Village Green Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Connecticut.
- Location
- 23 Fair Street, Bristol, Connecticut 06010
- CMS Provider Number
- 075198
- Inspections on file
- 29
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Village Green Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with a right femur fracture had orders for PRN Oxycodone and scheduled Lyrica for pain management. Pharmacy records and proof of delivery showed that two 30-count blister packs of Oxycodone and two 30-count blister packs of Lyrica were delivered and signed for by an RN. Facility video showed the RN handing four blister packs to an LPN, who placed them on top of a hallway med cart, did not verify the quantity at hand-off, left the controlled drugs unsecured while administering another resident’s meds, and later documented receipt of only three blister packs (two Lyrica and one Oxycodone). CSDRs were completed for two Lyrica packs and only one Oxycodone pack, leaving one Oxycodone blister pack unaccounted for and demonstrating failure to follow the facility’s double-lock and immediate recording requirements for controlled substances.
A resident with severe cognitive impairment and multiple medical conditions fell out of bed and sustained serious injuries due to inadequate supervision and failure to call for help during a change in condition. Additionally, the facility's smoking area was found to have a non-flame-resistant canopy, posing a safety hazard.
A resident with cognitive impairment and urinary incontinence had their indwelling catheter bag visibly exposed, causing frustration. Despite a care plan and physician's order for Foley management, the urinary bag was not covered by the resident's pants. An LPN acknowledged the issue but was unsure why the Foley was loosely fitted and visible.
A facility failed to ensure a clean and sanitary environment in a resident's room, who had a neurological disorder and chronic respiratory failure. The resident's family reported infrequent housekeeping, leading to a pink stain and plastic caps from medical equipment remaining on the floor. Observations confirmed these issues, and the facility lacked documentation for daily cleanings and a housekeeping policy.
A resident's personal cigarette lighters were used by other residents without consent, violating the facility's policy on protecting personal belongings. The resident, who requires supervision while smoking and uses oxygen, had their lighters used by others, and the facility failed to provide separate lighters for each resident, leading to a breach of the abuse prohibition policy.
A facility failed to notify a resident's responsible party of the bed hold policy during a hospital transfer. The resident, with COPD and acute respiratory failure, was transferred due to increased respiratory secretions. The facility's policy required notification of bed hold conditions, but no documentation or notification was provided. Upon readmission, the resident's bed was prepared for another due to infection control needs, leading to a grievance about the handling of belongings. Staff interviews revealed uncertainty about notification requirements, contributing to the deficiency.
A facility failed to accurately code the MDS assessment for a resident with schizoaffective disorder bipolar type, who met PASRR requirements for a serious mental illness. The resident was incorrectly coded as not meeting these requirements, despite being at risk for complications related to psychotropic drugs. The Director of Social Services admitted the coding error was an oversight.
The facility failed to develop baseline care plans for two residents with respiratory conditions within 48 hours of admission, as required by policy. One resident with COPD and acute respiratory failure did not have a respiratory care plan initiated, despite a physician's order for oxygen therapy. Another resident with acute and chronic respiratory failure was admitted with a CPAP machine, but their care plan did not include respiratory care. The MDS Coordinator acknowledged the oversight, and the facility could not provide the Admission Nursing Assessment for the second resident.
The facility failed to conduct proper elopement evaluations for a resident with dementia, lacked a comprehensive care plan for a resident with a history of seizures, and did not develop a respiratory care plan for a resident with COPD and pneumonia. These deficiencies were identified through clinical record reviews and staff interviews, highlighting lapses in adherence to facility policies.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident with diabetes and dementia developed a pressure ulcer, but the care plan was not updated. Another resident with heart failure had conflicting weight monitoring orders, and the care plan was not revised. A third resident with a cervical spine injury had outdated care plan instructions for hand splints, which were no longer in use. Staff acknowledged these oversights, citing issues with record-keeping and communication.
A facility failed to ambulate a resident with COPD and CHF according to the care plan, leading to a deficiency. The resident, who required assistance for ambulation, was not ambulated during several shifts despite a physician's order. Interviews revealed concerns about staffing and documentation inconsistencies, with no recorded refusals from the resident to ambulate.
Two residents at an LTC facility experienced deficiencies in pressure ulcer care due to inconsistent completion of weekly skin checks and risk assessments. One resident developed a stage one pressure ulcer, while another had a stage II pressure injury that was not properly assessed upon readmission. Issues with electronic documentation and adherence to facility policies contributed to these deficiencies.
