Candlewood Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Milford, Connecticut.
- Location
- 30 Park Lane East, New Milford, Connecticut 06776
- CMS Provider Number
- 075416
- Inspections on file
- 21
- Latest survey
- June 7, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Candlewood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a secure environment in a memory care unit, as several doors, including 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were not fully closed, latched, or locked. The 'Shower' door was also unlocked. Interviews revealed that moisture prevented proper door closure, and the Director of Maintenance was unaware of the locking requirement. No facility policy for a safe environment was provided.
The facility failed to properly store and label medications, as observed in four medication carts. A resident's medication was not refrigerated as required, and two residents' medications were not labeled correctly on the Apple Blossom Unit. Additionally, an expired medication was found in the Dogwood unit. Staff interviews revealed a lack of adherence to facility policy, which mandates proper storage, labeling, and expiration checks.
The facility failed to maintain cleanliness in the laundry room, with vents and a smoke detector covered in debris. The Laundry Supervisor was unsure of the last cleaning date, and cleaning logs were not readily available. The IP/LPN confirmed that vents should be cleaned weekly, but the policy was not followed. A review of logs showed specific cleaning dates in May, but the June log lacked a specific date, only stating cleaning occurred on the surveyor's inquiry day.
Two residents experienced a lack of dignity and respect from a nurse aide (NA) who delayed assistance with toileting and raised her voice when addressed. One resident, with COPD and respiratory failure, reported the incident, but the facility failed to document a thorough investigation. The other resident, requiring total assistance due to hemiplegia, was left waiting for help, contrary to facility policy.
A resident with acute kidney failure and duodenitis experienced recurring diarrhea after admission to a facility. Despite the symptoms, the nursing staff failed to notify the physician in a timely manner. Interviews revealed communication lapses, with an LPN assuming the condition was documented and not reporting it to a supervisor or physician. The Medical Director was not informed of the recurrent episodes until later, contrary to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment was struck in the chest by another resident with similar conditions in an unprovoked altercation. The incident was witnessed by an LPN, who confirmed no prior signs of agitation. The facility's policy requires intent to harm for abuse classification, but the incident was reported, and the involved resident was placed under observation and sent for evaluation.
A resident with Alzheimer's and insomnia was not administered medications as prescribed, as pills were found in their nightstand drawer. Despite no swallowing disorders, the resident was at risk for aspiration and required a ground diet. Staff interviews revealed that oral checks to confirm medication ingestion were not consistently performed, although it was a standard practice learned during nursing education.
A resident with acute kidney failure and duodenitis experienced diarrhea and gastric upset after eating shrimp, but the nursing staff did not report the change of condition to a supervisor or physician. Additionally, the resident had a nosebleed that was not followed by a documented nursing assessment. The facility lacked a policy for RN assessments, leading to a deficiency in care.
A resident with multiple health conditions, including diabetes and cancer, developed new pressure wounds, but the facility failed to reassess their nutritional status. Despite weekly discussions with the interdisciplinary team, the Dietitian was unaware of the new wounds and did not conduct a reassessment, contrary to the facility's policy on pressure injury management.
Two residents experienced deficiencies in respiratory care due to improper storage of equipment. A resident with COPD had a nebulizing mouthpiece left uncovered, while another with sleep apnea had a CPAP mask and oxygen tubing improperly stored. Staff interviews confirmed the equipment should have been stored in bags, but the facility's policy was not provided.
A facility failed to re-evaluate the use of PRN Lorazepam for a resident with anxiety disorder, Major Depressive Disorder, and vascular dementia. Despite the resident's behavioral records showing no change, the medication was administered without documented review or justification. Staff interviews revealed inconsistencies in managing PRN psychotropic medications, and the facility's policy did not address medication use requirements.
The facility failed to honor the food preferences of two residents, leading to deficiencies in care. One resident, with diverticulitis and atherosclerosis, wanted eggs and hash browns more often than provided, but the facility did not consistently accommodate this preference. Another resident, with macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite indicating a dislike for it. The facility's dietary policy and Residents' Rights emphasize accommodating preferences, yet these were not consistently followed.
A facility failed to provide a resident's medical records within 48 hours as required. The resident, who had cognitive impairment and required assistance with daily activities, had a family member request discharge paperwork. The social worker miscommunicated the process, directing the family to the acute care facility for records. Additionally, the medical records staff could not recall or find documentation of the request, violating the facility's policy for timely access to records.
A resident's family member was overcharged for copies of medical records, with inconsistencies in the rates quoted by facility staff. The facility's administrator was unaware of the overcharge, which exceeded the state statute and facility policy limits.
