Civita Care Meadowbrook
Inspection history, citations, penalties and survey trends for this long-term care facility in Granby, Connecticut.
- Location
- 350 Salmon Brook Street, Granby, Connecticut 06035
- CMS Provider Number
- 075367
- Inspections on file
- 31
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Civita Care Meadowbrook during CMS and state inspections, most recent first.
A non‑ambulatory, cognitively impaired resident, fully dependent on staff and a Hoyer lift for transfers, was care planned and ordered for two‑person mechanical lift transfers and bed‑level ADL and toileting care. During morning care, the resident suddenly screamed in pain when socks were applied, and staff notified LPNs but proceeded with Hoyer lift transfers to and from a wheelchair, reporting no issues and administering scheduled acetaminophen. The next day, the resident exhibited increased body and lower extremity pain, with a swollen, tender left leg, and was again observed in a wheelchair before being returned to bed for further assessment. Imaging subsequently showed displaced proximal tibia/fibula fractures and a right femur fracture requiring surgery; providers reported no known trauma or falls and, based on the resident’s dependence and injury pattern, one APRN identified the probable cause as related to mechanical lift transfers, while the medical director noted possible osteoporosis‑related fragility fractures potentially associated with lift use.
A resident with advanced dementia and schizoaffective disorder, who had severely impaired cognition (BIMS score of 0) and was rarely/never understood, had documented needs for emotional support, care coordination, and advocacy, as well as care plan interventions for expression of thoughts and feelings and provision of psychiatric services. However, required SW documentation was missing, including quarterly progress notes for an eight-month period and an annual assessment for over a year, with the sole SW acknowledging these were missed due to oversight and no SW documentation/assessment policy provided when requested.
Two residents experienced deficiencies in care due to failures in medication reconciliation and adherence to physician orders. One resident received medications not included in their hospital discharge instructions because of incorrect transcription and lack of proper verification by nursing staff. Another resident did not receive timely administration of a prescribed bowel regimen following a syncopal episode and signs of constipation, with significant delays in following the facility's bowel protocol. These events occurred despite established facility policies intended to prevent such errors.
A resident admitted after a hospital stay with elevated kidney function labs did not have hydration needs properly assessed or documented. Required intake and output (I&O) monitoring was incomplete, estimated fluid needs were not consistently recorded, and no hydration or nutritional assessment was completed after admission or following a syncopal episode. Staff interviews confirmed that facility policy for hydration assessment and documentation was not followed.
A resident with a history of diabetes, hypertension, and dementia was admitted with a rib fracture, but the facility failed to develop a baseline care plan addressing this condition. Despite hospital documentation indicating a rib fracture, the facility did not document or manage the resident's pain effectively, nor did they inform the rehabilitation department. The resident experienced falls, and staff interviews revealed an expectation for a care plan that was not met, highlighting a lapse in the facility's care planning policy.
A resident receiving IV therapy for recurrent UTIs had critical lab values that were not communicated to the physician in a timely manner. The lab results, which included elevated BUN, creatinine, and Vancomycin trough levels, were reported to the facility but not acted upon until 28 hours later. The delay resulted in the resident being transferred to the hospital with acute kidney failure related to Vancomycin toxicity. The facility lacked a specific policy for reporting critical lab results, and the responsible staff failed to notify the physician as required.
A resident with multiple diagnoses, including a methicillin-resistant staphylococcus aureus infection, did not receive IV Vancomycin as ordered, with doses administered outside the prescribed time frame. Additionally, Vancomycin was not discontinued as per new physician orders, with evidence suggesting a potential extra dose was given. The facility lacked a policy on IV administration, contributing to the deficiency.
A resident with multiple health conditions was not properly monitored for intake and output (I & O) as required by physician orders. The facility failed to provide I & O records for several days, and on the days records were available, the resident's fluid intake was significantly below the estimated daily needs. Despite this, a dehydration evaluation was not conducted as required by the facility's policy. Interviews with the DON and ADON revealed a lack of awareness and adherence to the facility's hydration policy.
