Avon Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Avon, Connecticut.
- Location
- 652 West Avon Rd, Avon, Connecticut 06001
- CMS Provider Number
- 075244
- Inspections on file
- 25
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avon Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and mobility issues, who required two staff for all ADLs per physician orders and care plan, was provided incontinent care by a single NA. During care, the resident became resistive and fell from the bed, resulting in a femur fracture. The NA did not check the care card or follow the two-staff assist directive, leading to the incident.
A resident with multiple chronic conditions reported missing cash and a credit card from their bedside wallet, later discovering unauthorized charges. Investigation found that an agency nurse aide accessed the wallet while delivering a meal tray, removed the items, and returned the wallet, violating the facility's policy against misappropriation of resident property.
The facility failed to follow its policy for changing and storing nebulizer tubing for residents requiring respiratory treatment. A resident with emphysema had tubing that was not changed weekly, and two other residents with respiratory conditions had nebulizer masks improperly stored without bags. An LPN and the DNS confirmed the expectation for weekly changes and proper storage according to the facility's policy.
A resident with cognitive impairment and dysphagia was improperly administered extended-release and delayed-release medications by an LPN who opened and crushed the capsules, contrary to facility policy and physician orders. The resident spit out the capsules, and a pharmacist later confirmed that the medications should not have been opened.
The facility did not label Morphine Sulfate 100 MG with an open date sticker after it was opened for a resident. An LPN documented the open date elsewhere, contrary to the facility's policy requiring a date open sticker on the medication container. An RN later prompted the LPN to correct this.
The facility failed to ensure proper infection control practices, as observed with a dietary aide not performing hand hygiene between glove changes and a nurse aide handling soiled linens and assisting residents without washing hands. The facility's hand hygiene policy was not followed, and no additional staff education was provided during a recent COVID-19 outbreak.
The facility failed to ensure advanced directive forms were completed and signed for two residents. One resident's DNR status was not properly documented with a signed form, despite verbal consent and a physician's order. Another resident's form lacked a facility representative's signature, despite the family's signature being present. The facility's policy did not specify when the directive needed to be signed, leading to documentation lapses.
A resident with moderate cognitive impairment reported being slapped by a nursing aide during care. The facility's internal investigation was incomplete, lacking interviews with other staff or witnesses. The incident was not documented in the medical record or reported to the state agency, violating the facility's abuse policy.
A resident with moderate cognitive impairment reported that a nursing aide slapped their hand during care. The incident was not documented in the medical record or reported to the state agency, as required by the facility's abuse policy. The Director of Nursing Services conducted an internal investigation but did not interview other staff or witnesses, concluding that the incident did not constitute abuse.
A resident with cognitive impairment reported being slapped by a nursing aide during care. The facility failed to document and thoroughly investigate the allegation, as required by their abuse policy. The DNS conducted a limited investigation without interviewing other staff or witnesses, and the incident was not recorded in the resident's medical file.
The facility failed to provide adequate supervision during meals for a resident with dysphagia, resulting in unsupervised eating despite care plan requirements. Another resident with chronic pain lacked nonpharmaceutical interventions in their care plan, relying solely on opioids. Additionally, a resident receiving antianxiety medication did not have a behavioral care plan, hindering the evaluation of intervention effectiveness.
A resident with cognitive impairment and dysphagia was involved in an incident where an LPN improperly disposed of a narcotic medication by leaving it in a cup on an uncovered trash receptacle. The LPN was unaware of the facility's policy for proper disposal, and an RN later identified the correct procedure, which was not followed due to the unavailability of a Drug Buster.
A facility failed to provide therapeutic recreation activities for a non-verbal resident with Alzheimer's, leaving them without stimulation for hours. Despite a care plan that included escorting the resident to activities and offering music, observations and interviews revealed a lack of engagement and coordination between nursing and recreation staff.
The facility failed to conduct timely nutritional assessments and reposition two residents with pressure ulcers. One resident with Multiple Sclerosis developed a stage II pressure ulcer without a subsequent nutritional assessment. Another resident with diabetes and Alzheimer's disease developed two new pressure injuries and was not repositioned as per the care plan, remaining in a wheelchair for extended periods. Facility policies for wound management and nutrition therapy were not followed.
