Abbott Terrace Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterbury, Connecticut.
- Location
- 44 Abbott Terrace, Waterbury, Connecticut 06702
- CMS Provider Number
- 075351
- Inspections on file
- 29
- Latest survey
- September 24, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Abbott Terrace Health Center during CMS and state inspections, most recent first.
A resident reported being hit by a staff member, but the LTC facility failed to report the allegation within the required timeframe. The incident was initially reported to a physical therapist, who informed a nurse, but the nurse did not escalate the report because the resident later denied the incident. The facility's policy requires immediate reporting of abuse allegations, but the incident was not reported to the appropriate authorities until two days later.
A resident with multiple diagnoses was found with medication left at her bedside, which she did not consume. An LPN left the medications intending to return but forgot, violating the facility's policy requiring staff to ensure medication is taken in their presence.
A resident with a history of falls and unsafe behaviors was not provided with a properly assessed wheelchair, leading to unsafe movements. Despite recommendations for specific wheelchair modifications, these were not implemented until after surveyor observations. Staff were unaware of the required modifications, and the resident was placed in a non-assigned wheelchair due to restlessness.
A resident with type II diabetes and dysphagia experienced a significant unverified weight loss due to the facility's failure to obtain and verify weekly weights as per the care plan. Despite the dietitian's repeated requests for re-weighs, the nursing staff did not respond, leading to a 21-pound weight loss without verification.
The facility failed to remove expired medications from medication carts and did not date a multiuse vial of insulin when opened. Observations revealed expired medications for several residents and an undated insulin vial. Interviews indicated confusion among staff about responsibility for checking expiration dates, with policies stating that licensed personnel should ensure compliance with storage requirements.
The facility failed to cohort residents with MDROs appropriately, did not review infection control policies annually, and neglected to conduct required environmental rounds and maintain water management logs. Two residents with different MDROs were placed together, and another resident without an MDRO history was cohorted with one who had a known MDRO. The infection control policies were not reviewed in 2022, and environmental rounds were incomplete in several months. Additionally, the facility did not maintain logs for water flushing and eyewash stations as required.
The facility failed to maintain an effective pest control program, leading to a resident environment infested with mice. Observations and interviews revealed mouse traps and droppings in resident rooms and common areas. Pest control services were suspended due to non-payment, resulting in increased mouse activity. The issue persisted despite attempts to mitigate it, such as purchasing food storage bins for residents.
The facility did not complete the required 12 hours of annual training for three nurse aides, missing essential topics like Resident Rights, Communication, and Behavioral Health. Training records for 2022 and 2023 were incomplete, and the Staff Development Nurse, who started in August 2023, could not locate the missing records. The Corporate Nurse was also unable to find the 2022 training records.
A resident with paraplegia and anxiety disorder, requiring total assistance for transfers, was not accommodated according to their preference to get out of bed following breakfast. Despite the availability of clean Hoyer pads in the laundry, staff did not retrieve one, resulting in the resident remaining in bed longer than desired. The nursing supervisor was not informed of the issue, and the resident was assisted out of bed later than preferred.
A resident transferred to the facility with diagnoses including schizophrenia and intellectual disabilities did not receive a required Level II PASRR evaluation. The Director of Social Work failed to request a new PASRR screening upon admission, despite the resident's serious mental health condition.
A resident with paraplegia and anxiety disorder had a care plan that failed to include their preference for getting out of bed after breakfast. Despite staff awareness, the resident often had to wait due to the unavailability of a Hoyer pad needed for transfers. The facility's policy required care plans to accommodate resident preferences, but this was not adhered to.
A resident with COPD, morbid obesity, and hypertension experienced chest pain and was transferred to the emergency department without a documented nursing assessment. Interviews revealed that the expected assessment was not completed, and the facility lacked policies for such assessments and chest pain protocol.
