Hewitt Health & Rehabilitation Center, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelton, Connecticut.
- Location
- 45 Maltby Street, Shelton, Connecticut 06484
- CMS Provider Number
- 075047
- Inspections on file
- 25
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Hewitt Health & Rehabilitation Center, Inc during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities exhibited new, escalating behavioral symptoms including anger and agitation, but staff did not notify the provider or nursing supervisor as required by facility policy. Instead, the behaviors were only documented in a psychiatric APRN book, delaying appropriate assessment and intervention. Staff interviews confirmed that the provider should have been notified of the significant change in condition.
The facility did not provide adequate nursing staff coverage on weekends for two consecutive quarters, as shown by PBJ data and confirmed by staff interviews. Staffing challenges were attributed to frequent call-outs and retention issues, resulting in the facility triggering for low weekend staffing during the review period.
The facility did not consistently complete or document advance directives for several residents, resulting in missing or unsigned consent forms and delays in obtaining code status orders. In some cases, residents' choices for life-sustaining treatment were not properly recorded or accompanied by physician orders, and staff interviews revealed inconsistent processes for reviewing and documenting advance directives.
The facility did not notify resident representatives or physicians of significant weight loss or gain in several residents, despite clear evidence of these changes and requirements in care plans, physician orders, and facility policy. Staff interviews and record reviews confirmed that notifications were not made or documented, resulting in a failure to communicate important changes in resident condition.
Surveyors found that the facility did not complete timely smoking assessments, failed to supervise residents during smoking, and did not secure smoking materials as required by policy. Multiple residents with significant medical conditions were observed smoking unsupervised on facility property, possessing lighters and cigarettes, and sharing smoking materials, while staff were unclear about their responsibilities for securing these items.
A resident with severe cognitive impairment and a seizure disorder was given Lorazepam by an LPN for agitation and insomnia, despite the medication being ordered only for seizures. The LPN, after consulting with the nursing supervisor, administered the medication without obtaining a new physician order and documented it under the existing seizure order, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions was found with significant bruising and swelling on the right upper extremity, identified as an injury of unknown origin. Although facility policy required prompt reporting to the State Agency, the DNS delayed notification while investigating the incident, resulting in the injury not being reported within the mandated timeframe.
Two residents did not receive timely RN assessments after significant events, including the discovery of a new pressure ulcer and a fall. In both cases, LPNs either did not notify the RN supervisor or failed to ensure proper documentation, resulting in missed assessments as required by facility policy.
A resident who was dependent on staff for ADLs and had significant physical and cognitive impairments was found to have lengthy, unclean fingernails with a dark substance underneath, despite facility policies and care plans requiring regular nail care. Multiple staff members observed the issue but did not address it, citing being too busy or unclear responsibilities, resulting in the resident's hygiene needs not being met.
A resident with heart failure and related conditions was not weighed daily as ordered by the physician, with 38 missed weights over a period of several months. Both an LPN and the DON confirmed that daily weights were not consistently obtained or documented, despite the care plan and facility policy requiring adherence to physician orders.
A resident with a stage 3 sacral pressure ulcer did not receive wound care in accordance with physician orders, as an LPN attempted to use an incorrect dressing and failed to follow proper hand hygiene. Additionally, the frequency of dressing changes was incorrectly transcribed from the wound APRN's recommendations, resulting in care that did not match the prescribed treatment plan.
A nurse failed to administer ordered doses of Aspirin and Miralax to a resident with dementia and a history of blood clots, but documented in the MAR that the medications were given. This omission led to a medication error rate above 5%, as required medications were not provided and documentation was inaccurate.
Staff failed to follow PPE and hand hygiene protocols during wound care for two residents on enhanced barrier precautions. In one case, an LPN did not wear an isolation gown as required, and in another, both an LPN and a nurse aide did not perform hand hygiene before donning PPE or between glove changes, despite facility policies and posted signage. These actions resulted in noncompliance with the infection prevention and control program.
