Woodlake At Tolland
Inspection history, citations, penalties and survey trends for this long-term care facility in Tolland, Connecticut.
- Location
- 26 Shenipsit Lake Road, Tolland, Connecticut 06084
- CMS Provider Number
- 075382
- Inspections on file
- 24
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Woodlake At Tolland during CMS and state inspections, most recent first.
A resident with CHF, protein-calorie malnutrition, and colon cancer, who was cognitively intact and normally ate independently, developed an abnormal bradycardic pulse and later a significant change in eating ability and mental status. An LPN documented a manual pulse of 47 BPM but there was no documentation that a provider was notified, despite policy requiring notification for vital signs significantly deviating from baseline. Later that day, staff observed the resident not eating, requiring assistance, and becoming lethargic and confused, while a family member reported the resident was breathing heavily and dribbling liquid as a NA continued spoon-feeding. An RN then documented low BP and lethargy, an APRN assessed the resident with hypotension, bradycardia, pallor, and concern for possible sepsis, and EMS found severe hypoxia before hospital transfer, where imaging showed bilateral pleural effusions and lower lobe consolidation/atelectasis and the resident subsequently expired.
A resident with CHF, malnutrition, and colon cancer, who was cognitively intact and normally ate independently, experienced a decline in condition over the course of a day. An LPN recorded bradycardia but did not document notifying a provider, despite facility policy requiring notification for abnormal vitals. Later, staff noted lethargy, hypotension, and altered mental status, and an APRN ordered transfer to the ED. Around this time, a visitor observed a CNA spoon-feeding liquid to the resident, who was breathing heavily and dribbling liquid from the mouth, even though the resident had eaten independently the prior day and was on aspiration precautions. EMS arrived to find the resident alone behind a closed door, in respiratory distress with severe hypoxia and no staff present or interventions initiated; staff interviews confirmed that after calling 911, nursing staff left the resident’s room and no one remained with the resident until EMS assumed care.
A resident with severe cognitive impairment and a history of falls was witnessed by staff to fall and strike their head, resulting in altered mental status and inability to obtain vital signs. Despite these symptoms, the supervising RN directed staff to move the resident from the floor to a wheelchair and then to bed, rather than waiting for EMS as required by protocol. The resident was later transferred to the hospital and expired a few hours after the incident. Staff interviews and documentation confirmed that the resident should not have been moved following the fall.
During a kitchen tour, it was observed that opened refrigerator items lacked date labels, spoiled food was not discarded, and frozen food items were uncovered. Specifically, opened Lactaid cartons and tomato juice were not labeled with open dates, spoiled iceberg lettuce and undated bread were found, and unsealed bags of rice were observed. Additionally, unwrapped food items were stored in the walk-in freezer, and a refreshment cart for breakfast service contained soiled items. The Dietary Director acknowledged these issues, indicating that staff were expected to label opened containers, inspect perishable items upon delivery, date undated bread, wrap all food items after opening, and maintain cleanliness on service carts. The facility's policies on date marking, food storage, and sanitation were not consistently followed, leading to these deficiencies.
A resident with intact cognition and independence in eating was not asked for consent before a nursing assistant applied a clothing protector during a meal. The resident expressed a preference to be asked first, and the facility's policy on resident rights was not followed.
The facility failed to notify the APRN or physician when daily weights were not obtained for a resident with edema, congestive heart failure, and dementia. Multiple missed weights were not documented or explained, and the APRN or physician was not informed, contrary to the facility's policies.
A facility failed to protect a resident from perceived abuse by a nursing assistant, who was later terminated after an altercation with the resident's spouse. The incident revealed significant gaps in the facility's hiring and screening processes, including missing documentation and background checks.
The facility failed to develop a comprehensive care plan for a resident with chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The use of a CPAP was not included in the care plans until after surveyor inquiry, despite physician orders being in place 120 days post-admission. Interviews revealed that the MDS coordinator missed including the CPAP in the initial care plans.
The facility failed to conduct required neurological assessments for a resident after an unwitnessed fall and did not provide continuous 1:1 monitoring for another resident with suicidal ideations, leading to significant lapses in care and safety.
