Civita Sheriden Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in Bristol, Connecticut.
- Location
- 321 Stonecrest Drive, Bristol, Connecticut 06010
- CMS Provider Number
- 075350
- Inspections on file
- 37
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Civita Sheriden Woods during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, impaired cognition, generalized weakness, poor balance, visual deficits, and a documented fall history was care planned and ordered as an assist of one for ADLs and toilet transfers. A NA assisted the resident to sit on the bedside to use a urinal, then, after the resident requested privacy, pulled the privacy curtain and left the resident sitting at the bedside, out of line of sight, to care for the roommate, despite knowing the resident’s fall risk and inconsistent call-bell use. Within minutes, the NA heard a noise and found the resident on the floor by the bed with active head bleeding and the urinal on the floor, then left the resident unattended again to walk down the hall to notify an RN instead of immediately calling for help. Nursing documentation and staff interviews confirmed that the resident sustained facial lacerations requiring hospital treatment and that the resident should not have been left unsupervised behind the curtain while using the urinal.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a left wrist fracture had an initial care plan and RCC completed at admission, identifying fall risk and related interventions. A subsequent quarterly MDS showed severely impaired cognition and need for substantial assistance with mobility, but no RCC was documented to coincide with that assessment, and the next RCC was not held until more than a month later. The MDS coordinator acknowledged RCCs are required at least quarterly and that one should have been scheduled around the time of the quarterly MDS, but there was no documentation that the planned RCC occurred or that invitations were sent while the coordinator was on vacation. The DON confirmed RCCs must correlate with MDS dates and be documented, and facility policy required quarterly care plan review with resident/representative notification and participation, yet no separate RCC policy was provided.
A resident with Alzheimer’s disease, aphasia post-CVA, weakness, and a prior wrist fracture was initially assessed as not at risk to low fall risk, but the care plan documented fall risk due to cognitive impairment and generalized weakness, with interventions such as call light within reach and assistance with transfers. A subsequent quarterly MDS showed severely impaired cognition (BIMS 3) and need for substantial assistance with mobility, yet no Fall Risk Evaluation was completed for several months, including around the time of the quarterly assessment. The resident later experienced a fall, was found on the floor with a reddened hip and, later, a bump on the head and inability to move the neck, and was transferred to the ED, where an acute displaced type II odontoid fracture was diagnosed. The DON reported that Fall Risk Evaluations were expected on admission, quarterly, and with changes in condition, but no specific policy on Fall Risk Evaluations was available.
Two residents with significant cognitive and mobility impairments experienced falls, and in both cases the assigned RNs failed to document complete post-fall nursing assessments in the medical record as required by facility policy. For one resident with Parkinson’s disease and a history of falls, the RN recorded discovery of the resident on the floor with a facial laceration, EMS transfer, and provider/representative notification, but did not document range of motion (ROM), neurological findings, or a full assessment via SBAR. For another resident with dementia, prior wrist fracture, and severe cognitive impairment, the RN documented the resident on the floor with a reddened hip, vital signs, and provider notification, but did not document ROM, additional injury assessment, new monitoring orders, or an SBAR. Both RNs later stated they had performed full assessments but had not recorded their findings, contrary to the facility’s Falls Protocol and charting policies requiring detailed documentation of post-fall assessments and changes in condition.
The facility failed to consistently provide substantial evening snacks to residents. Surveyors observed that the snack shelf and snack cart often contained only beverages and minimal crackers, with no other substantial snack items available, and the café refrigerator held a limited number of Jello, pudding, or fruit cups despite a resident capacity of 125. The FSD reported that snacks were delivered weekly but routinely ran out early in the week due to a reduced snack budget, and the Administrator was aware of the shortage. The dietician stated that snack availability had significantly declined since a change in ownership, that requests for additional snacks were not approved, and that snacks needed for diabetics or residents who did not eat meals for caloric supplementation were not always available.
A resident with dementia, depression, and mood disorder who used a wheelchair and required limited assistance for care was receiving incontinent care from three NAs when the resident became combative and refused care. Two NAs held the resident’s arms while the third provided care, and one NA slapped the resident’s arm and used profanity, as witnessed by two staff. The witnesses did not immediately report the incident, and all three NAs continued working for additional days before the allegation was brought to an RN and investigated, contrary to facility policy requiring immediate action to prevent abuse.
A resident with dementia and mood disorders, who required limited assistance with ADLs and used a wheelchair, became combative and refused incontinent care while three NAs attempted to change a soaked brief and bedding. During this care, one NA allegedly slapped the resident’s arm while using profanity, and two other NAs reported witnessing the slapping but did not immediately report the incident, each assuming the other would do so. The event was not brought to an RN supervisor until days later, and only then was the DNS notified and an investigation initiated, resulting in a substantiated abuse finding. This sequence of delayed reporting and notification failed to meet requirements for timely reporting of alleged abuse to the state survey agency.
A resident with osteoarthritis, rheumatoid arthritis, and non-ambulatory status, who required a two-person stand-pivot transfer with a walker per care card and provider order, was transferred by a single NA who did not use a gait belt or walker. The NA assisted the resident to stand from a wheelchair using the bed rail and instructed the resident to pivot toward the bed, during which a pop/grinding sound was heard from the left knee and the resident experienced immediate pain. Initial nursing assessment noted pain with movement but no visible swelling or redness, and the provider was not notified until hours later when swelling and continued pain were reported by an LPN. A STAT X-ray subsequently revealed an acute comminuted fracture of the distal left femoral shaft, and the resident required hospital transfer and surgical repair.
