Apple Rehab Guilford
Inspection history, citations, penalties and survey trends for this long-term care facility in Guilford, Connecticut.
- Location
- 10 Boston Post Rd, Guilford, Connecticut 06437
- CMS Provider Number
- 075144
- Inspections on file
- 28
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Apple Rehab Guilford during CMS and state inspections, most recent first.
A resident with a history of sexually inappropriate behaviors and moderately impaired cognition was able to inappropriately touch another resident with dementia and similar cognitive impairment. Despite care plan interventions for monitoring and redirection, staff did not adequately supervise the resident, resulting in an incident of unwanted physical contact. Facility leadership acknowledged that staff vigilance was lacking and that the incident constituted inappropriate behavior under the facility's abuse policy.
Two residents with dementia and impaired cognition were involved in an incident where one was observed touching another inappropriately. An LPN student intervened and notified the charge nurse, but the facility did not report the event to the State Agency as required by policy, despite the incident meeting the definition of sexual abuse.
Several residents did not receive required neurological assessments after falls, with documentation either incomplete or missing, despite facility policy and physician orders. Additionally, a resident at risk for pressure ulcers did not have Braden Scales or weekly body audits completed as ordered, and their low air loss mattress was not set according to manufacturer guidelines or physician order, with staff inconsistencies in following proper procedures.
The facility did not consistently document food temperatures prior to meal service as required by policy, with multiple instances of missing or incomplete temperature records for supper food items. Dietary staff acknowledged that while temperatures were generally taken, they were not always recorded, resulting in noncompliance with established food safety procedures.
A resident with intact cognition and mobility impairments reported that two nurse aides were unpleasant during a hoyer lift transfer, causing pain and discomfort. The aides' behavior, including a sarcastic comment about gratitude, was deemed disrespectful, though no intentional harm was found. The facility's policy on resident rights was not upheld, as residents are expected to be treated with dignity and respect.
A resident with cognitive impairment was admitted with a full code status, but the facility did not obtain a valid, signed advance directive consent form from the resident's representative. Despite policy requiring the form to be signed and documented, the representative's signature was missing, and there was no evidence of follow-up attempts or proper documentation by nursing staff.
The facility failed to promptly notify providers and resident representatives of significant changes in condition for three residents, including a resident expressing suicidal ideation, another experiencing unplanned weight loss with dietary changes, and a third sustaining injuries from an unwitnessed fall. Required notifications and documentation were not completed according to facility policy, resulting in deficiencies related to communication and timely response to resident needs.
A resident with a history of depression and anxiety developed new symptoms of paranoia and delusions, resulting in a diagnosis of psychotic disorder with delusions. Despite this, the facility did not promptly notify the State-designated authority or update the care plan and MDS assessments to reflect the new diagnosis, due to unclear communication and responsibility among staff.
A resident with a stage III pressure ulcer did not receive weekly Braden Scale assessments or body audits as ordered, and their low air loss mattress was not set according to manufacturer weight guidelines. Documentation and staff interviews confirmed missed assessments and improper equipment settings, resulting in a deficiency in pressure ulcer care and prevention.
A resident with right-sided hemiplegia and contracture risk did not receive care in accordance with their care plan and physician orders, resulting in the absence of a required hand splint and rolled washcloth during multiple observations. Staff interviews revealed a lack of awareness and adherence to the care plan, and the physician's order for the splint was discontinued without clear justification, despite the resident's ongoing need for the device.
A resident with a history of heart attack and recent influenza did not have weights obtained and documented as ordered by the physician and required by facility policy. Several weekly and monthly weights were missed, and a significant weight loss was not promptly reweighed or reported. Staff interviews confirmed that nurse aides were self-directed in obtaining weights, and the process lacked consistent oversight, resulting in missed documentation and failure to follow established protocols.
Two residents requiring enhanced barrier precautions (EBP) due to a surgical wound with MRSA history and an indwelling dialysis catheter were not initially placed on EBP. Staff failed to consistently use PPE during direct care, and appropriate signage and PPE were not reliably provided or used, despite facility policy and care plans indicating the need for these infection control measures.