Inadequate Protection of Dependent Resident During Mechanical Lift Transfers Resulting in Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate protection from injury for a non‑ambulatory, cognitively impaired resident who was totally dependent on staff and a mechanical lift for transfers. The resident had dementia with severely impaired cognition (BIMS score of 0), was always incontinent, and was care planned and ordered for Hoyer lift transfers with assist of two staff, and assist with ADLs and toileting at bed level. The resident’s care plan and orders specified non‑ambulatory status, total lift use, and a customized wheelchair with headrest and bilateral leg rests. Prior to the incident, an APRN documented baseline confusion, no pain, movement of all extremities, and bilateral knee contractures, and a skin check shortly before the event showed no new skin impairments. On one day, a nursing assistant reported that during morning care when applying socks, the resident suddenly began screaming, prompting the NA to stop care and notify the night‑shift LPN and the day‑shift LPN. The resident, who had baseline lower extremity edema but no noted discoloration or bruising the prior day, was nonetheless transferred with a Hoyer lift and two‑person assist to a wheelchair and later back to bed, with staff reporting no issues during the transfers and that the resident appeared comfortable after receiving scheduled acetaminophen. The following morning, the charge nurse was notified that the resident had increased generalized body pain, including lower extremity pain, and was uncomfortable during personal care. At that time, the resident’s left leg was noted to be swollen and painful to touch, though the skin was intact, and the resident was observed in the dining room in a wheelchair appearing uncomfortable. Subsequent assessment by an APRN led to orders for a Doppler ultrasound to rule out DVT and an x‑ray of the lower left extremity. Imaging revealed displaced, angulated, recent‑appearing proximal tibial and fibular fractures, and the resident was transferred to the ED, where additional right femur fracture was identified, requiring surgical intervention. The physician and APRNs noted there was no known trauma or recent falls, and one APRN stated that, given the resident’s dependence and lack of reported falls, the injuries were unlikely to have occurred from rolling in bed or an unwitnessed fall, and identified the probable cause of injury as related to use of the Hoyer lift during transfers. The medical director, after reviewing hospital documentation, stated there was no clear etiology but that the injuries could represent osteoporosis‑related fragility fractures potentially associated with mechanical lift transfers.
Failure to Provide and Document Required Social Work Services
Penalty
Summary
The facility failed to provide and document medically-related social services for a resident with dementia and schizoaffective disorder. The resident had a POA for health decisions and was documented in an annual social work (SW) assessment as being primarily alert to self with cognitive deficits related to place and time, as well as confusion. The annual assessment noted that the SW was available for emotional support and for concerns or complaints. A subsequent SW quarterly assessment documented that the resident continued to have severe cognitive impairment due to advanced dementia, with stable mood, calm and friendly affect, and poor insight and judgment, and stated that the SW would remain available for ongoing support, care coordination, and advocacy for the resident’s needs and comfort. The resident’s MDS showed severely impaired cognition with a BIMS score of 0 and that the resident was rarely or never understood. The resident’s care plan identified long-term care needs and psychiatric diagnoses of schizoaffective disorder and bipolar disorder, with interventions including encouraging the resident to express thoughts and feelings, providing support and validation as needed, and providing psychiatric services within the facility. Despite these identified needs and planned interventions, the clinical record lacked required SW documentation. There were no SW quarterly progress notes for an eight-month period following the last note dated 7/2/25, and no SW annual assessments for a period of one year and four months following the last annual assessment dated 11/13/24. The DNS confirmed there were no additional SW notes in the resident’s record. In an interview, the sole facility SW acknowledged that the resident’s annual and quarterly progress notes had been missed due to an oversight, noted that the electronic medical record did not prompt her to document, and stated that progress notes should be completed at least quarterly and annually. When requested, the facility did not provide a SW documentation and assessment policy.
