Autumn Lake Healthcare At Glen Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Danbury, Connecticut.
- Location
- 1 Glen Hill Rd, Danbury, Connecticut 06811
- CMS Provider Number
- 075031
- Inspections on file
- 15
- Latest survey
- June 9, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Glen Hill during CMS and state inspections, most recent first.
An open, overflowing garbage can was observed without a lid and placed near the steam table during meal plating, remaining uncovered for about half an hour. The Dietary Manager acknowledged that the garbage can should have been covered and not in proximity to the food service area, in accordance with facility policy requiring sanitary conditions and covered trash containers.
Two residents with cognitive impairment and special dietary needs were left waiting for lunch while another resident at their table was served and ate, resulting in delays of over an hour before the waiting residents received their meals. Staff confirmed that all residents at a table should be served at the same time, and acknowledged the delay was not standard practice.
A resident with severe cognitive impairment and total dependence on staff was found with a fractured thumb of unknown origin. The facility failed to conduct a thorough investigation, as required by policy, by not identifying or interviewing all staff involved in the resident's care or documenting how care was provided during the relevant period.
A resident who was totally dependent on staff did not receive care according to their care plan, which required two staff members for all care, resulting in care being provided by only one staff member. Another resident with respiratory issues did not have interventions for respiratory care or hearing aid maintenance included in their care plan, despite staff acknowledging these omissions. The facility failed to ensure care plans were comprehensive and followed as required.
A resident with overactive bladder, urge incontinence, and CHF was identified as a good candidate for scheduled toileting by multiple screeners and urology consults, but the care plan was not updated to reflect these findings or specialist recommendations. The care plan continued to state the resident could not participate in retraining, and no toileting program was trialed, despite the resident being cognitively intact and requiring substantial assistance with toileting.
A resident with chronic health conditions who required assistance with toileting and preferred female caregivers experienced a significant delay in receiving incontinence care. Despite the care plan reflecting this preference, the resident waited over an hour for a female aide to become available, as the unit was staffed with two male aides and only one female aide. Staff interviews confirmed the delay and the challenges in accommodating resident preferences during the shift.
A resident with overactive bladder, urge incontinence, CHF, and a history of bladder cancer was identified as a good candidate for bladder retraining and scheduled toileting by multiple quarterly screeners and urology consults. Despite being cognitively intact and able to participate, no toileting program was initiated, and the care plan focused only on perineal care and monitoring. The lack of communication and follow-through on screener results and specialist recommendations led to a failure to provide appropriate continence care.
A resident with a history of acute respiratory failure and pneumonia had a standing order for continuous oxygen, but was observed multiple times without oxygen in use and confirmed not receiving it. The care plan lacked respiratory interventions, and staff interviews revealed the resident had been titrated off oxygen without updating the physician's order. Nursing staff and the DNS acknowledged the lapse in ensuring orders were current and accurately implemented.
A resident with a suprapubic urinary catheter was observed multiple times with their foley catheter drainage bag dragging on or touching the floor while attached to their wheelchair, despite facility policy and care plan directives requiring the bag to be kept off the floor. The deficiency was confirmed by the Infection Control Preventionist, who stated that staff are responsible for ensuring proper positioning of the drainage bag.
A resident with severe cognitive impairment and significant physical limitations was left alone on the toilet by a nurse aide who stepped out to retrieve supplies. During the absence, the resident attempted to stand, fell, and sustained injuries to the forehead and knee, despite care plan interventions specifying the resident should not be left alone.
The facility did not make grievance forms accessible to residents, family members, or visitors, and residents were not informed about how to file grievances. During interviews, multiple residents reported being unaware of the grievance process or the location of forms. Observations confirmed the absence of forms on units and that posted policies were not easily visible or instructive for those in wheelchairs. Staff could not provide evidence that the grievance process had been reviewed with residents.
Uncovered Garbage Can Near Food Service Area
Penalty
Summary
During the noon meal plating service, an open industrial garbage can filled to the top with trash was observed without a lid and positioned approximately 15 feet from the steam table where food was being plated. The garbage can remained open for about half an hour during the food service period. The Dietary Manager confirmed that the garbage can should have been covered and not located near the steam table during meal service, and that all kitchen staff are responsible for ensuring trash containers are covered and removed from the serving area. Facility policy requires all food preparation and service areas to be maintained in safe and sanitary conditions, including keeping all trash containers covered in leak-proof containers to prevent cross-contamination.