A resident on a mechanical soft diet due to missing teeth was served inappropriate fruit salad, leading to a choking incident. Despite being on a modified diet, the resident received honeydew melon and pineapple, which were not suitable. The LPN and other staff attempted to assist the resident, but emergency services were ultimately required. The dietary manager and Speech Language Pathologist confirmed the dietary error, and the DON acknowledged the failure to follow the prescribed diet.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with a known history of verbally abusive and sexually inappropriate behaviors was able to inappropriately touch another resident. The resident with these behaviors had diagnoses including vascular dementia, adjustment disorder, and anxiety, and was identified as having moderately impaired cognition. The care plan for this resident included interventions such as monitoring behaviors, redirection, removal from public areas when behavior was disruptive or unacceptable, and psychiatric follow-up as needed. Despite these interventions, the resident was observed by a student nurse with their hand under another resident's shirt, touching the upper chest area. The incident was reported and classified as inappropriate behavior. The resident who was touched also had dementia and moderately impaired cognition. The facility's Director of Nursing acknowledged that staff should have been vigilant in monitoring the resident with known behaviors to prevent such incidents. The facility's abuse policy defined sexual abuse as any unwanted touching between residents. The report did not identify whether the resident who was touched had the capacity to consent, nor did it explain why staff failed to monitor the location and behaviors of the resident with a history of inappropriate conduct, leading to the incident.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency in a timely manner for two residents with moderately impaired cognition. One resident, with a history of verbally abusive and sexually inappropriate behaviors, was observed by an LPN student with their hand under another resident's shirt, touching the upper chest area. The LPN student intervened by stopping the behavior, moving the affected resident away, and notifying the charge nurse. Facility documentation classified the incident as a Class E and implemented internal interventions, but did not report the event to the State Agency as required. The Director of Nursing (DON) stated that the incident was not reported because it was witnessed, there was no intention of harm, no injuries occurred, no signs of distress were observed, and families did not express concerns. However, the facility's own abuse policy defined sexual abuse to include unwanted touching between residents and required notification of the Department of Public Health and submission of an online report within two hours. Review of the State's event tracking system confirmed that the incident was not reported as mandated.
Failure to Complete Neurological Assessments and Pressure Ulcer Prevention Protocols
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for multiple residents, specifically in the areas of post-fall neurological assessments and pressure ulcer prevention. For three residents with a history of falls, the facility did not complete neurological assessments as required by facility policy after unwitnessed falls or head strikes. In several instances, neurological checks were either not initiated, not completed for the required duration, or not documented at all, despite clear policy directives and physician orders. These lapses were confirmed through review of clinical records, facility documentation, and interviews with the Director of Nursing Services (DNS), who acknowledged the assessments were incomplete or missing. In one case, a resident with Parkinson's disease and repeated falls experienced multiple unwitnessed falls, but the neurological assessments were either not started or not completed according to the required schedule. Another resident with dementia and a history of falls sustained a witnessed fall with a head strike, but there was no documentation that neurological assessments were performed as per policy. A third resident with ataxic cerebral palsy and epilepsy had two unwitnessed falls, with incomplete or missing neurological checks and post-accident assessments, even after developing altered mental status and being sent to the hospital. Additionally, the facility failed to follow protocols for pressure ulcer prevention for a resident at risk. The Braden Scale, used to assess risk for pressure ulcers, was not completed weekly as ordered, and weekly body audits were missed on several occasions. Furthermore, the resident's low air loss (LAL) mattress was not set according to manufacturer recommendations or the resident's actual weight, and there was no physician order for the mattress. Interviews revealed confusion among staff regarding mattress settings, with some staff setting mattresses to 'comfort' rather than weight, contrary to manufacturer instructions and hospice guidance.
