Vanderman Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Willimantic, Connecticut.
- Location
- 595 Valley Street, Willimantic, Connecticut 06226
- CMS Provider Number
- 075425
- Inspections on file
- 31
- Latest survey
- June 3, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vanderman Place during CMS and state inspections, most recent first.
Surveyors identified that kitchen staff failed to consistently wear hair coverings, properly label and date food items, and discard expired foods. Expired and unlabeled food was found in both refrigerated and dry storage areas, and staff interviews confirmed these practices did not meet facility expectations.
Multiple residents were started on new psychotropic medications without timely or properly documented informed consent from themselves or their responsible parties. In several cases, consent was obtained only after significant delays, and forms were not always signed by the staff who obtained verbal consent. Staff interviews revealed confusion about the consent process and lack of familiarity with facility policy.
Three residents with dementia and wandering behaviors were able to access soiled utility rooms on multiple units, where surveyors observed uncovered trash, soiled linens, hazardous waste, and unsecured equipment, including an unlocked specimen refrigerator on an unstable surface. Staff acknowledged that the risk of wandering residents entering these rooms had not been previously addressed.
Surveyors found that medication rooms contained food, personal items, and unlabeled containers stored alongside medications, with surfaces stained and unclean. Staff could not identify the owners of personal belongings or explain the presence of residue. Additionally, a medication cart was left unlocked and unattended in a hallway while the responsible LPN was assisting a resident, contrary to facility policy requiring secure storage of medications.
Staff did not consistently perform hand hygiene or use required PPE when providing care to residents on precautions, including failing to sanitize hands after glove removal, improperly disposing of used gloves, and entering precaution rooms without PPE. An LPN also conducted a dressing change without appropriate hand hygiene and placed used gloves on a resident's bed, with clean supplies stored next to food items.
Multiple residents with cognitive and behavioral impairments were involved in physical altercations and verbal threats, including incidents where one resident struck another and a resident verbally threatened to strangle a roommate. Staff intervened after the events occurred, but the facility did not prevent the abuse or ensure residents were free from harm.
Staff did not immediately report or document a verbal threat of abuse made by one resident toward another, despite facility policy requiring prompt notification to the Administrator and DON. The incident, involving a cognitively impaired resident and a roommate with depression and anxiety, was not reported to leadership or external authorities until several hours later, and no immediate investigation or written statements were obtained.
A resident with multiple medical conditions was transferred to the hospital after vomiting dark black emesis. Although the provider and responsible party were notified of the transfer, there was no written notification or documentation provided regarding bed-hold options at the time of transfer, and staff interviews revealed a lack of process for ensuring this required notification.
A resident with dementia and wandering behaviors was involved in an aggressive incident that was not addressed by specific care plan interventions, despite prior knowledge of such behaviors. Another resident with right-sided paralysis repeatedly refused a physician-ordered hand splint, but staff were unclear about their responsibilities and the care plan did not address the refusals, leading to inconsistent application and monitoring of the splint.
A resident with dementia, anxiety, and diabetes who was frequently incontinent of bowel and bladder did not have their care plan updated to include the offering of a bowel and bladder retraining program or documentation of any refusals to participate. Although the care plan addressed incontinence and resistance to care, there was no evidence that retraining programs were offered or refused, as confirmed by nursing staff interviews and record review.
A resident with dementia, schizophrenia, and depression did not receive multiple prescribed medications and required care interventions on several occasions, with no documentation of refusal or reason for omission. The MAR and nursing notes lacked evidence that medications and treatments were administered or that refusals were recorded, contrary to facility policy and physician orders.
The facility did not provide staff with education about the COVID-19 vaccine or information on alternative locations to receive the vaccine when it was unavailable at the facility. An ADNS reported not being offered the vaccine, not receiving education about it, and not being informed of other options for vaccination. The facility was also unable to obtain the vaccine from the pharmacy for staff.
Two residents with physician orders and nursing evaluations supporting the use of bed rails did not have this intervention documented in their care plans. Despite observations confirming the use of bed rails and facility policy requiring such documentation, the care plans failed to include directives for side rail usage, as acknowledged by the DON.