A resident with osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder had a current physician order for bed mobility assist of two and transfer assist of two with a rolling walker, and therapy discharge documentation showed the resident performing stand-pivot transfers with assist of two. Despite this, the resident’s care plan, last reviewed by the IDT and MDS nurse, continued to list the resident as a total lift for transfers and was not revised to reflect the updated mobility status and orders, contrary to the facility’s comprehensive care planning policy requiring ongoing review and revision with condition changes.
A resident with osteoarthritis and rheumatoid arthritis, who had a PRN order for acetaminophen every six hours for pain, sustained a left distal femur fracture during a transfer and experienced significant pain with movement. Initial PRN acetaminophen given in the late afternoon was documented as effective, but when the resident later yelled out in pain and swelling was observed, an LPN did not administer another PRN dose despite the order parameters. During the night, another LPN observed ongoing discomfort but delayed giving acetaminophen until early morning, assuming it had already been given and not checking the MAR. The early-morning dose was documented as ineffective for 10/10 pain, and although this unrelieved pain was reported to a supervisor, the provider was not notified and no additional pain medication was obtained before the resident was sent to the hospital. The facility’s pain policy requiring frequent reassessment of acute pain, MAR review, and reporting of prolonged unrelieved pain was not followed.
The facility did not complete required annual performance evaluations for a nurse aide working the 3–11 PM shift. Review of the aide’s personnel file showed a hire date more than a decade earlier and a last documented evaluation several years ago, with no evidence of subsequent yearly evaluations. The Administrator reported that all employees must receive annual evaluations based on their hire-date anniversary and that HR was responsible for notifying when evaluations were due, routing them to nursing supervisors, and ensuring they were filed. Facility policy specified that evaluations should summarize counseling sessions to identify trends, review job description performance ratings with the employee, and be filed per policy, but this process was not followed for the identified aide.
A resident in hospice care with Alzheimer's and other conditions did not receive prescribed medications due to facility errors. Lorazepam and Atropine were not administered as ordered because of pharmacy delivery issues and miscommunication. Nurses documented medication administration without actually giving it, and oral Acetaminophen was improperly continued despite swallowing difficulties. These failures led to inadequate symptom management during the resident's end-of-life care.
A resident in hospice care did not receive prescribed Lorazepam due to unavailability, yet two LPNs inaccurately documented its administration in the e-MAR. The nurses failed to correct the documentation or notify the supervisor, leading to a deficiency in accurate clinical record-keeping.
A resident with COPD and nicotine dependence experienced multiple documented smoking incidents, including possessing cigarettes and smoking on facility grounds, despite having a care plan addressing smoking cessation. The care plan was not updated to reflect these incidents or to include new interventions, and facility leadership confirmed the lack of timely care plan revision.
A resident with COPD and nicotine dependence was repeatedly found in possession of or using smoking materials independently, despite facility policies prohibiting this. Staff documented the incidents but did not complete required accident/incident reports or investigations, nor did they report the events to the State Agency as mandated by policy.
Two residents experienced misappropriation of their controlled medications, including Morphine and Lacosamide, along with missing controlled substance records. In both cases, medications were removed from secure storage without authorization, and the facility was unable to account for the missing drugs or identify the responsible party, violating policies against misappropriation of resident property.
A resident with mobility and incontinence issues was not treated with dignity and respect by a nurse aide, who yelled at the resident after an incontinence episode, threw items around the room, and failed to assist the resident back to bed. The incident was witnessed by a roommate and confirmed by staff interviews, in violation of the facility's policy on resident rights.
The facility failed to ensure congruence between physician's orders and advanced directive forms for several residents, leading to discrepancies in code status documentation. For instance, a resident's advanced directive indicated DNR, but the care plan and physician's orders showed full code. Another resident's code status was changed by a Probate Decree, but this was not updated in the clinical record until later. Additionally, a resident's desire for CPR was not reflected in the physician's orders, and the facility did not verify the authority of the POA to make medical decisions.
A resident with dementia and other conditions was prescribed Gabapentin 300 mg, but the intent was 100 mg twice daily. The pharmacy consultant failed to identify this discrepancy during monthly reviews. An LPN administered the incorrect dosage, and the pharmacy provider did not follow protocol to clarify the order, leading to a deficiency in medication management.
A resident with severe cognitive impairment and physical limitations was found with excessively long and thick fingernails, indicating a deficiency in personal hygiene care. Despite care plans and physician's orders for regular nail maintenance, staff failed to adequately address the resident's nail condition. Interviews revealed a lack of awareness and communication among staff, leading to neglect in nail care.
A resident with multiple health issues had a wound on the right great toe that was not assessed by an RN upon initial observation, nor monitored weekly as required. Interviews with staff revealed that the wound nurse was not informed, leading to a lack of proper monitoring, contrary to facility policy and state regulations.
A facility failed to ensure that a resident's pressure ulcer was assessed by an RN as required by policy. The resident, at risk for pressure ulcers, had a new deep tissue injury on the right heel initially assessed by an LPN. The wound was not assessed by an RN until much later, despite policy requirements for initial and weekly RN assessments.
A facility failed to discuss and provide a written summary of a baseline care plan to a resident admitted with Covid-19, atrial fibrillation, hypertension, and polyarthritis. Despite the policy to develop a care plan within 48 hours, there was no documentation of the interdisciplinary team meeting with the resident or their representative to discuss the plan. Interviews with staff confirmed the oversight.