The facility failed to follow its bowel management protocol for a resident with Parkinson's disease, resulting in the resident having no bowel movement for five days without the necessary interventions being initiated as required by the facility's policy.
A resident with chronic kidney disease and high potassium levels repeatedly received high potassium foods despite a prescribed renal diet. This led to elevated potassium levels and required additional medical interventions. Interviews confirmed the dietary errors, and the facility's nutritional management policy was not followed.
The facility failed to ensure respiratory equipment was cleaned, changed, and stored per policy and manufacturer's recommendations for two residents. One resident's oxygen therapy equipment was not dated or properly stored, and another resident's CPAP machine was not properly maintained, with missing labels, dates, and necessary physician orders for cleaning and maintenance.
The facility failed to ensure nursing staff were competent in caring for a JP drain for a resident with dementia and other medical conditions. Observations and interviews revealed improper handling and lack of education on JP drain care, with staff admitting to not receiving relevant training in the past two years.
A pharmacy failed to identify a non-crushable medication for a resident with Parkinson's disease and other conditions, leading to the medication being improperly administered crushed 720 times. Facility staff, including an LPN, APRN, and pharmacists, were unaware of the medication's status, despite policies requiring reference checks for drug administration.
A resident with diabetes type 2 had a critical glucose level of 41 mg/dl, but the facility failed to monitor blood sugars further or issue new orders, contrary to its diabetes protocol.
A resident admitted with dementia, PTSD, and anxiety was prescribed multiple psychotropic medications, but the facility failed to ensure targeted behavior monitoring was in place upon admission. Despite the care plan indicating the need for monitoring, it was not ordered until nine days later, following incidents of suicidal ideation. Interviews confirmed this oversight, which was against the facility's policy.
The facility failed to maintain sanitary conditions for a resident with a JP drain, did not consistently follow transmission-based precautions for a COVID-19 positive resident, and did not sanitize shared medical equipment between uses, leading to potential infection control issues.
A resident admitted with hypertension and diabetes mellitus did not receive the pneumococcal vaccine as required. The resident's immunization record showed they had not received the vaccine since 2013, and the quarterly MDS assessment failed to provide a reason for the missing vaccination. The new Infection Control Nurse was unaware of the resident's vaccine status, and the resident was missed by the previous nurse. The DNS expected all vaccines to be offered upon admission and eligibility, which was not done in this case.
The facility failed to notify the State LTC Ombudsman when two residents were transferred to the hospital. The social worker responsible for sending the reports was unaware that incorrect reports were being sent, and the issue was discovered during a review of the reports.
The facility failed to provide bed hold notices to residents or their representatives upon hospital transfer for three residents with various medical conditions. Interviews with staff revealed that the facility does not issue these notices, and no documentation or policy was provided upon request.
Failure to Notify Provider of Abnormal Vital Signs and Change in Eating Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provider notification of a significant change in condition for one resident, resulting in delayed medical intervention and subsequent hospital transfer. The resident was admitted with acute on chronic CHF, protein-calorie malnutrition, and malignant colon cancer, and was care planned for nutritional problems with interventions to monitor and report signs of dysphagia such as pocketing, choking, coughing, drooling, holding food in the mouth, multiple swallowing attempts, and refusal to eat. On admission, the resident was documented as cognitively intact, independent with supervision for feeding, and without chewing or swallowing problems, with a regular diet and thin liquids ordered. Progress notes shortly before the event documented ongoing nausea, aspiration precautions, and use of Zofran with good effect, with instructions to continue monitoring for nausea and vomiting. On the morning of the incident date, a nursing note documented the resident as alert, able to make needs known, with stable vital signs and no distress. Later that morning, an LPN obtained a manual pulse of 47 BPM, which was outside the normal range of 60–100 BPM, but the clinical record contained no evidence that a provider was notified of this abnormal vital sign, despite facility policy requiring provider notification and documentation when vital signs significantly deviate from baseline. A subsequent nursing note by the same LPN that afternoon described the resident as alert with some forgetfulness, stable vital signs, no respiratory or cardiac distress, no cough or congestion, denial of nausea, and fair appetite, again without documentation of provider notification regarding the earlier abnormal pulse. Later that day, staff identified more pronounced changes in the resident’s condition. According to interviews, a nursing assistant reported to an LPN that the resident, who normally ate independently, was not eating and required assistance, and the LPN instructed the assistant to help feed the resident and reported altered mental status and poor intake to an RN. A family member reported arriving and finding the resident lying on the side with the head of bed flat, breathing heavily, dribbling liquid from the mouth while a nursing assistant continued spooning liquid into the resident’s mouth, prompting the family member to seek the nursing supervisor and state the resident was gasping for air and needed hospital care. An RN assessment documented the resident as lethargic, confused, not responding, with low BP and a pulse of 52 BPM, and an APRN note identified low BP, bradycardia, pallor, cool skin, and concern for possible sepsis in the setting of chronic wounds, leading to transfer to the ED. EMS records documented severe hypoxia on arrival, and hospital records showed bilateral pleural effusions and lower lobe consolidation/atelectasis; the resident expired the same day. Interviews with the APRN and DNS confirmed expectations that abnormal vital signs and significant changes in eating status or mentation should trigger timely provider notification and assessment, which were not documented in this case.