The facility did not provide education or obtain informed consent for bed rail use for several residents with cognitive and physical impairments. Required bed and side rail safety audits were not performed at the mandated intervals, and audit documentation lacked dates. Additionally, a bed rail safety test was not conducted according to manufacturer guidelines, and a loose bed rail was observed, with maintenance staff unable to explain the omission.
A resident with anxiety, schizoaffective disorder, and bipolar disorder was prescribed multiple antipsychotic medications, but staff failed to monitor and document behaviors as required by the care plan and facility policy. Reviews of orders, medication records, and nurse's notes showed no evidence of behavior monitoring, and staff interviews confirmed that such monitoring should have been in place.
A resident with complex medical conditions experienced a significant change in condition prior to a scheduled dialysis transport, displaying increased respirations, pallor, and weakness. While some vital signs were recorded, staff failed to document an oxygen saturation level, a full RN assessment, provider notification, and a physician's order for transfer to the ED, contrary to facility policy requiring thorough documentation of such events.
A resident with dementia, Parkinson's disease, and a history of behavioral disturbances and falls was identified as at risk for elopement, but the facility did not develop a care plan to address this risk. Multiple incidents occurred where the resident attempted or succeeded in leaving the facility, sometimes requiring police intervention, and the use of a Wanderguard device was not properly documented or incorporated into the care plan as required by policy.
A resident with Parkinson's disease, dementia, and a history of falls was identified as an elopement risk, but the facility did not obtain a timely physician's order for a Wanderguard or ensure staff monitored its placement and function as required by policy. The resident left the facility without being redirected, and documentation of device checks and care planning was lacking.
A resident with mental health diagnoses was moved to a new room due to issues with a roommate, but the facility failed to document the room change and did not provide or record required social service support during the transition, contrary to facility policy and staff responsibilities.
Deficiencies in Food Storage, Labeling, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations during a kitchen tour. A cook was seen in the kitchen without a required hair covering, and admitted to forgetting to put it back on after reentering the kitchen. In the walk-in refrigerator, several food items, including opened bags of waffles and cooked turkey, were found without proper labels indicating when they were opened or their use-by dates. Additionally, frozen burgers with a use-by date that had already passed were found in the walk-in freezer, and neither the administrator nor the cook could explain why these expired items had not been discarded. Further inspection of the dry storage room revealed ten cases of evaporated milk that had expired several months prior. Interviews with the Food Service Director confirmed that all kitchen staff are expected to check expiration dates, label and date food items once opened, and wear hair coverings at all times in the kitchen. Despite requests, the facility was unable to provide a food service policy during the survey.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent from residents or their responsible parties prior to initiating new psychotropic medications for multiple residents. In several cases, residents with cognitive impairments or conservators were started on medications such as antidepressants and antipsychotics without documented consent. For example, one resident with severe cognitive impairment and a conservator began receiving an antidepressant, but there was no evidence that the conservator was informed or provided consent before the medication was administered. Consent was only obtained over 100 days after the medication was started, and the form was not properly signed by the staff member who obtained it. Other residents, including those with dementia, schizophrenia, and anxiety disorders, were also started on various psychotropic medications without timely or properly documented consent. In some instances, verbal consent was obtained long after the medications had been initiated, and forms lacked signatures from the staff who obtained the consent. Staff interviews revealed confusion and lack of awareness regarding the process for obtaining and documenting informed consent, with some staff members unaware of the facility's policy on psychotropic medications. The facility's own policy required that consent be obtained from the resident or responsible party when starting a psychoactive medication and that they be notified of any dose changes. However, the policy was not consistently followed, and staff responsible for obtaining consent were not always familiar with the procedures. Documentation and interviews confirmed that the deficiency was systemic, affecting multiple residents and involving delays and omissions in the consent process.