The facility failed to maintain complete and accessible medical records for laboratory results for three residents. Despite having multiple blood tests conducted, the results were not present in the residents' records. Staff interviews revealed a lack of clarity and accountability in handling and filing these results, leading to incomplete medical documentation.
A facility failed to maintain complete hospice documentation for a resident with dementia and other conditions. Despite being admitted to hospice care, the resident's clinical record lacked necessary documentation, including interdisciplinary team notes and care plans. Interviews with staff revealed confusion about the location and organization of hospice records, exacerbated by changes in the hospice company's filing system.
Failure to Supervise High Fall-Risk Resident During Bedside Urinal Use
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an accident for a cognitively impaired, fall‑risk resident during bedside urinal use. The resident had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition (BIMS 11), impaired balance, unsteady gait, visual difficulty, and a documented history of falls including a prior fall with injury since admission. The care plan and physician orders identified the resident as an assist of one for ADLs and toilet transfers, with interventions including assistance for toileting at wheelchair level using a grab bar, use of simple language, reorientation as needed, and instruction to ask for assistance before transferring or ambulating. On the day of the incident, a nursing assistant (NA) entered the resident’s room when the resident requested to use a urinal. The NA assisted the resident to sit on the bedside to use the urinal. When the resident was unable to urinate, the resident requested privacy. Despite knowing the resident required assist of one for ADLs and toileting, had a history of falls, was sometimes confused, and had a history of not using the call bell, the NA pulled the privacy curtain around the bed, left the resident sitting on the bedside behind the curtain and out of her line of sight, and went to provide care to the roommate. Approximately two minutes later, the NA heard a bang, opened the curtain, and found the resident on the floor beside the bed with active bleeding from the head and the urinal on the floor. After discovering the resident on the floor, the NA briefly asked if the resident was okay and then left the resident unattended again while she walked down the hallway to notify the RN, without calling out for help or using the call bell. Subsequent nursing notes documented that the resident was found seated on the floor with a laceration to the face and active bleeding from the forehead, and that EMS was notified and the resident was transferred to the hospital, where multiple forehead lacerations were repaired with absorbable sutures. Interviews with the LPN, RN, and DON confirmed that, based on the resident’s plan of care and known fall risk, the resident should not have been left out of sight behind a privacy curtain while sitting on the bedside to use the urinal, and that the NA did not maintain appropriate supervision or immediately seek assistance while the resident was actively bleeding on the floor.
Failure to Complete and Document Quarterly Resident Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure Resident Care Conferences (RCCs) were completed at least quarterly and in conjunction with the required quarterly MDS assessment for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction, and the care plan dated 11/19/25 identified the resident as being at risk for falls due to new admission status, cognitive impairment, and generalized weakness. An RCC and interdisciplinary care plan meeting were documented on 11/19/25, and the quarterly MDS dated 2/3/26 showed severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. However, review of the clinical record from 11/20/25 through 3/8/26 did not show that an RCC was scheduled or held to correspond with the 2/3/26 MDS. The Interdisciplinary Care Plan Meeting Documentation showed the next RCC for this resident occurred on 3/9/26, more than one month after the quarterly MDS. The MDS Coordinator (RN #3) stated that RCCs are to be completed at least quarterly with review of the resident care plan and acknowledged that the resident should have had an RCC scheduled around the time of the 2/3/26 MDS. RN #3 reported an RCC was initially scheduled for 2/19/26 but could not provide documentation that the meeting occurred or that invitations were sent to the resident or representative, noting she had been on vacation when invitations should have been sent. The DON confirmed that all residents are to have quarterly RCCs that correlate with the MDS date and be documented in the clinical record, and that if an RCC is rescheduled, there should be documentation explaining the reason and new date. Review of the Comprehensive Care Planning policy showed requirements for informing residents of their right to participate in care planning, providing advance notice of conferences, documenting when participation is not practicable, and reviewing and updating the care plan at least quarterly with the MDS; no separate RCC policy was provided despite request.
Failure to Complete Quarterly Fall Risk Evaluation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not completing a required Fall Risk Evaluation at least quarterly for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction. A Fall Risk Evaluation dated 10/30/25 identified the resident as not at risk to low fall risk, while the Resident Care Plan dated 11/19/25 documented that the resident was at risk for falls due to new admission status, cognitive impairment, and generalized weakness, with interventions such as keeping the call light within reach, orienting to surroundings, and instructing the resident to ask for assistance before transfers or ambulation. A quarterly MDS assessment later identified severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. Despite these findings, review of the clinical record showed no Fall Risk Evaluation was completed between 10/31/25 and 2/9/26, including around the time of the quarterly MDS. On 2/10/26 at 1:31 AM, an RN documented that the resident had fallen and was found on the floor on the right side, with a reddened right hip but denying pain; vital signs were obtained and the provider was notified, but there were no documented orders for monitoring the reddened hip. Later that day, the DON documented that the resident had sustained a fall and was later noted to have a bump on the right side of the head and inability to move the neck, though still denying pain or discomfort, and the resident was evaluated by an APRN and transferred to the ED. Hospital records showed an admission from 2/10/26 through 2/16/26 for an acute displaced type II odontoid fracture following the fall. The DON stated that all residents should have a Fall Risk Evaluation on admission, quarterly, and with a change in condition, and acknowledged that this resident should have had a Fall Risk Evaluation completed around the time of the quarterly MDS. The facility’s Falls Protocol policy referenced review and documentation of fall risk factors and evaluation of falls, but a specific policy on Fall Risk Evaluations was not available.
