Whitney Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamden, Connecticut.
- Location
- 200 Leeder Hill Dr, Hamden, Connecticut 06517
- CMS Provider Number
- 075290
- Inspections on file
- 17
- Latest survey
- December 4, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Whitney Center during CMS and state inspections, most recent first.
The facility failed to support resident council meetings after the departure of the social worker who facilitated them. A resident expressed a desire to continue participating in these meetings, which had not been held for over a year. The DNS and administrator acknowledged the oversight in not designating another staff member to organize the meetings, and no resident council policy was provided.
The facility failed to ensure that residents' code status was reviewed and documented upon admission, leading to a deficiency. Several residents, despite being capable of making their own decisions, did not have their code status discussed or documented within the required timeframe. This resulted in a lack of signed Resuscitation Status Forms in their medical records, as acknowledged by the DNS and medical staff.
The facility failed to document hot and cold food temperatures appropriately, with missing and altered logs observed during a kitchen tour. The Dietary Director was unaware of the issue, and the Chef Manager later acknowledged the logs were filled in after the initial review. Despite having a policy on food temperatures, it was initially unknown to the Chef Manager.
A resident under hospice care for late-stage Alzheimer's experienced severe wrist pain, but the facility failed to notify the hospice provider and resident representative. The LPN observed the injury and reported it to an absent RN, resulting in a lack of consistent follow-up. The DNS was unaware of the issue until a surveyor inquiry, and the facility's policy on change of condition was not followed, leading to a deficiency.
A resident with severe Alzheimer's dementia experienced severe wrist pain of unknown origin, but the LTC facility failed to notify the state agency within the required timeframes. An LPN documented the injury, and an x-ray showed joint space narrowing without fracture. The DNS was unaware of the issue until a surveyor inquiry, and no investigation or report was initiated as required by facility policy.
A resident with severe Alzheimer's dementia experienced a swollen right wrist with severe pain, but the LTC facility failed to investigate the injury of unknown origin. The LPN reported the incident to an RN, but no assessment or investigation was conducted, and the event was not reported to the state agency, contrary to facility policy.
A facility failed to notify the state-designated authority of a new diagnosis of psychotic disorder with delusions for a resident, leading to a deficiency in the PASARR process. The resident was initially admitted with other diagnoses, and the new diagnosis was identified in a psychiatric progress note but not updated in PASARR records. Interviews revealed a lack of communication and procedural oversight, with staff unaware of the new diagnosis and no facility policy for PASARR updates.
The facility failed to follow physician orders and professional standards, resulting in missed weight monitoring for a resident on Lasix, lack of compression stocking application for a resident with lymphedema, and inadequate neurological checks after unwitnessed falls. Additionally, a resident with a wrist injury did not receive timely RN assessment or pain management, and documentation was incomplete.
A resident with limited mobility was improperly transferred by a single nurse aide, contrary to the physician's order requiring a Sara lift with two-person assistance. This led to the resident being lowered to the floor and subsequently diagnosed with a nondisplaced fracture. The nurse aide, from an agency, did not follow the care plan despite being informed of the transfer requirements.
A resident with late-stage Alzheimer's under hospice care experienced severe wrist pain, but the facility failed to assess and manage the pain adequately. The LPN noted the injury but did not administer pain medication or ensure a full assessment was conducted. The RN supervisor was on leave, and no consistent nurse covered her absence, leading to a lack of communication and documentation. The DNS was unaware of the issue until the surveyor's inquiry, highlighting a failure to follow the facility's pain management policy.
Failure to Support Resident Council Meetings
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident groups, specifically the resident council. The last documented resident council meeting was held over a year ago, and there were no meeting minutes available from December 2023 through November 2024. During an interview, a resident expressed that they used to attend these meetings regularly and found them beneficial for sharing ideas. However, the resident noted that the meetings had not occurred for a long time, and they wished to continue participating in them. The deficiency arose after the departure of the facility's social worker, who previously facilitated the resident council meetings. The Director of Nursing Services (DNS) confirmed that the meetings had not been held since the social worker left about a year ago. The facility administrator acknowledged that it was an oversight not to designate another staff member to organize the meetings. Despite daily communication with residents, the lack of formal meetings meant that no patterns in residents' concerns were identified. The facility did not provide a resident council policy when requested.