The facility did not complete required Significant Change in Status Assessments (SCSA) MDS for two residents who experienced declines in multiple health areas, including new or worsening pressure ulcers, significant weight loss, and increased dependence for ADLs. Staff interviews revealed a lack of understanding of SCSA criteria and insufficient communication among the interdisciplinary team, resulting in missed assessments despite documented changes.
A resident with diabetes, anxiety, and depression did not receive a required quarterly care conference after the originally scheduled meeting was postponed due to the resident being out of the building. Staff interviews confirmed the meeting was not rescheduled as required, and no facility policy on care conferences was provided.
A medication storage refrigerator was repeatedly documented as being out of the required temperature range, with temperatures below the facility's policy for safe medication storage. The refrigerator contained various medications, and staff responsible for monitoring temperatures were unaware of the ongoing issue. Maintenance and supervisory staff were not notified as required, and temperature logs for the previous year were not provided, indicating lapses in documentation and adherence to policy.
A resident with severe cognitive impairment and a history of falls suffered a significant leg laceration during a transfer when Geri-leg sleeves, ordered by the physician to prevent skin injury, were not confirmed to be in place. Staff interviews and documentation could not verify if the protective sleeves were applied at the time, leading to the resident's leg becoming caught on a bed rail and requiring sutures and steri-strips.
A resident with Alzheimer's and depression experienced increased anxiety and agitation after a change in Ativan dosage was not properly communicated to the pharmacy, resulting in multiple missed doses. Nursing staff did not follow up with the provider or pharmacy when the medication was unavailable, and the resident's behaviors escalated, requiring additional interventions and hospitalization. Interviews revealed a lack of clarity among staff regarding responsibility for ensuring medication orders were processed and followed up.
A resident with dementia and mood disorders reported to an LPN that a nurse aide had caused them harm by pulling a phone from their hand and hitting their shoulder. The LPN did not remove the nurse aide from care or report the allegation immediately, allowing the aide to continue providing care. The incident was only escalated after the resident called 911, and the supervisor was not informed until the aide had left the building, contrary to facility policy.
Two residents with significant fall risks and orders for assistive transfers experienced falls with injuries when staff failed to use gait belts during transfers and ambulation, as required by facility policy. In both cases, staff did not follow the mandatory gait belt protocol, resulting in one resident sustaining a femur fracture and another requiring staples for a head laceration.
Failure to Notify Provider of Resident's Change in Behavior
Penalty
Summary
A deficiency occurred when staff failed to notify the provider of a resident's significant change in behavioral symptoms. The resident, who had diagnoses including dementia with behavioral disturbances, anxiety, major depressive disorder, emphysema, and congestive heart failure, exhibited new and escalating angry outbursts and agitation over several days. These behaviors included throwing linens, screaming at staff, and throwing fluids, which were not part of the resident's documented baseline behavior. Despite these changes, there was no evidence that the nursing supervisor or provider were notified at the time the behaviors were first observed. The clinical record review showed that prior to these incidents, the resident had not exhibited similar angry outbursts. Staff attempted to redirect the resident but did not escalate the issue or seek provider input, even though the resident was unable to be redirected and had no available as-needed medication to address the agitation. The behaviors were only documented in a psychiatric APRN book, with no immediate notification to supervisory staff or the provider, contrary to facility policy which required provider notification for significant changes in condition. Interviews with staff confirmed that the provider should have been notified of the resident's behavioral changes, as these were not consistent with the resident's baseline and could have indicated an underlying medical issue. The delay in notification meant that potential interventions, such as ordering laboratory tests or adjusting medications, were not initiated in a timely manner. Facility policy also required documentation of provider and family notification, which was not completed at the time of the initial behavioral changes.
Deficiency in Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to provide the appropriate number of nursing staff on weekends during Quarter 1 and Quarter 2 of Fiscal Year 2024, as evidenced by Payroll Based Journal (PBJ) submissions that triggered for excessively low weekend staffing. Interviews revealed that the Scheduler was not responsible for PBJ submissions and was unaware of the low staffing trigger, while the HR coordinator, who is currently responsible for PBJ submissions, was not employed at the facility during the period in question. The Scheduler reported that weekend staffing was a challenge due to frequent call-outs by nursing and agency staff, as well as issues with staff retention. The VP of Clinical Operations confirmed awareness of the low weekend staffing during the specified quarters. The facility's policy manual requires complete and accurate electronic submission of direct care staffing information to CMS, and notes that noncompliance may result in enforcement actions. The deficiency was identified through review of PBJ data and staff interviews, which confirmed that the facility did not meet required weekend staffing levels during the specified timeframe.
