Apple Rehab Shelton Lakes
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Connecticut.
- Location
- 5 Lake Road, Shelton, Connecticut 06484
- CMS Provider Number
- 075300
- Inspections on file
- 23
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Apple Rehab Shelton Lakes during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a need for set-up assistance with showers was scheduled to receive weekly showers and preferred this method of bathing. Over a two-month period, documentation showed the resident received only two out of nine scheduled showers, with no records indicating showers were provided, refused, rescheduled, or that alternative hygiene measures were offered for the remaining dates. Facility policy required weekly bathing offers and proper documentation, which was not followed.
A resident with severe cognitive impairment and psychiatric diagnoses was not included, nor was their representative, in the development and implementation of their person-centered care plan. Required interdisciplinary team meetings were not documented or held within policy timeframes, and staff could not provide evidence or explanation for the omission, despite facility policy mandating collaborative care planning with the resident and/or family.
The facility failed to maintain a safe, clean, and homelike environment, with observations of stained and discolored toilet seats, marred walls, and stained tiles in various rooms. The Director of Maintenance was unable to provide documentation of environmental rounds or a plan to address these issues. Additionally, concerns about stained ceiling tiles were confirmed, although no mold was found. The facility's policy required department heads to correct identified issues, but no specific policy for maintaining cleanliness was provided.
A resident with CHF did not have daily weights conducted as per physician orders, with only partial compliance over three months. The ADNS could not explain why weights were signed off as completed but not documented, indicating a lapse in oversight and documentation.
The facility failed to provide timely audiology services for several residents, resulting in untreated hearing issues. Residents with cognitive impairments and other diagnoses were not evaluated due to missing physician's orders and lack of follow-up on recommendations. The DNS and Social Worker did not effectively oversee the process, leading to systemic issues in coordinating outside medical appointments.
The facility failed to properly store and label IV therapy supplies, with observations revealing loose heparin and saline flushes stored incorrectly, expired supplies, and mislabeled boxes. The Infection Preventionist acknowledged the issues, including the need to return resident-specific supplies after discharge. Additionally, a policy for drug destruction was not provided.
The facility failed to maintain sanitary food service practices and proper food storage. A dietary aide reused a plate cover for multiple meals, and another aide touched the inside of the cover with bare hands. Additionally, opened food items in the refrigerator were not dated, and dented cans were found in the dry storage room, violating facility policies.
The facility failed to adhere to infection control standards for catheter management and enhanced barrier precautions. A resident's urinary collection device was improperly placed on the floor, and another resident's Foley catheter bag was uncovered. Additionally, residents requiring enhanced precautions lacked proper signage and PPE availability, leading to staff confusion. During wound care, staff did not follow gowning protocols for a resident on enhanced precautions.
The call bell system in the rehabilitation wing failed to relay calls to the nursing station, lighting up outside rooms but not sounding at the station. Staff were unaware of the error message, and maintenance identified a malfunctioning part needing replacement. Facility records showed delays in repair due to part shipment issues, and previous repair documentation was unavailable.
A resident with dysphagia experienced significant weight fluctuations, but the facility failed to obtain re-weights as required by their policy. Despite a 5-pound discrepancy threshold, re-weights were not consistently conducted, and staff interviews revealed a lack of adherence to the policy. The dietician and nursing staff did not ensure proper weight monitoring, leading to the deficiency.
A facility failed to update the care plan for a resident who elected Hospice/End of Life services. Despite being admitted to hospice care, the resident's MDS assessment did not reflect this change. The Social Worker did not find a Hospice care plan in the resident's record, and the MDS Coordinator did not initiate one as required. Facility policy mandates care plans be updated to reflect changes in residents' status, which was not followed.
Two residents with urinary collection devices were not treated with dignity, as their devices were left uncovered and visible. One resident, who was moderately cognitively impaired, had their urine collection device exposed to view from the open room door. Another resident, who was cognitively intact, had their Foley bag uncovered on the floor. Facility staff were unaware of the requirement for privacy covers, contrary to the facility's policy.