A facility failed to specify the location for treatment application for a resident with a feeding tube. The resident had a physician's order to cleanse a site and apply Bacitracin, but the order lacked location details. The care plan included interventions for enteral feeding tube care. The DNS acknowledged the oversight, and a new order was issued after surveyor inquiry.
A facility failed to provide proper respiratory care for a resident with a tracheostomy, leading to a deficiency. The resident, with COPD and other conditions, experienced increased congestion and secretions, but staff did not notify the physician or obtain a suctioning order. Additionally, the emergency equipment area was disorganized, with supplies in open boxes on the floor and cluttered surfaces, potentially hindering emergency response. Staff interviews revealed communication lapses and protocol non-adherence, contributing to the deficiency.
The facility failed to ensure annual competencies for nurse aides in 2023 and 2024, lacking documentation for three aides. The absence of a dedicated staff development nurse and the unavailability of the DNS contributed to this oversight. The facility was transitioning ownership, with a regional staff development nurse temporarily managing education and competencies.
The facility failed to complete annual performance evaluations for nurse aides in 2023 and 2024. The HR Director, responsible for notifying the DNS of due evaluations, fell behind in updating the tracking document, resulting in missed evaluations for three nurse aides. The facility also lacked policies related to performance evaluations.
The facility failed to follow Enhanced Barrier Precautions (EBP) for two residents, one with a foot lesion and another with a gastrostomy tube. Staff were unsure about EBP requirements, leading to a lack of proper signage and protective measures. The Infection Control Preventionist confirmed the need for EBP, but it was not implemented until after surveyor inquiry. Additionally, an LPN did not wear a gown during a dressing change, and the Director of Nursing acknowledged the oversight.
The facility failed to ensure call bells were within reach for two ventilator-dependent residents. One resident, with severe cognitive impairment, had a call bell placed out of reach, while another resident, who was alert, had a call bell on the floor and struggled to activate it. The facility's policy mandates that call lights be within reach at all times.
The facility failed to conduct annual safety evaluations for two therapeutic modality machines and did not post required oxygen signage for a resident with COPD and Congestive Heart Failure. The machines lacked safety evaluation stickers, and staff were unclear about responsibilities for posting oxygen signs, leading to non-compliance with facility policy.
A resident with a history of repeated falls experienced an unwitnessed fall and, despite physician orders and facility protocol, did not receive all required neurological checks at the specified intervals. Documentation showed that multiple checks were missed, indicating a failure to follow post-fall assessment procedures.
A resident with multiple drug-resistant organisms, including MRSA, ESBL, and C. auris, did not have proper transmission-based precautions implemented as required. A respiratory therapist was observed exiting the room after providing ventilator and tracheostomy care while still wearing soiled gloves, then touched personal items and documented care before removing gloves and performing hand hygiene, contrary to facility policy and infection control protocols.
The facility did not ensure complete and accurate documentation of care for three residents, including those with dementia, heart failure, and chronic kidney disease. Wound care, medication administration, and other treatments were not consistently recorded in the medical records, despite staff interviews confirming the care was provided but not documented. This failure to document care as required by facility policy led to incomplete clinical records.
A resident with multiple wounds and significant medical needs received wound care from an LPN who failed to follow proper infection control practices, including double-gloving, not performing hand hygiene, and not treating each wound as a separate procedure. Interviews revealed the LPN was unaware of correct protocols, and facility policy confirmed these actions were not in compliance.
A resident with dysphagia was given regular milk instead of the prescribed nectar-thick consistency, leading to choking and respiratory distress. The nursing assistant assumed the milk was pre-thickened and did not verify its consistency. The resident was hospitalized with acute hypoxic respiratory failure and aspiration pneumonia. The facility's investigation revealed a lack of communication between dietary and nursing staff and no policy on following physician orders.
