Matulaitis Rehabilitation & Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Putnam, Connecticut.
- Location
- 10 Thurber Rd, Putnam, Connecticut 06260
- CMS Provider Number
- 075411
- Inspections on file
- 19
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Matulaitis Rehabilitation & Skilled Care during CMS and state inspections, most recent first.
A resident with dementia and a known elopement risk was found outside exterior fire doors after a fire alarm event in which a bathroom fan caught fire and activated the facility’s alarm system. Later observation showed that one of the exterior fire doors, controlled by a keypad and magnetic lock, did not latch shut on its own and had to be pulled closed, with interior weather stripping noted on the bottom of the door. The Maintenance Director reported that fire alarms disable door alarms and cause the doors to open automatically, acknowledged that the doors were old and known to require pulling to close, and stated that maintenance did not check the doors after the alarm to ensure they were secured. The DNS also confirmed that the exterior fire doors were not checked for secure closure following the fire event.
A resident with dementia, insomnia, repeated falls, and documented wandering was assessed as an elopement risk and placed in a room far from the nurses’ station and near an exterior exit. The care plan included only general interventions (e.g., orientation, frequent checks, familiar objects) and did not address specific behaviors such as nighttime wandering, confusion, searching for family, and packing belongings to leave. Psychiatric notes and staff interviews confirmed ongoing late-night wakefulness, agitation, and exit-seeking behaviors, and the resident was later found outside an alarmed exterior fire door. Despite facility policy requiring targeted elopement measures, the resident’s elopement care plan lacked individualized interventions tied to these known risk factors.
A resident with dementia, insomnia, a history of wandering, and moderately impaired cognition was assessed as at risk for elopement and had an elopement care plan, but no wander guard was applied despite facility policy. The resident was independently ambulatory, exhibited nighttime confusion and wandering, and was housed in a room far from the nurses’ station and closest to exterior fire doors. After a prior fire alarm event, maintenance did not verify that the exterior fire doors re-latched, even though the doors were known to require being pulled shut and had weather stripping that could impede closure. During the night, staff heard an alarm they did not recognize, later determined to be from the exterior fire doors, and found one door slightly ajar before discovering the resident missing and then located outside on the ground just beyond the doors. Staff, including nursing and CNAs, reported they had not participated in elopement drills, and leadership confirmed that no elopement drills had been conducted despite policy requiring periodic drills for residents at risk of wandering or elopement.
The facility failed to consistently document sanitizer concentration levels in the kitchen, as required by policy. Staff interviews and document reviews revealed missing entries in the sanitizer verification logs for several months, indicating that the sanitizing solution was not always checked before use. The Dietary Manager acknowledged the responsibility of dietary staff to verify and document the sanitizer concentration.
A resident admitted with a mid-back surgical incision did not have the surgical wound or related skin impairment included in their care plan, despite physician orders and facility policy requiring monitoring and care planning for such conditions. Interviews with the DNS and MDS Coordinator confirmed the omission, which was not addressed at the time of admission.
Two residents with altered skin integrity did not receive required wound measurements, and one used an external catheter device without a physician's order or staff training. Additionally, a Braden Scale pressure ulcer risk assessment was not completed on admission or at a change in condition for a resident with a worsening pressure ulcer, contrary to facility policy.
A resident admitted with a stage 4 pressure ulcer did not receive timely interventions, including delayed provision of an air mattress and turning schedule, and lacked prompt staging and assessment of the wound. The ulcer worsened significantly, and documentation of wound measurements was inconsistent, contrary to facility policy.
A resident with urinary incontinence and multiple comorbidities used an external catheter system without a physician's order, and staff interacted with the device without receiving any training. The family and a private aide managed the device without facility oversight, and there was no policy or staff education in place regarding its use.
A resident with dementia and other medical conditions was allegedly slapped by a nursing assistant during a night shift. The incident led to an investigation, conflicting statements from staff, and the termination of the nursing assistant for not adhering to the facility's dignity policy.