Failure to Follow Two-Staff Assist Orders Results in Resident Fall and Fracture
Penalty
Summary
A resident with severe cognitive impairment, Alzheimer's disease, anxiety, and osteoarthritis was admitted with orders for comfort care, do not hospitalize, and required extensive assistance from two staff for bed mobility and activities of daily living (ADLs). The resident's care plan and physician orders specifically directed that two staff members assist with all ADLs and that a Hoyer lift be used for transfers, as the resident was non-ambulatory and at high risk for falls due to impaired mobility, incontinence, and cognitive impairment. On the day of the incident, a nurse aide (NA) provided incontinent care to the resident alone, despite the care plan and physician orders requiring two staff for such care. During the process of turning the resident onto their side, the resident became resistive and rolled away from the NA, ultimately falling from the bed to the floor. The NA was unable to prevent the fall, which resulted in the resident sustaining an acute distal femur fracture. The NA later stated she believed only one staff member was needed for ADL care and was unaware of the requirement to check the resident care cards prior to providing care. Interviews with facility staff confirmed that the resident required two staff for all care, including turning and positioning, and that this information was available on the electronic care card accessible to all staff. The NA involved did not consult the care card before providing care and proceeded alone, contrary to established orders and care plans. The incident led to the resident requiring a hospital transfer for a closed reduction of the fracture, after initial management in the facility.
Failure to Protect Resident from Theft of Personal Property by Staff
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including acute-on-chronic diastolic heart failure, essential hypertension, and Type 2 diabetes, reported that their credit card and cash were missing from their wallet, which was kept at the bedside. The resident was alert, oriented, and required staff assistance with activities of daily living. The incident was discovered after the resident noticed unauthorized charges on their credit card and missing cash, with the last known presence of the items being the day before the charges began. Facility documentation and interviews revealed that a nurse aide, who was an agency staff member and had limited prior shifts at the facility, had access to the resident's wallet while delivering a meal tray. The aide took the wallet from the nightstand, removed the credit card and cash, and then returned the wallet. The facility's abuse policy prohibits misappropriation of resident property, defined as the wrongful use of a resident's belongings or money without consent. The aide was not available for a facility interview but later admitted to the theft during a police investigation.
Failure to Change and Store Nebulizer Tubing as per Policy
Penalty
Summary
The facility failed to adhere to its policy for changing and storing nebulizer tubing for residents requiring respiratory treatment. Resident #32, diagnosed with centrilobular emphysema and a cardiac pacemaker, had a nebulizer mask with tubing dated 7/2/24, which was not changed weekly as required. The Licensed Practical Nurse (LPN) confirmed the tubing should have been changed weekly, and the Director of Nursing Services (DNS) expected compliance with this policy. The facility's policy directed that nebulizer masks be changed weekly and stored in a clear bag when not in use. Similarly, Resident #51, with diagnoses including congestive heart failure and a history of acute respiratory failure, had a nebulizer mask left on the bedside table without a storage bag. The LPN acknowledged the mask should have been stored in a plastic bag, and the DNS confirmed this expectation. Additionally, Resident #52, diagnosed with chronic obstructive pulmonary disease, had a nebulizer mask on the bedside table without a bag, with tubing dated 12/13/23, indicating it was not changed weekly. The LPN and DNS both confirmed the expectation for weekly changes and proper storage according to the facility's policy.
Improper Administration of Extended-Release Medications
Penalty
Summary
The facility failed to ensure the proper administration of extended-release and delayed-release medications for a resident with essential hypertension, mood disorder, and gastric esophageal reflux. The resident, who was severely cognitively impaired and had dysphagia, required medications to be crushed. During a medication administration observation, an LPN was seen opening and crushing the capsules of Propranolol 120 MG extended-release and Duloxetine 60 MG delayed-release, mixing them with applesauce, and attempting to administer them to the resident. Upon intervention by the surveyor, the LPN acknowledged the error and repoured the medications, but the resident spit out the capsules. The facility's policy on medication crushing guidelines, dated June 2024, indicated that time-released capsules should not be opened without consulting a reference or pharmacist. A subsequent review with a pharmacist confirmed that the Propranolol and Duloxetine capsules should not be opened, as they are designed to release medication over a sustained period. The incident highlighted a significant medication error due to the improper preparation of medications, which was not in accordance with the facility's policy or the physician's orders.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to appropriately label medications once opened in one of its medication rooms. During an observation of the A/B Wing medication room, it was identified that Morphine Sulfate 100 MG prescribed to a resident was opened but did not have a date open sticker on the medication container. An interview with an LPN revealed that the date was documented elsewhere, specifically in the Medication Book, which indicated the Morphine was opened on 7/7/24. Following an inquiry, an RN prompted the LPN to place the open date on the container. The facility's Storage of Medications Policy requires that when the original seal of a manufacturer's container or vial is initially broken, the container or vial must be dated. The policy specifies that the nurse should place a date open sticker on the medication, which was not adhered to in this instance.