Unsecured Soiled Utility Rooms Accessible to Wandering Residents
Penalty
Summary
The facility failed to prevent access to soiled utility rooms on three units for residents with a history of wandering. Clinical record reviews identified three residents diagnosed with Alzheimer's disease or dementia, all of whom exhibited wandering behaviors and were noted to be oblivious to their own safety. Observations revealed that the soiled utility rooms on each unit could be accessed by simply pushing the door handle, making them easily accessible to residents. Inside these rooms, surveyors found uncovered garbage cans, soiled linen bags, hazardous waste containers, and equipment. On one unit, a specimen refrigerator was found unlocked and placed on an unstable surface, which tipped forward when the door was opened. Other units contained additional hazards such as a vacuum cleaner, a pipe-snaking machine, and a hopper with no lid. Staff interviews confirmed that the potential for wandering residents to enter these rooms had not been previously considered, and the rooms remained unsecured at the time of the observations.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies in the storage and security of drugs and biologicals in the facility. In the medication rooms on two separate wings, food and personal items such as an opened protein drink, unlabeled water bottles, tumblers, mugs, jackets, a backpack, and a purse were found stored alongside or near medications. The medication refrigerator contained a non-medical drink with no resident label, and the shelves were stained with residue. Additional issues included sticky and stained surfaces in the medication rooms, unlabeled and possibly expired medication containers, and personal belongings stored in areas designated for medication storage. Staff interviewed were unable to identify the owners of many of these items or explain the presence of residue and stains, and there was no policy provided for the storage of personal belongings in medication rooms. In a separate incident, a medication cart was observed left unlocked and unattended in a hallway outside a resident's room, with no licensed staff in the immediate area. A nurse aide was present but did not alert the responsible LPN, who later stated she had left the cart unlocked when responding to assist a resident. The facility's policy requires medication storage and preparation areas to be kept clean, safe, and sanitary, and for medications to be stored securely and separately from food, but these requirements were not met during the observations.
Failure to Ensure Proper Hand Hygiene and PPE Use During Resident Care
Penalty
Summary
Staff failed to consistently perform proper hand hygiene and use appropriate personal protective equipment (PPE) as required by the facility's infection prevention and control program. Observations revealed that nurse aides exited a resident room under Enhanced Barrier Precautions (EBP) without completing hand hygiene and one aide was seen carrying a used glove in the hallway. The charge nurse also left the same room without performing hand hygiene. Interviews indicated a lack of awareness among staff regarding the requirements for EBP and the use of hand sanitizer, as well as confusion about the application of PPE for residents on precautions. In another instance, two nurse aides entered a room with a droplet precaution sign without donning any PPE, stating they believed it was unnecessary for simply delivering a meal, despite facility policy and leadership confirming PPE was required. Additionally, during a dressing change for a resident with lymphedema and neuropathy, an LPN failed to perform hand hygiene after removing gloves and before donning new gloves, and disposed of used gloves on the resident's bed rather than in a sanitary manner. Clean dressing supplies were placed on an overbed table alongside food items, and the LPN was unaware of the need for hand hygiene between glove changes. Interviews with facility leadership confirmed that hand hygiene should have been performed after glove removal, and facility policy directed staff to wash hands after removing gloves.
Failure to Prevent Resident-to-Resident Abuse and Verbal Threats
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving resident-to-resident altercations and verbal threats. In one case, a resident with hemiplegia, hemiparesis, aphasia, and anxiety, who had mild cognitive impairment, was involved in a physical altercation with a cognitively intact roommate. The altercation escalated from an argument over closet space to physical contact, with one resident grabbing the other's arm and being struck in the face in return. Staff witnessed the incident and intervened, but the altercation had already occurred. Another incident involved a resident with vascular dementia and impaired mobility who was struck in the face by another resident known to wander into other rooms. The cognitively impaired resident could not recall the event, but staff confirmed the altercation occurred after hearing distress and intervening. The wandering resident had a history of entering other residents' rooms, and the incident took place when the resident entered the room and pulled the other resident's hair. A further deficiency was noted when a resident with dementia, Parkinson's disease, and confusion was verbally threatened by a roommate with a history of depression and anxiety. The confused resident was found yelling and attempting to get out of bed, prompting the roommate to threaten to strangle them. Staff separated the residents and monitored the situation, but the verbal abuse had already taken place. In all cases, the facility's failure to prevent these incidents and ensure residents were free from abuse constituted a deficiency.
