Laurel Ridge Center For Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Ridgefield, Connecticut.
- Location
- 642 Danbury Road, Ridgefield, Connecticut 06877
- CMS Provider Number
- 075395
- Inspections on file
- 25
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Laurel Ridge Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering experienced two separate changes in condition—lethargy and a significant decrease in activity after a fall—that were not properly reported to the provider by LPNs, despite facility policy requiring such notifications. The provider was not made aware of the resident's lethargy or the unusual inactivity following the fall, and the facility's change of condition policy was not followed.
The facility did not maintain sufficient nursing staff on weekends, as shown by PBJ data for a recent quarter. The Administrator confirmed that restrictions on using agency staff and on licensed staff working as Nursing Assistants contributed to the low staffing levels.
The facility did not submit accurate staffing data to CMS and failed to provide required RN and licensed nursing coverage on several days, as well as having excessively low weekend staffing. These deficiencies were attributed to incorrect coding and staffing restrictions imposed by the previous owner.
The facility did not promptly report incidents of suspected abuse, neglect, and injuries of unknown origin to the State Agency as required. In separate events, a resident was found with an unexplained eye injury, two residents were involved in a physical altercation, and four residents did not receive timely incontinent care. In each case, staff failed to notify the State Agency within the mandated timeframe, despite facility policy requiring immediate reporting.
A resident with severe cognitive impairment and incontinence did not receive timely incontinent care, and no RN assessment was performed after the delay was identified. An APRN evaluated the resident's skin nearly two days later but failed to document the visit until 17 days afterward, contrary to facility policy requiring timely documentation.
A resident with severe cognitive and visual impairments was not provided with recreational activities aligned with their documented interests, such as music, pet therapy, and fresh air, despite these being identified as important. The care plan lacked a recreational activities component, and staff interactions were limited to brief check-ins and television watching, with no individualized engagement or reassessment of preferences.
Residents repeatedly reported receiving cold food, including coffee, soup, and dinner, over several months. Observations showed that meals were often covered with plastic lids containing holes and that there were not enough insulated lids or hot plates to keep food at the required temperature. A test tray confirmed that some food items were served below the facility's policy standard of 140°F, and the Food Service Director acknowledged the deficiency.
The facility did not consistently offer snacks to residents after dinner and before bed, relying instead on residents to request them or be on a specific list. A resident with significant care needs reported not always being offered snacks, and staff interviews revealed inconsistent practices and lack of clarity regarding snack distribution, contrary to facility policy.
Multiple residents experienced physical altercations and neglect when staff failed to prevent resident-to-resident aggression and did not provide timely incontinent care. Despite care plans outlining supervision and regular checks, residents with cognitive and physical impairments were left without necessary care for extended periods, and staff did not seek help when unable to provide required assistance.
The facility did not ensure timely RN assessments following incidents involving injuries, resident altercations, and missed care. In several cases, residents with significant medical needs experienced injuries or prolonged periods without care, and although LPNs performed some assessments and notifications, required RN evaluations and documentation were not completed as per facility policy.
A resident with hemiplegia and multiple care needs was found with unexplained discoloration to the left eye. Although an LPN assessed the injury and notified the responsible party and APRN, the facility did not follow its policy to obtain statements from all staff and the resident to determine the cause of the injury. Interviews confirmed that the required investigation was not completed.
A resident with chronic illnesses, severe cognitive impairment, and significant vision loss was admitted with documented interests in music, outdoor activities, and pet interaction. Despite these preferences being identified in assessments, the care plan only addressed visual impairment and did not include interventions for the resident's activity needs. The resident was found unaware of available activities, lacked access to preferred music, and was not taken outside, with no care plan initiated to address these deficiencies.
Several residents were found with air mattresses set incorrectly for their weight, despite physician orders and manufacturer instructions, and staff were unable to adjust or verify the settings. In one case, a resident with a pressure ulcer was on an improperly set mattress, while another resident at risk for skin breakdown had a mattress set to a firm setting not suitable for their weight. Additionally, a resident with a non-pressure skin condition did not receive timely wound care or monitoring upon readmission, and another resident with malnutrition was on a mattress set for a much higher weight than their own, with staff failing to check or document the correct settings.