Failure to Document Complete Post-Fall Nursing Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete and document nursing assessments in the medical records at the time of residents’ falls, as required by facility policy and professional standards. For Resident #1, who had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition, and a history of falls, the care plan identified multiple fall risks and required assistance with ADLs and toileting. After a fall on 2/7/26, RN #1 documented that the resident was found seated on the floor attempting to get up, with a facial laceration and bleeding, that EMS was notified, the resident remained on the floor until EMS arrival, and that the resident was transferred to the hospital. The note also documented notification of the on-call provider and the resident’s representative. However, the clinical record for Resident #1 did not include documentation that range of motion (ROM) was assessed for additional injuries or pain following the fall, and there was no completed Situation, Background, Assessment, Recommendation (SBAR) form to show that a full assessment had been performed. In interview, RN #1 stated she had performed a full assessment, including ROM and neurological signs, but acknowledged she did not document her findings and that the assessment should have been documented before the end of her shift. This lack of documentation conflicted with the facility’s Falls Protocol policy, which directed nurses to assess and document vital signs, recent injury, musculoskeletal function including changes in ROM or weight bearing, cognition and neurological status, pain, and details of the fall. For Resident #2, who had a scaphoid fracture of the left wrist, weakness, Alzheimer’s disease, aphasia following cerebral infarction, severe cognitive impairment, and required substantial assistance with mobility, the care plan identified fall risk related to new admission, cognitive impairment, and generalized weakness. After a fall on 2/10/26, RN #2 documented that the resident was found on the right side on the floor, with the right hip reddened from lying on it, and that the resident denied pain; vital signs were obtained and the provider was notified. The record did not show any new orders for monitoring the reddened hip, did not document that ROM was assessed for further injuries, and did not contain an SBAR documenting a full assessment. Later documentation by the DON noted that the resident was subsequently found with a bump on the right side of the head and inability to move the neck, and hospital records showed admission for an acute displaced type II odontoid fracture. In interview, RN #2 stated she had performed a full assessment including movement and ROM but did not document it, and the DON confirmed that both RNs should have documented full post-fall assessments in the nurse’s notes or SBARs in accordance with the facility’s Falls Protocol and Charting Documentation policies.
Failure to Provide Substantial and Consistent Evening Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a substantial evening snack on a daily basis, as required by regulation and facility policy. Surveyor observations of the dietary department’s dry storage room on multiple dates showed that the designated snack shelf contained only a small quantity of items, such as one box of crackers and several 1-liter bottles of cola, with no chips, cookies, crackers, or other substantial snacks available. On another observation, there were no snacks available to residents at all. Review of the snack cart revealed it typically contained only a coffee carafe, a bottle of ginger ale, and at most a single or partial package of crackers, with no other food items present for residents. Further observations of the café refrigerator showed fewer than 20 containers of Jello, pudding, or fruit cups available for a facility with a capacity of 125 residents. In interviews, the Food Service Director (FSD) reported that snacks were delivered weekly on Thursdays but routinely ran out by Mondays due to a reduced snack budget of $315 per week. The Administrator acknowledged awareness of the lack of snacks and that the FSD had raised concerns. The dietician reported that snack availability had significantly declined since a change in ownership, that requests to purchase more snacks were not approved, and that snacks needed for residents who are diabetic or who did not eat meals were not always available, despite their importance for caloric supplementation.
Failure to Protect Resident From Physical Abuse and Delay in Reporting Incident
Penalty
Summary
The deficiency involves a resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder who was moderately cognitively impaired, used a wheelchair, and required limited assistance with mobility and personal care. The resident’s care plan identified a risk for refusing care and not waiting for assistance with transfers, with interventions including use of two staff for care and transfers, calm and gentle approach, and clear explanations. During an evening episode of incontinent care, three NAs entered the resident’s room when the resident did not want to be changed and became combative, swinging arms and feet. Two NAs held the resident’s arms while a third NA provided care. During this care, one NA slapped the resident hard on the arm and used an expletive, according to two staff witness statements, while the resident continued to resist by kicking and slapping. The deficiency also includes the failure of two staff members to immediately report the witnessed physical abuse. Both NAs who observed the slapping did not report the incident at the time it occurred, despite one believing the other would report it, and there was no discussion between them about reporting. As a result, the alleged abuser and the two witnesses continued to work in the facility for two additional days before the allegation was reported to the Nursing Supervisor near the end of a later shift. The facility’s policy required protections for residents through written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, and called for an immediate investigation when suspicion or reports of abuse occur, but the delay in reporting and the occurrence of the slapping incident demonstrate a failure to ensure the resident was free from mistreatment.
Failure to Timely Report Alleged Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of physical abuse to the state survey agency. A resident with neurocognitive disorder with Lewy bodies dementia, major depressive disorder, and mood disorder was moderately cognitively impaired, required limited assistance with ADLs, and used a wheelchair. The resident’s care plan identified risk for refusing care and not waiting for assistance with transfers, with interventions including assistance of two staff for care and transfers and use of a calm, gentle approach. During provision of incontinent care, the resident became combative and refused care while staff attempted to change a soaked brief and bedding. According to written statements, three NAs entered the resident’s room to provide care. One NA held the resident’s arms so another NA could change the brief, and a third NA assisted in holding the resident’s arms. One NA was alleged to have slapped the resident hard on the arm while using an expletive, and two NAs reported witnessing the slapping. One NA stated she should have reported the incident when it happened, and another NA stated she did not report the incident because she thought the other NA would report it, although they had not discussed reporting. The involved NAs continued to work in the facility on subsequent days because the allegation was not reported at the time of occurrence. The incident was alleged to have occurred several days before it was brought to the attention of the RN Nursing Supervisor, who was notified toward the end of a later shift that an NA had slapped the resident during care. The Nursing Supervisor documented that two NAs confirmed the allegation and that the incident had occurred days earlier, with no noted signs or symptoms of injury. The DNS was later notified via text message and began an investigation, during which statements were obtained and the allegation was ultimately substantiated based on two staff witnesses. The facility’s policy required immediate investigation when there was suspicion or reports of abuse, neglect, or exploitation, but the delay in reporting by staff and the delayed notification to the state survey agency constituted a failure to ensure timely reporting of the abuse allegation.