Failure to Respond to Change in Condition and Remain With Resident During Medical Emergency
Penalty
Summary
The deficiency involves the facility’s failure to recognize and appropriately respond to an acute change in condition for a resident with significant medical issues, including acute on chronic CHF, protein-calorie malnutrition, and malignant colon cancer. On admission, the resident was cognitively intact, independent with eating (with supervision), and had no documented chewing or swallowing problems. The care plan and nutrition assessment called for monitoring and reporting signs of dysphagia and aspiration risk, and the resident was on a regular diet with thin liquids. An APRN note identified ongoing nausea and that the resident was on aspiration precautions, and another APRN note documented recent nausea treated with Zofran and the need to continue monitoring for nausea and vomiting. On the morning of the incident date, nursing documentation indicated the resident was alert, able to make needs known, and without distress. Later that morning, an LPN obtained a manual pulse of 47 BPM, which was outside the normal range, but there was no documentation that the provider was notified, contrary to facility policy requiring notification and documentation when vital signs significantly deviate from baseline. In the early afternoon, another nursing note described the resident as alert with some forgetfulness, stable vital signs, and no respiratory or cardiac distress. By late afternoon, an RN documented via SBAR that the resident was lethargic, confused, not responding, and had low blood pressure, with vital signs showing hypotension and bradycardia. The APRN note from that time described low blood pressure, a heart rate of 52 BPM, pale cool skin, and concern for possible sepsis in the context of chronic wounds, leading to the decision to send the resident to the ED. Around this same time, a visitor reported entering the resident’s room and finding the resident lying on their side with the head of the bed flat while a nursing assistant spoon-fed liquid into the resident’s mouth, despite the resident having eaten independently the day before. The visitor observed heavy breathing and liquid dribbling from the resident’s mouth while the nursing assistant continued to insert more liquid, prompting the visitor to tell the assistant to stop and to seek the nursing supervisor, reporting that the resident was gasping for air and needed hospital care. An LPN later stated that this was the first time she had cared for the resident and that, after being told the resident was not eating, she evaluated the resident, learned the resident normally ate independently, and directed the nursing assistant to assist with feeding. She reported that she informed an RN that the resident was not eating, required assistance, and had altered mental status, and that after low blood pressure was identified, the RN notified the APRN and the APRN ordered transfer to the ED. EMS records and interviews revealed that EMS was dispatched and arrived within minutes, but the EMT found the resident’s room door closed and the resident alone, with no nurse or provider in or near the room and no staff meeting EMS on entry to the building. The EMT observed the resident lying on their side, drooling, with liquid on clothing, labored breathing, slightly purple lips, and severe hypoxia with an oxygen saturation of 55% on room air; oxygen was initiated at 4 L via nasal cannula. The EMT did not leave the resident to locate staff because it was unsafe to leave the resident unattended. The EMT’s partner arrived about 16 minutes later and then located the resident’s nurse, who reported that a nursing assistant had spoon-fed liquid food at about 5:00 p.m., that the resident was later found hypotensive with severely altered mental status, and that no interventions were provided before EMS arrival. Facility staff interviews confirmed that after the RN assessed the resident and called 911, she left the room to complete transfer paperwork and acknowledged that someone should have remained with the resident until EMS arrived. The DNS and APRN both stated that abnormal vital signs and significant changes in eating or mentation should be reported and that a staff member should remain with a resident during a medical emergency until EMS assumes care. Facility policies on change of condition, vital signs, and aspiration precautions required provider notification and documentation when vital signs significantly deviated from baseline, RN assessment and documentation of changes in condition, and specific positioning and speech therapy involvement for residents on aspiration precautions. The record showed no provider notification of the abnormal pulse earlier in the day, no documented interventions prior to EMS arrival despite the resident’s acute deterioration, and that the resident was left alone in the room during a medical emergency until EMS arrived and assumed care.
