Curtis Home St Elizabeth Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Meriden, Connecticut.
- Location
- 380 Crown Street, Meriden, Connecticut 06450
- CMS Provider Number
- 075365
- Inspections on file
- 17
- Latest survey
- March 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Curtis Home St Elizabeth Center, The during CMS and state inspections, most recent first.
A resident with dementia experienced multiple falls due to inadequate supervision and failure to follow care plan interventions, resulting in a head injury. Another resident, who smoked, was exposed to a fire hazard due to improper disposal of smoking materials. The facility's policies on fall prevention and smoking safety were not adequately followed.
The facility submitted inaccurate PBJ staffing data for the 3rd quarter of 2024, showing no RN coverage for 8 consecutive hours, low weekend staffing, and no licensed nurses 24/7. The Business Office Manager mistakenly submitted RCH staffing data instead of skilled nursing home staffing, leading to the error.
The facility failed to honor resident choices, impacting three residents. One resident's window was screwed shut, causing distress; another resident's preference to keep their door closed was ignored; and a third resident was taken out of bed against their wishes due to a misunderstanding about aspiration precautions.
The facility failed to consistently monitor and document weights for residents with CHF and nutritional risks, leading to missed daily and weekly weight checks as per physician orders. A resident with CHF was not weighed for three days, and another resident with nutritional risks did not have weekly or monthly weights documented. Additionally, a resident experienced significant weight gain without a documented nursing assessment. Staff cited being too busy and lack of communication as reasons for these oversights.
The facility failed to label and date opened food items in the Dietary Department, violating its food storage policy. Additionally, the nourishment room's freezer temperatures were inadequately documented, with only 2 out of 28 days recorded in February. The Dietary Director confirmed the lapses in both labeling and temperature monitoring practices.
A resident with a history of cancer and malnutrition experienced significant weight changes, but the facility failed to notify the dietician and responsible party as required. Despite a 16.5% weight gain in one month and a 14% loss over three months, there was no documentation of communication with the dietician or responsible party. Interviews revealed a lack of consistent weight tracking and communication, contributing to the deficiency.
The facility failed to report allegations of abuse involving two residents to the state agency in a timely manner. A resident with cognitive impairment was allegedly mishandled by a nurse aide during a transfer, and another resident reported witnessing the incident and experiencing verbal mistreatment. Despite being informed, the DNS did not report the incidents as required by the facility's abuse policy, resulting in a delay of 7 to 8 days before reporting.
Two residents reported abuse by a nursing assistant, including rough handling and use of profane language. Despite the facility's policy requiring prompt investigation, the Director of Nursing Services did not initiate an investigation until several days after being informed by a surveyor.
A facility failed to implement required respiratory assessments for a resident with CHF, as outlined in the Resident Care Plan. Despite the plan's directive for assessments each shift, records from December 2024 to January 2025 showed no documentation of these assessments. The DNS confirmed the oversight, acknowledging the absence of a specific form and the failure to document the assessments.
A diabetic resident with neuropathy and other conditions did not receive timely podiatry services due to administrative oversights and miscommunication within the facility. Despite having a physician's order and recommendations for podiatry care, the resident's toenails became excessively long and thick. The facility's process for scheduling podiatry services was flawed, leading to delays in care.
The facility failed to implement Enhanced Barrier Precautions for a resident with a growing stage 2 pressure ulcer and did not follow proper infection control procedures for blood glucose monitoring for another resident. The absence of EBP signage and precaution carts, along with the failure to disinfect a glucose meter after use, were observed. Interviews confirmed the facility's policies, but these were not adhered to, resulting in deficiencies in infection control practices.
The facility failed to complete annual performance evaluations for two nurse aides, one full-time and one per diem. The Human Resource Coordinator confirmed the absence of evaluations, and the DNS admitted to not having completed any evaluations due to time constraints. The issue was recognized by the DNS and the new administrator, with plans to address it through a QAPI plan.