Improper One-Person Transfer Without Gait Belt Leads to Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required two-person assistance for transfers was transferred per protocol, resulting in a preventable accident and an acute comminuted fracture of the left distal femoral shaft. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and was non-ambulatory at baseline. An annual MDS showed a BIMS score of 12/15 with some memory deficits, partial assistance needed for bed mobility and transfers, and wheelchair use for mobility. Therapy staff and the DON confirmed that, at the time of the incident, the resident required an assist of two for stand-pivot transfers with a walker per the care card and physician’s order. On the day of the incident, the resident reported feeling very tired and falling asleep in the wheelchair, with left foot discomfort. A nurse aide observed the resident leaning forward in the wheelchair with hands on the side rail and believed the resident was trying to stand. Although the aide knew the resident required two-person assistance and a walker for stand-pivot transfers, she did not call for help, did not use the call bell, did not apply a gait belt, and did not use the walker. Instead, she assisted the resident to stand while the resident held the side rail and instructed the resident to pivot toward the bed. As the resident attempted to pivot on the left leg, both the resident and the aide heard a pop or grinding sound from the left knee, and the resident experienced immediate pain. The aide then maneuvered the resident onto the edge of the bed and into bed without a fall occurring. Following the incident, the resident complained of pain with movement of the left leg and knee. The 3–11 PM RN supervisor assessed the resident around 4:15 PM but did not observe redness or swelling and did not immediately notify the provider. Later that evening, after the charge LPN reported swelling and continued pain, the RN supervisor reassessed the resident and contacted the provider, who ordered a STAT left knee X-ray, ice, and continued PRN Tylenol. The X-ray obtained early the next morning showed an acute comminuted fracture of the distal shaft of the left femur, and the resident was subsequently transferred to the hospital, where surgical intervention with open reduction internal fixation was performed. The incident was documented on the facility’s reportable incident form as occurring during a transfer performed by the 3–11 PM nurse aide, with a pop sound heard and increased left knee pain, and was identified as a preventable accident reflecting a breakdown in supervision and adherence to established protocols.
Failure to Update Mobility Care Plan to Match Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s mobility care plan to reflect a current physician’s order. The resident had diagnoses including osteoarthritis of the knee, rheumatoid arthritis, and generalized anxiety disorder, and had a BIMS score of 12/15 indicating some memory recall deficits. A physician’s order dated 3/2/25, and still current, directed that the resident receive bed mobility assistance of two and transfer assistance of two with a rolling walker. The annual MDS identified that the resident required partial assistance with bed mobility and transfers and used a wheelchair for mobility. However, the Resident Care Plan initiated on 1/6/24 and last reviewed on 1/16/26 identified the resident as requiring assistance with mobility due to decreased strength and listed interventions indicating the resident was a total lift for transfers, which did not match the physician’s order. Interviews and record reviews confirmed that the care plan had not been updated despite changes in the resident’s mobility status and existing orders. The PT and OT reported that the resident had been on therapy services until 12/18/25 and was discharged at that time as an assist of two for stand-pivot transfers between bed and wheelchair, consistent with the 3/2/25 activity orders. They stated they would have notified the charge nurse of the resident’s transfer status and that therapy staff do not update care plans, leaving that responsibility to nursing. They acknowledged the mobility care plan last reviewed on 1/16/26 was incorrect and that the resident had not required a total lift for transfers since 3/2025. The DON confirmed that the mobility care plan should have matched the 3/2/25 physician’s order and that both the IDT and the MDS nurse were responsible for reviewing and revising care plans, including during care plan meetings. The facility’s Comprehensive Care Planning policy directed that care plans be revised as residents’ conditions change and be reviewed and updated at significant changes and at least quarterly, but this was not done for this resident’s mobility care plan.