Failure to Timely Report and Investigate Resident-to-Resident Verbal Abuse
Penalty
Summary
Staff failed to immediately report an episode of verbal abuse between two residents, as required by facility policy. One resident, who had diagnoses including dementia and Parkinson's disease and was cognitively impaired, was admitted to the facility and shared a room with another resident diagnosed with major depression and anxiety. During the night, the cognitively impaired resident became agitated and began yelling, prompting the roommate to threaten to strangle them. Staff present at the time separated the residents by moving the agitated resident to the lounge and monitored them for safety. Despite the clear verbal threat, staff did not immediately notify the Administrator or the Director of Nursing Services (DNS) as required. The charge nurse and nursing supervisor were aware of the incident but did not document the altercation in either resident's clinical record, nor did they request written statements from staff involved. The DNS was not informed of the incident until the following morning, more than seven hours after it occurred, and only learned of it during a routine arrival at the facility. Facility policy mandates that all allegations or observations of abuse be reported immediately to the Administrator and DNS, with subsequent notification to the physician and initiation of an immediate investigation. The incident should also have been reported to the state agency and local law enforcement within two hours. These steps were not followed, resulting in a delay in both internal and external reporting and investigation of the abuse allegation.
Failure to Provide Written Bed-Hold Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written notification to a resident and their responsible party regarding the reason for transfer/discharge to the hospital, as well as information about bed-hold policies. The resident involved had diagnoses including GERD without bleeding, gastrostomy status, dysphagia, and cerebral infarction, and was assessed as having moderate cognitive difficulty. Following an incident where the resident vomited a large amount of dark black emesis, the provider and responsible party were notified, and the resident was sent to the hospital. However, there was no documentation in the clinical record indicating that the resident or responsible party was informed in writing about the bed-hold options at the time of transfer. Interviews with facility staff, including the ADNS, Administrator, and Business Office Manager, revealed a lack of clarity and process regarding written notification of bed-hold policies upon hospital transfer. The ADNS was unaware of the process, and the Administrator could not demonstrate how written notification was provided at the time of transfer. Although bed-hold information was included in the admission packet, there was no evidence of a specific form or documentation used to track or confirm that this information was provided in writing during the transfer event, as required by facility policy.
Failure to Develop and Implement Person-Centered Care Plans for Behavioral and Positioning Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with identified needs. For one resident with dementia, anxiety disorder, and Alzheimer's disease, the care plan noted wandering and intrusive behaviors but did not include specific interventions for known aggressive behaviors, despite documentation of an incident where the resident hit another resident. Staff interviews confirmed that the behaviors were known prior to the incident and should have been addressed in the care plan, but appropriate interventions were not included or updated as required by facility policy. For another resident with right-sided paralysis and a physician's order to wear a right-hand splint, the care plan required the splint to be worn continuously and for staff to assist as needed. However, records showed multiple refusals by the resident to wear the splint, and staff were inconsistent in offering or reminding the resident to use it. Interviews revealed confusion among staff regarding responsibility for applying the splint and a lack of awareness about the need to remind the resident, despite the physician's order. The care plan did not address the resident's refusals, and the facility's policy required nursing staff to ensure proper use and care of splinting devices.
Failure to Update Care Plan for Bowel and Bladder Retraining
Penalty
Summary
The facility failed to ensure that the care plan for a resident with bowel and bladder incontinence was updated to include the offering of a bowel and bladder retraining program, as well as documentation of any refusals to participate in such a program. The resident in question had diagnoses including unspecified dementia with behavioral disturbances, anxiety, and diabetes, and was assessed as moderately cognitively impaired. The Minimum Data Set (MDS) assessment indicated frequent incontinence of both bowel and bladder, while the care plan noted incontinence related to impaired mobility and cognition, with interventions such as two-hour checks and observation of incontinence patterns. The care plan also documented resistance to care, including refusals of weights, medication, and care. Despite these findings, there was no evidence in the clinical record or care plan that the resident was offered a voiding trial or a bowel and bladder retraining program, nor was there documentation of the resident refusing participation in such programs. Interviews with nursing staff confirmed that while the care plan addressed resistance to care, it did not specifically mention offering or refusal of retraining programs. This lack of documentation and action led to the deficiency cited in the report.