Two residents experienced significant weight changes that were not accurately coded in their MDS assessments. One resident had notable weight loss on two occasions, while another had both significant weight gain and loss. The MDS Coordinator and dietician failed to ensure accurate documentation and coding, leading to deficiencies in care.
The facility failed to maintain a clean medication room, with observations noting a dirty floor and cluttered counter. RN and housekeeping staff interviews revealed confusion over cleaning responsibilities, with the Administrator confirming the need for daily cleaning. A housekeeping policy was not provided.
Inadequate Supervision and Safety Measures Lead to Resident Incidents
Penalty
Summary
The facility failed to provide adequate supervision to prevent a fall with injury for a resident diagnosed with dementia and other conditions. The resident, who was severely cognitively impaired and required assistance for mobility and transfers, had a care plan that included the use of a low bed with floor mats and a mechanical lift for transfers. Despite these interventions, the resident experienced multiple falls, including a significant incident where the resident rolled off the bed and sustained a head laceration. The nursing assistant involved in the incident had raised the bed and left the resident unattended, which was against the care plan's directives. Additionally, the facility failed to ensure a safe environment for a resident who smoked. The resident, who was severely cognitively impaired and required supervision while smoking, was observed using a wastepaper container to extinguish cigarettes, which posed a fire hazard. The facility's policy required the use of self-extinguishing devices, but the wastepaper container was not removed until after the surveyor's inquiry. Interviews with staff revealed inconsistencies in the accounts of the fall incident, and it was noted that the nursing assistant involved had not received proper orientation for the night shift. The facility's policies on fall prevention and smoking safety were not adequately followed, leading to these deficiencies in resident care and safety.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate Payroll Based Journal (PBJ) staffing data for the 3rd quarter of 2024, covering the period from April 1, 2024, through June 30, 2024. The submitted report indicated deficiencies such as no Registered Nurse (RN) coverage for 8 consecutive hours a day, low weekend staffing, and no licensed nurses available 24 hours a day. An interview with the Business Office Manager revealed that she inadvertently submitted incorrect data. She mistakenly removed the skilled nursing staff from the payroll list instead of the Residential Care Home (RCH) nursing staff, leading to the submission of staffing data that reflected RCH staffing rather than the skilled nursing home staffing. This error was realized after the submission had been made.
Failure to Honor Resident Choices in LTC Facility
Penalty
Summary
The facility failed to honor the resident's right to choose, as evidenced by the case of Resident #8, whose window was screwed shut by the Administrator. Despite being cognitively intact and independent in personal care, Resident #8 was unable to open the window for fresh air, which caused distress and anxiety. The Administrator justified this action by citing the cold weather and the comfort of the roommate, but did not acknowledge the resident's expressed dissatisfaction or the impact on their well-being. In another instance, Resident #11, who had moderate cognitive impairment and was dependent on assistance for mobility, expressed a desire to keep their door shut to prevent other residents from entering uninvited. However, staff insisted on keeping the door open, citing personal preference and facility practices. The Director of Nursing Services was unaware of the resident's preference and suggested implementing 15-minute checks to accommodate the resident's choice. Resident #45, who had intact cognition and was at risk for depression, expressed a desire to remain in bed past 7:00 AM, but was routinely taken out of bed against their wishes. This was due to a misunderstanding by staff regarding aspiration precautions, which were not applicable to the resident. Despite the facility's practice of honoring resident choices, the staff prioritized getting residents up for breakfast, which conflicted with Resident #45's expressed preferences.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to consistently obtain and document daily weights for residents with specific medical conditions, as per physician orders. Resident #28, diagnosed with chronic systolic congestive heart failure (CHF), was not weighed on three consecutive days despite a physician's order to monitor daily weight changes. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) involved were unable to provide a reason for the oversight, and the Director of Nursing Services (DNS) was unaware of the missed weights until informed. The charge nurse on duty admitted to not communicating the need for daily weights to the Nurse Aide (NA), citing being too busy as the reason for the lapse. Resident #45, who had a terminal condition and was at risk for nutritional deficits, did not have weekly weights taken as required by facility policy following admission. Additionally, monthly weights were not documented for two months, and reweights were not consistently obtained when significant weight changes occurred. The RN responsible for Resident #45's care was unable to explain the missing weights and reweights, indicating a lack of adherence to the facility's weight monitoring policy. Resident #58, with diagnoses including CHF and atrial fibrillation, experienced a significant weight gain over a short period, but the facility failed to document a nursing assessment when this occurred. The Advanced Practice Registered Nurse (APRN) was notified of the weight gain, but no parameters for notifying the physician or APRN about weight changes were specified in the orders. The DNS acknowledged that an RN should have completed an assessment with such a change in condition, but this was not done, highlighting a gap in the facility's response to significant weight changes.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper labeling and dating of opened food items in the Dietary Department. During a tour, it was observed that multiple bags of pasta, sugar, and other food items were opened without being labeled with the date they were opened, contrary to the facility's policy. The Dietary Director confirmed that all opened items should be labeled with the date, but this was not adhered to, leading to a deficiency in food storage practices. Additionally, the facility did not consistently document the temperatures of the nourishment room's freezer. For the month of February, temperatures were only recorded for 2 out of 28 days, and on 16 days, only check marks were noted without actual temperature readings. The Dietary Director acknowledged that the staff responsible for monitoring the temperatures were not maintaining the logs correctly and was unsure of the policy regarding temperature monitoring. This lack of proper documentation and adherence to policy resulted in a deficiency in monitoring refrigerator and freezer temperatures.
Failure to Notify Dietician and Responsible Party of Significant Weight Changes
Penalty
Summary
The facility failed to notify the dietician and responsible party of significant weight changes for a resident, leading to a deficiency in nutritional management. The resident, who was admitted with diagnoses including malignant neoplasm of the brain, moderate protein-calorie malnutrition, and IBS, experienced a significant weight gain of 44.8 lbs. (16.5%) in one month and a subsequent weight loss of 36.8 lbs. (14%) over three months. Despite these significant changes, there was no documentation indicating that the dietician or responsible party was informed, as required by the facility's weight policy. Interviews with facility staff revealed a lack of consistent weight tracking and communication regarding significant weight changes. RN #2 acknowledged that nursing staff did not track weight over time and relied on the dietician to review weight records independently. The dietician, hired in November 2024, was unaware of the resident's weight changes prior to her employment and was not informed of subsequent weight losses. The Director of Nursing Services indicated that reweighing should occur if a weight is suspected to be incorrect, but this practice was not followed. The facility's policy mandates reporting significant weight changes to the attending physician, responsible party, and dietician, which was not adhered to in this case.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the state agency in a timely manner. Resident #15, who had mild cognitive impairment and required assistance for transfers, was allegedly thrown into a wheelchair by a nurse aide (NA #3) during a transfer. This incident was witnessed by Resident #29, who reported it to the Director of Nursing Services (DNS) and the Administrator. Resident #29, who had PTSD, a history of alcohol abuse, depression, and dementia, also reported that NA #3 used profane language towards them. Despite these reports, the DNS did not recall the incidents and did not report them to the state agency as required by the facility's abuse policy. The facility's abuse policy mandates that allegations of abuse or mistreatment be reported to the state agency within specific timeframes, depending on the severity of the incident. However, the allegations involving Resident #15 and Resident #29 were reported 7 and 8 days after the facility was made aware of them, respectively. The DNS acknowledged the responsibility to report such allegations but misunderstood the nature of the incidents, leading to a delay in reporting. This failure to report in a timely manner constitutes a deficiency in the facility's compliance with regulatory requirements for handling allegations of abuse.
