Westside Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, Connecticut.
- Location
- 349 Bidwell Street, Manchester, Connecticut 06040
- CMS Provider Number
- 075252
- Inspections on file
- 33
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Westside Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, severe cognitive impairment, and total dependence for toileting and personal hygiene was observed receiving ADL care while fully visible from the hallway, with the room door and privacy curtain left open and no sheet or blanket covering the body. A NA removed a saturated brief by pulling and tugging it from under the resident, who was lying flat in bed, without asking the resident to roll or lift their buttocks, despite care instructions for gentle skin care. Interviews with a NA, an LPN, the ADNS, the Administrator, and the DNS confirmed that facility expectations and resident rights required closing doors/curtains during personal care and avoiding pulling briefs out from under residents.
A resident with dementia and severe cognitive impairment suffered a fall resulting in a head laceration and change in consciousness. Although emergency services and the provider were notified, only a single voicemail was left for the responsible party, with no documented follow-up attempts, contrary to facility policy requiring timely notification and documentation after a significant change in condition.
A resident with dementia and severe cognitive impairment was left unsupervised by a nursing assistant during an outpatient dental appointment. The staff member lost visual contact with the resident for several minutes while distracted by a phone call, resulting in the resident wandering away and being found two miles from the clinic. Facility policy required continuous line-of-sight supervision, which was not maintained.
A resident with severe cognitive impairment and acute osteomyelitis experienced high pain levels when their prescribed Oxycodone was unavailable. An LPN administered acetaminophen, which did not relieve the pain, but did not notify the supervisor or physician about the ongoing pain or medication shortage. Key nursing and administrative staff were unaware of the situation, and the physician was not contacted to provide an alternative pain management option.
A resident with behavioral health needs was physically abused by another resident following a verbal altercation in the dining room. The incident escalated when one resident, using a motorized wheelchair, caused the other to fall and then struck them in the head with a cane, resulting in a laceration requiring sutures. Staff and therapy personnel witnessed the event, and facility policies prohibiting abuse were not effectively implemented to prevent this incident.
Two residents did not receive their prescribed medications within the facility's required timeframe, with administration occurring up to several hours late. An LPN reported heavy assignments as the cause and did not notify supervisors, while the RN and DON were unaware of the delays. Facility policy required medications to be given within 60 minutes of the scheduled time and for staff to report delays, but these steps were not followed.
A resident with severe pain and a history of osteomyelitis did not receive prescribed Oxycodone-APAP for over 32 hours due to the facility running out of the medication and lacking an emergency supply. Despite the resident reporting high pain levels and acetaminophen being ineffective, staff failed to notify supervisors or providers in a timely manner, and no alternative pain management was arranged. Poor communication and lack of adherence to pain management protocols resulted in the resident experiencing prolonged, unrelieved pain.
Two residents, both with intact cognition and behavioral health diagnoses, were involved in a physical and verbal altercation in a common area. One resident approached another, yelled, and punched them, leading to a physical struggle. Staff and witness statements confirmed the incident, which was substantiated as abuse, indicating a failure to protect residents from abuse as required by facility policy.
Following a physical altercation between two residents, the facility did not document the required 1:1 and Q15 minute monitoring for a resident as mandated by policy. Despite orders and care plan updates for close observation, there was no record in the clinical file or on monitoring flowsheets to confirm that these checks were performed.
The facility failed to maintain a homelike environment, with numerous issues such as damaged walls, broken furniture, and missing tiles observed across two units. Key staff, including the Regional Maintenance Director and Administrator, were unaware of these issues, indicating a breakdown in communication and oversight.
The facility failed to protect residents from physical abuse by other residents with known histories of altercations. A resident with adjustment disorder was hit in the face by another resident after a verbal argument, despite interventions to maintain a no-contact boundary. In another incident, the same resident was punched by a different resident after refusing to leave a room. Additionally, a resident with dementia and PTSD was pushed and injured by another resident during an argument. These incidents highlight the facility's deficiency in preventing resident-to-resident altercations.
