Manchester Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Manchester, Connecticut.
- Location
- 385 W Center St, Manchester, Connecticut 06040
- CMS Provider Number
- 075333
- Inspections on file
- 24
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Manchester Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, high Braden risk, and existing stage 4 pressure ulcers had a care plan calling for turning, a low air-loss mattress, and heel offloading, but there was no physician order for offloading boots or for skin checks under the boots. Over several months, documentation did not show any directive to assess skin beneath the boots each shift, and a weekly skin check noted no new issues. Subsequently, an APRN and the ADON identified a new open area on the dorsal left foot, attributed by the ADON to rubbing from the boot strap, and a wound physician documented a full-thickness wound with 100% slough requiring ongoing treatment. Interviews with the APRN, the wound physician, and the ADON indicated the wound was not identified timely and that, had the boots been removed and the skin assessed every shift, the area could have been detected earlier and the wound’s progression potentially limited.
A resident with severe cognitive impairment, multiple chronic conditions, poor oral hygiene, and documented oral/dental problems was seen by a dental provider who found devastated dentition with cavities on every tooth, likely infection, and recommended full-mouth x‑rays, extractions, and frequent cleanings. The findings were not documented in the clinical record as progress notes, and the provider was not notified. Over the next several months, the resident repeatedly missed scheduled dental hygienist visits due to scheduling issues and hospitalizations, without evidence of nursing or provider notification or alternative follow-up. The social services director acknowledged seeing the dental note but did not inform nursing, the DON was unaware of the visit and missed appointments despite schedules addressed to her, and the APRN was not informed of the dental findings, contrary to the facility’s own notification-of-changes policy.
A resident with multiple diagnoses experienced an unwitnessed fall and was hospitalized. Upon return, required neurological monitoring was not completed or documented for several hours, and staff failed to follow the expected monitoring schedule. The facility did not have a clear policy guiding post-fall neurological checks, leading to missed assessments and inaccurate documentation.
A facility failed to honor a resident's advanced directive choices due to severe cognitive impairment. Despite a hospital directive for DNR status, the resident incorrectly signed as full code without a witness or physician's signature. The facility did not contact the resident's representative within 24 hours to confirm wishes, and no progress notes indicated attempts to reach them. The DNS acknowledged the need for representative involvement, and the case manager confirmed no legal forms were signed by the representative, despite daily visits.
A resident with a history of falls and hip replacement was not consistently ambulated as per physician orders, despite the care plan requiring ambulation twice daily with a walker. Nursing staff failed to document or provide rationale for missed ambulation opportunities, and the resident expressed concerns about not being walked regularly. Interviews revealed a lack of communication and adherence to the care plan, resulting in a deficiency in maintaining the resident's mobility.
The facility failed to conduct annual performance reviews for two nurse aides, as required by their policy. The Director of HR admitted that a process change led to missed evaluations, and the DNS, who was not in her role at the time, has since been completing evaluations as expected.
A facility failed to conduct behavior monitoring for a resident on Seroquel, an antipsychotic medication prescribed for dementia with insomnia. Despite recommendations to update the medication order with specific behaviors for monitoring, the resident's representative did not want changes. The APRN and DNS acknowledged that behavior monitoring was not implemented as required by the facility's policy, which mandates targeted behavior monitoring and non-pharmacological interventions for residents on psychotropic medications.
A malfunctioning call bell system in two units caused continuous ringing, disturbing residents and staff. The issue began several days prior, and attempts to fix it with an adapter failed. The Maintenance Director tried to contact the vendor, but the problem persisted over the weekend. The Administrator acknowledged the malfunction, which violated the facility's noise control policy.
