Apple Rehab Coccomo
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 33 Cone Ave, Meriden, Connecticut 06450
- CMS Provider Number
- 075345
- Inspections on file
- 26
- Latest survey
- August 4, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Apple Rehab Coccomo during CMS and state inspections, most recent first.
A resident who sustained a femur fracture from a fall and was readmitted after surgery did not have their care plan or care card promptly updated to reflect new physician and therapy orders for non-weight bearing status and mechanical lift transfers with two staff. Staff interviews revealed confusion about the resident's current transfer status, and the facility's policy requiring timely updates to care plans was not followed.
Multiple observations revealed persistent issues with cleanliness and maintenance, including soiled floors, peeling paint, leaking sinks, broken tiles, and non-functioning lights across several units. Residents expressed dissatisfaction with the facility's condition and lack of completed repairs. Staff interviews highlighted inadequate training, missing maintenance records, and housekeeping staffing shortages, with supervisors unable to confirm recent cleaning. The facility could not provide a maintenance policy when requested.
A resident receiving IV antibiotics for osteomyelitis did not receive the full prescribed dose on three occasions because nursing staff failed to flush the IV line after medication administration, resulting in a significant portion of the medication remaining in the tubing and being discarded. This occurred despite facility policy requiring safe and accurate medication administration.
A resident reported a grievance about a broken television remote, but the facility did not act to replace it. Observations found that three residents had remotes with missing pieces or taped parts, and interviews confirmed they had reported the issue to staff without resolution. The Regional Director of Maintenance was unaware of the problem and could not verify if it had been addressed.
A resident with dementia and impaired decision-making left the facility alone despite an order requiring accompaniment, and staff were unaware of the resident's absence for over six hours. Multiple staff failed to follow the missing resident policy, including not conducting an overhead alert, not searching outside, and not notifying police. The resident was later found by law enforcement after a vehicle accident and exposure to cold, resulting in an Immediate Jeopardy finding.
A resident with cognitive impairment was subjected to verbal abuse by an LPN, who made derogatory remarks about the resident's alleged drug use and criminal behavior during a loud argument at the nurse's station. Several nursing assistants witnessed the incident but did not immediately report it, resulting in a delay in facility response. The facility's policies prohibit such mistreatment, but the resident was not protected from verbal abuse.
A resident with cognitive impairment was subjected to inappropriate and derogatory comments by an LPN during a loud argument, which was witnessed by multiple nursing assistants. The staff did not immediately report the incident to supervisors, and there was a significant delay in notifying the DON and submitting the required report to the state agency, contrary to facility policy.
A resident with chronic wounds and diabetes repeatedly refused wound care treatments, a therapeutic beverage, and prescribed offloading boots. Despite these refusals being documented in clinical records, the care plan was not updated to address or manage the resident's refusals, contrary to facility policy and expectations confirmed by the DON.
A resident with chronic wounds and diabetes did not receive a low air-loss mattress as ordered by a wound consultant, due to the facility's failure to obtain the necessary physician order and to maintain the specialized mattress in place. Staff replaced the low air-loss mattress with a standard one after it broke, despite having additional mattresses available, and did not promptly restore the required pressure relief device.
A resident with dementia and a history of alcohol abuse left the facility unaccompanied, contrary to LOA orders, and was later involved in a motor vehicle accident. The facility did not perform an elopement risk assessment upon the resident's return, and when an assessment was eventually completed, it inaccurately indicated no history of elopement, despite the recent unauthorized absence.