The facility failed to protect residents from involuntary seclusion by not providing independent egress from a locked dementia unit. Residents who chose to live on the unit or did not meet the criteria were not given access codes to leave independently. The facility also failed to conduct required assessments and document discussions with residents or their representatives regarding their placement. Staff interviews revealed a lack of awareness and completion of necessary assessments.
The facility failed to maintain cleanliness in the nourishment refrigerator and food transport carts, leading to deficiencies in food safety and hygiene. Observations revealed unlabeled, expired, and partially eaten food items in the refrigerator, along with unsanitary conditions. Additionally, food transport carts used for serving meals were soiled and not properly cleaned. The dietary department was responsible for these tasks, but failed to adhere to the facility's policies, resulting in the observed deficiencies.
The facility failed to implement proper infection control measures for three residents requiring transmission-based precautions. Two residents with COVID-19 were observed in communal areas without masks, contrary to isolation orders. Another resident with MRSA did not have appropriate signage or PPE outside their room, increasing the risk of transmission. Staff interviews confirmed a lack of adherence to infection control protocols.
A resident with dementia and dysphagia was fed by a standing nurse aide, contrary to facility policy requiring staff to be seated at eye level. The resident, with severely impaired cognition and no natural teeth, was silent during the meal, and there was no dialogue. Staff interviews confirmed training to sit while feeding, indicating non-compliance with the policy.
A facility failed to accurately document a resident's advance directive, resulting in a discrepancy between the resident's DNR preference and the facility's records, which listed the resident as Full Code. Despite the resident's signed consent for DNR, the facility's documentation and physician's orders incorrectly identified the resident as Full Code, contrary to the facility's policies on advance directives and order transcription.
The facility failed to notify the physician or APRN of a resident's change in condition, did not inform a resident's representative of multiple smoking incidents, and neglected to document and communicate a resident's refusal of showers. These actions violated facility policies requiring timely notification and documentation of significant changes in residents' conditions.
Three residents in a facility did not receive their scheduled weekly showers, with one resident not showered for months due to an unsuitable bariatric chair, and another preferring showers over bed baths but not receiving them due to staffing issues. Additionally, a resident with a history of falls did not receive the required 72-hour neurological monitoring after an unwitnessed fall, highlighting deficiencies in care and documentation.
The facility failed to adhere to physician orders and facility policies, resulting in inadequate care for several residents. One resident did not receive an RN assessment after a change in condition, and weights were not obtained as ordered. Another resident was not monitored for fluid intake and output, and weights were inconsistently recorded. Additionally, neurological checks were not completed for a resident after an unwitnessed fall with a head strike, contrary to facility policy.
The facility failed to ensure safety for residents, including a smoker not using a required apron, a fan with exposed blades, and a cognitively impaired resident smoking indoors. Staff discretion and lack of documentation contributed to these deficiencies.
A resident with hepatic encephalopathy and liver failure experienced a significant medication error due to incorrect transcription of Lactulose orders, leading to hospitalization for acute encephalopathy. The error was discovered after the resident showed increased lethargy and altered mental status. Facility staff interviews revealed confusion over the correct dosage, and the facility's policies for handling medication orders were not adequately followed.
The facility failed to document education on the benefits and side effects of the influenza vaccine for three residents before administration. An LPN provided the Vaccine Information Statement (VIS) but did not record this in the clinical records, contrary to facility policy. The Regional Director of Infection Control was unaware that documentation was required.