Failure to Consistently Document Food Temperatures Prior to Service
Penalty
Summary
The facility failed to ensure that food temperatures were routinely monitored and documented prior to food service, as required by facility policy and professional standards. Review of the Cooked Foods Temperature Charts and Meal Serving Temperature Charts over multiple weeks revealed numerous instances where supper food item temperatures were either not documented at all or only partially recorded. There were also periods where temperature charts were not provided for review. The facility's policies require that food temperatures be measured and recorded at specific times to ensure food safety, but these procedures were not consistently followed. Interviews with dietary staff confirmed that while food temperatures were generally taken, documentation was sometimes omitted. The cook acknowledged forgetting to record temperatures on occasion, and the Director of Dietary was aware of the ongoing issue with missing documentation. The facility had multiple cooks, most of whom were Servsafe certified, and the responsibility for obtaining and documenting food temperatures before service was clearly assigned to the cooks. Despite this, the required documentation was incomplete for several dates, indicating a failure to adhere to established procedures for monitoring and recording food temperatures.
Resident Dignity Compromised During Transfer
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity during a transfer involving a hoyer lift. The resident, who had intact cognition and required assistance with activities of daily living due to impairments, reported that two nurse aides were unpleasant during the transfer. The resident's care plan included interventions for managing accusatory and manipulative behaviors, as well as assistance with transfers. However, during the transfer, the resident's leg was bumped, causing pain, and the resident felt that the aides were not respectful. The incident was reported to the social worker, and an investigation was initiated. Statements from the nurse aides involved revealed that one aide chose to remain silent during the care due to past threats from the resident. After the transfer, the resident thanked one aide, prompting a sarcastic comment from another aide about the lack of gratitude towards all involved. The investigation concluded that there was no intentional harm or injury, and the allegation of abuse was unsubstantiated, but the aides' behavior was deemed disrespectful. Interviews with the resident and staff highlighted the resident's perception of the aides' rudeness and lack of competence during the transfer. The Director of Nursing Services, who was not in the position at the time of the incident, acknowledged that the behavior was disrespectful and emphasized the importance of treating residents with dignity and respect. The facility's policy on resident rights underscores the expectation for residents to be treated with consideration and respect, which was not upheld in this instance.
Failure to Obtain and Document Valid Advance Directive Consent
Penalty
Summary
The facility failed to ensure that a resident's or their representative's wishes regarding advance directives and code status were properly obtained and implemented. A resident with dementia and moderately impaired cognition was admitted with a full code status, and although a care conference was held and a new advance directive consent form was requested, the form was not signed by the resident representative. The clinical record showed that the representative's name was typed on the form, but there was no valid signature, and there was no documentation of further attempts to contact the representative or have them sign the form. The facility's policy required that the advance directive consent form be signed by the resident or representative, the physician, and the nurse who explained the directive, and that it be kept in the resident's medical record. Interviews with nursing staff revealed that it was the admitting nurse's responsibility to complete the advance directive consent form at admission, and if the representative was not present, to call and document attempts to reach them. However, there was no evidence in the record that these steps were completed for this resident. The advance directive was not found in the overflow files, and the required documentation and signatures were missing, resulting in the resident's advance directive wishes not being properly documented or implemented according to facility policy.
Failure to Notify Providers and Representatives of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician and/or resident representative of significant changes in condition for three residents, as required by facility policy. For one resident with a history of psychiatric disorders, including major depressive disorder and PTSD, the social worker documented that the resident expressed suicidal ideation during a quarterly assessment. Although this information was relayed to nursing and noted in the psychiatric APRN referral book, there was no immediate notification to the psychiatric APRN or physician. The APRN later confirmed that such comments should be reported right away to allow for timely risk assessment and intervention, but this did not occur. The facility lacked a specific policy on suicidal ideation, and staff interviews revealed uncertainty about the appropriate response and documentation for such disclosures. Another resident with advanced dementia and a history of weight loss experienced a significant unplanned weight loss over a one-month period. The clinical record showed that the resident's weight dropped by more than 7%, and the dietitian increased the resident's nutritional supplements. However, there was no documentation that the resident's representative was notified of either the weight loss or the change in dietary orders. Interviews with the dietitian and APRN confirmed that the charge nurse was responsible for this notification, but the required communication and documentation were not completed as per facility policy. A third resident with a history of falls experienced an unwitnessed fall resulting in injuries, including abrasions and bruising. The nurse on duty attempted to contact the on-call provider but was unsuccessful and did not document further attempts or escalate the notification to the medical director, as required by policy. The clinical record lacked evidence of timely provider notification following the fall, despite the resident's recent history of multiple falls and sustained injuries. The facility's policy directs that the attending physician or covering provider must be notified of any significant change of condition or accident, and if unavailable, the medical director should be contacted, but this protocol was not followed.