Unsecured Controlled Substances and Missing Oxycodone Blister Pack
Penalty
Summary
The deficiency involves the facility’s failure to secure and account for controlled substances in accordance with its own Controlled Substance Administration & Accountability policy. A resident admitted with a right femur fracture had physician orders for Oxycodone 5 mg every four hours as needed for pain and Lyrica (Pregabalin) 200 mg twice daily for nerve pain, and the resident’s care plan included administration of pain medication as ordered. Pharmacy documentation showed that two 30-count blister packs of Oxycodone 5 mg and two 30-count blister packs of Lyrica 200 mg were delivered for this resident and signed for by an RN. The facility’s documentation identified that Controlled Substance Disposition Records (CSDRs) were created for two 30-count Lyrica blister packs and only one 30-count Oxycodone blister pack, despite the pharmacy packing slips and proof of delivery indicating that two Oxycodone blister packs had been delivered. A reportable event completed by the DNS documented that video review showed the RN receiving four blister packs (two Lyrica and two Oxycodone) from the pharmacy driver and delivering them to an LPN, who was observed on video with all four blister packs at the nursing station and then at the medication cart. However, only three blister packs (two Lyrica and one Oxycodone) were documented as received by the LPN. In interview, the LPN stated she was working the 11:00 PM to 7:00 AM shift when the RN brought the controlled substances to her unit. She reported that the RN placed the blister packs on top of her medication cart in the hallway, that she did not verify the number of blister packs at the time of transfer because she was in a rush, and that she left the controlled substances unsecured on top of the cart while she went to administer another resident’s medication. She later returned and signed in only three blister packs into the controlled substance records. The DNS described the facility’s process, which requires the supervisor and unit nurse to verify each blister pack at hand-off, immediately record the medications on the appropriate drug disposition record, and store patient-specific controlled substances under double lock, and confirmed that controlled substances should not be left unattended and should always be secured. One 30-count blister pack of Oxycodone remained unaccounted for.
Failure to Prevent Resident Fall and Smoking Area Hazard
Penalty
Summary
The facility failed to ensure necessary care and services were provided to prevent a fall with major injury for a resident who exhibited a change in condition. The resident, who had a history of cerebrovascular accident with right-sided hemiparesis, epilepsy, and chronic respiratory failure with a tracheostomy, was severely cognitively impaired and required assistance with activities of daily living. During a bed change, the resident began moving around excessively, and the nurse aide, who was at the head of the bed, did not call for help when the resident showed signs of distress. As a result, the resident fell out of bed, sustaining a severe comminuted fracture of the right maxillary sinus and orbital floor, as well as a corneal abrasion. The incident was witnessed by nursing staff, and the resident was sent to the emergency department for evaluation. The nurse aide's failure to call for help and the positioning at the head of the bed, rather than the side, contributed to the inability to prevent the fall. The Director of Nursing Services identified the root cause as the nurse aide not calling for help when the resident began moving around and showing signs of distress. The facility did not provide a policy for nurse aide reporting of a change of condition. Additionally, the facility failed to ensure the designated smoking area was free from accident hazards. A canopy made of cloth-like material, which was not flame-resistant, was placed in the smoking area. The Director of Maintenance acknowledged the canopy was a replacement for one damaged in a storm, and it was removed after surveyor inquiry. The facility did not provide a policy for ensuring a safe environment.
Failure to Maintain Dignity in Urinary Device Management
Penalty
Summary
The facility failed to handle a resident's urinary collecting device in a dignified manner, as observed in the case of Resident #26. The resident, who has diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia, and a history of falls, was identified as cognitively impaired and requiring assistance with personal hygiene and toileting. Despite a care plan and physician's order for managing the resident's urinary incontinence and Foley catheter, an observation revealed that the resident's indwelling catheter bag was visible from the hallway, causing the resident frustration. The resident expressed concern that the urinary bag was not covered by their pants, and an LPN confirmed that the situation was inappropriate but was unsure why the Foley was loosely fitted and visible.
Failure to Maintain a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the room of a resident who was admitted with a neurological disorder and chronic respiratory failure. The resident, who was cognitively intact and dependent on activities of daily living, had a tracheostomy, an enteral feeding tube, and a urinary catheter. During an interview, the resident's family member reported that housekeeping services were infrequent, sometimes taking several days to clean spills. An observation confirmed the presence of a pink stain on the floor and several plastic caps from medical equipment scattered around the room. Further observations with the Housekeeping Director revealed that while the pink stain had been removed, the plastic caps remained. The Housekeeping Director stated that rooms are cleaned daily, including dust mopping and wet mopping, and that debris should be swept up and discarded. However, the facility did not maintain quality control documentation for daily room cleanings, and no policy on housekeeping or daily room cleaning was provided upon request. The room was scheduled for a deep cleaning, but the lack of documentation and oversight contributed to the deficiency in maintaining a clean environment.