Failure to Maintain Resident Privacy and Dignity During ADL Care
Penalty
Summary
The deficiency involves a failure to maintain a resident’s privacy and dignity during the provision of ADL care. Resident #2 had Alzheimer’s disease, a BIMS score of 3/15 indicating severe cognitive impairment, no behaviors, and was dependent on staff for toileting, bed mobility, and personal hygiene. The resident’s care plan and NA care list directed assistance of one staff for bed mobility, personal hygiene, and total dependence for brief changes at bed level, with instructions to protect sensitive skin and avoid scrubbing. During a surveyor observation, NA #1 was providing ADL care at the bedside while the room door and bedside curtain facing the hallway were left open, leaving Resident #2 fully visible from the hallway. The surveyor observed Resident #2 lying supine in bed, undressed, without a shirt or pants, and not covered by any sheet, blanket, towel, or bath blanket. The resident’s chest was exposed, and NA #1’s body only partially blocked the view of the hips/groin area. The surveyor further observed NA #1 pulling and tugging a moderately to heavily saturated adult brief out from under the resident’s hips while the resident remained flat on their back; NA #1 was not heard asking the resident to roll over or lift their buttocks during the brief removal. Subsequent interviews with NA #1, an LPN, the ADNS, the Administrator, and the DNS confirmed that facility expectations and the resident’s rights required closing the door and/or privacy curtain during personal care and that briefs should not be pulled or tugged out from under a resident lying flat, particularly given the need for gentle skin care. The facility’s Residents’ Rights policy also stated residents had a right to privacy when receiving personal and medical care and treatment.
Failure to Timely Notify Responsible Party After Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to notify the responsible party in a timely manner following a significant change in condition for a resident with dementia and severe cognitive impairment. The resident, who was at risk for falls and required specific interventions such as wearing grippy socks, experienced a witnessed fall resulting in a head laceration and a change in level of consciousness. Emergency services were called, and the resident was transferred to the hospital. Documentation showed that the provider was notified at 5:15 AM, but the responsible party was only left a voicemail at 9 AM, with no evidence of further attempts to reach them. Interviews with nursing staff revealed inconsistencies and lack of clarity regarding who was responsible for notifying the family, with some staff assuming others had made the call. The facility's policies required timely notification and documentation of all attempts to contact the responsible party, especially after a serious injury. However, the clinical record and interviews confirmed that only a single voicemail was left, and no additional follow-up or documentation of further attempts was found.
Resident Left Unsupervised During Outpatient Appointment
Penalty
Summary
A deficiency occurred when a resident with dementia, diabetes mellitus, and a history of stroke was not adequately supervised during an outpatient dental appointment. The resident was identified as severely cognitively impaired and had demonstrated behaviors such as frustration and anger, with interventions in place to allow adequate response time and anticipate needs. Despite an exit-seeking risk assessment indicating no known risk factors for exit-seeking, the resident was disoriented. During the dental appointment, the resident was accompanied by a nursing assistant (NA) who, after the appointment, waited outside the clinic with the resident for transportation. While waiting, the resident moved around the area, including using the bathroom twice and sitting or standing near the NA. At one point, the NA was distracted by a phone call regarding transportation and lost visual contact with the resident for approximately five minutes. Upon realizing the resident was missing, the NA searched the clinic and surrounding area before notifying facility staff. The incident was escalated to the facility administration, and local authorities were contacted to assist in the search. The resident was eventually found unharmed at a gas station two miles from the clinic and was transported to the emergency department for evaluation. The facility's policy required staff to maintain close proximity and line-of-sight supervision of residents during appointments, which was not followed in this instance, resulting in the resident being left unsupervised.
Failure to Notify Physician of Unavailable Pain Medication and Ineffective Alternative
Penalty
Summary
The facility failed to notify the physician when a resident's prescribed pain medication, Oxycodone 5-325 mg, was unavailable, and when the alternate pain medication administered, acetaminophen, was ineffective. The resident, who had acute osteomyelitis of the left ankle and foot and severe cognitive impairment, experienced pain levels ranging from five to ten. On the day in question, the resident reported a pain level of nine, received acetaminophen, and subsequently reported that the medication was ineffective, with pain remaining at eight. Despite this, the physician was not informed of the unrelieved pain or the unavailability of the prescribed Oxycodone, and no alternative pain management was sought. Interviews with facility staff revealed that the LPN did not notify the supervisor or the physician about the medication shortage or the resident's ongoing pain. The nurse supervisor, ADNS, and DON all confirmed they were not informed of the situation, and the Medical Director stated that he would have expected to be notified to provide an alternative medication. Facility policy required assessment and physician notification in the event of a significant change in condition, which did not occur in this instance.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with bipolar disorder and anxiety, who was alert and oriented, was not protected from physical abuse by another resident. The incident began with a verbal altercation in the dining room over condiments, escalating when one resident, who used a motorized wheelchair and had a history of anxiety and depression, drove towards the other, causing them to fall. While on the floor, the resident who had fallen attempted to use their cane defensively, but the other resident took the cane and struck them in the head, resulting in a significant laceration that required emergency medical attention and sutures. Multiple staff members, including a social worker, physical therapy assistant, and certified occupational therapy assistant, witnessed or responded to the altercation. Their accounts confirmed that the altercation escalated quickly from a verbal dispute to physical violence, with the use of a cane as a weapon. The staff intervened after the incident had already resulted in injury, and both residents were subsequently separated and evaluated. Facility documentation and policies reviewed indicated that residents are to be free from abuse by anyone, including other residents. Despite these policies, the facility failed to prevent the physical abuse that occurred during the altercation, resulting in harm to one of the residents. The deficiency was identified through clinical record reviews, staff interviews, and facility documentation.