Infection Control Deficiencies in Dietary and Nursing Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed by staff, as observed during a survey. Dietary Aide #1 was noted to have a facial hair covering that did not adequately cover the facial hair of the upper lip while plating food. After being advised by the Dietary District Manager, the aide adjusted the facial hair net but failed to perform hand hygiene between glove changes. The facility's hand hygiene policy requires hand washing after glove removal, which was not adhered to in this instance. Additionally, Nurse Aid (NA) #4 was observed handling soiled linens and interacting with residents without performing necessary hand hygiene. NA #4 exited a resident's bathroom with dirty linens and gloves, used the gloved hand to open doors, and accessed the dirty linen cart without removing the gloves. Furthermore, NA #4 was seen eating chips and licking fingers before assisting a resident with a tissue, again without washing hands. The facility's hand hygiene policy mandates hand washing before and after resident care and glove use, which was not followed. The Director of Nursing Services (DNS) acknowledged the lack of additional staff education on infection control during a recent COVID-19 outbreak.
Failure to Complete and Sign Advanced Directive Forms
Penalty
Summary
The facility failed to ensure that the advanced directive election forms were completed and signed by the resident or responsible party after verbal consent was obtained to change the election, and a physician order was written. For Resident #8, despite a physician's progress note and order indicating a Do Not Resuscitate (DNR) status, the advanced directive election form reflecting this change was not signed by the resident. The resident's care plan and Minimum Data Set (MDS) assessment indicated a DNR status, but the facility could not locate a signed form confirming this. Interviews with the Director of Nursing Services (DNS) and a Registered Nurse (RN #3) revealed that the form was missing, and a new form was awaiting signature, indicating a lapse in ensuring proper documentation. For Resident #405, the facility also failed to have the advanced directive form signed by a facility representative, despite the family's signature being present. The resident was identified as cognitively impaired and required extensive assistance, with a care plan indicating DNR and Do Not Intubate (DNI) status. However, the facility's policy did not specify when the advanced directive needed to be signed, leading to a lack of clarity and proper documentation. The DNS was unable to explain why the form was not signed by the facility representative, highlighting a deficiency in the facility's adherence to its own policies regarding advanced directives.
Failure to Implement Abuse Policy and Document Incident
Penalty
Summary
The facility failed to implement its abuse policy for an allegation of abuse involving a resident with moderate cognitive impairment and requiring substantial assistance with personal care. The resident, who was receiving palliative care, reported to a social worker that a nursing aide had slapped their hand during care. The internal investigation conducted by the Director of Nursing Services (DNS) concluded that the aide had not slapped the resident, but the investigation lacked thoroughness as it did not include interviews with other staff or potential witnesses. The incident was not documented in the resident's medical record, and no Accident/Incident report was filed. Additionally, the incident was not reported to the state agency's online Reportable Event portal. The facility's abuse policy requires thorough investigation and documentation of all allegations, but these procedures were not followed in this case. Interviews with staff revealed inconsistencies in the reporting and documentation of the incident. The social worker and DNS provided conflicting dates regarding when the incident was reported and investigated. The social worker did not document the date of the allegation, and the DNS admitted to writing the wrong date on the internal investigation. The facility's failure to adhere to its abuse policy and properly document and report the incident resulted in a deficiency.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a resident to the state agency. The resident, who had moderate cognitive impairment and required assistance with personal hygiene, reported that a nursing aide slapped their hand during care. The incident was reported to the social worker by a third party, but there was no documentation in the medical record or any report made to the state agency. The Director of Nursing Services conducted an internal investigation but did not interview other staff or witnesses, concluding that the incident did not constitute abuse. The facility's abuse policy requires that all allegations of abuse be investigated, documented, and reported according to federal and state guidelines. However, the facility did not follow these procedures, as evidenced by the lack of documentation and failure to report the incident to the state agency. The Director of Nursing Services did not consider the incident an allegation of abuse, which led to the deficiency in reporting and documentation as required by the facility's policy.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to initiate and complete a thorough investigation for an allegation of abuse involving a resident with moderate cognitive impairment and multiple health conditions, including heart disease and diabetes. The incident involved a nursing aide allegedly slapping the resident's hand during personal care. The resident reported the incident to a third party, who then informed the social worker. However, the facility did not maintain proper documentation of the investigation, and there was no record of the incident in the resident's medical file. The Director of Nursing Services (DNS) conducted an internal investigation but did not interview other staff or potential witnesses, relying solely on interviews with the resident and the nursing aide involved. The facility's abuse policy requires thorough investigation and documentation of all allegations, but this was not adhered to in this case. The DNS acknowledged a mistake in recording the date of the incident and did not document the incident in the electronic medical record, citing no change to the care plan. The nursing aide involved, who was a floating aide, denied slapping the resident and stated they were assisting the resident with handwashing. The lack of documentation and comprehensive investigation led to the deficiency noted by the surveyors.