Failure to Follow Protocol After Resident Fall with Head Injury
Penalty
Summary
Staff failed to follow professional standards of care after a resident with dementia, heart failure, and severe cognitive impairment experienced a witnessed fall with a head injury. The resident, who was known to be at risk for falls and had a history of recent illness, was observed by a nurse aide to become dizzy, spin, and fall, striking their head on the floor. Following the fall, the resident exhibited altered mental status, was unable to follow commands, and staff were unable to obtain vital signs. Despite these significant changes in condition and the presence of a head injury, the supervising RN directed staff to move the resident from the floor into a wheelchair and then into bed, rather than leaving the resident in place and awaiting EMS as per standard protocols for suspected head or spinal injury. Multiple staff, including an LPN and the APRN, later acknowledged that the resident should not have been moved given the circumstances. Facility policy and medical references reviewed also indicated that residents with head injuries and neurological compromise should not be moved and should be referred immediately for emergency care. The resident was eventually transferred to the hospital by EMS after oxygen was applied, but expired a few hours later. Documentation and interviews confirmed that the decision to move the resident was made by the RN, and that other staff present did not question this directive, despite recognizing it was not consistent with best practice or facility policy for post-fall care involving head injury and altered mental status.
Observations of Inconsistent Food Storage and Labeling Practices
Penalty
Summary
During a facility kitchen tour, it was observed that opened refrigerator items were not dated, spoiled food products were not discarded, frozen food items were uncovered, and beverage items were not stored in a sanitary manner. Specifically, opened Lactaid cartons and tomato juice were not labeled with open dates, spoiled iceberg lettuce and undated bread were found, unsealed bags of rice were observed, and unwrapped food items were stored in the walk-in freezer. Additionally, a refreshment cart set for breakfast service contained soiled items, contrary to the facility's policies on food storage, labeling, and sanitation. The Dietary Director acknowledged the deficiencies during interviews, indicating expectations for staff to label opened containers, inspect perishable items upon delivery, date undated bread, wrap all food items after opening, and maintain cleanliness on service carts. The facility's policies on date marking, food storage, and sanitation were not consistently followed, leading to the identified deficiencies in food handling and storage practices.
Failure to Honor Resident's Rights During Meal
Penalty
Summary
The facility failed to honor Resident #68's rights during a meal. Resident #68, who was admitted with diagnoses including metabolic encephalopathy, hypothermia, and congestive heart failure, was identified as having intact cognition and being independent with eating. During an observation, NA #2 applied a large clothing protector to Resident #68 without asking for consent or providing the option to refuse. Resident #68 expressed that this was the first time a clothing protector had been applied and would have preferred to be asked first. NA #2 admitted during an interview that she should have asked Resident #68 if they wanted the clothing protector. The Director of Nursing Services (DNS) confirmed that Resident #68 should have been asked and had the right to decide whether to use a clothing protector. The facility's policy on resident rights emphasizes treating residents with respect and allowing them to make choices about their lives, which was not followed in this instance.