Failure to Administer Medications Timely per Facility Policy
Penalty
Summary
The facility failed to administer medications in accordance with its own policy for two of three residents reviewed for medication administration. For one resident with diagnoses including schizoaffective disorder, major depressive disorder, and Crohn's disease, the care plan required medications to be given as ordered and monitored for effectiveness. Physician orders specified exact times for multiple medications, but documentation showed that these medications were administered between one hour and fifty-three minutes to over two hours after the scheduled times. Another resident, diagnosed with metabolic encephalopathy, traumatic brain injury, and adjustment disorder, also had specific medication orders with scheduled administration times. Observations and record reviews revealed that this resident's medications were administered two and a half to three and a half hours past the scheduled times. Both residents had care plans and physician orders that required timely administration of medications, but these were not followed as per facility policy. Interviews with staff indicated that the late administration of medications was due to heavy resident assignments and was a known issue within the facility. The LPN responsible did not notify supervisors about the delays, and the RN and Director of Nursing were unaware of the ongoing problem. Facility policy required medications to be administered within sixty minutes of the scheduled time and for staff to notify supervisors if unable to do so, but these procedures were not followed.
Failure to Provide Timely Pain Medication Due to Unavailability and Poor Communication
Penalty
Summary
A deficiency occurred when a resident with acute osteomyelitis of the left ankle and foot, who was prescribed both acetaminophen and Oxycodone-APAP for pain management, was not provided with adequate pain relief due to the unavailability of their prescribed narcotic pain medication. The resident's care plan required administration of analgesics as ordered and monitoring of effectiveness, but the facility ran out of Oxycodone-APAP and also had no emergency supply available. Despite the resident reporting significant pain, ranging from 5 to 10 on a pain scale, and acetaminophen being ineffective, the resident did not receive Oxycodone for over 32 hours. Nursing staff were aware of the medication shortage and the resident's unrelieved pain but failed to notify the nurse supervisor or provider in a timely manner. The LPN did not inform the supervisor or request an alternative pain medication from the provider, and the nurse supervisor was not made aware of the resident's ongoing pain or the lack of Oxycodone. The Assistant Director of Nursing and Director of Nursing were also not notified about the resident's unrelieved pain after acetaminophen administration. The on-call nurse practitioner service was contacted for a refill, but the urgency of the resident's pain was not communicated, and the refill was not ordered as a stat, resulting in a delay in medication delivery. Documentation and interviews confirmed that the facility's pain management policy, which includes both pharmacologic and non-pharmacologic interventions, was not followed. The lack of communication among staff and with providers, as well as the failure to ensure medication availability, led to the resident experiencing prolonged, unrelieved pain. The medical director stated that unresolved pain should have prompted notification and consideration of alternative medications.