Deficiencies in Supervision, Pain Management, and Behavioral Care Plans
Penalty
Summary
The facility failed to provide adequate supervision during meals for a resident diagnosed with Alzheimer's disease, dysphagia, and dyskinesia of the esophagus. Despite orders for aspiration precautions and supervision during meals, the resident was observed eating independently without staff supervision. The Speech Therapist later adjusted the care plan to require assistance as needed, but documentation of meal assistance was inconsistent, with many instances of missing records and incorrect levels of assistance noted. Another deficiency involved a resident with chronic pain who was prescribed opioid medications. The care plan did not include nonpharmaceutical interventions for pain relief, and there was no evidence of alternative pain management strategies being explored. The facility's policy emphasized the importance of using interventions to prevent pain from interfering with quality of life, yet the care plan lacked documentation of any non-medication interventions. Additionally, the facility failed to address specific behaviors and interventions in the care plan for a resident receiving antianxiety and antidepressant medications. Although there were orders for behavioral monitoring, the care plan did not include strategies for managing the resident's anxiety. This oversight was acknowledged by staff, who noted that without a behavioral care plan, the effectiveness of interventions could not be evaluated.
Improper Disposal of Narcotic Medication
Penalty
Summary
The facility failed to ensure the proper disposal of a narcotic medication during medication administration for a resident diagnosed with essential hypertension, mood disorder, and gastric esophageal reflux. The resident, who was severely cognitively impaired and had dysphagia, was prescribed Propranolol and Duloxetine. During a medication administration observation, an LPN indicated the need to dispose of medications, including a narcotic, before repouring them for the resident. However, the discarded medications were left in a cup on top of an uncovered trash receptacle, indicating improper disposal. The LPN involved admitted to not knowing the facility's policy for proper disposal of medications, including narcotics. An RN later identified that the medication should have been disposed of using a Drug Buster, which was not available at the time. The facility's policy required that controlled medications be destroyed in the presence of two licensed nurses if not administered. Despite a request, the facility did not provide the specific policy for narcotic disposal, highlighting a deficiency in adherence to professional standards of quality in medication management.
Failure to Provide Therapeutic Recreation Activities
Penalty
Summary
The facility failed to provide therapeutic recreation activities to meet the psycho-social needs of a resident diagnosed with diabetes mellitus, pain, and Alzheimer's disease. The resident was identified as severely cognitively impaired, non-verbal, and dependent for all aspects of care. The Resident Care Plan included interventions such as informing, inviting, and escorting the resident to appropriate recreation programs, offering music in the room, and providing one-on-one recreation visits to promote socialization. However, observations on a specific date revealed that the resident was left in a wheelchair at the bedside without any form of stimulation for several hours. Interviews with the Recreation Director and Recreation Therapists indicated that the resident was brought to activities and provided with sensory stimulation like stuffed animals and music. However, documentation showed that the resident was only engaged in activities on one day during the week in question, with no further activities or one-on-one visits documented. The Recreation Therapists acknowledged challenges in getting residents to activities, particularly non-verbal residents, due to a lack of coordination between the nursing and recreation departments. The Recreation Director also noted that the nursing department did not consistently follow through with bringing residents to activities.
Failure to Conduct Nutritional Assessments and Reposition Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper nutritional assessment and care for two residents with pressure ulcers. Resident #25, diagnosed with Multiple Sclerosis, was identified as being at risk for pressure ulcers. Despite the development of a stage II pressure ulcer on the left heel, no subsequent nutritional assessment was conducted to determine if dietary modifications were needed. The dietitian, who was responsible for monitoring residents with wounds, did not assess Resident #25's nutritional status after the pressure ulcer was reported, as confirmed by the Director of Nursing Services. Resident #42, with diagnoses including diabetes mellitus and Alzheimer's disease, developed two new pressure injuries on the left heel. Despite being at high risk for skin impairment, no nutritional assessment was conducted following the development of these injuries. The resident's care plan directed repositioning every two hours and a maximum of two hours in a wheelchair, but observations revealed the resident remained in the wheelchair for extended periods without repositioning. Interviews with nursing staff confirmed the care plan was not followed, and the resident was not repositioned as required. The facility's policies for wound management and medical nutrition therapy were not adhered to, as evidenced by the lack of timely nutritional assessments and failure to reposition residents according to their care plans. The Director of Nursing Services acknowledged the expectation for repositioning residents with pressure injuries every 2-3 hours, which was not met 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