Medication Reconciliation and Bowel Regimen Protocol Failures
Penalty
Summary
The facility failed to ensure accurate medication reconciliation and adherence to physician orders for two residents. For one resident admitted with multiple fractures, delirium, glaucoma, GERD, depression, and dementia, the hospital discharge summary listed specific medications to be continued. However, during the admission process, two medications—gabapentin and senna-s—were incorrectly transcribed into the electronic physician's orders, despite not being included in the hospital discharge instructions. The resident subsequently received two doses of gabapentin and one dose of senna-s before the error was identified. The medication reconciliation process required a second nurse to verify the accuracy of transcribed orders, but this verification failed, allowing the error to proceed undetected until after administration. For another resident admitted with a cervical spine fusion, cognitive communication deficit, and weakness, the facility did not follow the prescribed bowel regimen as per physician order and facility policy. The resident, who was receiving scheduled oxycodone, had not had a bowel movement for several days. Although a bowel regimen was ordered after the resident experienced a syncopal episode and was found to have a firm, distended abdomen, the medications were not administered according to the protocol. There were significant delays between the ordering and administration of each step in the bowel regimen, with the first medication given 17 hours after the order and subsequent steps delayed further, contrary to the facility's bowel evacuation protocol. Interviews with nursing staff revealed lapses in the medication reconciliation and bowel regimen processes. The admitting nurse acknowledged accidentally transcribing incorrect medications, and the verifying nurse failed to catch the error. In the case of the bowel regimen, staff could not recall whether medications were administered as ordered, and documentation did not support timely administration. The facility's policies for medication reconciliation and bowel management were not followed, resulting in medication errors and delayed care.
Failure to Assess and Document Resident Hydration Needs
Penalty
Summary
A deficiency was identified regarding the facility's failure to adequately assess and document the hydration needs of a resident following admission. The resident, who had recently been discharged from the hospital with a noted increase in creatinine and BUN levels, was admitted with multiple diagnoses including cervical spine fusion, cognitive communication deficit, and weakness. Upon admission, the resident was alert and oriented, with normal abdominal findings and independence in eating. However, the medical provider's note did not specify fluid intake goals, and a physician's order was issued to monitor intake and output (I&O) every shift for 72 hours and document it on the appropriate flowsheet. Review of the I&O documentation revealed significant gaps. There was no I&O documentation for the day of admission, and incomplete records for the following day, with missing entries for several hours and no 24-hour estimated fluid needs recorded. Over the subsequent days, the resident's total fluid intake was consistently below the estimated needs, and the required estimated fluid needs were not documented until several days after admission. Additionally, there was no evidence of a nursing hydration assessment or a nutritional assessment after admission or following a syncopal episode and findings of constipation and abdominal distension. Interviews with facility staff confirmed that hydration assessments should be completed on admission and readmission, and that both nursing and dietary staff are responsible for calculating and documenting fluid needs. The dietitian acknowledged that she may not have assessed the resident due to her limited schedule and the resident's hospital stay. The facility's hydration policy requires at-risk residents to be reviewed and provided with interventions to promote hydration, and mandates that I&O be documented for each shift for 72 hours post-admission. These requirements were not met in this case, resulting in the identified deficiency.
Failure to Develop Baseline Care Plan for Resident with Rib Fracture
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident with fractured ribs. The resident, who had a history of diabetes, hypertension, metabolic encephalopathy, and dementia with behavioral disturbances, was admitted with a nondisplaced left posterior 10th rib fracture, pleural effusion, and suspected malignancy. Despite these conditions being identified in the hospital's discharge summary, the facility did not document or address the rib fracture in the resident's care plan, nor did they communicate this critical information to the hospital upon the resident's transfer. The resident's clinical records and staff interviews revealed that the facility did not adequately assess or manage the resident's pain related to the rib fracture. A handwritten note in the resident's file incorrectly identified a right rib fracture, and subsequent evaluations by medical staff failed to address the left rib fracture. The resident exhibited non-verbal signs of pain, and although Tylenol was administered, there was no comprehensive plan to manage the rib fracture or associated pain. The rehabilitation department was not informed of the rib fracture, which could have influenced the resident's therapy and care. The facility's failure to communicate and document the resident's rib fracture led to inadequate care planning and pain management. The resident experienced two falls while at the facility, and the lack of a care plan addressing the rib fracture meant that appropriate interventions were not in place. Interviews with facility staff, including the ADNS and RN, indicated that there was an expectation for a care plan to be developed, but this was not done. The facility's care planning policy requires an interim plan of care within 24 hours of admission, but this was not adhered to in this case.