Failure to Secure Doors in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe and secure environment on a locked memory care unit for residents with special needs. During an observation, it was found that several doors, including those labeled 'Soiled Utility,' 'Supply Room,' and 'Clean Utility,' were unable to be fully closed, latched, and locked. Additionally, the 'Shower' door was not locked. Although there were no accessible sharps or hazardous materials in these rooms and no residents were in the immediate area, the doors were expected to remain securely locked. Interviews with the Director of Nursing Services confirmed that the doors should have been locked, and the Director of Maintenance identified moisture as the reason for the doors not closing properly. The Director of Maintenance was not previously aware of the requirement for the doors to be locked. The facility did not provide a policy for ensuring a safe and secure environment when requested.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications according to professional standards and facility policy, as observed in four out of seven medication carts. On the Elm Tree unit, a medication prescribed to a resident was not stored in the refrigerator as required after opening, and the Licensed Practical Nurse (LPN) was unsure of when it was opened. The medication was last administered the previous evening, and the LPN acknowledged that medications should be stored according to directions, with the last nurse responsible for proper storage. On the Apple Blossom Unit, two residents' medications were not labeled correctly. One resident's inhaler was not labeled at all, and another resident's medication lacked a date indicating when it was opened. The Registered Nurse (RN) interviewed was unable to explain the labeling issue and stated that the pharmacy is responsible for labeling, while staff should check orders before administration. Additionally, in the Dogwood unit's medication room, a resident's medication was found to be expired. The LPN interviewed confirmed that expired medications should be reviewed and discarded, and nurses are responsible for checking expiration dates. The facility's policy requires medications to be stored in pharmacy-labeled containers, with opened medications dated and refrigerated if necessary.
Laundry Room Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness in the laundry room, as observed during a tour on June 5, 2024. Two vents and a smoke detector were found covered in gray debris, with one vent located in the dirty laundry area and the other in the clean laundry area near a folding table. The smoke detector was also in the clean laundry area. During an interview, the Laundry Supervisor admitted uncertainty about the last cleaning date and mentioned that cleaning logs were not readily available in the laundry area. The Infection Preventionist (IP)/LPN confirmed that the vents should be cleaned weekly by the laundry aide and that cleaning logs exist, but was unsure why the policy was not followed. A review of the cleaning logs for May and June 2024 revealed that the vents were cleaned on specific dates in May, but the June log lacked a specific date, only stating that the vents were cleaned on the day of the surveyor's inquiry. The facility's policy, dated February 20, 2024, directed that vents be cleaned weekly, which was not adhered to.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the actions of a nurse aide (NA #1) towards two residents. Resident #23, who was diagnosed with Chronic Obstructive Pulmonary Disease (COPD), emphysema, and chronic respiratory failure, required supervision and assistance with activities of daily living (ADL). Despite being cognitively intact and able to make needs known, Resident #23 reported that NA #1 raised her voice when asked to assist another resident, Resident #30, who needed to use the bathroom. This incident was reported to the nursing supervisor (RN #2), but there was no documented investigation attached to the grievance report. Resident #30, diagnosed with weakness, hemiplegia, and hemiparesis, required total assistance with toileting and was non-ambulatory. On the day of the incident, Resident #30 requested assistance from NA #1 to use the bathroom. NA #1, who was busy clearing trays, told Resident #30 to wait and did not inform another staff member to assist. It was only after Resident #23 intervened that NA #1 assisted Resident #30, approximately 15 minutes after the initial request. This delay in assistance and the manner in which NA #1 responded to the residents were not in line with the facility's policy to treat residents with care, courtesy, and respect. The facility's grievance policy requires a prompt and thorough investigation of all grievances, which was not adhered to in this case. The nursing supervisor acknowledged the incident as a customer service issue but failed to document the investigation properly. The lack of documentation and the failure to prioritize resident needs, such as toileting assistance, contributed to the deficiency in maintaining resident dignity and rights.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in status for Resident #427, who was exhibiting recurring symptoms of diarrhea. Resident #427, who had been diagnosed with acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing loose stools and requested medication for relief. Despite these symptoms, there was no documentation of how the change in condition was addressed, and the physician was not notified in a timely manner. Interviews with various nursing staff revealed a lack of communication and reporting regarding the resident's condition. LPN #6, who was on duty during the episodes of diarrhea, did not report the change of condition to a nursing supervisor or physician, believing it was already documented in the APRN communication book. The Medical Director was not informed of the recurrent episodes until later, and the Director of Nursing Services expected that any change of condition should be reported. The facility's policy directed that significant changes in status should be reported to the Nursing Supervisor, which was not followed in this case.
