Chestelm Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Moodus, Connecticut.
- Location
- 534 Town St, Moodus, Connecticut 06469
- CMS Provider Number
- 075307
- Inspections on file
- 18
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Chestelm Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of constipation and recent rectal bleeding was prescribed hydrocortisone suppositories, but due to a drug interaction alert and lack of follow-up, the medication was not available or administered for several days. Nursing staff did not notify the provider or pharmacy about the missed doses, and supervisors were not informed of the issue. This failure to communicate and follow facility policy resulted in the resident experiencing ongoing symptoms and requiring hospital intervention.
A resident with a history of constipation and other risk factors experienced rectal bleeding, but nursing staff failed to perform a full GI and abdominal assessment or provide continued monitoring as required. The nurse did not review the resident's clinical record prior to assessment, resulting in missed information about the resident's history and current bowel regimen. The resident's condition worsened over several days, leading to hospital transfer for urgent intervention.
The facility failed to perform weekly body audits for 15 residents as per policy and physician orders, leading to gaps in monitoring skin conditions. Residents with various diagnoses, including cerebrovascular disease and diabetes, were at risk for pressure injuries. Despite orders for audits on specific days, many were missed, with some residents going weeks without assessments. Interviews revealed that unit nurses were responsible for audits, but there was no documentation or explanation for the lapses.
A resident with chronic lung disease experienced coughing and spitting up while eating, indicating a change in condition. An LPN observed the incident but failed to document it or notify the supervisor and physician. The facility's policy requires such changes to be reported and documented, which was not adhered to in this case.
A temporary agency LPN administered incorrect medications to a resident after failing to verify the resident's identity, leading to a significant medication error. The facility did not provide medication administration education to agency nurses, contributing to the incident.
A resident with hemiplegia and severe cognitive impairment fell from bed during incontinence care due to the failure of nursing assistants to use side rails as per the care plan. The resident was rolled over without the side rail being raised, resulting in the resident sliding off the bed. The incident highlights a lapse in following the care plan, as confirmed by the DNS.
The facility failed to follow provider orders for weight monitoring and notification of significant weight changes for two residents. One resident experienced a significant weight loss without a reweight or provider notification, while another resident with CHF was not weighed daily as ordered. The facility's Weight Trending Policy was not adhered to, leading to deficiencies in nutritional care.
A resident with a history of gastrointestinal bleeding and an allergy to NSAIDs was mistakenly given another resident's medications, including Aspirin, due to an LPN's failure to verify the resident's identity. The DNS did not document neuro-checks or complete a Medication Error Occurrence Record as required by facility policy, and the APRN's progress note was entered 47 days late.
The facility failed to inform residents about the grievance process, with grievance forms inaccessible and no records maintained for 2023 and 2024. Observations showed the grievance folder was empty and placed at an inaccessible height for wheelchair users. Interviews revealed a misunderstanding of grievances by the Administrator, and residents were unaware of how to file grievances. The facility did not adhere to its policy of maintaining grievance records for three years.
The facility failed to submit SCSA MDS assessments for three residents who experienced significant changes in functional abilities. One resident showed a decline in 14 areas, another had a cognitive decline and a decrease in nine functional areas, and a third resident experienced both decline and improvement in multiple areas. The RN did not realize the extent of changes or the requirement for SCSA submission.
Failure to Notify Provider and Pharmacy of Missed Medication Administration
Penalty
Summary
A deficiency occurred when nursing staff failed to notify the provider and pharmacy regarding the unavailability and non-administration of a newly ordered medication for a resident with a history of constipation, failure to thrive, and aphasia following a stroke. The resident was prescribed hydrocortisone acetate suppositories for rectal bleeding, but a drug interaction alert with aspirin was triggered by the pharmacy. The pharmacy contacted the facility for clarification, faxed a form for completion, and did not send the medication due to lack of response. Despite this, the medication was not administered for several scheduled doses, and there was no documentation that the provider was notified of the missed doses or the medication's unavailability during this period. Nursing staff, including charge nurses and supervisors, did not follow up with the pharmacy or notify the provider each time the medication was not available or administered. Some staff believed the issue had already been reported, while others documented the missed administration in a provider book but did not ensure direct communication. Interviews revealed that staff signed off on medication administration in error and acknowledged they should have contacted the pharmacy and provider but did not do so. Nursing supervisors were also not informed of the ongoing issue and stated they would have assisted if notified. The facility's policy required nursing staff to notify the physician or prescriber for any held medications or suspected adverse drug reactions, but this was not followed. As a result, the resident experienced ongoing rectal bleeding and severe constipation, ultimately requiring transfer to the emergency department for evaluation and urgent intervention. The lack of timely communication and follow-up regarding the medication order and administration led to the identified deficiency.