Failure to Prevent Resident-to-Resident Physical and Verbal Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse, as evidenced by an altercation between two residents in the first-floor dining room. One resident, with a history of fibromyalgia and mood disorder, and another resident, with diagnoses including a sternal fracture, Tourette's disorder, and ADD, were involved. The first resident, who had a care plan noting a tendency to yell and threaten others when upset, approached the second resident, yelled at them, and punched them in the face. The second resident responded by placing the first resident in a headlock to prevent further assault. Witnesses, including staff, confirmed the sequence of events, and the incident was substantiated through consistent statements. Prior to the incident, the first resident's care plan included interventions such as psychiatric therapy, medication management, and strategies to separate them from others if bothered. Despite these interventions, the resident was able to approach and physically assault another resident in a common area. The second resident, who was sitting at a table coloring, was confronted and physically attacked without provocation, leading to a physical struggle between the two. The facility's abuse policy prohibits abuse, exploitation, and mistreatment of residents by anyone, including other residents. However, the incident demonstrates a failure to prevent resident-to-resident abuse, as the first resident was able to engage in both verbal and physical aggression toward the second resident. The event was witnessed by staff, and the facility's documentation and interviews confirm that the altercation occurred and was substantiated as abuse.
Failure to Document Required Close Observation After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to complete and document required 1:1 and every fifteen-minute (Q15) checks for a resident following a resident-to-resident abuse incident, as mandated by facility policy. After an altercation in which one resident was punched by another in the dining room, both residents were immediately separated and placed on 1:1 observation. Psychiatry later evaluated both residents, discontinued 1:1, and initiated Q15 checks. However, there was no documentation in the clinical record or on the required monitoring flowsheets to show that these checks were performed for the affected resident. The resident involved had diagnoses including a sternal fracture, Tourette's disorder, and ADD, and was assessed as alert, oriented, and cognitively intact. The care plan and physician orders reflected the need for close observation following the incident. Despite these directives and the facility's policy requiring documentation of such monitoring, the Director of Nursing Services and Administrator were unable to locate any records of the 1:1 or Q15 checks for the resident on the day of the incident. The facility's policy specifies that initiation and ongoing monitoring must be documented in the clinical record or on designated flowsheets, which was not done in this case.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed during a survey on two of its four units. The survey identified numerous issues, including damaged, chipped, stained, or marred bedroom walls and radiators, broken or missing furniture knobs, damaged window blinds, cracked ceilings, and missing or broken floor and wall tiles. These deficiencies were noted in multiple rooms across both A and B wings, indicating a widespread issue with the facility's maintenance and upkeep. Interviews with the facility's staff, including the Regional Maintenance Director, Administrator, and Interim DNS, revealed a lack of awareness regarding these issues. The Regional Maintenance Director mentioned that the facility was in the process of transitioning to a computerized maintenance log system and that staff were responsible for reporting maintenance problems. However, the lack of awareness among key staff members suggests a breakdown in communication and oversight, contributing to the failure to address these environmental deficiencies in a timely manner.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #97 from physical abuse by other residents with known histories of altercations. Resident #97, who was admitted with adjustment disorder, anxiety, and mood disorders, was involved in a physical altercation with Resident #217. After a verbal argument, Resident #217 entered Resident #97's room and hit them in the face, causing swelling and pain. Despite interventions to maintain a no-contact boundary, the altercation occurred, indicating a lapse in monitoring and enforcement of safety measures. In another incident, Resident #97 was involved in an altercation with Resident #71. Resident #97 was in Resident #7's room when Resident #71 asked them to leave. After Resident #97 refused and knocked over a cup of milk, Resident #71 punched Resident #97 in the face. This incident highlights the facility's failure to prevent resident-to-resident altercations, despite the known behavioral issues of the residents involved. Resident #59, who has dementia, PTSD, and a traumatic brain injury, was also a victim of physical abuse by another resident, Resident #73. During an argument in the dining room, Resident #73 pushed Resident #59, causing them to fall and sustain a head injury. The facility's inability to prevent this altercation, despite Resident #73's known history of explosive behavior, demonstrates a deficiency in protecting residents from abuse.