Misuse of Resident's Personal Belongings
Penalty
Summary
The facility failed to protect a resident's personal belongings, specifically cigarette lighters, from being used by other residents without consent. Resident #41, who has a history of nicotine dependence and requires supervision while smoking, had their personal lighters used by other residents. The facility's policy mandates that smoking materials be maintained by staff to ensure supervision and safety, especially since Resident #41 also uses oxygen. Despite this, observations revealed that a nurse aide used Resident #41's lighter to light another resident's cigarette, and the lighter was later returned to the medication room without proper consent from Resident #41. Further investigation showed that the facility did not have separate lighters for each resident, as only Resident #41's lighters were found in the smoking bin. Interviews with staff confirmed that lighters labeled with Resident #41's name were used by other residents, and the facility's social worker indicated that lighters should be labeled as 'Facility' for communal use. The facility's policy on abuse prohibition defines misappropriation of patient property as the deliberate temporary use of a patient's belongings without consent, which was violated in this instance.
Failure to Notify Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party of the bed hold policy when a resident was transferred to the hospital. The resident, who had diagnoses including Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and acute respiratory failure, was transferred to the hospital due to increased respiratory secretions. Although the facility's policy required notification of the bed hold policy upon transfer, there was no documentation or notification provided to the responsible party. The facility's policy, as per Connecticut State Agencies Section 17-134 d-79, mandates informing residents and their representatives of the conditions under which a bed is reserved, but this was not adhered to in this case. The resident was readmitted to the facility after the hospital stay, but the bed had been prepared for another resident due to an infection control issue. The facility's administrator and staff were aware of the situation, and the responsible party was encouraged to file a grievance regarding the handling of the resident's belongings. Interviews with staff revealed uncertainty about the requirement for written notification of the bed hold policy, although it was included in the Admission Agreement packet. The facility's failure to provide the necessary notification and documentation led to the deficiency identified in the report.
Inaccurate MDS Coding for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accurate coding of a Minimum Data Set (MDS) assessment for a resident identified with a serious mental illness. The resident, diagnosed with schizoaffective disorder bipolar type, was determined to meet Preadmission Screening and Resident Review (PASRR) assessment requirements for a serious mental illness as per the report dated 12/11/18. However, the annual MDS assessment inaccurately coded the resident as '0', indicating they did not meet PASRR requirements for a serious mental illness. The care plan noted the resident was at risk for complications related to psychotropic drugs, with interventions to monitor mental status and obtain psychiatric evaluations as ordered. The Director of Social Services, responsible for MDS coding related to PASRR criteria, acknowledged the coding error as an oversight during an interview on 3/12/25. The MDS 3.0 Resident Assessment Instrument (RAI) Manual directs that a '1' should be coded if the PASRR level II screening determined the resident had a serious mental illness.
Failure to Develop Baseline Respiratory Care Plans
Penalty
Summary
The facility failed to develop a baseline care plan to meet the essential respiratory care needs of two residents within 48 hours of their admission, as required by their policy. Resident #224, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), pneumonia, and acute respiratory failure, had a physician's order for oxygen therapy via a trach mask. However, no respiratory care plan was initiated during the resident's stay, despite the facility's policy mandating a baseline care plan within 48 hours of admission. This oversight was confirmed during an interview and record review with RN #4. Similarly, Resident #274, who had acute and chronic respiratory failure with hypoxia and hypercapnia, was admitted with a physician's order for respiratory therapy using a CPAP machine. The baseline care plan for this resident did not include respiratory care, focusing instead on skin infection risk, ADL/self-care deficit, and nutritional problems. The MDS Coordinator acknowledged that the respiratory care should have been included in the care plan. Additionally, the facility was unable to provide a copy of the Admission Nursing Assessment for this resident, and the MDS was not completed before the resident was transferred back to the hospital.