A resident was not referred for a Level II PASRR evaluation after being diagnosed with a new psychotic disorder by an APRN. The facility's process relied on psychiatry providers to report new diagnoses to Social Services, but this step was missed because the diagnosis came from a medical provider. No PASRR policy was provided when requested.
Failure to Notify Provider of Resident's Change in Condition
Penalty
Summary
The facility failed to ensure that a change in condition was reported to the provider on two separate occasions for a resident with severe cognitive impairment, dementia, diabetes, and anxiety disorder. The resident was known to wander and had a care plan in place to monitor for changes in mental status and ensure a safe environment. On one occasion, a nurse documented that the resident was lethargic and had decreased meal consumption, but only the decreased meal intake was reported to the provider. The provider was present in the facility at the time and stated that, had they been informed of the lethargy, they would have evaluated the resident further. On a subsequent occasion, the resident experienced a fall after tripping near the nurse's station. Following the fall, the resident, who was typically very active and ambulatory, remained in bed for the rest of the day, which was unusual for their baseline behavior. Both the day and evening shift LPNs observed this change in activity level but did not notify the provider of the resident's altered condition. The provider later confirmed that remaining in bed was a significant change for this resident and should have been reported. The facility's policy required that any significant change in a resident's physical, mental, or psychosocial status be evaluated, documented, and reported to the provider and the resident's representative. Interviews with staff and review of documentation confirmed that these requirements were not met in both instances, resulting in a failure to follow the facility's change of condition policy.
Failure to Maintain Adequate Weekend Nursing Staff
Penalty
Summary
The facility failed to provide an adequate number of nursing staff to meet resident needs every day, as required. Payroll Based Journal (PBJ) data for Quarter 2, 2024, revealed excessively low staffing levels on weekends. During an interview, the Administrator confirmed that the previous owner did not permit the use of agency staff or allow licensed staff to work as Nursing Assistants, which contributed to the insufficient staffing. The facility's mandatory PBJ submissions to CMS reflected these staffing shortages, particularly on weekends, during the specified quarter. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Failure to Accurately Report and Maintain Required Staffing Levels
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS, as required. Payroll Based Journal (PBJ) submissions for Quarter 1, 2025, showed that the facility had no Registered Nurse (RN) hours and lacked licensed nursing coverage for 24 hours per day on multiple consecutive days. Additionally, the PBJ report for Quarter 2, 2024, indicated excessively low weekend staffing. During an interview, the Administrator stated that these issues were due to incorrect coding by the previous owner and restrictions on using agency staff or allowing licensed staff to work as Nursing Assistants, which contributed to inadequate staffing levels. The facility did not meet the mandatory requirement to electronically submit accurate staffing information based on payroll data.
Failure to Timely Report Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, and injuries of unknown origin to the State Agency as required by regulation. In one instance, a resident with hemiplegia and multiple comorbidities was found with discoloration around the left eye, which was identified as an injury of unknown origin. Although the injury was assessed by nursing staff and the responsible party and provider were notified, the incident was not reported to the State Agency. Both the LPN and the Nursing Supervisor acknowledged that the injury should have been classified as an injury of unknown origin and reported, but this did not occur. In another case, a resident-to-resident altercation occurred when one resident, with a history of agitation and aggression, punched another resident in the face in the dining room. The incident was witnessed and reported to an LPN, who assessed the involved residents and notified the provider and responsible party. However, the altercation was not reported to the State Agency until over 17 hours after the event, well beyond the required reporting timeframe. The DON stated that the delay was due to not being made aware of the incident until the following day. Additionally, four residents with varying degrees of cognitive impairment and incontinence did not receive timely incontinent care. The incident was identified by an LPN, who found multiple residents in need of care, and it was later determined that care had not been provided for an extended period. Although the supervisor was made aware of the neglect, the State Agency was not notified until nearly two days after the facility became aware of the situation. Facility policy and staff education materials indicated that such allegations should be reported immediately to supervisors and to the State Agency within two hours, but this protocol was not followed in these cases.