Failure to Notify Physician of Missed Daily Weights
Penalty
Summary
The facility failed to ensure that the APRN or physician was notified when daily weights were not obtained for a resident with diagnoses including edema, congestive heart failure, and dementia. The resident had a physician's order to complete daily weights and notify the provider for significant weight gains. However, there were multiple missed opportunities for obtaining daily weights over several months, and the clinical record did not reflect any refusals or explanations for the missed weights. Additionally, the APRN or physician was not notified of the missing weights or refusals, as required by the facility's policy. The resident's care plan and physician's orders emphasized the importance of daily weights due to the resident's medical conditions. Despite this, the treatment administration records showed numerous missed weights, and the progress notes did not document any refusals or reasons for the missed weights. An interview with the DNS confirmed that the charge nurse was responsible for ensuring daily weights were obtained and that the APRN or physician should be notified if weights were missed or refused. The facility's policies on weight management and change of condition were not followed, leading to the deficiency.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement policies to protect residents from abuse, as evidenced by an incident involving a resident with dementia, emphysema/COPD, and depression. The resident believed a nursing assistant (NA) was making a joke about their move by singing a song, which upset the resident and their spouse. The NA was sent home pending investigation, but the interim Director of Nursing Services (DNS) could not substantiate the abuse allegation as no other staff or residents heard the exchange. Despite this, the NA was placed on final warning and later terminated after another altercation with the resident's spouse in the parking lot. Further review revealed significant gaps in the facility's hiring and screening processes. The NA's personnel file lacked documentation of the incident, a final warning, or a background check. The Human Resources (HR) Director could not locate any preliminary screening associated with the NA's employment application. The DNS confirmed that it is expected for employees to be screened and background checks completed before hiring, but these procedures were not followed in this case. The facility also failed to provide a policy for hiring and screening when requested.
Failure to Develop Comprehensive Care Plan for Respiratory Equipment
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for Resident #75, who was admitted with diagnoses including chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea. The admission MDS assessment did not indicate the use of a CPAP, and the baseline care plan did not identify the use of a CPAP. The comprehensive care plan also failed to include the diagnosis of sleep apnea or the use of the CPAP. It was only after 120 days from admission that the physician's orders directed the use of the CPAP, specifying its usage and maintenance. However, the care plan still did not reflect this until after the surveyor's inquiry. Interviews with the DNS and the MDS coordinator revealed that the MDS coordinator, who works remotely, was responsible for including the use of the CPAP in the care plans based on physician orders. The MDS coordinator admitted that the CPAP was not included in the initial admission orders, leading to its omission in the care plans. The facility's Care Plan Policy mandates an interdisciplinary care plan to address all resident needs, but this was not adhered to in the case of Resident #75, resulting in a deficiency in the care provided.
Failure to Conduct Neurological Assessments and Provide 1:1 Monitoring
Penalty
Summary
The facility failed to ensure that neurological assessments were completed per policy for Resident #47 after an unwitnessed fall with injury. Resident #47, who had a history of dementia, diabetes, and difficulty in walking, experienced an unwitnessed fall resulting in a nasal fracture. Despite the facility's Fall Prevention Program Policy requiring neurological assessments at specific intervals following an unwitnessed fall, there was no evidence in the clinical record that these assessments were conducted after the resident returned from the emergency room. The Director of Nursing Services (DNS) confirmed that the neurological assessments should have been restarted upon the resident's return to the facility but were not completed as required by policy. The facility also failed to provide appropriate behavior observation and monitoring for Resident #84, who required 1:1 constant supervision due to suicidal ideations. Resident #84, diagnosed with dementia with agitation, PTSD, and anxiety, expressed a desire to harm themselves and was placed on 1:1 monitoring per physician's orders. However, the clinical record lacked documentation of continuous 1:1 monitoring on 3/18/24 and 3/19/24. Interviews with nursing staff revealed that the monitoring was not consistently provided by facility staff, and the responsibility was inappropriately placed on the resident's significant other during their visit. The DNS acknowledged that 1:1 monitoring should have been maintained by trained facility staff until the resident was cleared by psychiatric providers. The deficiencies in both cases highlight a failure to adhere to established policies and procedures for resident safety and monitoring. The lack of proper neurological assessments for Resident #47 and the inadequate 1:1 supervision for Resident #84 demonstrate significant lapses in care that could have serious implications for resident well-being. These findings were corroborated by interviews with facility staff and a review of the clinical records, underscoring the need for strict adherence to care protocols to ensure resident safety and proper documentation of care provided.