Failure to Provide and Document Weekly Showers for Resident Requiring ADL Assistance
Penalty
Summary
A resident with diagnoses including dementia, cerebral infarction, and anxiety disorder, and a BIMS score indicating severe cognitive impairment, was identified as requiring set-up assistance for showers and had a care plan specifying assistance with activities of daily living (ADLs). The resident's care card scheduled weekly showers and noted a preference for showers. However, documentation review for a two-month period showed that out of nine scheduled weekly shower opportunities, the resident received only two showers. There was no documentation for the remaining seven scheduled shower days to indicate that a shower was provided, refused, rescheduled, or that alternative hygiene measures were offered. Further review of clinical records did not reveal any evidence that the resident refused showers on the missed dates, nor was there documentation of staff re-attempting or notifying the nurse as required by facility policy. The DON confirmed that if a shower is not documented as given or refused, it is considered not performed. The facility's Bathing/Shower Policy requires that each resident be offered a full bath or shower at least weekly, with staff responsible for assisting and ensuring safety throughout the process.
Failure to Include Resident and Representative in Care Plan Development
Penalty
Summary
The facility failed to ensure the inclusion of a resident and/or their representative in the development and implementation of a person-centered care plan. Clinical record review showed that a resident with schizophrenia and depression, who had severe cognitive impairment and was dependent on personal care, was admitted with a designated responsible party holding Power of Attorney. The care plan directed family involvement, but there was no documentation of any interdisciplinary team (IDT) meetings from admission through several months, despite facility policy requiring such meetings within specific timeframes. The facility was unable to provide evidence that an admission care plan meeting or any subsequent meetings occurred as required. A social services note eventually documented a telephone care plan meeting with the responsible party, and a later IDT care plan meeting document failed to clarify if the resident or their representative were present or invited. Interviews with staff confirmed that required care plan meetings had not been conducted as per policy, and they could not explain the omission. Facility policy explicitly required inviting the resident and/or family to all care plan conferences and developing the care plan collaboratively, but this was not followed in the resident's case.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of environmental deficiencies. On December 2, 2024, various rooms were found with discolored and stained toilet seats, marred walls, stained tiles, and other forms of damage such as exposed sheetrock and rusted metal trim. Additionally, brown stains were observed on curtains and walls, and some areas had missing or damaged baseboards. The Director of Maintenance acknowledged responsibility for overseeing maintenance and housekeeping but could not provide documentation of environmental rounds or a plan to address these issues. The facility's policy for Infection Control Surveillance and Safety Rounds required regular surveillance by the infection control nurse or designee, with department heads responsible for correcting identified issues, but no specific policy for maintaining a clean environment was provided. Further concerns were raised through the state agency's online reporting system regarding stained ceiling tiles and potential mold in ceiling registers. A tour on December 4, 2024, confirmed the presence of scattered stained tiles, including a cracked tile in the chapel and stained tiles in the resident lounge and hallway. However, no mold was observed by the state agency's Building Fire and Safety inspection team. The facility's policy indicated that department heads were responsible for addressing issues identified during surveillance rounds, but the report does not mention any corrective actions taken to resolve these deficiencies.
Failure to Conduct and Document Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to consistently conduct daily weights for a resident with Congestive Heart Failure (CHF) as per physician orders. The resident, who is cognitively impaired and requires assistance with personal hygiene and dressing, had a physician's order for daily morning weights due to CHF. However, a review of the clinical records revealed that the facility only conducted 4 out of 8 daily weights in December, 7 out of 30 in November, and 14 out of 31 in October. This inconsistency in monitoring the resident's weight, which is crucial for managing CHF, was not in compliance with the physician's orders. Interviews with the Assistant Director of Nursing Services (ADNS) revealed that weights are documented in the facility's electronic records, and if a resident refuses, it should be noted in the progress notes. Despite the expectation that weights are documented, the ADNS could not explain why daily weights were signed off as completed but not documented in the clinical record. The charge nurse, ADNS, and Director of Nursing Services (DNS) are responsible for ensuring that tasks are completed, indicating a lapse in oversight and documentation processes within the facility.