Resident-to-Resident Altercation in LTC Facility
Penalty
Summary
The facility failed to protect a resident from abuse during a resident-to-resident altercation. Resident #48, who has Alzheimer's disease and severe cognitive impairment, was struck in the chest by another resident, Resident #75, who also has Alzheimer's disease and severe cognitive impairment. The incident occurred while Resident #48 was walking in the hallway with another person. Resident #75, who had no prior history of aggression, unexpectedly hit Resident #48 and yelled profanities. The altercation was witnessed by LPN #4, who confirmed that there was no provocation or signs of agitation from either resident prior to the incident. The facility's policy defines resident-to-resident altercation as a physical or verbal act between two residents, regardless of injury. The policy also states that cognitively impaired residents must possess intent to harm for an act to be considered abuse. Despite this, the incident was reported, and the supervisor, physician, and police were notified. Resident #75 was placed on 1:1 observation and sent to the hospital for evaluation following the altercation.
Failure to Ensure Proper Medication Administration for a Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #48, was administered medications as prescribed by the physician and in accordance with professional practice standards. Resident #48, who had diagnoses including Alzheimer's disease and insomnia, was found to have severe cognitive impairment and required assistance with personal hygiene and dressing. Despite having no swallowing disorders, the resident was at risk for aspiration and was on a ground diet consistency. The care plan included administering psychotropic medications as ordered and monitoring the resident's behaviors and sleep. However, an internal investigation revealed that pills, which were supposed to be administered to the resident at bedtime, were found in the resident's nightstand drawer. These pills included Melatonin, paroxetine, donepezil, quetiapine, and memantine. Interviews with staff indicated that the pills were identified by their appearance and imprints, and it was suspected that the resident may have had the pills in their mouth and spit them out. The facility acknowledged that ensuring cognitively impaired residents take their medications completely is part of the standard of practice. Despite this, it was noted that oral checks to confirm medication ingestion were not consistently performed. An LPN confirmed that checking if a resident swallowed their medications properly was a standard practice learned during nursing education. Observations during a medication pass showed that oral checks were performed, but not all staff had participated in the in-service training on oral checks, highlighting a gap in consistent practice across the facility.
Failure to Conduct Nursing Assessment for Change of Condition
Penalty
Summary
The facility failed to ensure a nursing assessment was completed for a resident experiencing a change of condition. Resident #427, who had diagnoses including acute kidney failure and duodenitis, was discharged from the hospital with a stable condition. However, upon admission to the facility, the resident began experiencing symptoms of diarrhea and gastric upset after consuming shrimp. Despite the resident's request for medication to address these symptoms and documentation in the APRN communication book, the nursing staff did not report the change of condition to a nursing supervisor or physician. Interviews revealed that the nursing staff believed the symptoms were food-related and did not require further reporting or assessment. Additionally, the resident experienced an episode of epistaxis, which was noted in the shift report but not followed by a documented nursing assessment. The Director of Nursing Services indicated that any change of condition should be reported and assessed, but this protocol was not followed. The lack of a policy for RN assessments was noted, and interviews with nursing staff confirmed that the change of condition was not communicated to the appropriate personnel, leading to a deficiency in care.
Failure to Reassess Nutritional Needs for Resident with New Pressure Wounds
Penalty
Summary
The facility failed to reassess the nutritional status and needs of a resident with newly identified pressure wounds. Resident #103, who had diagnoses including type II diabetes mellitus, obstructive sleep apnea, and malignant neoplasm of the urethra/bladder, was identified as being at risk for pressure ulcers. Despite the presence of unhealed pressure ulcers and the development of new wounds on the left ankle, sacrum, right hip, and right knee, there was no documented reassessment of the resident's nutritional status following these developments. The resident was receiving palliative care, and while some nutritional interventions were noted, such as the addition of liquid protein, the lack of a formal reassessment was a significant oversight. Interviews with the Dietitian and the Director of Nursing Services (DNS) revealed that wounds were discussed weekly with the interdisciplinary team, including the Dietitian. However, the Dietitian was unaware of the new wounds and had not conducted a reassessment of the resident's nutritional needs. The facility's policy for Pressure Injury Prevention and Management required that residents at high risk for pressure injuries or with existing pressure injuries receive appropriate interventions, and that the plan of care be revised as necessary. The failure to reassess the nutritional needs of Resident #103 following the identification of new wounds was a deviation from this policy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and maintenance of respiratory equipment for two residents, leading to deficiencies in respiratory care. Resident #71, diagnosed with chronic obstructive pulmonary disease and essential hypertension, was observed with a nebulizing mouthpiece left uncovered on top of the nebulizing equipment. Despite having a care plan that included nebulizer treatments, the mouthpiece was not stored in a bag after use, as confirmed by a registered nurse who admitted to the oversight. The Director of Nursing Services and the registered nurse both acknowledged that all respiratory equipment should be stored in a bag when not in use. Resident #103, who has obstructive sleep apnea, was found with a CPAP mask placed on top of the machine without a cover and oxygen tubing labeled with an outdated date. The resident used the CPAP during the night and oxygen during the day, but the equipment was not stored properly when not in use. Interviews with a nurse aide and the Director of Nursing Services confirmed that the CPAP mask and oxygen tubing should have been stored in a bag and changed weekly, respectively. The facility's policy for storage guidelines was not provided, contributing to the deficiency.