Failure to Consistently Complete and Document Advance Directives
Penalty
Summary
The facility failed to follow its own policy regarding the completion and documentation of residents' advance directives for four residents. In multiple cases, the required Medical Interventions Consent Form, which records a resident's choices for life-sustaining treatments and other medical interventions, was either missing from the clinical record or not signed by the resident or their representative. For example, one resident with diagnoses including paranoid schizophrenia and kidney cancer, who was cognitively intact, did not have a completed or signed consent form in the record, despite a physician order indicating CPR as the code status. Similarly, another resident with dementia and chronic kidney disease, who was moderately cognitively impaired, also lacked a signed consent form, even though a physician order for CPR was present. In another instance, a resident with severe cognitive impairment and multiple diagnoses had a Medical Interventions Consent Form completed by a representative via telephone, indicating comfort measures only and do-not-resuscitate/do-not-intubate status. However, after a psychiatric hospitalization and re-admission, there was a period during which no physician order for advance directives was present in the clinical record. Staff interviews revealed that the process for obtaining and documenting advance directives was inconsistent, with responsibilities split between nursing supervisors and social workers, and follow-up with representatives sometimes limited to leaving phone messages. Additionally, a resident admitted with sepsis, heart failure, and endocarditis, who was cognitively intact, did not have a code status order in place for eight days after admission. During this time, the resident would have been classified as full code and provided CPR by default. Staff interviews confirmed that code status should be established upon admission, and that verbal consent could be obtained if the resident was unable to sign. The facility's policy required that advance directives be reviewed with the resident or representative, documented on the consent form, and accompanied by a physician order, but these steps were not consistently followed.
Failure to Notify Responsible Parties and Physicians of Significant Weight Changes
Penalty
Summary
The facility failed to notify resident representatives and physicians of significant weight changes in multiple residents, as required by policy and physician orders. For three residents with cognitive impairment and designated representatives, there was no documentation that the responsible party was informed of substantial weight loss, despite clear evidence in the clinical record and dietician notes of weight declines exceeding 5% in one month or 10% in six months. In each case, the care plans and facility protocols required notification, and staff interviews confirmed that nurses were responsible for this communication, yet the notifications were not documented. One resident with congestive heart failure had physician orders specifying that the physician should be notified of a weight gain of 3 pounds in 24 hours or 5 pounds in one week. Despite documented weight gains meeting these criteria, there was no evidence that the physician was notified. Staff interviews confirmed awareness of the protocol and the expectation to notify the physician, but could not provide documentation that this occurred. The facility's heart failure protocol and weight monitoring policy both required timely reporting of significant weight changes to the physician and family. The deficiency was identified through review of clinical records, facility documentation, and staff interviews. The lack of notification was confirmed by the absence of progress notes or other documentation in the electronic medical record, as well as direct statements from staff that notifications had not been made. The facility's own policies and protocols, as well as physician orders, were not followed in these instances, resulting in a failure to communicate significant changes in resident condition to the appropriate parties.