Deficiencies in Care Planning and Risk Assessment
Penalty
Summary
The facility failed to conduct proper elopement evaluations and maintain an updated care plan for a resident with dementia and a history of wandering. Resident #2, who was diagnosed with dementia with behavioral disturbances, had an elopement evaluation that did not indicate a score to determine the level of risk for elopement. Despite having a history of wandering and elopement, the resident's Wander guard bracelet was discontinued without a clear rationale. The acting Director of Nursing Services was unaware of the frequency of elopement evaluations and how the risk of elopement is determined, indicating a lack of adherence to the facility's policy. Another deficiency involved Resident #124, who had a history of epilepsy but did not have a comprehensive care plan addressing seizure precautions. The resident was severely cognitively impaired and required assistance with activities of daily living. Despite a reportable event where the resident's body started to flop, indicating a possible seizure, the care plan lacked specific interventions for seizure management. The Nurse Practitioner acknowledged that a seizure protocol should have been in place, and the Director of Nursing Services confirmed that the care plan should have included padded rails for safety. Lastly, the facility failed to develop a comprehensive respiratory care plan for Resident #224, who had diagnoses including COPD, pneumonia, and acute respiratory failure. Although there were physician's orders for oxygen therapy and tracheostomy care, there was no evidence of a respiratory care plan during the resident's stay. The facility's policy required a comprehensive care plan to be developed within seven days of admission, but this was not adhered to, as confirmed by the acting Director of Nursing Services.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for three residents, leading to deficiencies in their care. Resident #24, diagnosed with type 2 diabetes mellitus and vascular dementia, developed a stage 1 pressure ulcer on the left heel. Despite a treatment order to apply skin prep and elevate heels, the care plan was not updated to reflect this new condition. The wound nurse acknowledged the oversight, citing issues with electronic record-keeping and Wi-Fi connectivity, which led to a reliance on paper documentation. Resident #38, with diagnoses including encephalopathy, chronic systolic congestive heart failure, and end-stage renal disease, had conflicting physician orders regarding weight monitoring. The care plan included daily weights as an intervention for heart issues, but the orders specified weights only after specialized treatment. The MDS Coordinator admitted the care plan should have been revised to align with the new orders but failed to do so until prompted by the surveyor. Resident #324, admitted with a cervical spine injury, had a care plan indicating the use of hand splints, which were no longer in use following multiple hospitalizations. Despite signage and care cards indicating splint use, there were no active physician orders for them. The Director of Rehabilitation confirmed that splints would not be ordered without a proper evaluation, and the MDS Coordinator acknowledged the care plan should have been updated to reflect the discontinuation of the orthotic device.
Failure to Ambulate Resident as Per Care Plan
Penalty
Summary
The facility failed to ensure that Resident #8 was ambulated according to the plan of care, which led to a deficiency in the resident's rehabilitation and restorative care. Resident #8, who has diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), and anxiety, was identified as cognitively intact and required maximal assistance with personal care. The care plan specified assistance for stand pivot transfers and ambulation with a rolling walker. However, the Treatment Administration Records (TAR) showed that Resident #8 did not ambulate during four shifts in March 2025, despite a physician's order directing ambulation with assistance every shift. Interviews with Resident #8 and staff revealed a lack of adherence to the ambulation schedule. Resident #8 expressed concerns about insufficient staff to assist with ambulation, leading to a perceived decline in mobility. Nursing Assistant #7 and LPN #5 indicated that ambulation schedules were documented but not consistently followed. The Director of Rehabilitation Services confirmed that staff from various departments were responsible for assisting with ambulation but could not explain the missed ambulation sessions. The nurse's notes for March 2025 did not document any refusal from Resident #8 to ambulate, highlighting a gap in the facility's documentation and execution of the care plan.
Inconsistent Skin Assessments Lead to Pressure Ulcer Deficiencies
Penalty
Summary
The facility failed to ensure consistent completion of weekly skin checks and skin risk assessments for two residents, leading to deficiencies in pressure ulcer care. Resident #24, diagnosed with type 2 diabetes mellitus and vascular dementia, was identified as at risk for pressure ulcers. Despite this, there were multiple weeks where no skin checks were documented, and a Braden Scale assessment was not completed as required. This lack of consistent monitoring resulted in the development of a stage one pressure ulcer on the resident's left heel, which was not promptly addressed in the care plan. Similarly, Resident #47, who had diagnoses including type II diabetes and neoplasm of the colon, experienced lapses in weekly skin assessments. The resident was readmitted with a stage II pressure injury, yet the admission assessment failed to include a comprehensive description of the wound. Additionally, the Braden Risk Assessment was not completed on readmission or weekly thereafter for the first month, as per facility policy. This oversight in documentation and assessment contributed to inadequate pressure ulcer management. Interviews with the wound nurse and facility administrator revealed ongoing issues with the electronic scheduler and documentation processes, which contributed to the inconsistencies in skin assessments. The facility's policies for skin integrity and wound management were not adhered to, resulting in a failure to provide adequate pressure ulcer prevention and care. The lack of a policy for weekly skin checks further compounded the issue, as staff were unable to consistently track and document the necessary assessments.