Failure to Re-evaluate PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure the re-evaluation of a psychotropic medication for a resident diagnosed with anxiety disorder, Major Depressive Disorder, and vascular dementia. The resident, who was cognitively impaired and required maximal assistance with daily activities, had a physician's order for Lorazepam to be administered every four hours as needed for restlessness and agitation. Despite the medication being prescribed on a PRN basis, the facility did not provide documentation or rationale for the continued use of this medication. The resident's behavioral flow records indicated no change in behaviors, yet the PRN Lorazepam was administered without a documented review or justification. Interviews with facility staff revealed inconsistencies in the management and documentation of PRN psychotropic medications. An RN indicated that PRN orders should be reevaluated every 14 days, while an LPN noted that targeted behaviors and interventions should be documented when psychotropic medications are used. However, the facility's policy on psychotropic medication did not address the requirements for medication use, and there was no rationale provided for the continued PRN order for Lorazepam. The facility's DNS mentioned that psychotropic medications are not usually prescribed as PRN, highlighting a lack of adherence to the facility's usual practices.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to deficiencies in their care. Resident #121, who has diagnoses including diverticulitis and atherosclerosis, expressed a preference for eggs and hash browns more frequently than the once-weekly offering. Despite communicating this preference to the dietary staff, the Food Service Director stated that eggs could not be provided more often due to preparation constraints, and hash browns were not consistently set aside for the resident. The Director of Nursing Services acknowledged the resident's numerous preferences and expected reasonable accommodations, but the facility did not ensure these preferences were consistently met. Resident #52, with diagnoses including macular degeneration and heart failure, repeatedly received sandwiches with mayonnaise despite expressing a dislike for it and indicating this preference on meal tickets. The Kitchen Supervisor acknowledged the issue, attributing it to confusion among new staff, which led to the resident receiving incorrect meals. The facility's dietary notice policy and the Residents' Rights emphasize the importance of accommodating individual preferences, yet these were not adhered to, resulting in the residents' preferences being overlooked.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide copies of a resident's medical record within the required 48-hour timeframe. This deficiency was identified during a review of the clinical records, facility policy, and staff interviews for a resident who was admitted with multiple diagnoses, including metabolic encephalopathy and cognitive impairment. The resident required substantial assistance with daily activities, as noted in their care plan. A family member, identified as the resident's emergency contact, requested a copy of the resident's discharge paperwork. However, the social worker informed the family member that they could not provide the paperwork and directed them to the acute care facility for the records. Further investigation revealed inconsistencies in the facility's handling of the request. The social worker later clarified that the request was for medical records from the acute care facility, not the discharge paperwork from the facility, and stated that the facility's policy required the family to obtain records from the outside facility. Additionally, a staff member from the medical records department could not recall receiving any request for copies of the resident's medical record and found no documentation of such a request. The facility's policy allows residents or their legal representatives to access and purchase copies of their records within two working days of the request, which was not adhered to in this case.
Inappropriate Charges for Medical Record Copies
Penalty
Summary
The facility failed to charge the appropriate amount for copies of a resident's medical records, leading to a deficiency in compliance with applicable laws and regulations. Resident #432, who was admitted with diagnoses including metabolic encephalopathy, essential hypertension, muscle weakness, hypothyroidism, and dysphagia, was identified as cognitively impaired and required substantial assistance with activities of daily living. The resident's family member, who was the emergency contact, requested copies of the medical records and was charged 75 cents per page and an additional 30 dollars for document retrieval. Interviews with facility staff revealed inconsistencies in the charges for medical record copies, with different staff members quoting different rates per page, none of which aligned with the Connecticut general state statute. The facility's administrator acknowledged that residents or family should not be charged more than 65 cents per page and was unaware of the reason for the overcharge. The facility's policy stated that the cost for copies should not exceed prevailing community rates, indicating a failure to adhere to their own policy and state regulations.
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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