Failure to Provide Independent Egress in Locked Dementia Unit
Penalty
Summary
The facility failed to protect residents from involuntary seclusion by not providing them with independent egress from a locked dementia unit. Four residents, who either voluntarily chose to reside on the unit or did not meet the criteria for placement, were not given access codes or other means to leave the unit independently. The facility's policy required that residents who choose to live in a secured unit and do not meet the criteria must have access to the method of opening doors independently, but this was not adhered to. The facility also failed to conduct initial and ongoing assessments as per the Greater Hartford Memory Care Center Program guidelines. The social worker was not educated on the required assessments, and the clinical records lacked documentation of discussions with residents or their representatives regarding their placement in the locked unit. Additionally, there was no documentation of the residents' involvement in the decision for placement, whether the placement was the least restrictive approach, or the impact and reaction of the residents to their placement. Interviews with facility staff revealed that the social worker had never seen or completed the required assessments, and the Director of Recreation, who was supposed to oversee the program, was unaware of its requirements. The facility's failure to document and assess the residents' placement in the locked unit, as well as to provide them with independent egress, resulted in a deficiency in protecting residents' rights to be free from involuntary seclusion.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain a clean and sanitary nourishment refrigerator and food transport carts, leading to deficiencies in food safety and hygiene. During an observation, it was noted that the first-floor nourishment refrigerator contained various food items that were not labeled or dated, including partially eaten and expired items such as sherbet cups, sausages, and watermelon. Additionally, the refrigerator and freezer were found to have unsanitary conditions, with a large black frozen substance and orange and brown spots. Interviews with RN #5 and the Director of Dietary revealed that the dietary department was responsible for cleaning and discarding unlabeled or expired food items, but this was not consistently done. Furthermore, the food transport carts used to serve meals were observed to be soiled with stains and caked-on filth. The dietary aide placed plates of food on these dirty carts, which had not been properly cleaned. The Director of Dietary acknowledged the unclean state of the carts and stated that the dietary staff were responsible for maintaining their cleanliness. The facility's policies outlined the responsibilities for labeling, dating, and discarding food items, as well as maintaining cleanliness, but these were not adhered to, resulting in the observed deficiencies.
Failure to Implement Transmission-Based Precautions
Penalty
Summary
The facility failed to implement proper infection control measures for three residents requiring transmission-based precautions. Resident #64 and Resident #79, both diagnosed with COVID-19, were observed in communal areas without masks, contrary to physician orders for isolation and droplet/contact precautions. Despite the presence of signage and PPE carts, staff did not enforce these precautions, citing the residents' cognitive and behavioral issues as barriers. Observations revealed that staff were not wearing appropriate PPE, and residents were exposed to potential infection risks in communal dining areas. Resident #368, diagnosed with MRSA bacteremia, did not have appropriate signage or PPE outside their room to indicate the need for contact precautions. The resident was placed in a shared room with another resident who had no history of MRSA, contrary to the facility's policy and medical director's guidance. This oversight in implementing contact precautions increased the risk of MRSA transmission to the roommate and others. Interviews with facility staff, including the Infection Control Nurse and Medical Director, confirmed a lack of adherence to infection control protocols. Staff were unaware of the residents' non-compliance with isolation orders and the absence of necessary precautions for Resident #368. The facility's policies on droplet and contact precautions were not followed, leading to potential exposure and spread of infections among residents and staff.
Failure to Feed Resident in a Dignified Manner
Penalty
Summary
The facility failed to feed Resident #317 in a dignified manner, as per the facility's policy. Resident #317, who was admitted with diagnoses including dementia and dysphagia, was observed being fed by a nurse aide who was standing while the resident was seated on a low-positioned bed. This resulted in the resident's head being at the nurse aide's mid-chest level, contrary to the facility's policy that requires staff to be seated at eye level with the resident during feeding. The resident, who had severely impaired cognition and was edentulous, was silent during the meal, and there was no dialogue between the resident and the nurse aide. Interviews with the RN and DNS confirmed that nurse aides had been trained to sit while feeding residents, indicating a failure to adhere to the training and policy.