Failure to Document and Review Code Status for Residents
Penalty
Summary
The facility failed to ensure that the code status of residents was reviewed and documented upon admission and as needed, which resulted in a deficiency. For Resident #14, the clinical record did not contain a signed advanced directive form or documentation of discussions regarding advance directives with the resident's representative. Despite having orders for do not resuscitate (DNR) and do not hospitalize (DNH), there was no care plan related to these choices, and the Director of Nursing Services (DNS) acknowledged issues with completing advance directive forms. Resident #174 was admitted without a documented code status in the baseline care plan or physician orders. The admission assessment indicated the resident was alert and oriented, yet the code status was not addressed within the required 48 hours. It was only after surveyor inquiry that the Resuscitation Status Form was signed, indicating the resident's wish to receive cardiopulmonary resuscitation (CPR). Similarly, Resident #175 and Resident #176 did not have their code status discussed or documented upon admission. Both residents were capable of signing their own forms, but the facility failed to address their code status within the stipulated timeframe. Interviews with the DNS and medical staff revealed that the responsibility to verify and document code status was not fulfilled, leading to a lack of signed Resuscitation Status Forms in the residents' medical records.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to ensure that hot and cold food temperatures for meals were obtained and documented appropriately. During a tour of the facility kitchen, it was observed that multiple dates in the food service temperature logs were missing temperatures or were completely blank. Specifically, from 11/19/24 to 11/30/24, there were no breakfast logs available for review, and several meals had no recorded food temperatures. Additionally, the breakfast logs that were available listed identical meal items without dates, and there was no documentation related to cold food items. This lack of documentation was confirmed during an interview with the Dietary Director, who was unaware that the food temperatures were not being logged with every meal. Further investigation revealed that the food temperature logs had been altered after the initial review, with meal temperatures added for the dates previously reviewed. The Dietary Stock Clerk was unable to identify who altered the documents or why. The Chef Manager acknowledged the issues with the logs and stated that the logs had been filled in after the initial review. Despite the facility having a policy related to food temperatures, the Chef Manager was initially unaware of its existence. The policy directed that all food production staff were responsible for recording and maintaining proper food temperatures, and that logs should be maintained in the dietary department per the record retention policy.
Failure to Notify Hospice and Representative of Resident's Severe Wrist Pain
Penalty
Summary
The facility failed to immediately notify the hospice provider and the resident representative when a resident, who was under hospice care due to late-stage severe Alzheimer's dementia, experienced new severe wrist pain. The resident, admitted in December 2018, had diagnoses including Alzheimer's dementia, hypertension, and failure to thrive. The care plan for the resident included interventions to observe closely for signs of pain and notify the physician of breakthrough pain. However, when the resident complained of wrist pain and was found to have a swollen right wrist with tenderness and severe pain, the facility did not notify the hospice provider or the resident representative. The nurse's note documented the resident's wrist condition as a late entry, and an x-ray showed joint space narrowing with no fracture. Despite this, the clinical record lacked evidence of any additional monitoring, assessments, or documentation of the wrist injury after the initial report. Interviews with facility staff revealed that the LPN who observed the injury reported it to an RN, who was not present due to leave, and there was no consistent nurse covering during her absence. The DNS was unaware of the issue until the surveyor's inquiry and stated that the injury should have been reported to the state agency, and the resident's pain should have been assessed and monitored. The facility's policy on change of condition required licensed nursing staff to document any change in condition and notify the physician and resident representative within 24 hours. However, this protocol was not followed in the case of the resident's wrist injury. The failure to notify the appropriate parties and document the incident accurately led to a deficiency in the facility's care for the resident.
Failure to Report Resident Injury of Unknown Origin
Penalty
Summary
The facility failed to notify the state agency within the required timeframes when a resident, who had been under hospice care due to late-stage severe Alzheimer's dementia, complained of new severe wrist pain of unknown origin. The resident, admitted in December 2018, had severely impaired cognition and was dependent on staff for daily activities. On August 12, 2024, an LPN documented that the resident had a swollen right wrist with tenderness and severe pain, and a physician ordered an x-ray, which showed joint space narrowing but no fracture. However, the nurse's note was entered as a late entry the following day, and no reportable event form was initiated or submitted to the state agency regarding the incident. Interviews revealed that the LPN reported the injury to an RN, who was expected to conduct a full assessment and initiate an investigation, but this did not occur. The Director of Nursing Services (DNS) was unaware of the issue until the surveyor's inquiry and confirmed that an investigation should have been conducted and reported to the state agency. The facility was unable to provide a policy related to reporting injuries of unknown origin, although their existing policy directed staff to report any such injuries immediately to ensure proper investigation and documentation.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for Resident #8, who was under hospice care due to late-stage severe Alzheimer's dementia. The resident was admitted with diagnoses including Alzheimer's dementia, hypertension, and failure to thrive. On August 12, 2024, a nurse's note documented that Resident #8 had a swollen right wrist with tenderness and severe pain, and an x-ray was ordered, which showed joint space narrowing but no fracture. However, there was no reportable event form initiated or submitted to the state agency regarding this injury. Interviews revealed that the LPN assigned to Resident #8 on the day of the injury reported the incident to an RN, who was expected to conduct a full assessment and initiate an investigation. The Director of Nursing Services (DNS) was unaware of the injury until the surveyor's inquiry and confirmed that an investigation should have been conducted. The facility's policy mandates that any injury of unknown origin be thoroughly investigated and reported, but this protocol was not followed in this case.