Failure to Investigate Abuse Allegations Timely
Penalty
Summary
The facility failed to investigate an allegation of abuse in a timely manner for two residents. Resident #15, who has mild cognitive impairment and mobility issues, was allegedly thrown into a wheelchair by NA #3 during a transfer. Resident #29, who has PTSD, a history of alcohol abuse, depression, and dementia, witnessed the incident and reported it to the Director of Nursing Services (DNS) and the Administrator. Resident #29 also reported that NA #3 used profane language towards them. Despite these reports, the DNS did not recall the incidents and no investigation was initiated until prompted by a surveyor. The facility's abuse policy requires that all allegations of mistreatment, neglect, or abuse be investigated and reported promptly. However, the DNS failed to initiate investigations for the allegations involving Resident #15 and Resident #29 until several days after being informed by the surveyor. The DNS acknowledged the responsibility to investigate such allegations, regardless of the resident's history of accusatory behavior. This delay in investigation is a violation of the facility's policy and state law requirements for timely reporting and documentation of abuse allegations.
Failure to Implement Respiratory Assessments for Resident with CHF
Penalty
Summary
The facility failed to implement the interventions outlined in the Resident Care Plan (RCP) for a resident diagnosed with congestive heart failure (CHF), atrial defibrillation, type 2 diabetes, and a history of coronary bypass surgery. The RCP, dated December 17, 2024, identified a potential for respiratory distress and required a respiratory assessment to be performed every shift. However, a review of the Medication and Treatment Administration Records for December 2024 and January 2025 did not show that these assessments were completed as required. Further review of nursing notes from December 19, 2024, through January 28, 2025, revealed that while some observations were made, such as clear lungs and bilateral lower extremity edema, there was no documentation of the required respiratory assessments each shift. An interview with the Director of Nursing Services (DNS) confirmed that the RCP required these assessments, but they were not documented in the clinical record. The DNS acknowledged the lack of a specific form for respiratory assessments and the failure to complete the required documentation.
Failure to Provide Timely Podiatry Services to Diabetic Resident
Penalty
Summary
The facility failed to provide necessary podiatry services to a diabetic resident, identified as Resident #19, who had diagnoses including diabetes mellitus type 2 with neuropathy, gout, and Parkinson's disease. The resident required substantial assistance for personal hygiene and was dependent on staff for lower body dressing and transfers. Despite having a physician's order for podiatry services and recommendations from the Wound/Ostomy APRN for a podiatry consult due to toenail dystrophy, the resident did not receive timely podiatry care. The facility's process for arranging podiatry services was flawed, as evidenced by the correspondence between the podiatry service provider and the facility's DNS. The resident was placed on a do-not-treat list pending verification of VA-covered services, which delayed the provision of care. The DNS was unaware of the requirement to copy the Administrator on emails, which further prolonged the delay. Additionally, the facility's policy directed NAs to clip toenails unless the resident was diabetic or had thick nails, in which case the resident would be seen by the podiatrist. However, Resident #19 was not scheduled for podiatry services despite being on the list. Interviews with staff revealed a lack of clarity and documentation regarding the scheduling of podiatry services for Resident #19. The resident was overdue for podiatry care, having not received services since admission to the facility. The Director of Finance confirmed that the facility pays for all resident podiatry services, including those for veterans, and that the VA contract allowed for in-house services. Despite these provisions, the resident's podiatry needs were not met in a timely manner, resulting in excessively long and thick toenails that required attention.