Failure to Supervise and Secure Smoking Materials for Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents related to resident smoking. For three residents reviewed for smoking, there were multiple failures including untimely completion of smoking assessments, lack of supervision during smoking, and failure to secure smoking materials as required by the residents' care plans and facility policy. Observations showed residents smoking unsupervised on facility property, possessing lighters and cigarettes despite policies prohibiting such items, and sharing smoking materials with other residents. One resident with end stage heart failure, asthma, and a left leg amputation was observed smoking outside the facility unsupervised on several occasions. Although the resident's care plan required that smoking materials be secured by nursing staff and that the resident not possess such items, the resident was found with a lighter in their possession and admitted to purchasing and keeping smoking materials. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for securing smoking materials, with both nursing and front desk staff denying responsibility. Smoking assessments for this resident were not completed quarterly as required, and the resident was observed repeatedly smoking on facility property without supervision. Two other residents with histories of smoking and medical conditions such as diabetes, falls, osteoarthritis, substance abuse, and acute kidney failure were also found to have incomplete or delayed smoking assessments. One resident did not have a smoking assessment completed upon admission, and another had only one assessment completed months after admission. Both residents were observed smoking on facility property, sometimes sharing lighters, and staff interviews indicated a lack of awareness about the residents' smoking status and the location of their smoking materials. Facility policy required completion of smoking assessments on admission and securing of smoking materials, but these procedures were not consistently followed.
Psychotropic Medication Administered Without Proper Physician Order
Penalty
Summary
A resident with diagnoses including autistic disorder, developmental disorder, and unspecified convulsions was admitted with severe cognitive impairment and required significant assistance with daily activities. The resident's care plan included administration of medications as ordered for a seizure disorder. A physician's order specified Lorazepam 1 mg by mouth every 24 hours as needed for seizures. However, on one occasion, Lorazepam was administered by an LPN for agitation and insomnia, not for seizures as indicated by the physician's order. The LPN consulted with the nursing supervisor, who authorized the administration despite the absence of a seizure and without obtaining a new physician order for agitation or insomnia. The LPN documented the administration of Lorazepam under the existing order for seizures, even though the medication was not given for that purpose. The nursing supervisor attempted to contact the physician for a new order but was unsuccessful and still permitted the medication to be given. Both the LPN and the nursing supervisor later acknowledged that Lorazepam should not have been administered for agitation or insomnia without a valid physician order. Facility policy requires that all medications be administered only with a valid physician's order and in accordance with facility protocols.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
A resident with diagnoses including dementia, anemia, and non-thrombocytopenic purpura, who was severely cognitively impaired and dependent for care, was observed to have a large area of bruising and swelling on the right upper extremity. The injury, which included a skin tear and discoloration from the hand to the elbow, was first noted by staff, and the physician and family were notified. Facility documentation indicated that the injury was of unknown origin, and an investigation was not initiated at the time of discovery. Despite facility policy requiring prompt reporting of injuries of unknown origin to the State Agency (SA) within the required time frame, the Director of Nursing Services (DNS) did not report the injury to the SA while the investigation was ongoing. The DNS acknowledged responsibility for timely reporting but cited workload as a reason for the delay. The injury was ultimately reported to the SA several days after it was first identified, outside of the required reporting window.
Failure to Complete Required RN Assessments After Resident Incidents
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) assessments were completed following significant events for two residents. In the first case, a resident with dementia, fibromyalgia, and anxiety, who was at risk for skin breakdown, was found to have a new open area on the coccyx by an LPN. The LPN documented cleansing and dressing the wound and noted that the nursing supervisor was notified to obtain a treatment order. However, there was no subsequent RN assessment documented in the electronic medical record, as required by facility policy. The RN supervisor on duty did not recall being informed of the new pressure ulcer, and there was no evidence of an accident and injury report being completed for this event. In the second case, a resident with a history of femur fracture, autistic disorder, and seizures, who required assistance with mobility and transfers, was found on the floor by a family member. The LPN on duty, along with three other staff, assisted the resident off the floor and back into bed. The LPN did not inform the RN supervisor of the fall, citing the end of her shift and inability to locate the RN. As a result, the required RN assessment after the fall was not completed, and the resident was not assessed by an RN until the following day by an APRN. Facility policy required an RN assessment after any fall or significant change in condition, which was not followed in this instance. Both incidents demonstrate a failure to adhere to facility policies that mandate RN assessments following significant changes in resident condition, such as new pressure ulcers or falls. The lack of timely RN assessments and documentation after these events constituted deficiencies in meeting professional standards of quality care for the residents involved.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, dementia, and end stage renal disease was observed to have lengthy and unclean fingernails with a dark brown substance underneath. The resident was severely cognitively impaired and dependent on staff for activities of daily living, including personal hygiene and nail care. Facility documentation and care plans indicated that the resident required total assistance with bathing and nail hygiene, and that nail care was to be performed weekly during scheduled showers. Despite these requirements, multiple observations over several days revealed that the resident's fingernails remained untrimmed and unclean, with one lengthy thumbnail pressing into the side of another finger on a contracted hand. Interviews with nursing staff and nurse aides revealed that nail care was not consistently provided due to staff being too busy or unclear about responsibility for the task. Nurse aides acknowledged seeing the resident's long and dirty nails and reported the issue to nursing staff, but did not address it during their shifts. The Director of Rehab confirmed that the resident was unable to perform nail care independently and that nursing staff had been informed of the need for regular nail maintenance due to the risk of skin breakdown. Facility policy required individualized assistance with daily care, including nail hygiene, but this was not followed for the resident in question.