Two residents experienced deficiencies in care related to splint and treatment application. One resident, with left-sided weakness, did not have a splint consistently applied due to a lack of physician orders and documentation errors. Another resident, with contractures, did not receive prescribed rolled gauze treatment, which was inaccurately documented as completed by an LPN. These failures led to a decline in the residents' conditions.
A facility failed to maintain respiratory equipment and adhere to physician orders for a resident with COPD. The resident's oxygen tubing was not changed weekly as required, and the resident self-administered oxygen without a physician's order, despite being weaned off prior to admission. Staff were unsure of their responsibilities, and the facility's policy for oxygen administration was not followed.
A facility failed to provide constant supervision during a smoking session, leading to a resident with Parkinson's disease and identified as an elopement risk leaving the property unattended. The smoking attendant left the resident unsupervised, and the resident exited through a gate, walking about five minutes away before being brought back. The incident revealed lapses in supervision and record-keeping protocols.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident within the required timeframe as per their policy. The resident, who had intact cognition and required assistance with personal hygiene, reported to a physical therapist that the owner's daughter had hit them on the back. This allegation was made on 9/15/24, but the facility did not document or report the incident immediately as required. The resident's clinical records and facility documentation did not reflect any immediate communication, investigation, or protective measures following the reported abuse. Interviews with staff revealed that the allegation was not reported to the appropriate authorities or facility administrators until two days later, on 9/17/24. The resident had initially reported the incident to a physical therapist, who informed a nurse, but the nurse did not report it further because the resident later denied the incident when questioned. The facility's policy mandates that all allegations of abuse be reported to the administrator and state agency within two hours. However, due to a lack of proper documentation and communication among staff, this protocol was not followed. The delay in reporting and investigating the allegation of abuse resulted in a deficiency in the facility's compliance with its abuse reporting policy.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident consumed her medication in the presence of a staff member, as required by their policy. The resident, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, epilepsy, and hyperlipidemia, was observed with five medication tablets left in a cup at her bedside. The resident indicated that the medications were left for her to consume, but she did not want to take them. The medications included Januvia, Depakote Extended Release, Aspirin, AREDS, and Protonix, all of which were prescribed to be taken at 6:00 A.M. The incident was documented as a reportable event, and it was identified that an LPN left the medications at the bedside with the intention to return but forgot. The facility's policy on medication administration requires staff to stay with the resident until the medication is swallowed, which was not followed in this case. The Assistant Director of Nurses confirmed the LPN's actions during an interview, noting that the LPN received counseling and education regarding the incident.
Failure to Provide Properly Assessed Wheelchair for Resident
Penalty
Summary
The facility failed to provide a properly assessed seating system for a resident with a history of multiple falls and unsafe behaviors while seated in a wheelchair. The resident, who had diagnoses including vascular dementia and repeated falls, was observed in an adaptive wheelchair that was not correctly set up, leading to unsafe movements. Despite an occupational therapy evaluation recommending specific wheelchair modifications, these were not implemented until after surveyor observations. On the day of the survey, the resident was seen aggressively moving in the wheelchair, causing it to tip backward and connect with the wall, preventing a complete tip-over. Staff interviews revealed that the resident was placed in a non-assigned wheelchair due to restlessness and the need for supervision, but the staff was unaware of the specific wheelchair modifications required. The Assistant Director of Nurses confirmed that the recommended adaptive wheelchair was not provided until after the surveyor's observations.
Failure to Verify Resident Weight Discrepancy
Penalty
Summary
The facility failed to obtain and verify weights for a resident, leading to a significant weight discrepancy. Resident #88, who had diagnoses including type II diabetes, protein-calorie malnutrition, and dysphagia, was identified as being at nutritional risk following a recent hospitalization. The care plan required weekly weights, but the facility did not record weights for three successive weeks. A significant weight loss of 21 pounds (13%) was noted without a re-weight to verify the discrepancy. Despite the dietitian's requests for re-weighs through the facility's internal communication system, these requests were not responded to by the nursing staff. The facility's policy required re-weighs for weight changes of 5 pounds or more, but this was not adhered to in the case of Resident #88. The dietitian had made dietary amendments to address the potential weight loss, but the lack of re-weighs hindered the verification process. Interviews with the dietitian and the Regional Corporate Nurse confirmed that the nursing staff was responsible for completing weights and reporting discrepancies, which did not occur as required. This failure to follow protocol resulted in an unverified significant weight loss for the resident.