Failure to Ensure Timely Audiology Services for Residents
Penalty
Summary
The facility failed to ensure that residents received proper treatment to maintain adequate hearing, as evidenced by the cases of five residents. Resident #16, who was diagnosed with dementia and major depressive disorder, was identified as severely cognitively impaired and required assistance with activities of daily living. Despite being placed on a list for an audiology visit, the resident's hearing loss could not be evaluated due to ear wax, and recommendations for wax removal were not followed up. The Social Worker responsible for overseeing medical specialty services did not follow up on the provider requests, and the Director of Nursing Services (DNS) was unaware of the concerns related to residents not being seen or recommendations not being followed. Resident #18, diagnosed with anxiety disorder and arteriosclerosis, was cognitively intact but dependent on assistance for daily activities. The resident refused services initially and was rescheduled, but the evaluation could not proceed due to the absence of a physician's order. The Administrator and DNS acknowledged that the contracted vendor appointments are initiated upon admission, and the DNS is responsible for overseeing the process, but there was a lack of timely follow-up. Resident #23, with dementia and cataracts, was scheduled for an audiology consultation due to decreased responsiveness, but the evaluation did not occur due to missing physician's orders. Similarly, Resident #76, diagnosed with hypertension and Alzheimer's disease, had a recommendation for wax removal that was not followed up with a physician's order. Resident #83, with cerebral infarction and dementia, also had hearing loss evaluation hindered by ear wax, and there was no follow-up on the recommendations. The facility's policy for outside medical appointments was not effectively implemented, leading to a systemic issue of inadequate follow-up on audiology services.
Improper Storage and Labeling of IV Supplies
Penalty
Summary
The facility failed to ensure that Intravenous (IV) therapy supplies were stored and labeled appropriately, and that expired supplies were removed from storage. During an observation and interview with the Infection Preventionist (IP) RN, it was identified that individually wrapped loose IV heparin and saline flushes were stored in large boxes on a lower shelf, with clear bags containing resident-specific IV flush syringes placed on top. Additionally, central line dressings were scattered behind these boxes. The IP acknowledged that some of these supplies were extra and that certain resident supplies needed to be returned as the residents had been discharged. Further observations in the central supply closet revealed IV supplies in a box without labels indicating whether they were house stock or resident-specific. Another large box contained approximately 100 unused heparin flushes, with two randomly selected flushes showing an expiration date of 2021. The IP admitted responsibility for checking expiration dates and indicated that the supplies would be immediately checked. In the short-term unit medication room, a box labeled for Normal Saline flushes was found to contain Heparin flushes, prompting the IP to instruct the charge nurse to label the flushes correctly. The facility's policy on returning medications to the pharmacy was not followed, as unopened supplies were not returned within the specified timeframe, and a policy for drug destruction was not provided upon request.
Sanitation and Food Storage Deficiencies in Dietary Department
Penalty
Summary
The facility failed to ensure that dietary staff served food in a sanitary manner, as observed during a noon meal service. A dietary aide reused a plate cover for multiple resident meals, holding it against their clothing and placing it upside down on the steam table. Another dietary aide touched the inside of the plate cover with bare hands before plating a meal for another resident. The dietary aides admitted to the breach in sanitary practice, with one aide citing nervousness and a lack of clean covers as reasons for the reuse. The dietary manager confirmed that the facility had enough plate covers and that the practice of reusing them was against the facility's policy. Additionally, during a tour of the dietary department, it was observed that several food items in the walk-in refrigerator were opened without being dated, contrary to the facility's stock rotation policy. Furthermore, 13 dented cans of diced peaches were found in the dry storage room, which should have been removed according to the facility's damaged food container policy. The dietary manager acknowledged these issues, stating that all kitchen staff are responsible for dating opened items and that dented cans should be returned to the vendor.