Failure to Update Care Plan After Resident Readmission with New Transfer Needs
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for a resident upon readmission after the resident sustained a facility-acquired right femur fracture due to a fall. The resident, who had diagnoses including COPD, depression, and benign paroxysmal vertigo, was previously identified as a fall risk and had interventions in place such as calling for assistance when dizzy and using a call bell. After the fall, which occurred when the resident missed the wheelchair while attempting to sit, the RCP was updated to include use of a gait belt and instructing the resident to feel for wheelchair arms before sitting. However, following the resident's return from the hospital after surgery, new physician and therapy orders specified non-weight bearing status and transfer with a mechanical lift and assistance of two staff, but these changes were not reflected in the RCP or the Resident Care Card (RCC) in a timely manner. Staff interviews revealed confusion regarding the resident's current transfer status, with some staff relying on outdated RCC information and awaiting clarification before providing care. The facility's care planning policy required that care plans and care cards be updated as needed to reflect changes in the resident's status, but this was not done promptly after the resident's readmission and change in transfer needs. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed that the care plan and RCC did not direct staff to the updated transfer requirements following the resident's injury and hospital stay.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to ensure and maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations across several units. Surveyors noted soiled floors, peeling paint, leaking or non-functional sinks and faucets, stained sinks, closet doors off hinges and stained, broken or missing shower room floor tiles, dark substances covering shower room floor edges, and non-functioning bathroom lights. These deficiencies were observed in resident rooms, shower rooms, hallways, and nurses' stations on units 100, 200, and 300. Residents reported dissatisfaction with the facility's appearance and lack of repairs, stating that maintenance projects were started but not completed, and that requests for repairs had not resulted in visible improvements. Interviews with staff revealed further issues contributing to the deficiency. The Director of Maintenance, who had been in the role for four months, reported a lack of training and absence of maintenance logs or records from the previous director. The Director of Housekeeping/Laundry indicated staffing shortages and challenges in maintaining cleanliness, with cleaning schedules not consistently followed. The Interim Administrator acknowledged responsibility for the facility's condition and stated that the new Director of Maintenance and Corporate Project Manager were assessing repair needs. Additional observations confirmed ongoing cleanliness and maintenance issues, with staff unable to verify when cleaning last occurred and supervisors acknowledging the inadequacy of current cleaning efforts. The facility was unable to provide a policy for building maintenance when requested.
Failure to Ensure Complete IV Antibiotic Administration Due to Lack of Line Flushing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) antibiotics for a resident diagnosed with bilateral ankle osteomyelitis. Specifically, the facility did not secure or implement an order to flush the IV line after administering ceftriaxone, resulting in incomplete delivery of the prescribed medication. Review of the clinical records and medication administration records showed that, for three consecutive days, there was no order or documentation to flush the IV tubing after the antibiotic was given, and the tubing containing residual medication was discarded. This led to the resident not receiving the full dosage of antibiotics as prescribed. Interviews with the resident, the DON, and the pharmacist confirmed that the issue was brought to the attention of facility leadership after the resident and their responsible party noticed the problem. The pharmacist calculated that approximately 24% of the medication was not administered each day due to the lack of flushing, totaling a significant amount of missed medication over the three days. Facility policy required medications to be administered safely and accurately according to physician orders and protocols, which was not followed in this instance.
Failure to Address Resident Grievances Regarding Broken Television Remotes
Penalty
Summary
A deficiency was identified when a resident reported that their television remote control was in disrepair, but the facility failed to act on the grievance and did not replace the remote control. During a tour of the resident units, it was observed that three residents had television remote controls with missing pieces or that had been taped together. Interviews with these residents revealed that they had reported the broken or incomplete remote controls to several staff members, but were told the controls were still working and that no replacements were available. The Regional Director of Maintenance was unaware of the issue, could not locate the maintenance logbook to verify if the problem had been addressed, and was unable to explain why the remotes had not been replaced.
Failure to Supervise and Respond to Missing Resident Results in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure timely staff supervision and appropriate response when a resident with dementia, impaired memory, and a history of substance abuse was identified as missing. The resident, who was assessed as not having the capacity to meet minimal basic needs in the community, left the premises alone despite an order requiring accompaniment by a responsible party for leave of absence. Staff were unaware of the resident's whereabouts for over six hours, during which time the resident accessed their own vehicle and left the facility unaccompanied. Multiple staff members, including the receptionist, social worker, and nursing staff, did not follow the facility's missing resident policy. The receptionist allowed the resident to go to their car alone and did not ensure their return or notify others when the resident did not come back. When the social worker and nursing supervisor realized the resident was missing, they searched only inside the facility, did not call a code overhead to alert all staff, did not search the outside grounds, and did not notify the police. The DON was present in the building during the search but also did not ensure that the required steps were taken according to policy before leaving for the day. The facility's own policy required immediate overhead paging, a thorough search of both inside and outside the facility, and prompt notification of law enforcement when a resident's whereabouts were unknown. These steps were not followed, and the resident was ultimately found by police after being involved in a motor vehicle accident and being rescued from an icy pond. The failures in supervision, timely action, and adherence to policy resulted in a finding of Immediate Jeopardy.