Failure to Obtain Daily Weights as Ordered for Resident with Cardiac Conditions
Penalty
Summary
A deficiency was identified when a resident with diagnoses including congestive heart failure, pleural effusion, and cardiomyopathy was not weighed daily as ordered by the physician. The resident's care plan included daily weights as an intervention for cardiac risk, and a physician order dated 12/1/24 specified daily weights. However, review of the weight record from 12/1/24 to 5/15/25 showed that daily weights were missed on 38 out of 166 occasions. Interviews with an LPN and the Director of Nursing confirmed that the resident was not weighed daily according to the physician's order and that it was the nurse's responsibility to obtain and document the daily weight. The facility's weight monitoring policy required weights to be taken as ordered by the physician, but this was not consistently followed for the resident in question.
Failure to Provide Pressure Ulcer Care per Physician Orders and Accurate Transcription
Penalty
Summary
A deficiency was identified in the care of a resident with a stage 3 sacral pressure ulcer, who also had diagnoses of muscle weakness and osteomyelitis. The resident required substantial to maximal assistance for activities such as dressing, toileting, and repositioning in bed. The care plan specified that wound treatments should be administered as ordered and in accordance with facility protocols. However, during an observed wound treatment, an LPN failed to follow proper hand hygiene protocols and attempted to use a collagen matrix dressing instead of the physician-ordered calcium alginate with silver dressing. The LPN incorrectly believed the two dressings were interchangeable, but the Infection Prevention Nurse clarified that they were not, and the correct dressing was subsequently applied after intervention. Additionally, a review of the resident's wound care orders revealed that the frequency of dressing changes was incorrectly transcribed. The wound APRN had recommended dressing changes twice daily, but the order was entered as once daily. This transcription error was confirmed by the Infection Prevention Nurse, who was responsible for transcribing the recommendations. The facility's policies required that physician orders be complete and accurate, and that treatments be performed as ordered, but these requirements were not met in this instance.
Medication Error Rate Exceeds 5% Due to Omitted Doses and Inaccurate MAR Documentation
Penalty
Summary
A deficiency occurred when a nurse failed to administer medications as ordered to a resident with diagnoses including dementia, atrial fibrillation, and a history of venous thrombus and embolism. The resident, who was severely cognitively impaired and required significant assistance with daily activities, had physician orders for Aspirin EC 81mg once daily for atrial fibrillation and Miralax 17 grams twice daily for constipation. During a medication administration observation, the nurse prepared and dispensed all scheduled oral medications except for the Aspirin and Miralax, which were omitted from the administration. Despite not administering these medications, the nurse signed the Medication Administration Record (MAR) indicating that both Aspirin and Miralax had been given. The nurse later acknowledged that she had forgotten to administer the medications and had signed the MAR in error. Facility policy requires that all medications be administered safely and accurately in accordance with physician orders, and the omission resulted in a medication error rate of 7.14%, exceeding the acceptable threshold.