Infection Control Deficiencies in Catheter and Precaution Management
Penalty
Summary
The facility failed to adhere to infection control standards in the management of urinary catheters for two residents. Resident #28, who was moderately cognitively impaired, was observed with a urinary collection device placed in a basin on the floor without a privacy cover, contrary to physician orders and facility policy. The Director of Nursing Services and a Nurse Aide confirmed the improper placement of the urine collection device. Similarly, Resident #32's Foley catheter bag was repeatedly observed on the floor and uncovered, with staff unaware of the requirement for a privacy bag, indicating a lack of adherence to the facility's catheter care policy. The facility also failed to implement appropriate infection control measures for residents requiring enhanced barrier precautions. Resident #71, who had a urinary tract infection with ESBL, was observed without proper signage or a PPE cart outside the room, leading to confusion among staff about the necessary precautions. The Assistant Director of Nursing and the Infection Preventionist acknowledged the oversight and the need for immediate corrective action. Additionally, Resident #153, who had an indwelling urinary catheter and multiple wounds, was not placed on enhanced precautions upon admission, and no signage was posted to indicate the need for such precautions. Furthermore, the facility did not follow infection control practices during wound care for Resident #2, who had a stage 3 pressure ulcer and was on enhanced barrier precautions. During a wound care procedure, staff failed to gown, as required by the facility's policy, despite the resident's need for enhanced precautions. The Wound APRN and Infection Preventionist admitted to not following protocol during the procedure, highlighting a lapse in infection control practices.
Call Bell System Malfunction in Rehabilitation Wing
Penalty
Summary
The facility failed to ensure that the call bell system on the rehabilitation wing was functioning properly, as it did not relay calls directly to the centralized nursing station. A concern was raised by the state agency indicating that when a call bell was pushed, it would light up above the resident's door but would not ring at the nurse's station. During an observation, it was confirmed that the call lights outside the rooms lit up, but there was no sound at the nurse's station, and an error message was displayed. Staff interviews revealed that the issue was related to a malfunctioning part that needed replacement, and the system required rebooting to function temporarily. The facility records showed that a work order was signed with a vendor for repair of the call bell system, and although the majority of the system was returned to functionality, some areas remained unresolved. The vendor indicated delays in part shipment due to additional spare parts being ordered. The facility was unable to provide documentation regarding previous repairs done by a corporate regional electrician. The facility's policy requires non-functional call bells to be reported to maintenance promptly, and alternative methods of requesting assistance should be provided if there is an extended downtime, which was not documented in this case.
Failure to Adhere to Weight Monitoring Policy
Penalty
Summary
The facility failed to adhere to its policy on weight monitoring for a resident diagnosed with dysphagia, who experienced significant weight fluctuations. Upon admission, the resident's weight was recorded inaccurately, leading to a discrepancy with the hospital discharge weight. Over several months, the resident's weight varied significantly, with gains and losses exceeding the facility's threshold for re-weighing. Despite these fluctuations, re-weights were not consistently obtained as required by the facility's policy, which mandates re-weighing if there is a 5-pound discrepancy from the previous weight. Interviews with the dietician and nursing staff revealed a lack of consistent communication and adherence to the weight monitoring policy. The dietician acknowledged the discrepancies but did not recall requesting re-weights, and the charge nurse indicated that the decision for re-weighing was left to the dietician. The Assistant Director of Nursing Services (ADNS) confirmed that re-weights should have been obtained per policy. The facility's failure to consistently monitor and verify the resident's weight changes as per their policy led to the deficiency identified in the report.