Expired Medications and Undated Insulin Vial Found in Medication Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from medication carts and that a multiuse vial of insulin was dated when opened. During an observation of the 4th floor medication cart #2, it was found that a resident had five blister packs of expired medications, including Levetiracetam, Eliquis, and Clopidogrel, with expiration dates ranging from February to May 2024. Additionally, another resident's blister pack of Trazodone was also expired. An LPN indicated uncertainty about who was responsible for checking the medication cart, although it was suggested that the nurse on duty when medications arrive is responsible for putting them away and rotating stock. Further observations of the 4th floor medication cart #1 revealed a vial of Glargine insulin without an opening date and several expired medications for different residents, including Olanzapine, Darifenacin, Glipizide, Jardiance, and Mirtazapine. Interviews with nursing staff and pharmacy personnel indicated that all nurses were responsible for rotating stock and checking expiration dates, with the night shift nurse specifically tasked with this duty. The facility's policy requires medications to be stored according to manufacturer's specifications and state and federal requirements, with licensed personnel responsible for checking expiration dates.
Infection Control and Cohorting Deficiencies
Penalty
Summary
The facility failed to appropriately cohort residents with known Multidrug Resistant Organism (MDRO) colonization. Specifically, two residents with different MDROs were placed in the same room, contrary to the facility's policy that residents with colonized or infected MDROs should not be placed with roommates who are severely immunocompromised or have indwelling lines or open wounds. Additionally, another resident without a history of MDRO was cohorted with a resident with a known history of a colonized MDRO, which was against the facility's policy that residents with similar MDRO infections should be cohorted when possible. The facility also failed to review its infection prevention control program policies and procedures annually, as required. The review of the facility's Infection Control Program Policies and Procedure manual revealed that the policies and procedures manual was not reviewed in the year 2022. This oversight was acknowledged by the staff, who indicated that it was the responsibility of the infection prevention nurse at the time to ensure the review was completed. Furthermore, the facility did not conduct environmental rounds as required. Documentation showed that quarterly environmental rounds were not completed by the nursing department in several months across 2022 and 2023, and were also incomplete for the laundry and housekeeping department in April 2023. Additionally, the facility failed to maintain a monthly log for water flushing of low flow areas and eyewash stations, as per the Facility Water Management Plan Policy. The facility was unable to produce completed logs for the year 2022, indicating a lack of adherence to the established water management protocols.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a resident environment that was not free from pests. Observations in multiple rooms, including Resident #58's room, revealed the presence of mouse sticky traps and fecal droppings, indicating an ongoing issue with mice. Interviews with residents and staff confirmed sightings of mice and droppings in various areas, including resident rooms and the nurse's station. The Director of Maintenance acknowledged that pest control services had been suspended due to non-payment, leading to an increase in mouse activity, with approximately 40 mice trapped during the interim period. The pest control services were only reinstated in May 2024, and the facility had not conducted a comprehensive building-wide bait trap refresh for two to three years. The Administrator was aware of the suspension of services and the ongoing pest issue, but efforts to mitigate the problem, such as purchasing bins for resident food storage, were insufficient. The contracted pest control company confirmed that services had been suspended and that a more extensive treatment plan was necessary to address the widespread issue.