Failure to Timely Notify Physician of Critical Lab Values
Penalty
Summary
The facility failed to notify the physician of critical lab values in a timely manner for a resident receiving intravenous therapy for recurrent urinary tract infections. The resident had several diagnoses, including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician order required weekly lab work, including a Vancomycin trough, to be conducted on Mondays. On a Monday, the resident's lab results showed critical values, including a BUN of 77, creatinine of 4.1, and a Vancomycin trough greater than 50. These results were reported to the facility but not acted upon until 28 hours later. The facility's documentation and interviews revealed that the critical lab results were not communicated to the physician or the infectious disease office in a timely manner. The RN supervisor was responsible for handling incoming lab results, but there was no documentation that the physician was notified before 1 PM the following day. The facility was unable to verify who received the lab results, as the person named in the report did not exist in their records. The infectious disease office was unaware of the critical lab values until contacted by an external person, who then informed the facility. The delay in notifying the physician resulted in the resident being transferred to the hospital with acute kidney failure related to Vancomycin toxicity. The facility's Physician Notification Policy required lab results to be reported to the physician, but there was no specific policy for reporting critical lab results. Interviews with the ADON and DON confirmed that the physician should have been contacted regarding the critical lab values, but no explanation was provided for the delay.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to administer IV antibiotics to a resident in accordance with physician orders, leading to a deficiency in the quality of care provided. The resident, who had diagnoses including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression, was receiving Vancomycin IV therapy for recurrent UTIs. The physician's order specified that Vancomycin should be administered every 18 hours. However, the electronic medication administration record (eMAR) showed that the doses were not administered within the prescribed time frame, with one dose being an hour late and another being administered one hour and 47 minutes early. The Director of Nursing (DON) confirmed that medications should be administered within one hour before or after the scheduled time but could not explain the discrepancies. Additionally, there was a failure to discontinue Vancomycin as ordered by the physician. Despite a new order to discontinue Vancomycin and start Daptomycin, an empty Vancomycin IV bag was found labeled with a date six days after the discontinuation order. Interviews with the Assistant Director of Nursing (ADON) and the DON revealed uncertainty about whether an extra dose was administered, but the presence of labeled IV bags suggested a potential error. The facility did not provide a policy regarding IV administration, further highlighting the deficiency in adhering to physician orders and ensuring proper medication management.
Failure to Monitor Resident Hydration
Penalty
Summary
The facility failed to ensure proper monitoring of intake and output (I & O) for a resident with multiple health conditions, including methicillin-resistant staphylococcus aureus infection, urinary tract infection, dysphagia, and depression. A physician's order required monitoring of I & O every shift for 72 hours upon admission or readmission, with documentation on an I & O paper flowsheet. However, the facility did not provide I & O records for several days, and on the days records were available, the resident's fluid intake was significantly below the estimated daily needs. Despite these deficiencies, the facility did not conduct a dehydration evaluation as required by their policy when a resident's intake is below the estimated needs for three consecutive days. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that the facility's policy did not include performing a dehydration risk evaluation upon admission. Instead, nursing staff used other assessment measures to determine dehydration risk. The DON was unaware of the missing I & O flowsheets and could not explain why the low intake levels were not addressed. The facility's Hydration Policy required residents at risk for dehydration to be on I & O monitoring until adequate hydration status is achieved, but this was not followed for the resident in question.
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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