Failure to Ensure Exterior Fire Doors Securely Closed After Fire Alarm
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment by ensuring that exterior fire doors in a resident-accessible area were functional and able to securely close. A resident admitted with dementia, repeated falls, and insomnia had been identified as at risk for elopement, and an elopement care plan was in place. A reportable fire event occurred when a bathroom fan on one wing caught fire, triggering the fire alarm system and emergency response. Following this fire alarm, the exterior fire doors on another wing alarmed during the night, and a safety check revealed that the at-risk resident was found outside those exterior fire doors on their hands and knees, with no injuries identified at that time. Subsequent observation of the same exterior fire doors showed that, although they were locked and equipped with a keypad and magnetic locks, one of the two doors did not latch shut on its own and had to be pulled closed to secure it. The Maintenance Director stated that when the fire alarm is activated, the alarms on the exterior fire doors are disabled and the doors open automatically, and acknowledged that the prior fire alarm could have caused the doors to open and then not properly close and latch afterward. He also acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, despite knowing that the doors were old and required pulling to close, and that interior weather stripping might contribute to the failure to close securely. The DNS confirmed that after the fire event, the exterior fire doors were not checked to ensure they were secured and latched.
Failure to Individualize Elopement Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop a person-centered, individualized care plan to address an assessed elopement risk for one resident. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, leading to initiation of an elopement care plan. The Resident Care Plan documented that the resident was at risk for elopement related to dementia, with a history of wandering in the community and at the facility, and a past occupation as an elevator repair person who believed he had service calls and wanted to leave at night. Interventions listed were general in nature, such as introducing staff in a calm manner, explaining routines, orienting to room and environment, performing frequent checks, placing a picture in the business office, and encouraging family to bring familiar objects. The resident’s MDS showed moderately impaired cognition, independent ambulation of at least 150 feet, and wandering behaviors several days per week. Clinical documentation and interviews showed specific behaviors and circumstances that increased the resident’s elopement risk but were not reflected in individualized care plan interventions. Psychiatric notes over several months described late evening and early morning wakefulness, agitation, confusion, wandering, insomnia, and the resident looking for a family member at night, with PRN Trazodone ordered for agitation/insomnia. Staff interviews reported that the resident stayed up at night, wandered the hall, and packed belongings at night to go home. The resident’s room was located far from the nursing station and closest to an exterior fire door. An incident report documented that an exterior fire door alarm sounded during the night and the resident was found outside that door on hands and knees. Despite the facility’s written policy that residents identified as elopement risks would have a wander guard bracelet, photo ID placement, and periodic elopement drills, the care plan did not include individualized interventions addressing the resident’s nighttime wandering, confusion, searching for family, packing to leave, or room location near an exit, and the facility had not conducted or documented elopement drills.
Failure to Secure Exterior Fire Doors and Implement Elopement Interventions for At-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that exterior fire doors in a resident-accessible area were secured and to provide adequate supervision and interventions for an ambulatory resident assessed as at risk for elopement, resulting in the resident exiting the building unsupervised. The resident was admitted with dementia, repeated falls, and insomnia, had a responsible party, and was identified on an elopement evaluation as being at risk for elopement, with an elopement care plan initiated. The resident care plan documented dementia-related elopement risk, a history of wandering in the community and at the facility, and a past occupation as an elevator repair person with a pattern of thinking he had service calls and wanting to leave at night. Interventions listed included calm introductions, explanation of routines, orientation to room and environment, frequent checks as necessary, a picture in the business office, and encouraging family to bring familiar objects; no wander guard was initiated at that time. Clinical documentation showed the resident had late evening and early morning wakefulness, agitation, confusion, and wandering, including middle-of-the-night confusion and looking for a family member, with PRN Trazodone ordered for agitation/insomnia. The quarterly MDS identified moderately impaired cognition (BIMS 11), independent ambulation of at least 150 feet, and wandering behaviors occurring one to three days per week. A fall assessment tool identified the resident as high risk for falls. Despite these findings and the facility’s own policy stating that residents identified as elopement risks should have a wander guard bracelet initiated and checked each shift, the DNS stated the resident did not have a wander guard because the resident was not considered exit seeking or making statements of wanting to leave. The DNS also acknowledged that the resident’s room, which was the closest