Failure to Follow Bowel Management Protocol
Penalty
Summary
The facility failed to follow its policy to assist a resident in maintaining bowel function. Resident #12, who was admitted with diagnoses including Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions, was identified as having moderately impaired cognition and being incontinent of both bowel and bladder. The care plan for Resident #12 included a focus on constipation with specific interventions outlined in the facility's bowel management protocol. However, the facility did not adhere to these protocols as required. A physician's order directed the administration of various laxatives if the resident had no bowel movement in three shifts. Despite this, documentation revealed that Resident #12 had no bowel movement for five days, and the necessary interventions were not initiated on the fourth day as per the facility's policy. The DNS confirmed that the interventions should have begun on the fourth day without a bowel movement, but there was no documentation to support that the resident's bowels were monitored according to the policy and care plan. This lapse in following the bowel management protocol led to the deficiency identified in the report.
Failure to Follow Prescribed Renal Diet
Penalty
Summary
The facility failed to ensure that a resident's prescribed renal diet was followed according to the physician's order. Resident #19, who was admitted with diagnoses including acute metabolic acidosis, chronic kidney disease, and ileostomy, had a physician's order for a renal diet and medication to manage high potassium levels. Despite this, the resident repeatedly received high potassium food items such as tomatoes, tomato sauce, and potatoes. This was confirmed through observations, interviews, and clinical record reviews. The resident's potassium levels were elevated, necessitating additional medical interventions, including IV fluids and medication to lower potassium levels. Interviews with the Dietary Director, Dietician, Regional Dietician, and APRN confirmed that the resident should not have received high potassium foods. The Dietary Director acknowledged the error and indicated plans to re-educate staff. The Dietician and Regional Dietician were aware of the renal diet order but were not fully informed about the resident's elevated potassium levels and additional medical treatments. The facility's policy on nutritional management and renal diet guidelines was not followed, leading to the deficiency in providing appropriate dietary care for Resident #19.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to ensure respiratory equipment was cleaned, changed, and stored per policy and manufacturer's recommendations for two residents. Resident #5, who was admitted with COPD, centrilobular emphysema, and diabetes type 2, had oxygen therapy equipment that was not dated or properly stored. Observations revealed that the oxygen nasal cannula tubing was on the floor, and the nebulizer mask was on the bedside table without proper dating. LPN #1 confirmed that the dating of the tubing was supposed to be done on the Sunday 11-7 shift but could not explain why it was not completed. The Director of Nursing Services (DNS) confirmed that the oxygen tubing should be changed and dated on the 11 PM-7 AM shift on Sunday night but was not aware of the specific reasons for the lapse in procedure. Resident #75, admitted with chronic obstructive pulmonary edema, dementia, and obstructive sleep apnea, had a CPAP machine that was not properly maintained. The CPAP mask and tubing were not labeled or dated, and the mask was not stored in a bag when not in use. LPN #2 indicated that the CPAP tubing and mask should be labeled and dated each week after cleaning and that the mask should be bagged when not in use. The DNS was unsure of the specific cleaning and changing schedule for the CPAP equipment and had to refer to the facility policy and manufacturer's recommendations. It was found that the CPAP equipment had not been cleaned or changed since admission, and the necessary physician orders for cleaning and maintenance were missing. The facility's policy and the manufacturer's recommendations for CPAP equipment maintenance were not followed, leading to the failure to clean and change the equipment as required. The DNS confirmed that the CPAP mask and tubing were not dated when last changed and that the filter had a layer of dust on it. The facility's policy required daily cleaning of the CPAP mask and tubing, weekly disinfection, and monthly changes of the white disposable filter. The DNS acknowledged the oversight and indicated that the necessary physician orders for the care and cleaning of the CPAP equipment would be added.