Failure to Notify State of New Psychiatric Diagnosis
Penalty
Summary
The facility failed to notify the State-designated authority when a resident received a new psychiatric diagnosis. The resident was originally admitted with diagnoses including Parkinson's disease, depression, and anxiety, and the initial PASARR did not identify any major mental disorder or psychotic/delusional disorder. Over time, clinical documentation, including psychiatric notes and physician orders, indicated the development of new symptoms such as paranoia, delusions, and psychosis, leading to a diagnosis of psychotic disorder with delusions. Despite these changes, the care plan and MDS assessments did not consistently reflect the new diagnosis, and the required notification to the State-designated authority was not made in a timely manner. Interviews with facility staff revealed a lack of clear communication and responsibility regarding the process for updating the State when a new psychiatric diagnosis is made. The social worker indicated it was the psychiatric provider's responsibility to inform her of new diagnoses, while the psychiatric APRN identified the date when the new diagnosis was first documented. The failure to coordinate and communicate the new diagnosis resulted in a delay in submitting the necessary PASARR Level 1 screening to determine if a Level 2 evaluation was needed.
Failure to Follow Pressure Ulcer Prevention Protocols and Equipment Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for a resident at risk, as evidenced by multiple lapses in following physician orders and manufacturer recommendations. The resident, who had a history of fibromyalgia, delirium, stroke, and a stage III pressure ulcer to the sacrum, was admitted and readmitted with orders for Braden Scale assessments on admission and weekly for four weeks, as well as weekly body audits. However, documentation revealed that the Braden Scale was not completed weekly as ordered following both the initial admission and subsequent readmission. Additionally, weekly body audits were inconsistently performed, with several weeks missing documentation despite physician orders specifying the schedule and responsible staff. Further deficiencies were observed in the use of a low air loss (LAL) mattress for the resident. Physician orders and manufacturer guidelines required the LAL mattress to be set according to the resident's weight, with regular checks for function and placement. Observations showed that the mattress was set significantly above the resident's actual weight on multiple occasions. Interviews with facility staff revealed confusion regarding whether the mattress should be set to weight or comfort, and the responsible nurse was unable to provide a current list of residents using LAL mattresses or the manufacturer guidelines. Facility protocols required risk assessments and skin audits to be completed as specified, but these were not consistently followed. The lack of adherence to physician orders, incomplete documentation, and improper equipment settings directly contributed to the deficiency in pressure ulcer care and prevention for the resident.
Failure to Provide and Document Use of Adaptive Device for Resident with Contracture Risk
Penalty
Summary
A deficiency occurred when a resident with right-sided hemiplegia and contracture risk did not receive appropriate care and use of adaptive devices as outlined in their care plan and physician orders. The resident's care plan required the application of a resting hand splint after morning care, removal after evening care, and use of a rolled washcloth after the splint was removed. However, the physician's order conflicted with the care plan, directing the splint to be applied during the evening shift and removed after morning care. The order was later discontinued without clear justification, despite the resident's ongoing need for the splint due to contracture. Multiple observations revealed that the resident was found in bed with a contracted right hand, without the splint or rolled washcloth in place, at times when the care plan indicated these should have been applied. Interviews with nursing staff and nurse aides confirmed that morning care had been completed and that the resident had not refused care. One nurse aide, who was not regularly assigned to the resident, was unaware of the splint requirement and had not reviewed the care card prior to providing care. The Director of Rehabilitation, responsible for recommending the splint, had discontinued the physician's order but could not explain the rationale, and acknowledged the resident still needed the device. Further interviews with clinical staff, including an APRN, confirmed that the splint should not have been discontinued and that the lack of its use could negatively impact the resident. Review of facility policy indicated that splints are to be provided per physician order and care plan, with documentation and skin checks required. Documentation review showed no evidence that the resident refused the splint during the relevant period, and staff interviews indicated a lack of awareness and adherence to the care plan and physician orders regarding the use of the splint and adaptive devices.