Failure to Provide Timely and Effective PRN Pain Management After Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and timely pain management to a resident following an injury that resulted in a left distal femur fracture. The resident had diagnoses of osteoarthritis, rheumatoid arthritis, and generalized anxiety disorder, and had a standing PRN order for acetaminophen 325 mg, three tablets by mouth every six hours as needed for pain. The care plan identified the resident as having potential for pain related to arthritis, with interventions including administering medications as prescribed and monitoring effectiveness. On the date of the incident, during a transfer by a nurse aide, a popping sound was heard and the resident reported increased left knee pain. The nurse supervisor directed the charge nurse to obtain vital signs and administer acetaminophen around 4:15 PM, which was documented as effective at that time. Later that evening, around 10:40 PM, the charge nurse noted the resident yelled out in pain when the left leg was lifted and observed swelling of the left knee. Despite recognizing the resident’s pain at that time, the charge nurse did not administer another dose of acetaminophen, even though more than six hours had elapsed since the prior dose and the medication was ordered every six hours as needed. The provider was notified and ordered a STAT x-ray, continuation of PRN Tylenol, and application of ice. During the overnight shift, the oncoming LPN was informed that the resident had been in pain at the end of the prior shift and observed that the resident appeared uncomfortable throughout the night. However, this nurse did not administer acetaminophen until 5:12 AM, assuming the prior nurse had already given it and failing to verify the last administration time on the MAR. After the 5:12 AM dose, the resident continued to appear restless and uncomfortable during care, and the acetaminophen was documented as ineffective for a pain level of 10/10. Although the nurse reported the unrelieved pain to the nursing supervisor, there was no documentation that the provider was notified of the ineffective pain control or that any additional or alternative pain medication was obtained prior to the resident’s transfer to the hospital later that morning. The facility’s pain policy required acute pain to be assessed every 30–60 minutes until relief was obtained, review of the MAR to determine PRN use and effectiveness, and reporting of significant changes in pain level and prolonged, unrelieved pain to the practitioner. These steps were not followed, resulting in prolonged unrelieved pain for the resident after the injury and prior to hospital transfer.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete required annual performance evaluations for at least one nurse aide. Review of the personnel file for a 3–11 PM nurse aide (NA #1) showed a hire date of 11/26/12 and documented that the last performance evaluation was completed on 12/18/22, with no evidence that yearly evaluations were completed in 2023, 2024, or 2025. The Administrator stated that each employee was required to have an annual performance evaluation based on their hire-date anniversary and explained that, although the facility currently had no Human Resources (HR) staff member, HR had been expected to notify when evaluations were due, distribute them to nursing supervisors for completion, and ensure they were filed in the employee record. Facility policy titled “How to Complete the Performance Evaluation” indicated that the facility reviews and summarizes employee counseling sessions to identify trends and patterns, reviews job description performance ratings with the employee to ensure understanding of performance expectations, and files the performance evaluation per facility policy, but this process was not carried out for NA #1 for multiple consecutive years. No resident medical history or condition was described in relation to this deficiency.
Failure to Administer Prescribed Medications for Hospice Resident
Penalty
Summary
The facility failed to administer medications as prescribed for a resident receiving palliative care, leading to a deficiency in care. The resident, who had Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive, was admitted to hospice care and required specific medications for comfort during the end-of-life process. Despite physician orders for Lorazepam and Atropine to manage anxiety and secretions, these medications were not administered as prescribed due to a lack of delivery from the pharmacy and miscommunication regarding the medication orders. The report highlights several instances where the facility's staff did not follow proper procedures. On two occasions, nurses documented the administration of Lorazepam without actually administering it, failing to correct their records or notify supervisors. Additionally, the facility did not ensure that the necessary prescriptions were sent to the pharmacy, resulting in the unavailability of Lorazepam and Atropine. The pharmacy's requests for clarification on the Atropine order went unanswered, and the medication was not delivered to the resident. Furthermore, the facility continued to administer oral Acetaminophen despite hospice recommendations to discontinue all oral medications due to the resident's inability to swallow. This oversight was compounded by the discontinuation of a rectal Tylenol order, which was intended for pain management. The lack of communication and failure to adhere to medication orders contributed to the resident not receiving the necessary care to manage symptoms effectively during the end-of-life stage.
Inaccurate Medication Documentation for Palliative Care Resident
Penalty
Summary
The facility failed to ensure accurate clinical record documentation for a resident receiving palliative care, leading to a deficiency. The resident, diagnosed with Alzheimer's disease, dementia, anxiety, chronic kidney disease, and adult failure to thrive, was admitted to hospice care and required specific medications for comfort. On a particular day, the hospice recommended discontinuing all scheduled medications and starting Morphine, Lorazepam, and Atropine for comfort care. However, the electronic Medication Administration Record (e-MAR) inaccurately reflected that Lorazepam was administered twice when it was not available, and the nurses involved did not correct the documentation or notify the appropriate personnel. The deficiency was further compounded by the lack of communication and proper documentation procedures. One LPN signed the e-MAR before realizing the medication was unavailable and failed to strike off her signature or notify the supervisor. Another LPN also signed for the administration of Lorazepam without it being available and did not follow up with the necessary steps to rectify the situation. The Assistant Director of Nursing Services (ADNS) confirmed that the nurses should have corrected the e-MAR and informed the nursing supervisor to ensure the resident received the prescribed medications. The facility did not provide a policy to guide the staff on handling such situations, contributing to the deficiency.
Failure to Update Care Plan After Repeated Smoking Incidents
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was updated to address known smoking incidents for a resident with chronic obstructive pulmonary disease and nicotine dependence. The resident was cognitively intact and independent in mobility, with a care plan that initially included interventions such as instruction on the facility smoking policy, securing smoking materials, offering a nicotine patch, and addressing smoking cessation. However, clinical record reviews revealed multiple incidents where the resident possessed smoking materials, was observed smoking on facility grounds, and smoked while using a nicotine patch. Despite these documented incidents on three separate occasions, the care plan was not revised to reflect the new behaviors or to include additional interventions to prevent recurrence. An interview with the Assistant Director of Nursing confirmed that the care plan had not been updated following these events, and the facility was unable to provide a policy regarding the review and revision of comprehensive care plans.