Failure to Specify Treatment Location for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure that staff obtained a treatment order specifying the location for the application of treatment for a resident with a feeding tube. The resident, who had diagnoses including dysphagia and gastrostomy status, had a physician's order dated 1/14/2025 to cleanse a site daily with normal saline, apply Bacitracin, and cover with a dressing. However, the order did not specify the location for this treatment. The care plan indicated the resident had an enteral feeding tube and included interventions such as keeping the head of the bed elevated during feeding and monitoring the skin surrounding the gastrostomy tube site. During a clinical record review and interview, the Director of Nursing Services (DNS) acknowledged the missing location in the order and stated that staff should not assume the location is the G-tube site. Following surveyor inquiry, a new physician's order was issued specifying the application of treatment to the G-tube site.
Deficiency in Respiratory Care and Equipment Organization
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident with a tracheostomy, leading to a deficiency in care. The resident, diagnosed with COPD, pneumonia, acute respiratory failure, and neoplasm of the larynx, required oxygen therapy and was at risk for Multiple Drug-Resistant Organisms. Despite a physician's order for oxygen therapy, the facility staff did not notify the physician of a change in the resident's condition when the resident experienced increased congestion and respiratory secretions. The staff also failed to obtain a physician's order for suctioning when the resident presented with thick green mucous, which was a deviation from the facility's policy requiring provider notification for such changes. Additionally, the facility did not maintain an organized and accessible emergency equipment area at the resident's bedside. Observations revealed disarray, with treatment supplies stored in open cardboard boxes on the floor, a suction machine, and other items cluttering the tabletop and shelf. The presence of an open trach mask and tubing, along with multiple Ambu bags, further indicated a lack of organization and readiness in the emergency equipment area. This disorganization could have impeded timely access to necessary equipment in an emergency. Interviews with facility staff, including the APRN, LPN, and RN, highlighted a lack of communication and adherence to protocols. The APRN expected the nursing staff to notify the physician of the resident's condition change, but this did not occur. The LPN and RN involved were unaware of the need for a physician's order for suctioning and did not notify the physician of the resident's condition change. The facility's failure to follow its policies and maintain an organized emergency equipment area contributed to the deficiency in providing safe and appropriate respiratory care for the resident.
Failure to Complete Annual Competencies for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual competencies were completed for nurse aide staff for the years 2023 and 2024. Specifically, there was no documentation of annual competencies for 2023 for one nurse aide, and for 2024, two nurse aides lacked documentation of completed competencies. The facility's employee listing indicated the hire dates for the nurse aides involved, with one having been employed since 2000, another since 2012, and the third hired in late 2023. The absence of a dedicated staff development nurse and the unavailability of the Director of Nursing Services (DNS) contributed to the lack of oversight in ensuring the completion of these competencies. During an interview, the Infection Control Nurse acknowledged the absence of documentation or tracking sheets for the nurse aides' annual competencies. The facility was undergoing a change in ownership, and a regional staff development nurse from the new owner was expected to manage education and competencies temporarily. The facility's clinical competency validation checklist for 2023/2024 outlined specific competencies required for nurse aides, including hand hygiene, PPE use, and various care procedures. The facility assessment emphasized the necessity of staff training and competencies to provide appropriate care for the resident population.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for nurse aide staff for the years 2023 and 2024. Specifically, the facility did not provide documentation of completed annual performance evaluations for three nurse aides: one hired in 2000, another in 2012, and a third in 2023. The Director of Human Resources (HR) was responsible for notifying the Director of Nursing Services (DNS) when evaluations were due, but admitted to falling behind in updating the tracking document due to workload, resulting in a lack of notification to the DNS. The Director of HR maintained the evaluation schedule on an Excel document, which was not updated regularly, leading to missed evaluations. The facility also failed to provide any policies related to annual performance evaluations when requested. The HR Director confirmed that the DNS did not track evaluations independently, relying solely on HR notifications, which were not provided due to the HR Director's backlog.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions (EBP) guidelines for two residents, leading to deficiencies in infection prevention and control. Resident #46, who had a lesion on the right dorsal foot, was not placed on EBP as required by a physician's order. Observations revealed that there was no EBP signage on the resident's door, and the staff, including the Wound Care Nurse and RN #2, were unsure if the resident should be on EBP. It was later confirmed by the Infection Control Preventionist that the resident should have been on EBP, but this was not implemented until after surveyor inquiry. Similarly, Resident #224, who had a gastrostomy tube, was also not managed according to EBP guidelines. Although there was a physician's order for EBP, the signage was blocked, and LPN #11 did not wear a gown during the dressing change, which was required. The resident reported increased drainage and tenderness around the gastrostomy site, and the LPN acknowledged the need to notify the APRN for evaluation. The Director of Nursing Services confirmed that the signage and personal protective equipment should have been visible and that the LPN should have worn a gown during the procedure.