Failure to Perform GI Assessment and Monitoring After Rectal Bleeding
Penalty
Summary
A deficiency occurred when nursing staff failed to conduct a comprehensive gastrointestinal (GI) and abdominal assessment and provide continued monitoring for a resident following an incident of rectal bleeding. The resident, who had a history of constipation, impaired mobility, opiate use, and a prior ileus, was identified as being at risk for constipation and was dependent on staff for toileting. Despite these risk factors and a care plan that included monitoring for constipation and following a bowel protocol, the nurse's note documented only a visual assessment after the resident was found with bright red rectal bleeding. No abdominal assessment or evaluation of bowel sounds was performed at that time. Further review of the clinical record and nurse's notes revealed that, over the following days, there was a lack of documentation indicating that a GI or abdominal assessment was performed, even as the resident continued to experience rectal bleeding and discomfort. The hydrocortisone suppository ordered for suspected internal hemorrhoids was inconsistently administered due to unavailability, and there was no evidence of ongoing monitoring or reassessment of the resident's condition. The situation escalated when the resident exhibited worsening symptoms, including dark red rectal bleeding, nausea, and abdominal discomfort, eventually leading to the expulsion of a large blood clot and transfer to the emergency department for evaluation and urgent intervention. Interviews with facility staff confirmed that the nurse responsible did not review the resident's clinical record prior to the initial assessment and was unaware of the resident's history of constipation and current bowel regimen. Both the APRN and DON acknowledged that a full GI assessment should have been performed and that a more thorough review of the resident's history was necessary to ensure appropriate care and communication with the provider. Facility policy required monitoring and assessment for changes in condition, but these steps were not followed in this case.
Failure to Conduct Weekly Body Audits
Penalty
Summary
The facility failed to perform preventative weekly body audits according to facility policy and physician orders for 15 of 70 residents reviewed. These residents had various diagnoses, including cerebrovascular disease, congestive heart failure, and diabetes, and were at risk for developing pressure injuries. The facility's policy required weekly body audits to be conducted on specific days and shifts, with instructions to inspect for altered skin integrity and report findings to the provider. However, the audits were not completed on multiple occasions for each resident, leading to gaps in monitoring their skin conditions. For instance, one resident with severe cognitive impairment and at risk for pressure injuries had a provider order to perform a weekly body audit on Fridays. However, audits were not completed on several specified dates, resulting in a 21-day gap without an audit. Another resident with rheumatoid arthritis and anemia also had missed audits, with a 14-day period where no body audit was performed. These lapses in conducting body audits were consistent across multiple residents, with some residents going weeks without the required assessments. Interviews with nursing staff and the Director of Nursing revealed that the responsibility for completing these audits lay with the unit nurses, who were expected to perform them on shower days. Despite this, there was a lack of documentation and explanation for why the audits were not completed as ordered. The facility's failure to adhere to its policy and physician orders for weekly body audits resulted in deficiencies in monitoring and documenting the skin conditions of residents, potentially impacting their care and treatment.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident #45, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and pneumoconiosis. The resident was on a regular diet at dysphagia level 2, but an incident occurred where the resident was observed coughing and spitting up while eating meat. Despite this, there was no documentation in the nurse progress notes about the resident's trouble swallowing or coughing during meals. Licensed Practical Nurse (LPN) #3 witnessed the incident and requested a new meal without meat, but did not document the event in a progress note, nor did she notify the supervisor or the provider about the resident's condition. The Director of Nursing Services identified that LPN #3 failed to write a progress note, update the supervisor and provider, and monitor the resident for signs of aspiration. The Advanced Practice Registered Nurse (APRN) was not informed of the resident's difficulty swallowing and indicated that if notified, he would have assessed the resident's swallowing status and possibly ordered a speech screen and monitoring for aspiration. The facility's Change in Condition policy requires changes in a resident's baseline condition to be monitored, assessed, reported to the physician/APRN, and documented, which was not followed in this case.
Medication Administration Error Due to Lack of Agency Staff Training
Penalty
Summary
The facility failed to provide medication administration education to a temporary agency staff nurse, leading to a significant medication error. A temporary agency LPN administered the wrong medications to a resident after entering the incorrect room and failing to verify the resident's identity. The resident received another resident's medications, which included a range of drugs such as Amlodipine, Aspirin, Depakote, Cymbalta, Gabapentin, and others. The LPN did not use any resident identifier to confirm the correct resident and assumed the identity based on a name call, which the resident did not respond to. The error was realized when the LPN noticed the absence of an ordered medical device for the resident. The facility's Human Resources Director confirmed that agency staff are required to acknowledge receipt of the facility's Orientation for Pool Staff document, which does not include medication administration competency. The Director of Nursing Services (DNS) admitted that the facility does not provide orientation for agency nurses on medication administration competency. Although the DNS claimed that the LPN was educated on the 5 rights of medication administration after the error, there was no documentation to support this. The facility also did not implement any education for agency staff nurses related to medication administration following the incident.