Failure to Investigate and Report Resident Smoking Incidents
Penalty
Summary
The facility failed to ensure timely investigation of known smoking incidents involving a resident with chronic obstructive pulmonary disease and nicotine dependence. The resident, who was cognitively intact and independent in mobility, had a care plan that included instructions about the facility smoking policy, securing smoking materials, and offering nicotine patches. Despite this, nursing progress notes documented three separate occasions where the resident was found in possession of smoking materials or observed smoking independently on facility property. On each occasion, staff either removed the items or educated the resident, but no formal accident/incident reports or investigations were completed as required by facility policy. Additionally, the facility did not submit reportable events to the State Agency for any of these incidents. Interviews with facility leadership confirmed that no investigations were conducted to determine how the resident obtained smoking paraphernalia or to implement interventions to prevent recurrence. Facility policies clearly stated that residents were not permitted to possess smoking materials or smoke independently, and that all accidents and incidents must be documented and reported. However, these procedures were not followed in response to the documented smoking incidents.
Failure to Safeguard Residents' Controlled Medications and Records
Penalty
Summary
The facility failed to protect residents from the wrongful use or removal of their controlled medications and associated documentation. For one resident with Alzheimer's disease and colon cancer, an unopened bottle of Morphine Sulfate prescribed for pain and shortness of breath was discovered missing from the controlled medication box when the resident required a dose for comfort. The investigation revealed that the previous Director of Nursing had removed the controlled medications, including Morphine and Oxycodone from the emergency and drug destruction boxes, without authorization. The incident was not reported immediately upon discovery, and the missing medication was only reported to the current Director of Nursing the following day. In a separate incident, another resident with epilepsy and dementia was found to be missing a significant quantity of Lacosamide tablets, along with the controlled substance disposition record. The missing medication was identified during a routine narcotics count, and the investigation confirmed that a total of eighty-eight tablets were unaccounted for, but could not determine who was responsible for their removal. Both incidents were reported to the Department of Consumer Protection, Drug Enforcement Division, and were in violation of the facility's policy prohibiting misappropriation of resident property.
Failure to Treat Resident with Dignity and Respect During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a history of knee replacement, mobility difficulties, and incontinence was not treated with dignity and respect by a staff member. The resident, who was alert and oriented, required substantial assistance with personal hygiene and toileting. According to facility documentation and interviews, the resident reported that a nurse aide became upset and yelled at the resident after an episode of incontinence. The aide was also described as throwing items around the resident's side of the room and failing to assist the resident back to bed after providing care. The incident was witnessed by the resident's roommate. Interviews with facility staff confirmed that the resident alleged verbal abuse and disrespectful behavior from the nurse aide, including being yelled at for soiling themselves. The nurse aide acknowledged that the resident was upset and yelling, and called the charge nurse to intervene. The charge nurse also confirmed that the resident reported being yelled at by the aide. Facility policy states that residents have the right to be treated with consideration, respect, and dignity, which was not upheld in this instance.
Inconsistent Advanced Directive Documentation
Penalty
Summary
The facility failed to ensure that the physician's orders and the signed advanced directive forms were congruent for several residents, leading to discrepancies in their code status documentation. For Resident #33, there was a mismatch between the advanced directive form indicating a Do Not Resuscitate (DNR) status and the care plan and physician's orders, which indicated a full code status. Despite the resident's decision to change their code status to full code, the physical clinical record was not updated to reflect this change, as confirmed by interviews with staff. Resident #51's case involved a change in code status from full code to DNR and Do Not Intubate (DNI) as per a Probate Order Decree. However, the care plan and advanced directive form did not reflect this change until after surveyor inquiry. Similarly, Resident #69's advanced directive form indicated a DNR status, but the care plan and physician's orders showed a full code status. The facility was unable to provide a Probate Court order to support this change, highlighting a lack of documentation and communication. For Resident #78, a Probate Decree changed the code status to DNR/DNI, but this was not reflected in the resident's clinical record until after the decree was received. The facility's process for updating code status was not followed, as the order was entered before receiving the decree. Resident #107's case involved a discrepancy between the advanced directive form and the physician's orders, with the resident expressing a desire for CPR despite the orders indicating DNR/DNI. The facility failed to verify the authority of the Power of Attorney to make medical decisions, leading to further confusion in the resident's code status documentation.
Pharmacy Consultant Fails to Identify Medication Order Discrepancy
Penalty
Summary
The facility failed to ensure that the consultant pharmacist identified a discrepancy in a written physician's order for a resident with diagnoses including dementia, psychotic disturbance, type 2 diabetes mellitus, and pain. The resident's quarterly MDS assessment indicated moderately impaired cognition and required assistance with certain activities of daily living. A physician's order directed the administration of Gabapentin 300 mg, but the intent was to administer 100 mg twice daily. Despite monthly pharmacy regimen reviews, no recommendations addressed the discrepancy in the Gabapentin order. During a medication pass, an LPN was observed preparing three 100 mg Gabapentin capsules for the resident, contrary to the physician's order. Interviews with the Pharmacist Consultant Supervisor and the APRN who wrote the order revealed that the pharmacy consultant should have identified the confusing order and recommended clarification. The pharmacy provider's pharmacist acknowledged that the protocol to notify the facility of the discrepancy was not followed, as there was no record of communication, and the order was never corrected. The facility's pharmacy policy indicated that issues should be communicated and suggestions made for service improvement, which was not adhered to in this case.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to ensure proper nail care for a resident with severe cognitive impairment and physical limitations, leading to a deficiency in personal hygiene. The resident, who required total assistance with activities of daily living due to conditions such as dementia, anxiety, and a contracture of the right hand, was observed with excessively long and thick fingernails. Despite a care plan and physician's orders that included regular washing of hands and nails, the resident's nails were not adequately maintained. Observations revealed that the resident's right middle fingernail was particularly long, thick, and curved, indicating neglect in nail care. Interviews with staff revealed a lack of awareness and communication regarding the resident's nail condition. A nurse aide reported trimming the resident's nails two weeks prior but did not address the thick and discolored middle fingernail, assuming it was the responsibility of the charge nurse. The charge nurse and other staff members were either unaware of the nail condition or assumed it was being managed through routine washing. The facility's policies on nail care and weekly body audits were not effectively implemented, as evidenced by the failure to address the resident's nail condition during these assessments.