Failure to Timely Document APRN Visit and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure complete and timely documentation in the medical record for a resident with hemiplegia, aphasia, and severe cognitive impairment. The resident required assistance with activities of daily living (ADLs) and was always incontinent. On a specific date, an LPN identified that the resident had not received timely incontinent care, and this was documented in an incident report. Despite the identification of omitted care, no RN assessment was performed from the time the issue was discovered until the end of the shift. Additionally, an APRN evaluated the resident's skin condition nearly two days after the omitted care was identified, but did not document the visit until 17 days later as a late entry. Both the APRN and the Director of Nursing confirmed that the note should have been written at the time of the visit, in accordance with the facility's documentation policy, which requires documentation at the time of service or by the end of the shift. The failure to document the APRN visit in a timely manner resulted in an incomplete and inaccurate medical record for the resident.
Failure to Provide Activities Based on Resident Preferences and Needs
Penalty
Summary
A deficiency was identified when a resident with chronic kidney disease, diabetes, severe cognitive impairment, and significant visual impairment was not provided with recreational activities that met their documented interests and preferences. The resident's activity assessment indicated interests in music, pets, fresh air, and other activities, but the care plan failed to include a recreational activities component. Observations revealed that the resident was unaware of available activities, had no access to music in their room, and had not participated in pet therapy or been taken outside for fresh air, despite these being identified preferences. The activities calendar showed pet therapy was available, but it was not offered to the resident, and no individualized music therapy was provided. Interviews with the Assistant Director of Recreation and the Recreational Director confirmed that one-on-one activities were limited to brief social interactions and passive television watching, with documentation sometimes occurring without direct engagement. The staff acknowledged that the resident's interests in music, pets, and fresh air had not been addressed, and no reassessment of activity preferences had been conducted since admission. Facility policy required activities to be centered around individual interests and needs, but this was not implemented for the resident in question.
Failure to Maintain Palatable and Safe Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures, as evidenced by repeated resident complaints and direct observations. Residents consistently reported issues with cold food, including cold coffee, soup, and dinner, during multiple Food Committee and Resident Council meetings over the course of a year. Despite these ongoing concerns, the Food Service Director (FSD) advised residents to request reheating or replacement of cold meals but did not address the underlying issue. Observations revealed that meal plates were covered with plastic lids containing large holes, and hot plates or insulated lids were not used for residents on the first floor due to concerns about burn risks for those with dementia. The FSD could not explain the purpose of the holes in the lids or their impact on food temperature. Additionally, there were not enough insulated lids and hot plates for all residents on the second and third floors, resulting in inconsistent use of proper equipment to maintain food temperature. A test tray conducted on the third floor showed that food temperatures for certain items, such as pork loin and brussel sprouts, were below the facility's policy requirement of maintaining hot foods at 140 degrees Fahrenheit or more. The FSD acknowledged that the measured temperatures were low and attributed this to the lack of sufficient insulated covers and hot plates. Facility documentation confirmed that the policy required hot foods to be maintained at or above 140 degrees Fahrenheit, but this standard was not consistently met, as demonstrated by both resident feedback and direct temperature measurements.
Failure to Consistently Offer Snacks to Residents
Penalty
Summary
The facility failed to ensure that snacks were consistently offered to residents after dinner and before bed, as required by policy and resident needs. Resident interviews revealed that snacks were not always offered, and some residents had to request snacks rather than being proactively offered them. One resident with cerebral palsy, chronic kidney disease, and bipolar disorder, who required assistance with activities of daily living and set-up for meals, reported not always being offered snacks despite sometimes wanting one. Observations confirmed that while signage indicated snack times and available options, the process for distributing snacks relied on residents requesting them or being on a specific list. Staff interviews further indicated inconsistency and lack of clarity regarding the snack distribution process. Dietary staff delivered snacks based on a list provided by the dietician or nursing, but residents not on the list, including those who were bedbound, needed to ask for snacks. Nurse aides reported varying practices, with some not offering snacks to each room and others unsure of the policy. The administrator confirmed that staff were responsible for offering snacks but also stated that residents needed to request them. The facility's policy required snacks to be offered at bedtime and upon request, but the actual practice did not ensure all residents were proactively offered snacks as required.