Failure to Document Resident's Advance Directive Accurately
Penalty
Summary
The facility failed to accurately document a resident's life support choices, leading to a discrepancy between the resident's advance directive and the facility's records. Resident #103, who was admitted with diagnoses including hypertension, COPD, endocarditis, and heart valve disorders, had a Full Code status during a hospital admission. However, upon admission to the facility, the resident signed an Advance Directive/Code Status Consent indicating a DNR (Do Not Resuscitate) preference. Despite this, the Care Conference signature sheet and the November 2024 Physician's Orders incorrectly identified the resident as Full Code. Interviews and record reviews revealed that the Director of Nursing Services (DNS) acknowledged the oversight, noting that the resident's DNR status should have been updated in the physician's orders. The facility's policy requires that any advance directive documents be reviewed and included in the medical record upon admission or any time thereafter. Additionally, the Physician's Orders-Transcription policy mandates that physician orders be transcribed by a licensed nurse and followed through in accordance with quality standards. The failure to update the resident's code status as per their advance directive represents a deficiency in adhering to these policies.
Failure to Notify Physician and Representatives of Changes in Condition and Policy Violations
Penalty
Summary
The facility failed to notify the physician or APRN of a change in condition for a resident who was admitted with diagnoses including congestive heart failure, seizures, diabetes, and hypertension. The resident experienced increased tremors and weakness, requiring assistance from two staff members to return to bed. Despite the change in condition, the RN supervisor did not contact the physician or APRN directly, instead leaving a note in the APRN communication book, which was not an appropriate method of notification according to facility policy. The ADNS and DNS confirmed that the RN supervisor should have performed an assessment and contacted the physician directly. Another resident, admitted with dementia and nicotine dependence, was found smoking in their room, which was against the facility's smoking policy. Although the resident's representative was notified of one incident, subsequent incidents involving smoking materials found in the resident's room were not communicated to the representative. The facility's policy required that the resident representative be notified of significant clinical developments, which was not adhered to in this case. A third resident, with a history of traumatic brain injury and severe cognitive impairment, consistently refused scheduled showers. The facility failed to document these refusals adequately and did not notify the physician or the resident's representative of the ongoing issue. The care plan required assistance with bathing, but the lack of documentation and communication with the physician and representative indicated a failure to follow the established care plan and facility policy.
Failure to Provide Scheduled Showers and Incomplete Monitoring After Fall
Penalty
Summary
The facility failed to provide scheduled weekly showers for three residents, leading to deficiencies in their care. Resident #102, who was admitted with severe morbid obesity, paraplegia, and spinal cord compression, did not receive scheduled showers from July to October 2024. The facility's bariatric shower chair was deemed unsafe, and a new chair purchased in June 2024 was too wide to fit through the shower room door. Despite being aware of the issue, the facility continued to provide only bed baths, which did not meet the resident's preference for showers. Resident #76, admitted with congestive heart failure, peripheral vascular disease, and hypertension, also did not receive the preferred weekly showers. The resident expressed a strong preference for showers over bed baths, but the facility's nurse aides often cited time constraints and staffing shortages as reasons for not providing showers. Documentation was inconsistent, with some aides inaccurately recording that showers were given when only bed baths were provided. The resident's care plan did not reflect their preference for showers, and communication with the social worker and nursing staff did not result in any changes. Resident #116, admitted with a history of falls and a high risk for further falls, experienced an unwitnessed fall and reported hitting their head. The facility's policy required 72 hours of neurological monitoring following such incidents, but documentation showed that monitoring ceased after 50 hours. The lack of a care plan addressing the resident's fall risk and the incomplete neurological monitoring represent significant deficiencies in the resident's care. The medical director confirmed that the expected monitoring was not completed, which could have compromised the resident's safety.