Failure to Obtain and Document Resident Weights per Policy
Penalty
Summary
The facility failed to obtain and document resident weights according to physician orders and facility policy for one resident reviewed for nutrition. Specifically, a resident with a history of heart attack and recent influenza had physician orders for weekly weights, but three of nine required weekly weights were not obtained during the specified period. Additionally, a monthly weight was not recorded for January, despite ongoing monitoring for nutritional decline and a care plan that included regular weight checks. The weight log later showed a significant weight loss of 8 lbs. (6.6%) between late November and late February. Interviews with the dietitian and LPN revealed that nurse aides were responsible for obtaining and documenting weights and reweights, but the process was self-directed and lacked clear time frames for reweighing after significant discrepancies. The dietitian and DNS acknowledged that weights were missed and not always documented as required, and that significant weight changes should have triggered reweights and notifications per policy. Review of the facility's weight monitoring policy confirmed that weights should be recorded regularly, and significant discrepancies should prompt immediate reweighing and reporting, which did not consistently occur.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to develop and implement effective infection prevention and control policies for two residents with conditions requiring enhanced barrier precautions (EBP). One resident with a surgical wound and a history of colonized MRSA was not initially placed on EBP, despite the care plan identifying the need for advanced barrier precautions. Observations revealed the absence of appropriate signage and accessible PPE near the resident's room, and staff interviews indicated a lack of understanding regarding the necessity of EBP for residents with wounds or a history of MDROs. The Infection Preventionist incorrectly stated that only residents with specific novel or targeted MDROs required EBP, and the resident was not placed on precautions until after the deficiency was identified. Further observations showed that, even after EBP signage and PPE were provided, staff failed to consistently don PPE before providing direct care to the resident. Nursing assistants entered the room and performed care activities such as providing a bedpan without wearing the required PPE, later admitting that they forgot to do so. The facility's policy required adherence to CDC and CMS guidelines, including visible signage and readily accessible PPE, but these measures were not reliably implemented or followed by staff. A second resident with an indwelling medical device for dialysis was also not placed on EBP as required. The care plan and physician's orders identified the presence of a central venous catheter and the need for infection monitoring, but interventions did not include EBP. Observations and staff interviews confirmed the absence of EBP signage and PPE, and direct care staff were unaware of the need for precautions. The Infection Control Nurse and DNS both acknowledged that the resident should have been on EBP due to the indwelling device, but this was not done until after the issue was raised during the survey.
Failure to Provide Correct Diet Consistency Leads to Choking Incident
Penalty
Summary
The facility failed to provide the correct diet consistency for a resident who was on a modified diet due to missing teeth, which increased the difficulty of chewing. The resident, diagnosed with schizoaffective disorder, was discharged from the hospital on a regular diet but was later evaluated by speech therapy and recommended a mechanical soft diet with thin liquids. Despite this, the resident was served fruit salad, which was not suitable for their dietary needs, leading to a choking incident. The resident approached the nurse's station with difficulty breathing after consuming the fruit salad, which included pieces of honeydew melon and pineapple, items not allowed on a mechanical soft diet. The incident was further detailed through interviews with facility staff. The LPN on duty described the resident's distress and the unsuccessful attempts to clear the airway, including the Heimlich maneuver, until emergency services arrived. The dietary manager confirmed that the fruit served was inappropriate for the resident's prescribed diet. The Speech Language Pathologist also confirmed that the fruit served was not suitable for a mechanical soft diet. The Director of Nursing acknowledged that the staff did not adhere to the prescribed diet consistency for the resident.
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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