Deficiency in Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that three nurse aides (NA#7, NA#8, and NA#9) received the required minimum of 12 hours of training per year, including essential topics such as Resident Rights, Communication, and Behavioral Health. Training records for 2022 and 2023 were incomplete, with specific in-service records for Communication and Behavioral Health missing. Although a training schedule for 2023 was provided, it did not confirm the completion of these trainings. The Staff Development Nurse, who assumed her role in August 2023 and began working onsite in October 2023, confirmed conducting Abuse training for 2023 but could not locate records for other required trainings. The Corporate Nurse was also unable to find the 2022 training records. Despite requests, a policy regarding training was not provided, only the 2023 training schedule was available.
Failure to Accommodate Resident's Transfer Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, identified as Resident #20, who required assistance to get out of bed according to their preferences. Resident #20, who had diagnoses including paraplegia and anxiety disorder, was moderately cognitively impaired and required total assistance with transfers using a mechanical lift. The resident's care plan specified that they should be assisted out of bed to a manual wheelchair at 10:00 AM daily. However, observations and interviews revealed that Resident #20 preferred to get out of bed following breakfast, but often had to wait longer than desired due to the unavailability of a Hoyer pad, which was necessary for the transfer. On the morning of the observation, the nursing assistants identified that the required Hoyer pad was in the laundry and unavailable for use, with no alternative pads available. Despite the availability of clean Hoyer pads in the laundry room, the staff did not retrieve one, resulting in Resident #20 remaining in bed longer than preferred. The nursing supervisor was not informed of the issue, and the Director of Nursing Services confirmed that staff were expected to retrieve a pad from the laundry if not available on the linen cart. The deficiency was observed when the resident was finally assisted out of bed at 11:00 AM, later than their preferred time.
Failure to Conduct PASRR Evaluation for Transferred Resident
Penalty
Summary
The facility failed to ensure a referral was made to the state mental health authority for a resident who was transferred from another nursing home and had a previous negative Level I PASRR. The resident, who was admitted with diagnoses including schizophrenia, intellectual disabilities, anxiety, and depression, did not receive a Level II PASRR evaluation upon transfer. The admission Minimum Data Set (MDS) assessment indicated that the resident had intact cognition and required assistance with hygiene, transfers, and ambulation, but did not have a Level II PASRR evaluation despite having a serious mental illness and/or intellectual disabilities. The Director of Social Work (SW #1) acknowledged responsibility for submitting PASRR screening requests and admitted that a new PASRR screening should have been requested upon the resident's admission due to their serious mental health condition. The oversight occurred because the resident's qualifying diagnoses were not reviewed at the time of admission, leading to the failure to submit a request for a new PASRR screening. The facility did not provide a policy addressing the PASRR screening process.
Failure to Revise Care Plan for Resident's Transfer Preference
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with paraplegia and anxiety disorder to include their preference for getting out of bed. The resident was identified as moderately cognitively impaired and required total assistance with transfers using a mechanical lift. Despite the resident's preference to get out of bed following breakfast, the care plan did not reflect this, and the resident often had to wait longer than desired due to the unavailability of a Hoyer pad, which was necessary for their transfer. Interviews with staff and the responsible party confirmed awareness of the resident's preference to get out of bed by 9:00 AM. However, the staff did not consistently comply with this preference, as evidenced by the resident remaining in bed until 11:00 AM on one occasion due to the Hoyer pad being in the laundry. The facility's policy required the interdisciplinary team to develop and revise comprehensive care plans to accommodate resident preferences, but this was not done in this case.
Failure to Complete Nursing Assessment After Change of Condition
Penalty
Summary
The facility failed to complete a nursing assessment following a change of condition for a resident with chronic obstructive pulmonary disease, morbid obesity, and hypertension. The resident required extensive two-person assistance with bed mobility and transfers, and was prescribed medication to manage heart disease. The resident experienced chest pain and was transferred to the emergency department, but the clinical record did not include a documented change of condition or nursing assessment prior to the transfer. Interviews with the Director of Nursing and registered nurses involved revealed that a nursing assessment was expected but not completed. RN #1, the Nursing Supervisor at the time, acknowledged the lack of assessment, while RN #2 could not recall any assistance provided or documentation made. The facility was unable to provide policies for completing an RN assessment following a change of condition or for chest pain protocol and cardiac assessment.