Failure to Adhere to Physician Orders and Facility Policies
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice and physician's orders for several residents. For one resident, the facility did not document an RN assessment when the resident exhibited a change in condition, such as increased tremors and weakness, and failed to obtain weights according to facility policy and physician order. Interviews revealed that the RN supervisor was not aware of the resident's condition change, and no RN assessment was documented, including vital signs or a neurological assessment. Another resident, who was reviewed for nutrition, was not monitored for fluid intake and output and weights per the physician's orders. The facility's records showed incomplete documentation of fluid intake and output, and the resident's weights were not consistently recorded. Interviews with staff indicated that the intake and output records were not completed every shift, and the 24-hour totals were not calculated, which was against the facility's policy. Additionally, the facility failed to ensure neurological checks and post-fall assessments were completed for a resident who sustained an unwitnessed fall with a reported head strike. The facility's policy required 72 hours of neurological monitoring, but documentation showed that monitoring was not completed as required. Interviews with medical staff confirmed that the expected monitoring was not adhered to, and the facility's policy was not followed in this case.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to ensure the safety of Resident #20, who was a smoker with a history of behavioral symptoms and required a smoking apron as per the care plan. Despite the care plan's directive, the resident was observed smoking without a smoking apron on multiple occasions, leading to ashes being dropped on their clothing. Security Guard #1, who was responsible for supervising the smoking breaks, exercised personal discretion in deciding whether the resident needed a smoking apron, without consulting nursing staff or updating the care plan. This lack of adherence to the care plan and absence of proper training for security staff contributed to the deficiency. Resident #13 was found to have a pedestal fan in their room with the front cover missing, exposing the blades and creating a potential safety hazard. Despite multiple staff members, including nurse aides and housekeeping, being in the room, the missing cover went unnoticed for months. The facility lacked a policy related to the safety of fans in resident rooms, and there was no documentation of maintenance requests to address the issue, indicating a failure in ensuring a safe environment for the resident. Resident #111, who had severe cognitive impairment, was involved in multiple incidents of smoking inside the facility, contrary to the smoking policy. Despite these incidents, there was no documentation of reassessment or updates to the resident's care plan, nor were the incidents reported or investigated as required by the facility's policy. The facility also failed to notify the resident's conservator about these incidents, demonstrating a lack of communication and adherence to safety protocols.
Medication Transcription Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's medication orders were correctly transcribed and administered, resulting in a significant medication error. The resident, who had a history of hepatic encephalopathy, hepatic failure, and type 2 diabetes mellitus, was admitted to the facility with a care plan that identified a risk for falls due to comorbidities. The resident had been prescribed Lactulose to manage high ammonia levels associated with liver disease. However, a transcription error occurred when a telephone order was taken, leading to the resident receiving an incorrect dosage of Lactulose. The error was discovered after the resident experienced increased lethargy, weakness, and altered mental status, which led to a fall and subsequent hospitalization. The hospital discharge summary indicated that the resident was admitted with acute encephalopathy and high ammonia levels, which were attributed to the incorrect administration of Lactulose. The resident's condition improved after receiving the correct dosage of Lactulose and treatment for a urinary tract infection, and they were eventually discharged from the hospital. Interviews with facility staff revealed that there was confusion regarding the correct dosage of Lactulose, and the transcription error was not identified until after the resident's hospitalization. The facility's policies for telephone and verbal orders, as well as medication errors, were not adequately followed, contributing to the deficiency. The Director of Nursing Services and other staff members were unable to determine where the communication breakdown occurred, highlighting a gap in the facility's medication management processes.
Failure to Document Vaccine Education
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident #49, 78, and 94, or their representatives, were provided with education on the benefits and potential side effects of the influenza vaccine before its administration. During an infection control program review conducted as part of an annual recertification survey, it was found that the facility's documentation did not include evidence of education related to the influenza vaccine for these residents. The clinical records showed that Residents #78 and 94 received the influenza vaccination on October 15, 2024, and Resident #49 on October 18, 2024, without documented education on the vaccine's benefits, risks, or potential side effects. Interviews with LPN #2, who administered the vaccinations, and RN #8, the Regional Director of Infection Control, revealed that while the Vaccine Information Statement (VIS) from the CDC was provided to the residents upon administration, there was no documentation of this education in the residents' clinical records. RN #8 was under the impression that providing the VIS was sufficient and was unaware that the education provided should be documented. The facility's policy on Resident Influenza Immunizations required that residents or their legal representatives be educated about the risks and benefits of the influenza vaccine annually, be provided with a copy of the current VIS, and that this education be documented, which was not adhered to in these cases.
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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