Call Bell Accessibility Deficiency for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for two residents, both of whom were dependent on ventilators. Resident #40, who had severe cognitive impairment and required substantial assistance with mobility, was observed with a call bell placed two feet away on a tray table, out of reach. During the observation, the resident was unable to move their arms and was mouthing words to request pain medication. An LPN confirmed that the call bell should have been within the resident's reach. Resident #325, who was alert and able to communicate needs, was found with a call bell on the floor next to the bed. A nursing assistant, unfamiliar with the resident's ability to call, indicated that the call bell should have been clipped to the sheets. Although the resident attempted to use the call bell, they were unable to fully activate it. The nursing assistant suggested that the resident might benefit from an adaptive call bell that is easier to push. The facility's policy requires that all residents have a call light or alternative communication device within reach at all times when unattended.
Deficiencies in Equipment Safety Evaluation and Oxygen Signage
Penalty
Summary
The facility failed to ensure that two therapeutic modality machines in the Therapy Department were evaluated annually for safety in 2022 and 2023. During an observation, it was noted that the machines lacked stickers indicating the last safety evaluation. The Maintenance Director was unable to provide service documents for the evaluations and confirmed that the machines had not been serviced. The equipment servicing company was contacted to schedule a service visit, and the machines were removed from use until they could be serviced. Additionally, the facility failed to post signage indicating oxygen use for a resident with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure, who was receiving oxygen therapy. Observations revealed that there was no sign outside the resident's room, and interviews with staff indicated confusion over responsibility for posting the sign. The facility's policy requires a 'No smoking - Oxygen in use' sign in areas where high-pressure cylinders are stored, but this was not adhered to in the resident's case.
Failure to Complete Neurological Checks After Unwitnessed Fall
Penalty
Summary
A resident with a history of fibromyalgia and repeated falls was identified as being at risk for falls, with a care plan in place that included interventions such as assistance with ambulation and transfers, and the initiation of frequent neurological and bleeding evaluations per facility protocol in the event of a fall. The resident experienced an unwitnessed fall after attempting to go to the bathroom without staff assistance, resulting in a physician's order to continue neurological checks. Review of the neurological evaluation documentation revealed that the required neurological checks were not completed in full according to the facility's protocol. Specifically, several checks at 15-minute, 30-minute, and hourly intervals were missed following the fall. Facility policy and the neurological procedure required thorough and timely documentation of neurological status after unwitnessed falls, but these were not adhered to for this resident.
Failure to Implement Required Transmission-Based Precautions for MDROs
Penalty
Summary
A deficiency was identified when staff failed to implement required transmission-based precautions for a resident with multiple drug-resistant organisms (MDROs). The resident had chronic respiratory failure requiring ventilator support, dementia, ALS, epilepsy, and was colonized or infected with ESBL, MRSA at the tracheostomy site, and Candida auris. Physician orders and care plans directed the use of contact precautions and enhanced barrier precautions, including the use of gown and gloves during high-contact care and device care such as tracheostomy and ventilator management. On observation, a respiratory therapist (RT) was seen exiting the resident's room after providing ventilator and tracheostomy care, still wearing gloves used during care. The RT touched her eyeglasses, used a pen, and documented on a clipboard while still wearing the soiled gloves, and only removed the gloves and performed hand hygiene after these activities. The RT acknowledged she should have removed gloves and performed hand hygiene before exiting the room but did not do so. Facility policy and the infection control nurse confirmed that all staff were required to remove PPE and perform hand hygiene before leaving a resident's room, especially in the context of an MDRO outbreak. Facility documentation and interviews confirmed that all ventilator unit residents were on contact precautions due to an active outbreak of Carbapenem-resistant Acinetobacter baumannii and Candida auris. The infection control nurse stated that staff had previously received education on these requirements, and facility policies directed removal of PPE and hand hygiene upon room exit. The failure to follow these protocols was directly observed and confirmed through staff interview and policy review.