Infection Control Deficiencies in Wound Care and Glucose Monitoring
Penalty
Summary
The facility failed to adhere to infection control standards for Resident #4, who had a stage 2 pressure ulcer on the sacral region. Initially, the wound measured 0.8 cm x 0.8 cm, but it increased to 2.5 cm x 3.5 cm x 0.2 cm over time. Despite the facility's policy to implement Enhanced Barrier Precautions (EBP) for residents with large wounds, defined as 2.0 cm x 2.0 cm or greater, Resident #4 was not placed on EBP until the wound size increased significantly. Observations revealed the absence of EBP signage and precaution carts outside Resident #4's room, and a Licensed Practical Nurse (LPN) was seen performing a dressing change without wearing a gown. The facility also failed to follow proper infection control procedures for blood glucose monitoring for Resident #36, who had diabetes and other related complications. A Registered Nurse (RN) was observed using a glucose meter to check Resident #36's blood sugar level but did not clean or disinfect the meter after use before placing it back in the medication cart. This action was against the facility's policy, which required disinfecting glucose meters after each use. The RN acknowledged the oversight and subsequently cleaned the meter before using it for another resident. Interviews with the Infection Preventionist and the Director of Nursing Services (DNS) confirmed the facility's policy on EBP and the requirement to clean glucose meters after each use. However, the facility's failure to implement these policies resulted in deficiencies in infection control practices for both residents. The Infection Preventionist was unable to provide documentation supporting the criteria used for EBP, leading to a revision of the facility's policy to remove the term 'large' from the description of wounds requiring EBP.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure annual employee performance evaluations were completed for two of four nurse aides. A review of employee files and interviews revealed that performance evaluations for NA #3 and NA #5 were missing. NA #3, a full-time employee hired in 2011, and NA #5, a per diem employee hired in 2020, did not have documented evaluations in their files. The Human Resource Coordinator confirmed the absence of evaluations and noted that she had not received any from the Nursing Department. The Director of Nursing Services (DNS) admitted to not having completed any evaluations for nursing staff during her tenure, citing a lack of time as the reason. The DNS acknowledged the issue and mentioned discussions with the new administrator about addressing it through a Quality Assessment Performance Improvement (QAPI) plan.
Failure to Accurately Code MDS for Significant Weight Changes
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for significant weight changes for two residents, leading to deficiencies in their care. Resident #8, diagnosed with anxiety, hypothyroidism, and asthma, experienced significant weight loss on two occasions. The MDS assessments did not reflect these changes, despite the Yearly Weight Record showing a loss of 13.1 lbs. (8.1%) in one month and 16.4 lbs. (10.49%) over six months. The MDS Coordinator, RN #6, acknowledged the incorrect coding and indicated that it was the dietician's responsibility to document significant weight changes in the MDS. Resident #45, with diagnoses including malignant neoplasm of the brain, moderate protein-calorie malnutrition, and IBS, also had significant weight changes that were not accurately coded in the MDS. The resident's weight record showed a gain of 38.8 lbs. (17.1%) over three months and a loss of 39.4 lbs. (14.8%) over six months. However, these changes were not noted in the MDS assessments. The dietician, who was responsible for weight tracking, did not perform calculations for the MDS assessments due to not being employed at the facility during the relevant periods or uncertainty about the accuracy of previous weights. Interviews with the MDS Coordinator and the dietician revealed a lack of clarity and responsibility in ensuring accurate weight documentation and coding in the MDS. The MDS Coordinator relied on the dietician's information for data entry but did not verify its accuracy. The Resident Assessment Instrument (RAI) manual specifies that significant weight changes should be coded, but this was not adhered to, resulting in the deficiencies noted in the report.
Medication Room Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain a clean and sanitary medication room, as observed during a survey. The medication room floor was found to be dirty with a brown substance and littered with paper, while the counter was cluttered with brown boxes and papers. RN #2 acknowledged the condition of the room and stated that it was the responsibility of the housekeeping staff to keep the floor clean and the nurses to ensure the room was free of clutter. Interviews with housekeeping staff revealed confusion regarding the responsibility for cleaning the medication room. Housekeeper #1 and Housekeeper #2 both indicated that it was not their responsibility to clean the medication room, with Housekeeper #2 stating she only cleaned the nursing station. The Administrator confirmed that housekeeping was responsible for cleaning the medication room daily, but upon inspection, acknowledged the room's unclean state. A facility policy for housekeeping was requested but not provided.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