Lack of Competency in JP Drain Care
Penalty
Summary
The facility failed to ensure that the nursing staff were competent in caring for specialized medical equipment, specifically a Jackson Pratt (JP) drain, for Resident #88. Resident #88, who was admitted with diagnoses including dementia, chronic cholecystitis, and hydronephrosis with renal and ureteral calculus obstruction, had a JP drain following gall bladder removal. Observations revealed that the JP drain bulb was found touching the floor, and LPN #4 placed it back on the bed without disinfecting it. Additionally, the dressing at the insertion site was not labeled or dated, and LPN #5 admitted to not receiving education on JP drains for at least two years. Interviews with nursing assistants (NAs) and licensed practical nurses (LPNs) indicated a lack of proper training and understanding of JP drain care. NA #5 and NA #4 were unaware of the correct procedures for handling the JP drain, with NA #5 relying on common sense and NA #4 recalling education from certified nursing school but not from the facility. NA #7 also demonstrated a lack of proper technique and admitted to not using alcohol pads when handling the drain. RN #7 confirmed that nursing assistants do not typically empty the JP drain, and the dressing should be labeled with the date and nurse's initials. The Director of Nursing Services (DNS) and the Staff Development and Wound Nurse (RN #2) acknowledged the lack of ongoing education and competencies related to JP drains. RN #2 admitted that there had been no education or competencies provided in the past two years and that JP drains were not included in the general orientation checklist. The DNS and RN #2 both indicated that education should be provided if a need is identified, but this had not been done for JP drains, leading to the observed deficiencies in care for Resident #88.
Failure to Identify Non-Crushable Medication
Penalty
Summary
The pharmacy failed to identify a non-crushable medication for Resident #12, who was admitted with diagnoses including Parkinson's disease with dyskinesia, dysphagia, and unspecified convulsions. The resident's care plan included long-term use of antipsychotics for schizoaffective disorder and drug-induced tremors. A physician's order directed the administration of several medications, including Austedo 6 mg, which should not be crushed. However, the medication was administered crushed 720 times from April 2022 through April 2024, despite guidelines indicating it must be swallowed whole. Interviews with the LPN, APRN, and pharmacists revealed a lack of awareness and failure to identify the medication as non-crushable, leading to its improper administration. The facility's policy for medication administration required personnel to refer to reference materials when unfamiliar with a drug's pharmacology, contraindications, and specific indications. Despite this policy, the medication Austedo was not flagged as a do-not-crush medication by the pharmacy, nor was it acknowledged by the facility staff. The pharmacist and pharmacist supervisor confirmed the medication should not be crushed and failed to provide information on the efficacy or toxicity of administering it in crushed form. The APRN admitted responsibility for identifying whether a medication can be crushed but was unaware of the medication's status at the time of the decision. An interview with the medical director was not obtained.
Failure to Monitor Blood Sugars According to Professional Standards
Penalty
Summary
The facility failed to monitor blood sugars according to professional standards of care for a resident with diabetes type 2. The resident, who had moderately impaired cognition and was wheelchair dependent, had a critical glucose level of 41 mg/dl on 1/23/24, which was significantly below the normal range of 74-100 mg/dl. Despite this critical lab result, no new orders were issued, and the resident's blood sugar was not monitored further. The facility's diabetes protocol requires follow-up on significant changes in blood sugars, but this was not adhered to in this case. The APRN reviewed the critical lab results but did not take any action to address the low glucose level. The DNS confirmed that the critical glucose level warranted additional monitoring, which was not done. The facility's policy mandates that the physician follow up on acute episodes and adjust treatments based on lab results, but this protocol was not followed, leading to a deficiency in the resident's care.
Failure to Monitor Targeted Behaviors for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to ensure targeted behaviors were identified and monitored for a resident receiving psychotropic medications. Resident #84, who was admitted with diagnoses including dementia with agitation, PTSD, and anxiety, was prescribed multiple psychotropic medications. However, the clinical record did not include any orders or documentation related to targeted behavior monitoring following the resident's admission. Despite the care plan identifying the resident's risk for depression and the need for monitoring, the necessary behavior monitoring was not ordered until nine days after admission, following incidents of the resident verbalizing suicidal ideations. Interviews with the psychiatric APRN and the Director of Nursing Services (DNS) confirmed that behavior monitoring should have been ordered upon admission but was overlooked. The facility's policy on psychoactive medication use mandates that residents receiving such medications be monitored for effectiveness, adverse reactions, and specific behaviors. This oversight resulted in a failure to comply with the facility's policy and ensure the resident's targeted behaviors were appropriately monitored from the time of admission.