to the exterior fire doors and farthest from the nursing station, was the only room available at admission. On the night of the event, a bathroom fan fire on another wing had triggered the fire alarm the previous day, which the Maintenance Director stated could cause exterior fire doors to open and then not close and latch properly once the alarm was completed. He acknowledged that no one from maintenance checked the exterior fire doors after the fire alarm to ensure they were secured and latched, and that the D-wing exterior fire doors were known to require being pulled shut to secure, with weather stripping possibly contributing to incomplete closure. In the early morning hours, staff heard an alarm they did not recognize and initially did not know it was from the exterior fire doors; they required direction from the supervisor to check those doors. The NA found the D-wing exterior fire door slightly ajar, closed it, and then began a resident head count, discovering the resident missing from the room nearest the doors. When the exterior doors were opened, the resident—who had been last seen in bed around midnight and was known to pack belongings at night to go home—was found outside on hands and knees. Both the NA and RN reported they had not participated in any elopement drills, and the DNS confirmed the facility had not conducted elopement drills and had no documentation of such drills, despite policy requiring periodic elopement drills for residents at risk for wandering/elopement.
Inconsistent Sanitizer Verification in Kitchen
Penalty
Summary
The facility failed to consistently complete sanitation logs for the sanitizing sink according to its policy. During a kitchen tour, a dietary aide was observed washing a pitcher in a 3-bay sink, with two large gray baking pans soaking in the sanitizing sink. The dietary aide admitted to not checking the sanitizer concentration level, relying on the cook who checked it in the morning. A review of facility documentation revealed that the sanitizer level was not checked before washing and sanitizing breakfast dishes. Furthermore, the pot sink and bucket sanitizer verification logs from June to December 2024 showed missing documentation for breakfast and lunch times across several months. Interviews with staff revealed that the sanitizing sink was filled with solution in the morning, but the concentration test results were not always documented. The Dietary Manager confirmed that it was the dietary staff's responsibility to check the sanitizing solution before use and acknowledged that staff might forget to document the concentration. The facility's policy requires that testing of the sanitizing solution be documented each time the sink is refilled, and the person filling the sink is responsible for this documentation.
Failure to Timely Update Care Plan for Surgical Incision on Admission
Penalty
Summary
The facility failed to timely review and revise the care plan to address a surgical incision present on admission for one resident. The resident, who had a history of spinal fusion, chronic congestive heart failure, urinary incontinence, muscle weakness, and required assistance with personal care, was admitted with a mid-back surgical incision. The admission observation and physician's order both documented the presence of the incision and directed staff to monitor it for signs of infection every shift. However, the care plan did not identify the actual skin impairment related to the surgical wound. Interviews with the Director of Nursing Services and the MDS Coordinator confirmed that a care plan for the surgical incision should have been initiated upon admission, but this was missed. Facility policy required that the comprehensive, person-centered care plan include all identified problem areas and risk factors, but the surgical wound was not incorporated into the resident's care plan as required.
Failure to Assess Wounds, Obtain Orders for Medical Devices, and Complete Pressure Ulcer Risk Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with altered skin integrity. For one resident with a history of spinal fusion, chronic congestive heart failure, urinary incontinence, and muscle weakness, the facility did not measure two surgical incisions from admission through discharge, despite policy requiring weekly wound assessments including measurements. Documentation showed that staff were unable to assess the incision on admission due to family refusal, but there was no evidence of subsequent measurements or documentation throughout the resident's stay. Interviews with clinical staff confirmed that wound protocols were not followed, and the Director of Nursing was unable to explain the lack of measurements. Additionally, the same resident utilized an external catheter device throughout their stay without a physician's order, as documented in nursing notes. The device was applied and removed by the family and a private aide, with facility staff only turning it on/off or emptying it as needed, despite not being trained on its use. There was no facility policy or staff training regarding the external catheter, and the Director of Nursing acknowledged that a physician's order should have been obtained and that staff should not have managed the device without proper oversight. For a second resident with a right femur fracture, Parkinson's disease, dementia, and a stage 4 pressure ulcer, the facility failed to complete a Braden Scale pressure ulcer risk assessment on admission and at a change in condition, as required by policy. The resident was admitted with a pressure ulcer, which worsened during the stay, but the Braden Scale was not completed until 25 days after admission. Interviews with nursing leadership confirmed that the assessment should have been done on admission and with the change in condition, but they were unable to explain the omission.