Failure to Follow PPE and Hand Hygiene Protocols During Wound Care
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and hand hygiene during wound care for two residents on enhanced barrier precautions (EBP). For one resident with dementia, anemia, and venous/arterial ulcers, an LPN provided wound care without donning an isolation gown, despite EBP signage and care plan interventions requiring both gown and gloves for wound treatment. The LPN acknowledged not wearing the gown and was unaware it was required, even though training and signage were present. In a separate incident, another resident with a stage 3 pressure ulcer and osteomyelitis received wound care from staff who did not perform hand hygiene before donning PPE or between glove changes, as required by facility policy. During the wound care procedure, the LPN changed gloves without hand hygiene and applied a new glove with a contaminated hand, while the nurse aide also failed to perform hand hygiene before applying PPE. Both staff members were unable to clearly articulate the correct hand hygiene protocol during interviews. Facility policies for EBP and hand hygiene direct staff to perform hand hygiene before and after resident care, before donning PPE, and between glove changes, especially during high-contact activities such as wound care. Observations and interviews confirmed that these protocols were not followed during the wound care of both residents, resulting in a failure to implement the infection prevention and control program as required.
Failure to Complete Significant Change MDS Assessments After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) for two residents who experienced declines in multiple areas of health status. For one resident with dementia and a history of pressure ulcers, the clinical record showed a new Stage 2 pressure ulcer, a decline in functional mobility, and significant weight loss over several months. Despite these changes, which included increased assistance needs for eating, bed mobility, and transfers, as well as the development and worsening of pressure ulcers, no SCSA MDS was completed as required. Another resident with early onset Alzheimer's disease, diabetes, and epilepsy experienced a hospitalization for altered mental status and subsequently returned to the facility with increased dependence on staff for activities of daily living (ADLs) and eating. This resident also had a notable weight loss following hospitalization and required more assistance with meals. The quarterly MDS assessment documented declines in four functional mobility areas and weight loss, but again, a significant change MDS was not completed. Interviews with facility staff revealed a lack of understanding regarding the criteria for initiating a significant change MDS assessment. One LPN indicated she was unaware that weight loss plus a decline in one ADL met the criteria for a significant change, and that she relied on the dietician to code weight loss in the MDS. The facility's interdisciplinary team, including the dietician and nursing staff, did not effectively communicate or recognize the need for a significant change assessment despite regular risk meetings and documentation of the residents' declines.
Quarterly Care Conference Not Rescheduled After Postponement
Penalty
Summary
The facility failed to conduct a quarterly care conference for one resident whose diagnoses included diabetes, anxiety, and depression. The resident was identified as cognitively intact and independent in activities of daily living. According to the clinical record, the resident's care plan addressed risks related to mood changes and included interventions for emotional support. The quarterly care conference was scheduled but postponed because the resident was out of the building on a leave of absence, and the meeting was not rescheduled. Interviews with facility staff confirmed that the required care conference did not occur within the expected timeframe and that this was due to an oversight. No facility policy on care conferences was provided when requested.
Failure to Maintain Proper Medication Refrigerator Temperatures and Documentation
Penalty
Summary
The facility failed to maintain proper refrigerator temperatures for medication storage in one of its medication storage rooms. Observations and temperature logs revealed that the medication refrigerator on Unit 1C was repeatedly documented as being out of the required temperature range on multiple dates, with recorded temperatures between 28°F and 32°F, which is below the facility's stated acceptable range of 36°F to 46°F. The refrigerator contained various medications, including insulin products, suppositories, ophthalmic solution, and intravenous medications. Staff interviews indicated that the responsibility for monitoring and documenting refrigerator temperatures fell to the overnight nurse, but there was a lack of awareness among staff and supervisors regarding the out-of-range readings. The Maintenance Director was not notified of the temperature issues, and the Director of Nursing Services was also unaware of the ongoing problem. Review of facility policy and interviews further revealed inconsistencies in the understanding of acceptable temperature ranges and the required actions when temperatures were out of range. The policy required notification of maintenance and the supervisor on duty if temperatures were not within the specified range, but this was not consistently followed. Additionally, temperature logs for the previous year were not provided upon request, indicating a lack of proper documentation and oversight in medication storage practices.