Failure to Protect Resident from Verbal Abuse by LPN
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and a history of attention and concentration deficit was subjected to verbal mistreatment by an LPN. The resident, who required assistance with activities of daily living and had a care plan addressing ineffective coping and accusatory behaviors, was involved in a loud argument with the LPN at the nurse's station. During this exchange, the LPN made derogatory and inappropriate remarks about the resident's alleged drug use and criminal behavior, including calling the resident a 'crack head' and making further disparaging comments in front of other staff and residents. Multiple nursing assistants witnessed the incident but did not immediately report it to their supervisor. One nursing assistant later informed a family member about the event, which led to the incident being reported to facility management. The supervisor and DON were subsequently notified, and the facility began an investigation into the allegations. The investigation confirmed that the LPN had made inappropriate remarks to the resident. The facility's policies strictly prohibited abuse or mistreatment of any kind, including verbal abuse defined as the use of disparaging or derogatory language toward residents. Despite these policies, the incident occurred and was not promptly reported by staff who witnessed it, contributing to the deficiency in protecting the resident from verbal mistreatment.
Failure to Timely Report Alleged Verbal Abuse and Notify State Agency
Penalty
Summary
Staff failed to report an allegation of verbal abuse involving a resident with cognitive impairment and behavioral issues in a timely manner. The incident occurred when an LPN made inappropriate and derogatory comments to the resident, including references to drug use and jail, during a loud argument at the nurse's station. Multiple nursing assistants witnessed the exchange but did not immediately report the incident to their supervisor as required by facility policy. The incident was eventually brought to the attention of supervisory staff after a family member inquired about what had happened. Statements were then collected from the involved staff, and the Director of Nursing (DON) was notified later that evening. The DON confirmed that the incident was not reported to her or to the state agency within the required timeframe after the facility became aware of the allegation. Facility policy mandates immediate reporting of any witnessed or known abuse to supervisory staff and prompt notification to the state health authority within two hours of awareness. In this case, there was a delay of over 24 hours from the time the facility first became aware of the incident to when it was reported to the state agency. Interviews with staff confirmed the delay in reporting and a lack of immediate action following the incident.
Failure to Revise Care Plan for Repeated Refusals of Wound Care
Penalty
Summary
The facility failed to ensure that the care plan for a resident with chronic wounds and diabetes was revised in a timely manner to address repeated refusals of wound care and related treatments. Clinical record and documentation reviews showed that the resident refused wound dressing changes on multiple occasions, declined a therapeutic beverage intended for wound healing several times, and refused to wear prescribed offloading boots. Despite these documented refusals, the resident's care plan did not include any interventions or strategies to address or manage the refusals of care, medications, or wound treatments. Interviews with the Director of Nursing (DON) confirmed that the expectation is for residents who repeatedly refuse care to have these behaviors addressed in their care plans, with appropriate interventions documented. The DON was unaware of the resident's repeated refusals and acknowledged that the care plan should have included this information. Review of facility policy also indicated that care plans should be comprehensive and individualized, guiding caregivers to assist residents in achieving their highest practical level of well-being.
Failure to Provide Ordered Pressure Relief Device for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to act in a timely manner on a wound consultant's order and did not ensure that a low air-loss mattress was maintained in place as directed for a resident with significant wounds. The resident had a history of a non-pressure chronic left foot ulcer, diabetes mellitus, and was identified as having an unstageable ulceration and a stage four ankle/Achilles ulcer. The wound consultant ordered pressure relief devices, including a low air-loss mattress, but the order was not obtained from the attending physician, and the specialized mattress was not provided as required. Observations and interviews revealed that the resident was found on a standard mattress rather than the prescribed low air-loss mattress. Staff confirmed that the low air-loss mattress had previously been in place but was replaced with a regular mattress after the device broke, and no immediate replacement was provided despite additional mattresses being available in supply. Facility documentation and policy review indicated a lack of adherence to wound care protocols and physician orders, contributing to the deficiency.
Failure to Complete and Accurately Document Elopement Risk Assessment After Unauthorized Absence
Penalty
Summary
The facility failed to perform an elopement risk assessment after a resident returned following an unauthorized absence and did not accurately complete an elopement risk assessment after the incident. The resident in question had diagnoses including metabolic encephalopathy, dementia, depression, anxiety disorder, and a history of alcohol abuse. The care plan identified impaired memory and decision-making skills, and the resident was noted to have a history of behaviors that could place them at risk for seeking unescorted exit. Despite this, the elopement risk assessment completed prior to the incident indicated the resident was not at risk for elopement. On the day of the incident, the resident left the facility premises alone, despite an order requiring accompaniment by a responsible party, and was later involved in a motor vehicle accident. The facility did not become aware of the resident's absence until several hours later, after being notified by police. Upon the resident's return, the facility did not complete an elopement risk assessment, as required by facility policy, because the hospitalization was less than 24 hours. When an assessment was eventually completed, it inaccurately documented that the resident had no history of elopement, despite the recent unauthorized absence.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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