheduled for July 12, 2024, but it was not conducted. The Director of Maintenance admitted to losing track of time, resulting in the meeting not being held as planned. Further interviews with the administration confirmed that the water management meeting was not completed. The facility's practice was to document discussions regarding the water management plan in the safety committee meeting minutes, which did not occur. The Annual Water Management Plan Revision and Updates provided by the contracted company required the water committee to meet, review the plan, and record the meeting minutes with attendees' signatures. The facility's policy also required annual updates to environmental assessments, which were not completed due to the missed meeting.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that the physician's order accurately reflected the resident's chosen code status for one of the residents reviewed for advance directives. Resident #377, who was cognitively intact and had diagnoses including osteomyelitis, viral hepatitis C, and major depressive disorder, had elected a Do Not Resuscitate (DNR) status. This was documented in the Advance Directives/Code Status Consent form and signed by APRN #1. However, the physician's order in the clinical record incorrectly indicated a full code status, which contradicts the resident's expressed wishes. The discrepancy was identified during an interview with the Charge Nurse (LPN #5), who noted that the physician's order and the electronic health record indicated a full code, while the advance directive/code status consent form indicated DNR. APRN #1 acknowledged the error, stating that although she reviewed and signed the order for full code, it was done in error and should have reflected the resident's DNR status. The facility's Code Status policy requires that the attending physician document the resident's preferred status in the clinical record, which was not accurately done in this case.
Failure to Obtain Conservator Consent for Admission
Penalty
Summary
The facility failed to implement its admissions policy for a resident who was admitted with diagnoses including major depressive disorder, schizoaffective disorder, polyneuropathy, and extrapyramidal symptoms. The resident was identified as conserved, yet the facility did not complete necessary admission forms, such as the behavioral program unit resident review and behavioral health program individualized assessment. Additionally, the facility did not contact the resident's conservator to obtain required consents for admission, including consent to treat and consent for residing on a secured unit. Interviews with facility staff, including the Regional Clinical Director, social workers, and the Director of Nursing Services, revealed that the responsibility for obtaining the conservator's signature on admission paperwork was not fulfilled. The conservator was unaware of the resident's admission and had not been contacted by the facility. The facility's admission policy required the completion of admission documentation within 24 hours and identified specific consents to be signed, which were not obtained in this case.
Failure to Verify Admission Orders and Central Line Care
Penalty
Summary
The facility failed to ensure that admission orders for a resident were verified prior to administration, and did not ensure proper care and treatment for a central line catheter. The resident, who was admitted with diagnoses including osteomyelitis, viral hepatitis C, and major depressive disorder, had a peripherally inserted central catheter (PICC) upon admission. The hospital discharge medications and care instructions were not verified with the provider at the time of admission, leading to a lack of proper documentation and verification of orders in the resident's chart. Observations revealed that the resident was self-propelling in a wheelchair while an antibiotic was infusing via the PICC line, which was identified as a non-valve catheter. The medication administration record showed that several medications were administered from the time of admission without proper verification of orders. Interviews with various staff members, including the nursing supervisor, APRN, and infection preventionist, indicated a lack of communication and responsibility for verifying the admission orders. The orders were not transcribed onto the paper physician's order sheet or confirmed with the attending physician as required by facility policy. The facility's policy on physician orders transcription and central line catheter protocol was not followed, resulting in the deficiency. The central line catheter protocol required specific flushing procedures and care, which were not documented or verified. The DNS and ADNS were aware of the issue but did not ensure that the orders were properly documented and verified at the time of admission, leading to a delay in proper care and treatment for the resident.
Lack of Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a physician's order was in place for the use of oxygen therapy for a resident with multiple health conditions, including end-stage renal disease, chronic obstructive pulmonary disease, anxiety, and heart failure. The resident, who was cognitively intact and required moderate assistance with daily activities, was observed using oxygen at 2 liters via nasal cannula without a corresponding physician's order documented in the medical record. The care plan indicated the resident was at risk for breathing problems and included interventions such as providing oxygen as needed, but the quarterly MDS assessment did not reflect the use of oxygen. During an interview, an LPN confirmed that there should be an order for oxygen, as the resident typically used it after returning from dialysis. However, the LPN was unable to locate a physician's order for oxygen in the resident's medical records, including the medication administration record (MAR) and treatment administration record (TAR). The facility's policies required that prescribers' medication orders be accurately transcribed and executed in a timely manner, and that a physician's order be verified for oxygen administration. The deficiency was identified when a new order for oxygen was documented only after surveyor inquiry.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain medication in a timely manner to Resident #115, who was experiencing severe pain due to a gunshot wound. The resident was cognitively intact and required assistance with daily activities, using a wheelchair for mobility. The care plan included administering pain medication as ordered and addressing breakthrough pain. Despite having physician orders for Oxycodone and Ibuprofen, the resident did not receive the medication promptly on the evening of 8/14/24. On that evening, the resident rang the call bell multiple times requesting pain medication, but the nurse, LPN #3, was not responsive. The nursing assistant, NA#1, informed the nurse twice about the resident's request, but the nurse seemed annoyed and did not administer the medication. The resident waited over two and a half hours and eventually fell while trying to move due to intense pain. The nurse was on break and did not return until later, at which point she refused to administer the medication due to the resident's frustration. The facility's documentation showed that the medication was not signed off as administered, and the nurse claimed she was unaware of the resident's pain. The Director of Nursing Services (DNS) confirmed that it was the nurse's responsibility to assess and administer medication when informed of a resident's pain. The facility's policies on medication administration and pain management were not followed, leading to the resident's grievance and the deficiency finding.