Failure to Administer Medications and Perform Required Care as Ordered
Penalty
Summary
The facility failed to administer medications and perform required care interventions according to physician's orders for a resident diagnosed with unspecified dementia, paranoid schizophrenia, and depression. The resident was assessed as cognitively impaired and required significant assistance with daily activities. The care plan included administration of multiple psychotropic medications and monitoring for therapeutic effects and side effects, as well as completion of behavior monitoring sheets every shift. However, review of the Medication Administration Records (MAR) for May 2025 revealed that several medications, including Haloperidol, Melatonin, Mirtazapine, Trazadone, Guaifenesin ER, Acetaminophen Extra Strength, and Morphine, were not administered as ordered on specific dates. There was no documentation in the nursing notes indicating that the resident refused these medications. Additionally, the MAR indicated that other required care interventions, such as administration of Ensure Plus, pain assessments, assessments for shortness of breath, monitoring for signs and symptoms of antidepressant use, and application of compression stockings or ace wraps, were not performed on certain dates. Again, there was no documentation of refusal by the resident. Facility policy requires that medications be administered as prescribed and that any refusals or withheld doses be properly documented on the MAR. An interview with the ADNS confirmed the expectation for accurate documentation of medication administration and refusals.
Failure to Educate and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that staff were provided with education regarding the COVID-19 vaccination and information about alternative locations to receive the vaccine if it was not available at the facility. During an interview, the Infection Control Nurse, who also serves as the Assistant Director of Nursing Services (ADNS), stated that they were not offered the COVID-19 immunization, did not receive any education about the vaccine, and were not informed about where the vaccine could be obtained if the facility was unable to provide it. The ADNS further indicated that the facility was unable to obtain the COVID-19 vaccine from the pharmacy for staff use. This deficiency was identified through a review of the facility's Infection Control Program, facility documents, and staff interviews.
Care Plans Lacked Bed Rail Usage Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that the care plans for two residents included directives for the use of bed rails, despite physician orders and nursing evaluations indicating their necessity. One resident with dementia and contractures had a physician order for half side rails and a nursing evaluation recommending bilateral side rails as enablers to promote independence. However, the resident's care plan did not document the use of side rails. Similarly, another resident with dementia and anxiety disorder had a physician order for bilateral quarter side rails and a nursing evaluation supporting their use, but the care plan lacked any mention of side rail usage. Observations confirmed that bed rails were in use for both residents, yet their care plans did not reflect this intervention. The Director of Nursing acknowledged that the care plans should have included side rail usage and could not explain the omission. Facility policy required documentation of side rail use on the resident's plan of care following evaluation, but this was not followed for the residents in question.
Failure to Obtain Bed Rail Consents, Inadequate Audits, and Improper Safety Testing
Penalty
Summary
The facility failed to provide required education and obtain informed consent for the use of bed rails for four residents with varying degrees of cognitive impairment and physical dependency. Clinical record reviews revealed that, despite physician orders and care plans indicating the use of side rails or grab bars, there was no documentation that residents or their representatives were educated on the risks and benefits, nor that consent was obtained prior to bed rail implementation. Interviews with the DON confirmed the absence of consent forms and education documentation, attributing the lack of paperwork to changes made by a previous DON. Additionally, the facility did not adhere to its own policy regarding the frequency and documentation of bed and side rail safety audits. Audit forms for the residents' beds lacked dates, and the Director of Maintenance acknowledged that audits were performed annually and on a random basis, rather than at the required six-month intervals. There was also no documentation of the specific dates audits were conducted, contrary to facility policy that mandates biannual assessments and proper record-keeping. Further deficiencies were observed in the performance of bed rail safety tests. During an observation, a bed rail was found to be loose, and the Director of Maintenance did not accurately perform the manufacturer-recommended entrapment test for a specific safety zone. Instead, the wrong test procedure was used, and the required zone was not assessed, with the Director unable to explain how the bed could be considered compliant without this critical test being completed.
Failure to Monitor Behaviors for Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that behavior monitoring was completed for a resident receiving antipsychotic medications. The resident had diagnoses including anxiety disorder, schizoaffective disorder, and bipolar disorder, and was prescribed multiple antipsychotic medications such as Aripiprazole, Cariprazine, and Seroquel. The resident's care plan required staff to monitor for side effects and effectiveness of psychotropic medications every shift and to document occurrences of target behavior symptoms per facility protocol. However, a review of physician's orders, medication administration records, and nurse's notes over a two-month period did not show any evidence that behavior monitoring was ordered or performed as required. Interviews with facility staff, including a psychiatric APRN and the ADNS, confirmed that behavior monitoring should have been in place for the resident due to the use of several antipsychotic medications. Both staff members acknowledged the absence of documented behavior monitoring and indicated that such monitoring is necessary to guide treatment and assess the resident's condition. Facility policies also directed that behavioral symptoms be identified, evaluated, and documented, and that the effectiveness of antipsychotic medications be observed and reported. Despite these requirements, the facility did not obtain a physician's order for behavior monitoring or ensure that staff documented target behaviors every shift for the resident on antipsychotic medications.