Failure to Prevent Resident-to-Resident Altercations and Neglect of Timely Care
Penalty
Summary
The facility failed to prevent resident-to-resident altercations and did not ensure residents were free from neglect, as evidenced by multiple incidents involving several residents. In one instance, a resident with dementia and severe cognitive impairment was punched in the face by another resident with Alzheimer's disease and a history of agitation and aggression. The altercation occurred in the dining room and was witnessed by a visitor. Documentation revealed that the care plan for the aggressive resident included interventions such as keeping the resident near the nursing station and providing one-on-one supervision, but these measures were not effectively implemented at the time of the incident. The event was not documented in a timely manner, and the initial nursing note failed to identify the actual date of the altercation. Another incident involved a resident with Alzheimer's disease and behavioral disturbances who became agitated during morning care and pushed a nurse aide, then pushed another resident, causing that resident to fall. The care plan for the aggressive resident included interventions to approach the resident calmly and anticipate needs, but the resident had recently become more impulsive and difficult to redirect. Staff interviews confirmed that the resident was agitated and that the incident occurred while another resident was walking by. Additionally, the facility failed to provide timely incontinent care to four residents with varying degrees of cognitive impairment and physical dependency. Documentation and staff interviews revealed that these residents went extended periods—ranging from nearly 7 to over 10 hours—without receiving incontinent care, despite care plans directing checks every two hours. The nurse aide responsible for their care did not check on the residents as required and did not notify supervisory staff when assistance was needed. The facility's investigation substantiated that neglect had occurred, as the residents did not receive necessary care to avoid physical harm or distress.
Failure to Complete Timely RN Assessments After Incidents and Care Omissions
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) assessments were completed in a timely manner for multiple residents following incidents involving accidents, resident-to-resident altercations, and potential abuse. In one case, a resident with hemiplegia and other significant medical conditions was found with discoloration around the left eye. Although an LPN assessed the injury and notified the APRN, there was no documentation of an RN assessment or investigation into the cause of the injury, despite facility policy requiring such action for injuries of unknown origin. The Director of Nursing Services (DNS) confirmed that the RN supervisor was responsible for the assessment and documentation, but no explanation was provided for the omission. In another incident, two residents were involved in a physical altercation, with one resident punching another in the face. The event was witnessed and reported to an LPN, who performed an assessment and notified the APRN and responsible party, but did not notify the nursing supervisor. There was no evidence of an RN assessment for either resident following the altercation, contrary to facility policy that requires immediate notification of the nursing supervisor and a thorough assessment after any allegation or observation of abuse. The DNS acknowledged that the nursing supervisor should have been informed and an assessment completed. Additionally, four residents with significant cognitive and physical impairments did not receive timely incontinent care, with gaps ranging from nearly 10 to over 10 hours between care episodes. When this lapse was identified, there was no documentation of RN assessments or skin checks for these residents, despite facility procedures directing a physical assessment in such situations. Late entries by LPNs and an APRN note did not address the period during which care was omitted. The DNS confirmed that RN assessments were not completed as required after the incident was discovered.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
A deficiency occurred when the facility failed to conduct a complete investigation into an injury of unknown origin for a resident with hemiplegia, hypertension, and diabetes. The resident, who was cognitively intact but required extensive assistance for self-care and mobility, was found with discoloration around the left eye. Documentation shows that the LPN was notified of the injury, assessed the resident, and informed the responsible party and APRN, who ordered diagnostic tests and interventions. However, the required investigative process, including obtaining statements from all staff who worked with the resident in the previous 72 hours and from the resident, was not completed as per facility policy. Interviews with the LPN, RN Supervisor, and DNS confirmed that no staff or resident statements were collected to determine the cause of the injury. The RN Supervisor acknowledged not assessing the resident or initiating the investigation, and the DNS confirmed that statements should have been obtained but could not provide a reason for the omission. Facility policy mandates timely investigation and collection of staff statements for injuries of unknown origin, but this protocol was not followed in this case.