Failure to Accurately Document Resident Care and Treatments
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurate for three residents reviewed for quality of care. For one resident with dementia and a history of pressure ulcers, physician orders required specific wound care interventions to be performed and documented every day and evening shift. However, review of the Treatment Administration Record (TAR) revealed that wound care was not documented on several occasions across multiple months. Interviews with LPNs responsible for the care confirmed that while the care was reportedly provided, documentation was omitted due to forgetfulness. The Director of Nursing (DON) stated that nursing staff are expected to document care accurately and timely in the electronic medical record, as outlined in the facility's documentation policy. For another resident with heart failure and an open wound, physician orders directed specific wound care and medication administration. The TAR and Medication Administration Record (MAR) showed missing documentation for wound care and administration of Tylenol on multiple days. Interviews with LPNs revealed that the care and medication were provided but not documented, and staff acknowledged the omission. The facility's policy requires concise, clear, and timely documentation of care provided, which was not followed in these instances. A third resident with chronic kidney disease and heart failure also had missing documentation for ordered treatments, including application of splints and wound care. The responsible LPN confirmed that treatments were completed but not documented. The DON and Director of Nursing Services (DNS) both indicated that care should have been documented according to physician orders and facility policy. The failure to document care as provided resulted in incomplete and inaccurate clinical records for these residents.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
A deficiency was identified when wound care for a resident with chronic kidney disease, heart failure, severe cognitive impairment, and dependence on staff for activities of daily living was not performed according to accepted infection control practices. During an observed wound care procedure, an LPN wore two pairs of gloves on each hand, removed only the outer layer after handling soiled dressings, and then proceeded to apply clean dressings without performing hand hygiene or changing gloves as required. The LPN also treated both wounds consecutively without treating each as a separate procedure, contrary to facility policy and standard infection control protocols. Interviews with the LPN revealed a lack of knowledge regarding proper glove use, hand hygiene, and the correct sequence for wound care procedures. The LPN stated she wore two pairs of gloves because the gloves tore easily and was unsure about when to change gloves or perform hand hygiene. Review of facility policy and interviews with the wound nurse and Director of Nursing Services confirmed that only one pair of gloves should be worn, gloves should be changed, and hand hygiene performed after removing soiled dressings and before applying clean dressings, and that each wound should be treated as a separate procedure.
Failure to Provide Correct Liquid Consistency Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide a resident with dysphagia the correct liquid consistency as per physician orders, leading to a serious incident. The resident, who had a history of cerebrovascular infarction with hemiplegia and hemiparesis, dysphagia, and vascular dementia, was on a mechanically altered diet requiring thickened liquids. On the day of the incident, the resident was given regular milk instead of the prescribed nectar-thick consistency, resulting in choking and respiratory distress. The incident occurred when a nursing assistant (NA) fed the resident milk that was not thickened, assuming it was pre-thickened by the kitchen staff. The NA did not verify the consistency of the milk before serving it to the resident, which led to the resident coughing and subsequently experiencing respiratory distress. The resident was cyanotic and displayed signs of choking, prompting immediate intervention by the nursing and respiratory teams, who performed the Heimlich maneuver and provided suction and oxygen before transferring the resident to the hospital. The hospital confirmed the resident had acute hypoxic respiratory failure and aspiration pneumonia, necessitating treatment with antibiotics and respiratory support. The facility's investigation revealed that the kitchen had sent regular milk with a thick-it packet due to a backorder of pre-thickened milk, and there was a lack of communication between dietary and nursing staff regarding this change. The facility did not have a policy on following physician orders, which contributed to the oversight in providing the correct liquid consistency to the resident.
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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