Failure to Apply Geri-Legs as Ordered Results in Resident Leg Laceration
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, dementia, psychotic disorder, muscle weakness, and a history of falls did not have Geri-leg sleeves applied as ordered by the physician. The physician's order specified that Geri-legs should be applied in the morning and removed at night to prevent skin impairment. The resident's care plan also included this intervention due to the risk for skin impairment and required gentle handling during transfers. Despite these orders, during a transfer from wheelchair to bed, the resident's left lower leg became caught on the bed rail, resulting in a three-inch laceration that required sutures and steri-strips. Documentation and interviews with staff, including the nurse aide, LPN, and DON, revealed that none could confirm whether the Geri-legs were in place at the time of the incident. The resident was identified as having severe cognitive impairment and required extensive assistance with transfers. The incident was reported after the nurse aide noticed bleeding during the transfer, and the resident was subsequently sent to the emergency department for treatment. The facility's staff, including the DON, acknowledged that the expectation was for the Geri-legs to be applied if there was a physician's order, but could not verify compliance at the time of the accident. This failure to ensure the application of Geri-legs as ordered contributed to the resident sustaining a significant leg laceration during routine care.
Failure to Ensure Timely Communication and Administration of Changed Medication Order
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a change in an anti-anxiety medication order for a resident with Alzheimer's Disease and depression was properly communicated to the pharmacy and followed up by staff, resulting in multiple missed doses. The resident had a care plan identifying the risk for adverse effects from psychotropic drugs and required close monitoring of mood and behavior. A new order was written to change the Ativan dosage and schedule, but the prescription was not sent to the pharmacy in a timely manner, and staff did not follow up when the medication was unavailable. Nursing notes documented that the resident exhibited increased anxiety, agitation, and aggressive behaviors after the medication change, with several scheduled doses of Ativan not administered because the medication was not available. Staff failed to notify the provider or ensure the pharmacy was contacted regarding the unavailability of the medication. The resident's behaviors escalated, leading to interventions such as one-to-one observation and, eventually, transfer to the hospital. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for ensuring the prescription was sent to the pharmacy and for following up when the medication was not available. The facility's policy required staff to review medication orders and follow up with the pharmacy, but this was not done. The pharmacy confirmed that the new prescription was not received until several days after the order was written, resulting in missed doses and unaddressed behavioral symptoms.
Failure to Remove Staff After Abuse Allegation
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, anxiety, and depression reported to an LPN that a nurse aide had treated them badly, including pulling a phone from their hand, causing pain to their fingers, and hitting their right shoulder. The LPN, after being informed of the alleged abuse, allowed the nurse aide to continue providing care to the resident and did not immediately report the allegation to the Nursing Supervisor as required by facility policy. The resident subsequently called 911, and EMS was dispatched to the facility. Facility documentation, including a video timeline, confirmed that the nurse aide continued to enter and exit the resident's room after the allegation was made and after the facility was notified by 911 dispatch. Interviews with the DON and Nursing Supervisor revealed that the supervisor was not made aware of the allegation until after the nurse aide had left the building. The facility's abuse policy requires immediate reporting and removal of staff from resident care following an allegation, which was not followed in this instance.
Failure to Use Gait Belts During Transfers and Ambulation
Penalty
Summary
The facility failed to ensure the use of a required safety device, specifically a gait belt, during transfers and ambulation for two residents with significant fall risks and physician orders for assistance. In both cases, the residents had multiple risk factors for falls, including dementia, osteoporosis, deconditioning, unsteady gait, and poor safety awareness. Despite care plans and physician orders specifying the need for assistive devices and staff assistance, staff did not utilize a gait belt during transfers, contrary to facility policy. One resident experienced a witnessed fall during a transfer from the toilet when their leg gave out, resulting in a displaced femur fracture. The staff member involved admitted to not using a gait belt because it was lost. Another resident, with a history of falls and fractures, fell in the bathroom after using the toilet and struck their head, requiring hospital evaluation and staples for a laceration. In both incidents, fall scene investigations confirmed that gait belts were not used, and staff interviews corroborated the lack of adherence to the facility's mandatory gait belt policy.
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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