Failure to Provide Timely Pressure Ulcer Interventions and Assessment
Penalty
Summary
A deficiency occurred when a resident admitted with a stage 4 pressure ulcer did not receive timely and appropriate interventions as required by facility policy. Upon admission, the resident was noted to have a pressure ulcer to the coccyx, but the ulcer was not staged, and a Braden Scale assessment to identify risk for further skin breakdown was not completed in a timely manner. The initial care plan included interventions such as a pressure-relieving mattress and repositioning, but an air mattress was not provided until three days after admission, despite the presence of a pressure ulcer. Orders for regular turning and repositioning were also delayed until three days post-admission. The clinical record showed that the pressure ulcer increased in size significantly within a few days, and there was a lack of consistent and timely wound measurements and assessments, with a ten-day gap in documentation. The wound was not staged or assessed according to facility policy, which requires weekly assessments. The resident's condition deteriorated, with the ulcer worsening and signs of infection developing, leading to a transfer to the emergency department for further evaluation. Upon return, a wound care consult was ordered, and the wound was found to have slough and necrotic tissue, requiring debridement and specialized wound care products. Interviews with facility staff confirmed that the expected interventions, such as providing an air mattress and implementing a turning schedule, were not initiated on admission as required. The Director of Nursing Services and a registered nurse acknowledged the delay in implementing these interventions and the lack of timely wound assessment and staging. The facility's policies require immediate risk assessment, staging, and implementation of pressure ulcer prevention and treatment measures, which were not followed in this case.
Lack of Staff Training and Oversight for External Catheter Use
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for a resident using an external catheter system. The resident, who had a history of spinal fusion, chronic congestive heart failure, urinary incontinence, and previous UTIs, was documented as using an external catheter during their stay. However, there was no physician's order for the device, and the care plan only addressed general incontinence care without mention of the external catheter. Facility staff did not apply or remove the catheter, but did turn it on/off and emptied it as needed, despite not having received any training on the device. The family and a private aide were allowed to manage the catheter without facility oversight. Interviews with staff and administration confirmed that there was no policy or staff education regarding the use of the external catheter system. The DNS acknowledged that the facility permitted the family and private aide to manage the device and that staff interacted with the device without proper training. No policy on the external catheter system was provided when requested, and the APRN stated that the device should not have been used without a physician's order and appropriate staff training due to infection risks.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity. Resident #1, who had diagnoses including dementia with psychotic disturbances, infection to cystostomy catheter, heart failure, and depression, was involved in an incident where a nursing assistant (NA #1) allegedly slapped the resident. The incident occurred during the night shift when Resident #1 was restless and attempting to get out of bed. Another nursing assistant (NA #2) reported witnessing NA #1 slap Resident #1 in the face, which led to an immediate investigation and the removal of NA #1 from care duties. NA #1 denied slapping the resident but admitted to placing her hand over the resident's mouth to quiet him down, which was deemed inappropriate by the facility's Director of Nursing (DON). The facility's policy on dignity and respect was not followed, leading to the termination of NA #1's employment. The incident report and investigation revealed conflicting statements from the involved staff members, making it difficult to substantiate the abuse claim. However, the DON acknowledged that NA #1's actions were not in line with the facility's policy on treating residents with dignity and respect. The facility's Quality of Life - Dignity Policy emphasizes that each resident should be cared for in a manner that promotes their well-being and self-esteem. The failure to adhere to this policy resulted in the deficiency noted in the report.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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