Failure to Update PASARR for New Diagnosis
Penalty
Summary
The facility failed to notify the appropriate state-designated authority of a new diagnosis of psychotic disorder with delusions for a resident, leading to a deficiency in the Preadmission Screening and Resident Review (PASARR) process. The resident was admitted in August 2020 with diagnoses including Parkinson's Disease, depression, anxiety, and dementia. Initially, the PASARR Level 1 Screen did not identify a diagnosis of psychotic disorder or delusional disorder. However, a psychiatric APRN progress note dated June 7, 2021, identified the resident as having an active diagnosis of psychotic disorder with delusions. Despite this, the diagnosis was not updated in the PASARR records, and the state-designated authority was not notified. Interviews with facility staff revealed a lack of communication and procedural oversight. RN #2, responsible for updating diagnoses in the electronic medical record, added the diagnosis of psychotic disorder with delusions backdated to June 7, 2021, but did not ensure the PASARR was updated. The prior social worker, responsible for PASARR updates, indicated he was unaware of the new diagnosis and relied on facility staff to inform him of such changes. The Director of Nursing Services confirmed there was no facility policy for PASARR, contributing to the oversight and failure to notify the state-designated authority of the resident's new diagnosis.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and professional standards for several residents. For one resident with chronic leg edema, the facility did not consistently obtain weights as ordered every other day, which was crucial for monitoring fluid retention due to the resident's sedentary lifestyle and use of Lasix. Despite the physician's order and the resident's condition, weights were missed on multiple occasions, and there was no documentation of refusal or rationale for the missed weights. Another resident with hereditary lymphedema and Parkinson's disease did not receive compression stockings as ordered by the physician. Observations confirmed the absence of compression stockings on multiple occasions, and the resident expressed a strong desire to have them applied daily. The charge nurse acknowledged that the staff did not always apply the stockings and failed to document any refusals or notify the physician, contrary to the facility's expectations. The facility also failed to conduct necessary neurological checks and post-fall assessments for residents who experienced unwitnessed falls with potential head injuries. One resident had multiple unwitnessed falls with reported head strikes, yet there was no documentation of neurological monitoring or post-fall assessments. Another resident with Alzheimer's and a history of falls did not receive the required neurological assessments following two unwitnessed falls, and the facility's documentation was incomplete. Additionally, a resident with a wrist injury did not receive a timely RN assessment or adequate pain management, and there was a lack of documentation regarding the injury and subsequent care.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred according to the physician's order, which required the use of a Sara lift with the assistance of two staff members. This deficiency occurred when a nurse aide, identified as NA #3, attempted to transfer the resident by herself after the resident indicated that they could be transferred with one staff member. During the transfer, the resident became weak and had to be lowered to the floor, resulting in a fall. The resident involved in the incident was admitted to the facility with diagnoses including the presence of a left artificial knee joint, cardiac pacemaker, and atrial fibrillation. The resident's care plan and physician's orders specified the need for a Sara lift with two-person assistance for transfers due to limited mobility and a history of multiple surgeries. Despite these instructions, NA #3, who was from an agency, did not follow the plan of care and attempted the transfer alone, leading to the resident being lowered to the floor. Following the incident, the resident was assessed and initially showed no signs of injury. However, subsequent medical evaluation revealed a nondisplaced fracture of the left distal tibia and loosening of the fibula/tibial screw, indicating a significant injury resulting from the fall. The facility's documentation and interviews highlighted that NA #3 was informed of the resident's care plan but failed to adhere to it, contributing to the deficiency.
Failure to Manage Resident's Severe Wrist Pain
Penalty
Summary
The facility failed to adequately assess and manage a resident's severe wrist pain, leading to a deficiency in pain management. The resident, who had been under hospice care due to late-stage severe Alzheimer's dementia, was found to have a swollen and painful right wrist. Despite the resident's visible distress and complaints of pain, the clinical record did not reflect any administration of pain medication or a comprehensive assessment by the nursing staff during the relevant period. The Licensed Practical Nurse (LPN) assigned to the resident on the day of the incident noted the wrist injury and reported it to a Registered Nurse (RN) supervisor. However, the RN supervisor was on leave, and there was no consistent nurse covering her absence. Consequently, no full assessment was conducted, and the physician was not contacted. The facility's documentation failed to include any interventions or follow-up actions regarding the resident's pain and wrist injury. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition. The Director of Nursing Services (DNS) was unaware of the issue until the surveyor's inquiry and acknowledged that the injury should have been reported and investigated. The facility's policy on pain management, which requires individualized treatment plans and thorough assessments, was not followed, resulting in inadequate care for the resident's pain and injury.
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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