Failure to Assess and Monitor Resident's Wound
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a non-pressure related wound for a resident with multiple diagnoses, including heart failure and venous insufficiency. The resident's care plan included interventions for skin inspection and treatment, but the clinical record review revealed that the wound on the resident's right great toe was not initially assessed by a registered nurse upon observation, nor were there any documented weekly assessments as required by the facility's policy and state regulations. Interviews with facility staff, including two LPNs and the Director of Nursing Services (DNS), confirmed that the wound nurse was not informed of the resident's wound, resulting in a lack of weekly monitoring. The facility's policy mandates that non-pressure wounds be assessed and documented to ensure optimal outcomes, but this was not adhered to in the case of the resident's wound, leading to the identified deficiency.
Failure to Ensure RN Assessment of Pressure Ulcer
Penalty
Summary
The facility failed to ensure that the initial and weekly assessments of a wound for Resident #27 were completed by a registered nurse (RN), as required by their policy. Resident #27, who had diagnoses including type 1 diabetes mellitus and was at risk for pressure ulcers, was admitted with an unstageable pressure injury. The care plan included interventions such as weekly skin inspections and pressure-reducing measures. However, when a new deep tissue injury (DTI) was identified on the resident's right heel, it was initially assessed by an LPN instead of an RN, contrary to the facility's policy. The LPN responsible for wound care documented the assessments of the right heel wound on multiple occasions, but an RN did not assess the wound until much later. The Wound Specialist (APRN) also assessed the wound, but not until two weeks after the initial identification by the LPN. Interviews with the LPN and the Director of Nursing Services (DNS) confirmed that the wound should have been assessed by an RN initially and weekly, as per the facility's policy. This oversight led to a deficiency in the care provided to Resident #27.
Failure to Discuss Baseline Care Plan with Resident
Penalty
Summary
The facility failed to ensure that a written summary of the baseline care plan was discussed and provided to a resident and/or their representative. Resident #120, who was admitted with diagnoses including Covid-19, atrial fibrillation, hypertension, and polyarthritis, had their baseline care plan completed on January 13, 2024. The admission MDS assessment indicated that the resident had intact cognition and required extensive assistance for various activities of daily living. Despite the facility's policy to develop a care plan within 48 hours of admission, there was no documentation that the interdisciplinary team discussed this plan with the resident or their representative. Interviews with facility staff, including the RN nursing supervisor, the Admissions Coordinator, and the DNS, revealed that the interdisciplinary team, which includes rehabilitation, nursing, and social work staff, typically meets with residents and/or their representatives within 72 hours of admission to discuss the care plan. However, in this case, the Admissions Coordinator could not find any documentation indicating that such a discussion took place for Resident #120. The DNS confirmed that the interdisciplinary team did not discuss the baseline care plan with the resident or their representative, leading to the identified deficiency.
Incomplete Medical Records for Laboratory Results
Penalty
Summary
The facility failed to ensure that laboratory and diagnostic medical records were readily accessible and complete in the residents' physical charts and/or electronic medical record systems. For Resident #9, who had diagnoses including anxiety disorder and bipolar disorder, the last laboratory testing results in the medical record were from June 2023, despite having blood work drawn on nine occasions between November 2023 and March 2024. The Advanced Practice Registered Nurse (APRN) reviewed the results but was unaware of their subsequent handling, indicating a breakdown in the process of filing or uploading these results into the medical record system. Similarly, Resident #64, with diagnoses such as chronic obstructive pulmonary disease and type 2 diabetes mellitus, had no laboratory or diagnostic testing results in their clinical records for the past year, despite having blood work drawn on seven occasions. The Assistant Director of Nursing Services (ADNS) provided documentation from the laboratory company, but the results were not present in the resident's records, highlighting a failure in maintaining complete and accessible medical records. Resident #74, diagnosed with conditions including atrial fibrillation and hypertension, also lacked laboratory testing results in their clinical records for the past year, despite having blood work drawn on eight occasions. The facility's policy required complete and accurately documented medical records, but the process for reviewing and filing laboratory results was not effectively implemented, as evidenced by the absence of these results in the residents' records. Interviews with staff revealed a lack of clarity and accountability in the handling and filing of laboratory results, contributing to the deficiency.
Deficiency in Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that the clinical record for a resident receiving hospice care contained the necessary hospice documentation. The resident, who had diagnoses including senile degeneration of the brain, dementia, and abnormal weight loss, was admitted to hospice care as per a physician's order. Despite this, the clinical record lacked interdisciplinary team notes, the plan of care, and the Certificate/Recertification of Terminal Illness for specified periods. This deficiency was identified during a review of the clinical record and facility documentation. Interviews with facility staff, including an LPN, social workers, the Director of Nursing Services (DNS), and the Executive Director of Hospice, revealed confusion and uncertainty regarding the location and organization of hospice documentation. The hospice company was in the process of changing its filing system, which contributed to the missing documentation. The Executive Director of Hospice was unable to explain the absence of the required documentation for the resident. The facility's Medical Record policy mandates that all medical records be complete, accurately documented, and readily accessible, which was not adhered to in this case.
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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