Failure to Monitor Offloading Boots and Prevent New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and monitoring for a dependent resident at high risk for skin breakdown. The resident had multiple diagnoses including dementia, Parkinson’s disease, CKD stage 3, hypothyroidism, protein-calorie malnutrition, and type 2 diabetes, and was dependent on staff for personal hygiene, bed mobility, and transfers. A quarterly MDS documented severely impaired cognition and three unhealed stage 4 pressure ulcers present on admission, and the care plan identified impaired skin integrity with interventions such as turning and repositioning every two hours, use of a low air-loss mattress, and offloading heels as tolerated. A Braden Scale assessment identified the resident as high risk for pressure injuries, and a wound care note documented that a prior left medial foot wound had resolved. Despite these identified risks and care plan interventions, the clinical record from mid-May through late September did not contain any physician order to utilize offloading boots or to check the skin under the boots every shift. A weekly skin check on 9/21/25 documented no new skin issues. On 9/23/25, an APRN was asked to evaluate a wound on the resident’s left foot and documented a left dorsal foot wound requiring daily cleansing and silver alginate dressing. Later that day, the ADON documented discovering an open area on the left dorsal foot, approximately 3 cm by 0.5 cm, and attributed it to the resident’s skin rubbing against the strap of the offloading booties. The ADON noted that the offloading boots were removed and replaced, and that new dressing orders were obtained, but there was no prior order directing use of the boots or skin checks under them. On 9/25/25, the wound care physician documented a new full-thickness wound on the left dorsal foot measuring 1.1 cm by 0.9 cm by 0 cm with 100% slough and moderate serosanguinous drainage, and recommended offloading heels per facility protocol. A later note on 3/19/26 showed the left dorsal foot wound persisted as a stage 4 pressure ulcer. Interviews with the APRN, the wound care physician, and the ADON indicated that the wound was not identified timely, that the resident should have had an order to offload both heels while in bed, and that offloading boots, once used, should have been removed every shift to assess the underlying skin. They stated that if the skin under the boots had been assessed every shift, the area could have been identified earlier and the progression to a full-thickness wound might have been prevented or less severe. The facility’s pressure injury policy referenced systematic prevention and management based on risk factors such as impaired mobility, comorbidities, cognitive impairment, and malnutrition, but there was no available policy specific to offloading boots.
Failure to Notify Provider and Follow Up on Significant Dental Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify the resident’s provider and nursing staff of significant dental findings and to follow up on recommended dental care. A resident with dementia, Parkinson’s disease, stage 3 chronic kidney disease, hypothyroidism, protein-calorie malnutrition, type 2 diabetes mellitus, and three unhealed stage 4 pressure ulcers was care planned for oral/dental health problems, including poor oral hygiene and the need to monitor and report signs and symptoms of oral/dental issues. A dental visit on 9/25/25 documented that the resident had cavities on every tooth, devastated dentition likely infected or a great source of bacteria, and that the resident would be healthier without the remaining teeth. The dentist recommended an FMX to determine the best referral for further intervention and dental cleanings every three months due to poor oral health. However, from 9/25/25 through 3/25/26, the clinical record contained no progress notes about this dental visit, the need for x‑rays, the condition of the dentition, or any notification to the provider about these issues. Subsequent dental hygienist schedules showed that the resident was not treated on multiple dates over approximately six months, with reasons including not being on the hygienist’s list and the resident being at the hospital, and there was no evidence that these missed visits were communicated to nursing or the provider. The Director of Social Services, who managed outside providers, acknowledged seeing the 9/25/25 dental note but did not ensure nursing was aware of the findings or arrange additional follow-up, and confirmed the resident was repeatedly on the list but not seen. The DON stated she was unaware of the 9/25/25 dental visit and the missed hygienist visits, despite schedules being addressed to her, and indicated that the Director of Social Services should have notified nursing and a provider of the missed visits. The APRN reported she was unaware of the dental findings and would have evaluated and treated the resident if notified, and that alternative arrangements should have been made after missed appointments due to hospitalization. The facility’s Notification of Changes policy required informing and consulting with the provider and notifying the resident or representative when there is a significant change requiring alteration of treatment, but there was no policy available for outside consults and follow-up.
Failure to Complete and Document Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely and complete neurological monitoring following an unwitnessed fall involving a resident with diagnoses including Parkinson's disease, cervicalgia, and bipolar disorder. The resident, who was cognitively intact and independently ambulatory, was found outside the facility after an apparent elopement attempt. Initial assessments documented that the resident denied head injury and pain, and neurological checks were performed prior to the resident's transfer to the hospital. Upon return from the hospital, documentation of required neurological monitoring was missing for several hours, and the monitoring schedule was not followed as per facility standards. Further review revealed that neurological assessments were not resumed or documented upon the resident's return, despite the expectation for hourly checks to continue. The nurse responsible stated that vital signs were taken and the resident refused neurological monitoring at one point, but this refusal was not documented. Additionally, the nurse did not recall completing or attempting the required neurological assessments at the scheduled times, and documentation inaccurately indicated the resident was still hospitalized during periods when the resident was present in the facility. The facility lacked a clear policy or procedure directing staff on when to conduct post-fall neurological monitoring, relying instead on electronic medical record prompts. The Director of Nursing confirmed that neurological monitoring should have resumed upon the resident's return and continued for 72 hours, but acknowledged that the facility did not have a written policy to guide staff. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed the failure to complete and document neurological assessments as required.