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain medical equipment in a sanitary manner for Resident #88, who had a JP drain following a laparoscopic cholecystectomy. Observations revealed that the JP drain collection bulb was touching the floor, and an LPN placed it back on the resident's bed without disinfecting it. Additionally, the LPN did not check the placement of the tubing at the insertion site. Interviews with the DNS and RN #2 confirmed that the JP drain should not touch the floor and should be disinfected if it does. The facility's policy on JP drains was not followed, leading to potential infection control issues. The facility also failed to maintain transmission-based precautions for Resident #91, who tested positive for COVID-19. Despite being on contact/droplet precautions, there was confusion among staff regarding the resident's status. Observations showed that the precaution signage and PPE cart were inconsistently placed and removed. Interviews with the DNS, RN #3, and LPN #9 revealed a lack of clarity and communication about the resident's COVID-19 status, leading to lapses in infection control measures. Furthermore, the facility did not ensure that shared medical equipment was sanitized between use on residents. NA #3 was observed using the same vital sign monitoring equipment on two residents without sanitizing it in between. Interviews with NA #3, RN #3, and LPN #9 confirmed that the equipment should be sanitized between uses, but this practice was not consistently followed. The facility's policy on cleaning durable medical equipment was not adhered to, increasing the risk of cross-contamination and infection among residents.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide the pneumococcal immunization to Resident #74, who was admitted with diagnoses including hypertension and diabetes mellitus. The resident's immunization record showed they received PCV13 in 2013, but the quarterly MDS assessment indicated they were not up to date with the pneumococcal vaccination. The assessment did not provide a reason for the missing vaccination. An interview with the Infection Control Nurse revealed that she was unaware of the resident's vaccine status and eligibility, as she had only started in her role in November 2023. Further investigation confirmed that the resident had not received the pneumococcal vaccine since 2013, and the resident was missed by the previous Infection Control Nurse. A physician's order was issued to administer the pneumococcal vaccine, and the resident's responsible party consented to the vaccination, which was then administered. The Director of Nursing Services (DNS) stated that it was expected for all applicable vaccines to be offered to residents upon admission and whenever they are eligible. The DNS also expected the Infection Control Nurse to audit residents' clinical records for vaccine eligibility. The facility's policy aligns with CDC recommendations for pneumococcal vaccinations, which were not followed in this case, leading to the deficiency.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure the State Long-Term Care Ombudsman was notified when two residents were transferred to the hospital. Resident #28, who had diagnoses including chronic obstructive pulmonary disease, morbid severe obesity, congestive heart failure, and asthma, was transferred to the hospital and readmitted to the facility without the Ombudsman being notified. Similarly, Resident #46, with diagnoses including diabetes, asthma, and atrial fibrillation, was also transferred to the hospital and readmitted without the required notification to the Ombudsman. The facility's Admit/Discharge Report did not reflect these notifications, indicating a failure in the process of informing the Ombudsman about hospital transfers. Interviews with facility staff revealed that the social worker responsible for sending the reports was unaware that incorrect reports were being sent. The Administrator and Director of Nursing Services confirmed that the social worker was responsible for ensuring the reports were sent to the Ombudsman. The issue was discovered when the facility reviewed the reports and found that the wrong ones had been sent from January to March 2024. The Administrator acknowledged the problem and indicated that the issue would be discussed with the Regional Admission Director, and in-service training would be provided to the social worker.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives upon transfer to the hospital for three residents. Resident #24, admitted with diagnoses including anxiety disorder, pneumonia, and acute respiratory failure, was transferred to the hospital due to altered mental status and readmitted with metabolic encephalopathy and pneumonia. The clinical record did not reflect that a bed hold notice was provided upon transfer. Similarly, Resident #28, with chronic obstructive pulmonary disease, morbid severe obesity, congestive heart failure, and asthma, was transferred to the hospital and readmitted, but no bed hold notice was documented. Resident #46, admitted with diabetes, asthma, and atrial fibrillation, was also transferred to the hospital and readmitted without a bed hold notice being provided or documented in the clinical record. Interviews with facility staff, including the Social Worker, DNS, and Admission Director, revealed that the facility does not issue bed hold notices upon hospital transfers. The DNS indicated that the Admission Director is responsible for ensuring that bed hold notices are provided, and that a packet for transfer should include the notice. However, no documentation or policy regarding bed hold notices was provided upon request. The facility's policy states that beds will be reserved for private-pay residents as long as payment is available and for Medicaid-assisted residents for up to seven days, with a possible extension of an additional eight days, provided the resident is expected to return at the same level of care.
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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