Deficiencies in Splint and Treatment Application for Residents
Penalty
Summary
The facility failed to ensure proper application and documentation of splint usage for Resident #124, who was admitted with diagnoses including schizophrenia, cardiovascular accident with left-sided weakness, and anxiety. Despite having intact cognition and functional limitations in range of motion, the resident's care plan included interventions for pressure ulcer prevention and splint application. However, observations and interviews revealed that the splint was not consistently applied, and there was no physician's order for the splint in the electronic system. The resident reported that the splint and ace bandage for swelling were not applied as required, and the nurse aide care card did not reflect the need for a splint. The Rehabilitation Director and occupational therapist confirmed that the splint order was not reinstated after the resident's hospital readmission, leading to a decline in the resident's range of motion. Resident #159, with diagnoses including aphasia, hemiplegia, and contracture of the left hand and forearm, also experienced deficiencies in care. The resident's care plan required rolled gauze and inter dry application to the left hand to prevent further contraction and maintain skin integrity. However, observations showed that the treatment was not consistently applied, and the Treatment Administration Record was inaccurately signed off as completed by LPN #8, who admitted to being distracted by other tasks. The DNS confirmed that signing the TAR indicates task completion, and any omissions should be reported and documented. The facility's failure to adhere to treatment protocols and ensure accurate documentation resulted in deficiencies for both residents. The lack of consistent application of prescribed treatments and failure to reinstate necessary orders upon readmission contributed to the decline in residents' conditions. The facility's policies on treatment administration and documentation were not followed, leading to these deficiencies.
Failure to Maintain Respiratory Equipment and Adhere to Physician Orders
Penalty
Summary
The facility failed to maintain respiratory equipment and provide respiratory services in accordance with physician orders for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and myocardial infarction. The resident's care plan indicated an activity in daily living deficit, and physician orders required weekly changes of oxygen tubing. However, observations revealed that the oxygen tubing was not changed within the specified timeframe, and staff were unsure of their responsibilities regarding the tubing change. The facility's policy directed that oxygen tubing should be replaced and dated weekly, but this was not adhered to, as evidenced by the tubing being dated beyond the seven-day requirement. Additionally, the resident was observed using oxygen intermittently without a physician's order, despite having been weaned off oxygen prior to admission. Interviews with staff and the resident confirmed that the resident self-administered oxygen when experiencing shortness of breath, although there were no physician orders for such use. The Director of Nursing acknowledged that there should not have been orders for oxygen tubing changes if there was no order for oxygen use, highlighting a lack of adherence to the facility's policy for oxygen administration by nasal cannula.
Failure to Supervise Resident During Smoking Session
Penalty
Summary
The facility failed to provide constant supervision during a smoking session, leading to a resident leaving the facility property unattended. Resident #1, who had diagnoses including Parkinson's disease and was identified as an elopement risk, was left unsupervised during a smoking break. The resident's care plan included interventions such as routine checks and the use of a wander guard, but these measures were not effectively implemented. On the day of the incident, the smoking attendant left the smoking area to handle a pack of cigarettes, during which time Resident #1 exited through a gate that had been opened for a car. The resident walked about five minutes away from the facility before being brought back by the smoking attendant, who had to run through a neighboring business's parking lot to catch up with the resident. The nurse's notes failed to document that Resident #1 had left the facility property during the smoking session, indicating a lapse in proper record-keeping and supervision protocols. Interviews with the Director of Nursing (DON) and the smoking attendant confirmed that the facility's policy required constant supervision of residents during smoking sessions. The DON stated that smoking attendants should not leave residents unattended and should wait until all residents have finished smoking before returning them to the building. Despite these policies, the smoking attendant left the residents unsupervised, leading to the elopement incident. The facility's smoking and elopement policies were not adhered to, resulting in a significant safety breach for Resident #1.
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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