Failure to Develop Comprehensive Activity Care Plan for Resident with Visual and Cognitive Impairments
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan addressing the activity needs and preferences of a resident with chronic kidney disease, diabetes, bilateral cataracts, and hypertension. The resident was admitted with a history of interests such as drawing, fishing, music, and being outdoors, and was identified as having severe cognitive impairment and highly impaired vision. The resident's Minimum Data Set assessment indicated that it was very important for them to listen to preferred music, go outside for fresh air, and be around animals. However, the care plan only addressed impaired visual function and included interventions such as one-on-one staff visits, without addressing the resident's specific activity preferences. During observation and interview, the resident was found lying in bed with the television on, without access to a radio or music player, and was unaware of available recreational activities. The resident reported not being involved in activities or taken outside for fresh air. Review with the Assistant Director of Recreation confirmed that no care plan had been initiated for the resident's activity needs, and there were no interventions in place to provide appropriate activities as identified in the resident's assessment.
Failure to Ensure Proper Air Mattress Settings and Timely Wound Care
Penalty
Summary
The facility failed to ensure that air mattresses were set at the appropriate settings according to physician orders, resident weight, and manufacturer instructions for multiple residents. In one case, a resident with a stage 3 pressure ulcer was observed lying on an air mattress set at a level inconsistent with the resident's weight, as indicated by the attached instruction card. Nursing staff were unable to confirm or adjust the settings appropriately and did not reference the manufacturer's instructions, despite the presence of clear guidance on the mattress and from the vendor. The facility's policy required nurses to set the correct air mattress setting based on the resident's current weight, but this was not followed. Another resident, who was at risk for pressure ulcers and receiving hospice care, was found on an air mattress set to a firm setting, which was not appropriate for the resident's weight. Nursing staff were unable to explain or adjust the settings and did not know the correct correlation between the resident's weight and the mattress setting. The settings card on the pump was left blank, and staff relied on maintenance or the vendor for guidance rather than following facility policy or physician orders. Documentation indicated that staff signed off on checking the settings every shift, but observations showed the settings remained incorrect over several days. Additionally, the facility failed to initiate timely treatments for a resident with a non-pressure skin condition. Upon readmission from the hospital, the resident had wounds that were not measured or described in the nursing assessment, and no treatment or monitoring orders were put in place for several days. The hospital discharge paperwork included wound care instructions, but these were not implemented by the nursing staff. The Director of Nursing confirmed that it was expected for hospital treatment orders to be followed upon readmission, but could not explain why this was not done. Another resident with malnutrition was found on an air mattress set for a much higher weight than their own, despite staff documentation indicating the setting was checked every shift. The resident and a family member reported the mattress felt excessively hard, and staff admitted to not verifying the settings as required.
Failure to Refer for Level II PASRR After New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a new mental disorder was identified. The resident was admitted with diagnoses of cerebral infarction and Parkinson's disease, and at admission, no mental disorder was present. The initial Level I PASRR screening indicated that a Level II evaluation was not required, but also stated that a new screening must be submitted if new information or changes occurred. Subsequently, an Advanced Practice Registered Nurse (APRN) documented a new diagnosis of psychotic disorder with delusions due to a known physiological condition. Despite this new diagnosis, the facility did not initiate a Level II PASRR evaluation. During interviews, the Director of Social Services confirmed that the process for identifying new mental disorders relied on psychiatry providers reporting new diagnoses to Social Services, who would then notify the appropriate agency for a Level II PASRR. However, in this case, the diagnosis was made by a medical APRN rather than a psychiatry provider, resulting in the process being missed. Additionally, the facility was unable to provide a policy for PASRR when requested.
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.