Failure to Document Assessment and Provider Notification During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure complete and accurate documentation for a resident with multiple complex diagnoses, including acute and chronic respiratory failure, congestive heart failure, and chronic kidney disease, who experienced a significant change in condition. The resident became pale, cold, and complained of blurry vision and weakness while awaiting transport for dialysis. Although vital signs were recorded, including blood pressure, heart rate, temperature, and respirations, there was no documentation of an oxygen saturation (SpO2) level, a full RN assessment, or provider notification in the clinical record. Additionally, there was no documented physician's order for the transfer to the emergency department (ED). Interviews with nursing staff revealed that while some assessments and notifications may have occurred, they were not documented as required by facility policy. The nursing supervisor acknowledged assessing the resident and obtaining an oxygen level, as well as notifying the provider and obtaining a transfer order, but admitted these actions were not recorded due to the hectic circumstances. Facility policy directs that all care, assessments, and provider communications related to a change in condition must be documented in the resident's medical record, which was not followed in this instance.
Failure to Develop Elopement Risk Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop and implement a care plan addressing elopement risk for a resident with multiple diagnoses, including Parkinson's disease, dementia with behavioral disturbances, adjustment disorder, and a history of repeated falls. Despite an Elopement Risk Evaluation identifying the resident as at risk, and multiple documented incidents where the resident attempted or succeeded in leaving the facility—sometimes requiring police intervention—there was no care plan in place to address this risk. The clinical record also lacked timely physician orders for the use of a Wanderguard device, and the care plan was not updated to reflect the use of this device as required by facility policy. Nursing notes documented several episodes where the resident was unable to be redirected, became agitated or aggressive, and exited through various doors, often accompanied by staff and sometimes resulting in police involvement. Interviews confirmed that the resident had exited the facility on multiple occasions and that a care plan for elopement risk should have been developed following the initial risk assessment. Facility policies required care plans to contain necessary information for resident care and for the use of Wanderguard devices to be reflected in the care plan, which was not done in this case.
Failure to Timely Obtain Physician Order and Monitor Wanderguard for Elopement Risk
Penalty
Summary
A deficiency occurred when the facility failed to obtain a timely physician's order for a Wanderguard device after a resident was identified as being at risk for elopement. The resident, who had diagnoses including Parkinson's disease, dementia with behavioral disturbances, adjustment disorder, and a history of repeated falls, was assessed as an elopement risk on 6/24/24. Despite this assessment, there was no care plan addressing elopement risk, and the clinical record lacked documentation or physician's orders for the Wanderguard, as well as instructions for staff to check its placement and functionality, from the time of risk identification through 9/10/24. On 9/7/24, the resident attempted to leave the facility and was not able to be redirected by staff, resulting in police involvement before the resident returned. Documentation showed that a Wanderguard was applied after this incident, but prior orders did not specify the device's location or ensure that checks were carried over to the Treatment Administration Record (TAR). Facility policy required a physician's order, care plan updates, and regular checks of the Wanderguard's placement and function, none of which were consistently documented or implemented for this resident.
Failure to Document and Provide Social Service Support During Room Change
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a room change for a resident with major depressive disorder and conversion disorder was properly documented and that social service support was provided during the transition. The resident, who had intact cognition and required moderate assistance for transfers and ambulation, was moved to a new room after expressing agitation about a roommate's disruptive behaviors. Nursing notes indicated the resident's distress and subsequent adjustment to the new room, but there was no corresponding documentation from social services regarding the room change or support provided at the time of the move. Further review revealed that social service notes for the relevant month did not mention the room change until several days after it occurred, and even then, the change was not documented. Interviews with facility staff confirmed that social services are responsible for handling, documenting, and following up on all room changes, including communication with families and ensuring resident adjustment. The facility's policy also requires specific documentation of room transfers, which was not present in this case.
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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