Failure to Honor Resident's Advanced Directive Choices
Penalty
Summary
The facility failed to ensure that the advanced directive choices for a resident with severe cognitive impairment were reviewed and honored. The resident was admitted with a hospital discharge directive indicating a do not resuscitate (DNR) status, and a physician's order confirmed this status along with do not intubate (DNI) and a registered nurse may pronounce (RNP) orders. However, the advanced directive form in the clinical record was incorrectly signed by the resident as a full code, without a witness or physician's signature, despite the resident's severe cognitive impairment. The facility did not contact or educate the resident's representative to confirm the resident's wishes regarding the advanced directive. Interviews revealed that the resident's representative was not contacted within the expected 24-hour period after admission to discuss the resident's code status, and no progress notes indicated attempts to reach the representative. The Director of Nursing Services (DNS) acknowledged that the resident's cognitive impairment required the representative's involvement, and the current code status form was invalid. The case manager, responsible for coordinating care conferences, confirmed that the resident's representative was not asked to sign any legal forms, despite being present at the facility daily. The facility's policy required that decisions regarding advanced directives be documented and honored, but this was not adhered to in this case.
Failure to Provide Prescribed Ambulation for Resident
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the mobility of a resident, identified as Resident #80, who was admitted with diagnoses including falls, hip replacement, and chronic pain. The care plan required ambulation of 150 feet with a rolling walker and minimal assistance. However, the nursing assistant flow sheets revealed numerous missed opportunities for ambulation, with many instances lacking documentation or rationale for the failure to ambulate. Despite physician orders and the resident's expressed desire to ambulate twice daily to regain strength and independence, the nursing staff did not consistently follow through with the prescribed ambulation. Interviews with the resident, Director of Rehabilitation, nursing assistant, Director of Nursing Services (DNS), and APRN highlighted a breakdown in communication and adherence to the care plan. The resident reported that ambulation did not occur as ordered, and the nursing assistant admitted to not offering ambulation due to the resident's therapy and recreation schedule. The DNS and Administrator expected compliance with physician orders, and the APRN indicated a need for notification if ambulation did not occur. However, no notifications were made, and the resident's ambulation was not documented or communicated effectively, leading to a deficiency in care.
Failure to Complete Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for two certified nurse aides, NA #3 and NA #4, as required by their Performance Evaluation policy. NA #4, who was hired in 1995, did not have a documented performance review for 2023, with the last review dated in 2022. Similarly, NA #3, hired in 2022, also lacked a documented performance review for 2023. This deficiency was identified through a review of personnel files and interviews with facility staff. The Director of Human Resources acknowledged that the facility was undergoing a process change for completing annual evaluations, which resulted in some evaluations being missed. The Director of Nursing, who was not in her current role during the time the evaluations were missed, stated that she has since been completing evaluations around the anniversary of hire dates. The facility's policy mandates annual reviews to assess position goals and provide feedback, but this was not adhered to for the two nurse aides in question.
Failure to Monitor Behavior for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure behavior monitoring was conducted for a resident on antipsychotic medications, specifically Seroquel, which was prescribed for dementia with insomnia. The resident, who had severely impaired cognition and required total assistance with daily activities, was admitted with a physician's order for Seroquel. Despite the pharmacy's recommendation to update the antipsychotic order with a specific behavior that could be quantitatively and objectively documented, the APRN noted that the resident representative did not want the medications changed. The APRN indicated that behavior monitoring should have been initiated upon admission, but it was not implemented. Interviews with the psychiatric APRN and the DNS revealed that behavior monitoring flow sheets were not in place as required by the facility's policy. The DNS acknowledged that the nurse supervisor was responsible for ensuring behavior monitoring was initiated on admission, but it was not done for this resident. The facility's policy mandates that residents on psychotropic medications must have targeted behavior monitoring and receive non-pharmacological interventions to facilitate reduction or discontinuation of the medications. However, this was not adhered to in the case of the resident on Seroquel.
Call Bell System Malfunction Causes Disturbance
Penalty
Summary
The facility failed to maintain a homelike environment due to a malfunctioning call bell system that affected two of the three units. Observations identified continuous call bell ringing on the North unit, and an LPN confirmed the malfunction began several days prior. An email from the Maintenance Director indicated that the issue was known and an adapter was installed, but it did not resolve the problem. The Maintenance Director attempted to contact the vendor, but the issue persisted over the weekend, causing disturbances to residents and staff. The Administrator acknowledged the malfunction and agreed to contact the vendor for an immediate resolution. The facility's policy on noise control emphasizes providing care in a calm and comfortable environment, which was not upheld in this instance.
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.
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