Failure to Ensure Access to Emergency Medication and Proper Controlled Substance Management
Penalty
Summary
The facility failed to ensure access to emergency supply medication and did not implement a system to account for the receipt, usage, disposition, and reconciliation of medications. Resident #73, who had diagnoses including an unspecified open wound on the left foot, anxiety disorder, and post-traumatic stress disorder, was affected by this deficiency. Upon returning from the hospital, Resident #73 requested Lorazepam 1mg PRN for anxiety, but the medication was not available. This unavailability led to the resident becoming agitated and punching the wall, resulting in an injury. The facility's system for managing controlled substances was inadequate. The nurse on duty, LPN #9, and the supervising RN #5, who was an agency nurse, did not have access to the Omni-cell, which contained emergency medications. Consequently, the medication was borrowed from another resident, which is against policy. The Director of Nursing Services (DNS) acknowledged that the receipt and disposition records for the Lorazepam could not be located, and the facility's policy for handling unavailable medications was not followed. Additionally, the facility's process for receiving and auditing controlled substances was flawed. The ADNS admitted that the yellow Controlled Substance Disposition Record (CSDR) sheets were not properly managed, and the reception area where these records were kept was unsecured. The ADNS was unaware of the proper procedure for conducting controlled substance audits, which should have involved comparing delivery slips with CSDR sheets. The facility's policy required controlled drug audits twice a month, but the ADNS's interpretation of an audit was merely counting the medication carts with the nurses, without verifying the records.
Deficiencies in Medical Record Documentation and Accessibility
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and accessibility. For Resident #32, who had diagnoses including alcohol-induced dementia and anxiety disorder, the facility did not provide complete documentation of one-to-one observation and every 15-minute checks as ordered by the physician. Despite multiple requests, the facility was unable to locate the necessary flowsheets for the specified period, indicating a lapse in record-keeping and adherence to the facility's policy on close observation documentation. Resident #59, diagnosed with major depressive disorder and schizoaffective disorder, was admitted without the necessary conservator paperwork and signed admission documents. The facility's records lacked documentation of contact with the resident's conservator regarding admission paperwork, including consents for treatment and residency on a secured unit. Interviews revealed that the admission paperwork was not present in the clinical chart, and the social worker had kept the documents in a separate file, contrary to the facility's policy. For Resident #78, who had a diagnosis of diffuse traumatic brain injury and vascular dementia, the facility failed to include pharmacy review recommendations and lab results in the clinical chart. The process for handling pharmacy recommendations was not followed, as the recommendations were not signed by the APRN and were not included in the resident's chart. The facility's policy required that pharmacy recommendations be kept in the chart for at least one year, highlighting a deficiency in the facility's documentation practices.
Failure to Label and Date Food Items
Penalty
Summary
The facility failed to ensure that food items were appropriately labeled and dated when opened or stored, and removed once expired. During a kitchen tour, surveyors observed five brown bags in the walk-in refrigerator without any identifiable information, dates, or resident names. These bags were identified by the Food Service Director (FSD) as lunches prepared for dialysis residents, which should have been labeled and dated with each resident's name. Additionally, four large bins were found, two containing white rice, one of which was undated, and another with powdered thickener that was expired. A bin with flour was also found without a label or date. The facility's Food Storage and Marking policies require that dry food items have a date including the month, date, and year of delivery or a manufacturer's printed Best By/Use by date. The policy also mandates that refrigerated, ready-to-eat, potentially hazardous foods be clearly marked at the time of preparation to indicate the date of preparation and discarded within 72 hours of being opened. The FSD acknowledged that the bins should have been labeled once opened or filled, and the powdered thickener was expired. The failure to adhere to these policies led to the deficiency identified during the survey.
Failure to Document Resident's Refusal of Recovery Services
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with a substance abuse disorder. Resident #2, who was admitted with diagnoses including substance abuse disorder with opioid addiction and cervical spine degeneration, was identified as alert, oriented, and walking independently. The Resident Care Plan (RCP) directed that the resident be encouraged to participate in the facility's substance use recovery services and that refusals should be documented. However, the facility did not document the resident's refusals to attend the Recovery Program groups, as confirmed by interviews with the Director of Social Work (SW #2), the Director of Nursing (DON), and the Clinical Director. The medical record lacked documentation of the offered recovery program groups and the resident's refusals to attend. Interviews with the Director of Social Work, the Director of Nursing, and the Clinical Director revealed that the refusals should have been documented in the social services notes and the medical record. Despite requests, the facility was unable to provide a documentation policy for review during the survey. This failure to document the resident's refusals to participate in the recovery program constitutes a deficiency in maintaining a complete and accurate medical record in accordance with accepted professional standards.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