Failure to Revise Care Plan for Hospice Resident
Penalty
Summary
The facility failed to revise the care plan for a resident who elected Hospice/End of Life services. The resident, diagnosed with dementia and arteriosclerotic heart disease, was admitted to hospice care on 11/23/2024. However, the annual Minimum Data Set (MDS) assessment did not reflect this change, as it indicated the resident did not receive Hospice services and did not have a prognosis of six months or less. During an interview and record review on 12/6/2024, it was revealed that the Social Worker responsible for hospice residents did not find a Hospice care plan in the resident's record. The MDS Coordinator was expected to initiate a hospice care plan at the time of the Significant Change MDS, but this was not done. The facility's policy requires care plans to be updated at least quarterly and as necessary to reflect changes in residents' status, which was not adhered to in this case.
Failure to Ensure Dignity for Residents with Urinary Devices
Penalty
Summary
The facility failed to ensure that residents with urinary collection devices were treated with dignity, as evidenced by observations and interviews involving two residents. Resident #28, who was moderately cognitively impaired and required assistance with activities of daily living, was observed with a urinary collection device without a privacy cover, exposing the device to view from the open room door. The Director of Nursing Services (DNS) was unaware of the requirement for a privacy cover, and a nurse aide admitted to routinely leaving the urine collection device on the floor without a cover. The facility's policy directed that a privacy bag should be used to ensure dignity. Similarly, Resident #32, who was cognitively intact but required maximal assistance for personal hygiene, was observed with an uncovered Foley bag on the floor. A registered nurse was unsure of what a privacy bag was and failed to ensure the Foley bag was covered. The facility's catheter care policy required the use of a privacy bag to maintain resident dignity, which was not adhered to in these cases.
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 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 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 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 significant cardiac and respiratory diagnoses experienced respiratory symptoms and wheezing that prompted multiple APRN evaluations and orders, including a chest x-ray and IV Lasix. Staff notes later documented hypoxia, oxygen administration, and stat orders for labs and a chest x-ray on the day the resident died from heart failure related to sick sinus syndrome and COPD. However, the clinical record lacked documentation of an earlier chest x-ray order, any reason it was not performed, and respiratory assessments prior to the acute decline, despite staff recalling prior wheezing. Leadership acknowledged that nursing staff should have documented the change in condition and related assessments in accordance with the facility’s documentation policy.
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.
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 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 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 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 Document Respiratory Change in Condition and Ordered Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with multiple cardiac and respiratory diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease. The resident’s care plan directed staff to administer medications as ordered and monitor for abnormal breath sounds, difficulty breathing, and signs of heart failure. An APRN evaluated the resident due to respiratory symptoms and increased wheezing and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from that period did not contain an order for the chest x-ray, nor any documentation explaining why the x-ray was not performed. Subsequently, the APRN again evaluated the resident at nursing’s request for a change in respiratory condition and documented that there were no signs of dyspnea, CHF, or glycemic issues, and that the resident was not in apparent distress. Later, the APRN documented another visit for increased respiratory distress, during which Lasix 40 mg IV was administered and a stat chest x-ray was ordered. Nursing notes documented that 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 ordered stat labs, a stat chest x-ray, and continuation of oxygen. The resident’s death was later pronounced the same day, with the death certificate listing heart failure due to sick sinus syndrome and COPD as the primary cause of death. Record review showed no documentation of the chest x-ray order on the earlier date, no documentation for the reason the chest x-ray was not performed, and no documentation of respiratory-related assessments prior to the later date, despite staff recalling episodes of wheezing and respiratory concerns in the week prior. The APRN confirmed she had ordered a chest x-ray and discussed the plan with a nurse but could not recall which staff member or why the order was not entered or carried out, and could not locate documentation explaining the omission. The ADON and the President of Clinical Services stated that nursing staff should have documented the change in condition and related assessments when the APRN was asked to see the resident for respiratory changes, and that the facility failed to follow its Documentation Policy requiring complete, accurate, and timely documentation by the end of the shift in which assessments or care occurred.
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.
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