Failure to Use Side Rails Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the proper use of side rails for a resident with hemiplegia, dementia, anxiety, and generalized muscle weakness, resulting in a fall. The resident, who was severely cognitively impaired and dependent on assistance for activities of daily living, was being provided incontinence care by two nursing assistants. During this care, the resident was rolled over without the side rail being raised, leading to the resident sliding off the bed and onto the floor. The resident was found with their torso on the floor and legs still on the bed, and although no injuries were noted, the resident complained of pain. The incident occurred because the nursing assistants did not follow the resident's care plan, which required the use of two quarter side rails for positioning and bed mobility. Both nursing assistants acknowledged that the side rail was down at the time of the fall and that it could have helped prevent the resident from falling. The Director of Nursing Services confirmed that the care plan was not followed, but could not explain why the side rails were not used during the incident.
Failure in Weight Monitoring and Provider Notification
Penalty
Summary
The facility failed to adhere to provider orders for weight monitoring and notification of significant weight changes for two residents, leading to deficiencies in nutritional care. Resident #22, who was admitted with multiple diagnoses including heart failure and anemia, had a provider order for weekly weights. Despite a significant weight loss recorded on 11/19/24, a reweight was not obtained as ordered, and the provider was not notified of the weight change. The Director of Nursing confirmed the oversight and acknowledged that the reweight was not conducted, and the weight loss was not communicated to the provider. Resident #34, diagnosed with congestive heart failure and other conditions, had a physician's order for daily weights to monitor potential weight gain due to fluid retention. However, daily weights were not recorded for several days, and there was no documentation of weight refusals or any communication to the provider regarding the lack of weight monitoring. Both the RN and the Director of Nursing confirmed the failure to obtain daily weights as ordered, which was crucial for managing the resident's cardiac condition. The facility's Weight Trending Policy and Procedures were not followed, as evidenced by the lack of reweights and failure to notify providers of significant weight changes. The policy required reweights for discrepancies and communication of weight changes to the provider, family, and weight committee, which did not occur in these cases. This oversight in weight monitoring and communication contributed to the deficiencies identified during the survey.
Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to administer medications to the correct resident, resulting in a significant medication error. A resident with a history of gastrointestinal bleeding and an allergy to NSAIDs was mistakenly given another resident's medications, including Aspirin, which is contraindicated for them. The error occurred because the LPN did not verify the resident's identity, as the resident was not wearing a name identification bracelet, and the LPN assumed the identity based on incorrect assumptions. The Director of Nursing Services (DNS) and the Advanced Practice Registered Nurse (APRN) were notified of the error. The APRN assessed the resident and initiated a monitoring protocol due to the potential for adverse effects from the medication error. However, the DNS failed to document the neuro-checks as directed by the APRN and did not complete a Medication Error Occurrence Record according to the facility's policy. Additionally, the DNS did not obtain a written statement from the LPN regarding the incident. The facility's policy requires that medication errors be documented and reviewed to identify risks and implement corrective actions. However, the DNS did not follow this policy, and the APRN's progress note regarding the incident was entered into the medical record 47 days late. The lack of proper documentation and adherence to protocol highlights deficiencies in the facility's handling of medication errors and staff education.
Deficiency in Grievance Process and Record Maintenance
Penalty
Summary
The facility failed to adequately inform residents about the grievance process, as evidenced by the lack of accessible grievance forms and the absence of completed grievance records for the years 2023 and 2024. Observations revealed that the grievance folder and suggestion box were placed at a height inaccessible to residents using wheelchairs, and the folder was empty, lacking necessary forms. Interviews with the facility's Administrator indicated a misunderstanding of what constitutes a grievance, as she considered grievances to be only unresolved complaints, which led to the absence of documented grievances. During a Resident Council meeting, 12 cognitively intact residents expressed unawareness of how to complete a grievance form or where to find them. The facility's grievance policy requires the Grievance Officer to acknowledge grievances promptly and maintain records for three years, which was not adhered to. This lack of awareness and accessibility to grievance forms, combined with the facility's failure to maintain grievance records, highlights a significant deficiency in upholding residents' rights to voice grievances without discrimination or reprisal.
Failure to Submit SCSA for Residents with Significant Changes
Penalty
Summary
The facility failed to submit significant change in status (SCSA) Minimum Data Set (MDS) assessments for three residents who experienced a decline in more than two functional ability areas. Resident #45, who was admitted in February 2021 with diagnoses including dementia and COPD, showed a decline in 14 functional mobility areas between quarterly MDS assessments. Despite this, no SCSA was submitted, as the registered nurse (RN) believed the decline was due to the progression of dementia and did not realize the extent of the decline in functional areas. Resident #58, admitted in January 2023 with conditions such as traumatic hemorrhage of the cerebrum and diabetes, experienced a significant decline in cognition and nine functional mobility areas. The resident's cognitive status deteriorated from being cognitively intact to severely impaired, yet the facility did not submit an SCSA. The resident's care plan included interventions for impaired cognition and activities of daily living (ADL) function, but the necessary assessment to document the significant change was not completed. Resident #61, admitted in April 2023 with dementia and macular degeneration, showed a decline in 15 functional mobility areas and later an improvement in 12 areas. Despite these changes, the facility did not submit an SCSA for either the decline or the improvement. The RN acknowledged understanding the requirement for SCSA submission within 14 days but had not realized the need for submission in cases of improvement in functional mobility areas.
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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