Failure to Serve Meals Simultaneously Compromises Resident Dignity
Penalty
Summary
Two residents with cognitive impairment and dysphagia were observed waiting for lunch in the lounge area while another resident at their table received their meal significantly earlier. One resident received their meal 1 hour and 50 minutes after the other, while the second resident waited 1 hour and 5 minutes. Both residents were care planned for nutritional risk and required specific dietary accommodations, but were left to watch another resident eat while they waited for their own meals. Staff interviews confirmed that all residents at a table should be served at the same time, and that it was not normal practice for residents to wait such a long period while others ate. The delay in meal service was attributed to the kitchen staff delivering one resident's tray at the time meals were served in the main dining room, while the other two residents' trays were not brought until much later. The nurse aide acknowledged that she should have either provided snacks or obtained the trays for the waiting residents, and reported the delay to the kitchen staff. Facility policy on resident rights emphasized dignity and respect, but a specific dining policy was not provided upon request.
Failure to Conduct Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a thorough investigation into an injury of unknown origin sustained by a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis. The resident was totally dependent on staff for all activities of daily living and required two-person assistance for bed mobility and transfers, as documented in the care plan. The resident was found with a swollen, red left thumb, which was later diagnosed as a fracture. The incident was reported as a reportable event, and the responsible party and physician were notified. The investigation initiated by the Director of Nursing Services (DNS) was incomplete. Statements from nurse aides and licensed staff did not identify which staff provided care to the resident during the relevant shifts, nor did they provide details about how care was delivered or whether any unusual occurrences took place. The DNS was unable to determine who provided care to the resident on the day prior to the injury, and some staff could not recall their involvement. Additionally, the DNS did not directly interview all relevant staff, and the investigation lacked documentation and clarity regarding the circumstances of the injury. Medical review revealed conflicting diagnoses regarding the nature of the fracture, with initial suggestions of a pathological fracture due to osteoporosis, but later clarification indicated it was not pathological. The facility's abuse policy requires immediate and thorough investigation of injuries of unknown origin, including identification and interviews of all involved individuals, but this was not followed in this case, resulting in an incomplete investigation.
Failure to Follow and Develop Comprehensive Care Plans for Resident Needs
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, involuntary movements, and osteoarthritis, who was totally dependent on staff for personal hygiene, transfers, toileting, and bed mobility, did not receive care according to their individualized care plan. The care plan and care card specified that two staff members were required to assist with all care, including bed mobility. However, a nursing assistant was observed providing care alone, despite being aware of the two-person assistance requirement. This deviation from the care plan was identified during an investigation into an injury of unknown origin, specifically a fractured left thumb, which may have resulted from care being provided by only one staff member. Another deficiency was identified for a resident with acute respiratory failure, hypoxia, pneumonia, and insomnia. The resident was cognitively intact and required oxygen therapy. The care plan for this resident did not include any interventions to address respiratory care needs, nor did it document any behaviors related to refusal of care. Nursing staff acknowledged that the omission of respiratory interventions was an oversight and that all residents on oxygen should have a care plan addressing this need. Additionally, the same resident was observed using hearing aids, but the care plan did not include interventions for the care or maintenance of the hearing aids. Staff interviews confirmed that the facility is responsible for the care and maintenance of hearing aids and that this should have been included in the care plan. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents in question.
Failure to Revise Care Plan for Incontinence Management
Penalty
Summary
The facility failed to revise the care plan for a resident with overactive bladder, urge incontinence, and congestive heart failure to reflect the resident's current status and needs. Despite multiple quarterly Bowel and Bladder Program Screeners and urology consults indicating the resident was a good candidate for scheduled toileting (timed voiding), the care plan continued to state the resident was unable to cognitively or physically participate in a retraining program due to impaired mobility. The resident was cognitively intact and required substantial assistance with toileting, but no trial of a toileting program was initiated, and the care plan was not updated to reflect recommendations from the urologist or the results of the screeners. Physician orders and specialist recommendations advised interventions such as timed toileting, limiting nighttime fluids, and avoiding irritants, but these were not incorporated into the care plan. The Director of Nursing Services confirmed that the care plan had not been updated to reflect the resident's candidacy for retraining or the recommendations from the urologist, and that the resident had not been interviewed regarding their wishes for a toileting program. Facility policy required ongoing revision of care plans as resident conditions changed, but this was not followed in this case.
Delay in Incontinence Care Due to Staffing and Resident Preference
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease and heart disease, who was cognitively intact and required partial to moderate assistance for toileting hygiene, did not receive prompt incontinence care. The resident, who was frequently incontinent of the bladder and had a documented preference for female caregivers, reported having to wait approximately two hours for incontinence care after an episode. Staff interviews confirmed that on a specific evening, the resident requested assistance from a male aide but declined care, expressing a preference for a female aide. The male aide informed the resident that they would need to wait for the female aide to become available, and the resident ultimately waited about one hour to one hour and fifteen minutes before receiving care from a female aide. Further interviews with nursing staff revealed that the unit was staffed with two male aides and one female aide at the time, and the challenge of accommodating multiple female residents' preferences for female caregivers was noted. The LPN on duty was unable to assist due to other responsibilities, and the nursing supervisor was notified of the staffing issue. The care plan for the resident had been updated to reflect the preference for female caregivers, but the resident still experienced a significant delay in receiving incontinence care.
Failure to Implement Scheduled Toileting for Incontinent Resident
Penalty
Summary
The facility failed to implement appropriate interventions to restore or manage bladder and bowel continence for a resident with a history of overactive bladder, urge incontinence, congestive heart failure, and prior bladder cancer. Despite multiple quarterly Bowel and Bladder Program Screeners indicating the resident was a good candidate for retraining or scheduled toileting, and urology consults recommending timed toileting and other interventions, there was no evidence that a toileting program or bladder retraining was trialed. The resident was cognitively intact, required substantial assistance with toileting, and had functional limitations, but the care plan and clinical record did not reflect any attempt to initiate a toileting program as recommended by both the screeners and the urologist. The care plan interventions focused on perineal care, monitoring for infection, and use of disposable briefs, but did not address the recommendations for scheduled toileting or retraining. Physician orders for medications related to bowel and bladder management were present, but the lack of communication and follow-through on the results of the continence screeners and urology recommendations led to a failure in providing appropriate care aimed at restoring or improving continence. The Director of Nursing confirmed that the nursing staff did not inform the care team of the screener results, resulting in missed opportunities to trial a toileting program.
Failure to Maintain Current Physician's Orders for Oxygen Therapy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including acute respiratory failure with hypoxia and pneumonia had a physician's order for continuous oxygen at 1 liter per minute via nasal cannula. Despite this order, multiple observations over several days showed the resident was not receiving oxygen, and the oxygen machine in the room was not in use. The resident confirmed not having received oxygen, and there was no documentation of refusal of treatment in the nurse's notes. The care plan did not include interventions for respiratory care, nor did it document any refusal behaviors. Interviews with staff revealed that the resident had been titrated off oxygen the previous week, but the physician's orders had not been updated to reflect this change. Nursing staff acknowledged responsibility for ensuring orders are accurate and implemented as written. The Director of Nursing Services (DNS) stated that orders should be updated immediately when changes occur but could not explain why the resident was not receiving oxygen as ordered or why the orders were not current. The physician's order was only updated after inquiry to reflect as-needed oxygen administration.
Foley Catheter Drainage Bag Found Touching Floor During Resident Transport
Penalty
Summary
A deficiency was identified when a resident with a suprapubic urinary catheter was observed multiple times with their foley catheter drainage bag attached to the back of their wheelchair, dragging on or touching the floor as the wheelchair was moved. The resident had diagnoses including congenital stricture of the urethra, obstructive and reflex uropathy, and urinary retention, and required moderate assistance for personal hygiene, dressing, and transfers. The resident's care plan and physician orders specified interventions for catheter care, including keeping the drainage bag below the level of the bladder and off the floor, but these were not followed during the observed periods. The facility's policy on urinary catheter care directed that catheter tubing and drainage bags be kept off the floor and handled with clean technique. Despite these requirements, the drainage bag was repeatedly seen touching the floor during several observations. The Infection Control Preventionist confirmed that the drainage bag should not be dragging or touching the floor and that staff responsible for the resident's care should ensure proper positioning of the drainage bag throughout the shift.
Resident Left Unattended in Bathroom Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, stroke with right-sided hemiplegia and hemiparesis, and vascular dementia was left unsupervised in the bathroom. The resident was severely cognitively impaired and required maximal assistance with toileting hygiene, personal hygiene, and toilet transfers, as documented in the Minimum Data Set assessment. The resident's care plan specifically identified falls as a concern and included interventions such as not leaving the resident alone and gathering all necessary items before providing care. Despite these interventions, a nurse aide left the resident alone on the toilet to retrieve an incontinent brief from the hallway. During this time, the resident stood up without assistance, fell forward, and sustained injuries including an abrasion and large bump to the forehead and an abrasion to the left knee. The incident was confirmed through clinical record review, staff interviews, and direct observation of the resident's injuries. The facility's policy required staff to implement interventions tailored to the resident's fall risk, which was not followed in this instance.
Failure to Ensure Grievance Process Accessibility and Resident Awareness
Penalty
Summary
The facility failed to ensure that grievance forms were readily available to residents, family members, and visitors, and did not adequately inform residents about the process for filing grievances. During a meeting with twelve residents who regularly attend resident council meetings, all participants stated they were unaware of the grievance process and did not know where the forms were located. Further interviews and observations revealed that no grievance forms were present on the units, and only an empty folder was found in a file drawer. The posted grievance policy was placed high above the State Ombudsman contact form, making it difficult for individuals in wheelchairs to see or read, and the policy did not provide instructions on how to obtain a form or who to contact. Although a social worker stated that the grievance process had been reviewed with residents, no evidence of this could be provided. The facility's policy supported the right to voice grievances but lacked a date and did not ensure accessibility or awareness of the grievance process.
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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