Nathaniel Witherell, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenwich, Connecticut.
- Location
- 70 Parsonage Rd, Greenwich, Connecticut 06830
- CMS Provider Number
- 075117
- Inspections on file
- 27
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Nathaniel Witherell, The during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, dementia, glioblastoma, and severely impaired cognition was identified as high risk for falls and care planned to use a call light and appropriate footwear, including non-skid socks. After an initial fall with an abrasion, the resident experienced additional falls, including episodes where the resident was found on the floor, reported hitting the head, and was transferred to the hospital. Documentation showed the resident was wearing regular socks at the time of one fall, despite the care plan requiring non-skid socks, and subsequent care plan updates repeated the same sock intervention or focused only on neurological checks and abrasion care. No new fall-prevention interventions were added after later falls, and interviews with the DON and ADNS confirmed that staff did not follow the existing care plan and that no additional interventions were documented, contrary to facility policy requiring care plan updates after falls.
A resident with dementia, metabolic encephalopathy, glioblastoma, severely impaired cognition, and a known history of falls was care planned as high risk for falls, with interventions including call light access and appropriate footwear such as non-skid socks. Despite this, the resident experienced multiple falls, including events where the resident was found on the floor with abrasions and after hitting the head, and one fall occurred while the resident was wearing regular socks. The care plan was only updated to emphasize non-skid socks, and interviews with the DNS and ADNS did not identify any additional supervision or interventions implemented after a later fall to prevent another incident. The resident ultimately sustained a subsequent fall without calling for assistance, resulting in head pain and hospital evaluation that revealed intracranial hemorrhages and bifrontal contusions.
A resident with dementia, a history of falls, muscle weakness, and impaired mobility, who required staff assistance for transfers but was independent in wheelchair use, wheeled themself into a shower room to toilet without calling for help and sustained an unwitnessed fall. The resident was found on the floor with a commode frame on top, legs crossed and bent, and complained of hip pain with apparent swelling. Despite facility policy directing that residents not be moved before a nurse’s assessment after a fall, a CNA removed the commode frame and attempted to reposition the resident’s legs using her foot, which caused the resident to cry out in pain. The CNA acknowledged she knew residents should not be moved after a fall and could not explain why she attempted to move the resident or why she used her foot, and nursing leadership confirmed this action was inconsistent with the facility’s fall management policy.
A resident with hemiplegia and muscle weakness, dependent for transfers, did not have their transfer status or use of a mechanical lift documented in their care plan. This omission led to a nurse aide transferring the resident alone with a mechanical lift, resulting in a fall. The DON confirmed the care plan lacked required details, and no physician order for transfer status was found.
A resident with Type 2 diabetes did not receive routine hemoglobin A1C monitoring for over a year, despite care plan directives and periodic glucose checks. After a fall and hospital transfer, the resident was found to have critically high blood glucose and was admitted for hyperosmolar hyperglycemic state. Facility staff confirmed that A1C testing should have occurred, but no documentation was available, and there was no policy for diabetic management.
A resident with hemiplegia and hemiparesis was transferred using a mechanical lift by a single nurse aide, despite facility policy requiring two staff for such transfers. The improper attachment of the lift sling led to the resident falling and sustaining a shoulder dislocation. Staff interviews and documentation confirmed the transfer was performed without the required assistance.
Two residents with severe cognitive impairment were subjected to verbal abuse and inappropriate sexual gestures by a nursing assistant, as witnessed by two student NAs during care. The incidents included derogatory comments, sexually suggestive remarks, and obscene gestures, and were substantiated by the facility's investigation.
The facility did not ensure that student nurse aides received and documented abuse education before being placed on nursing units. The policy lacked specific direction for pre-placement abuse training, and the DNS confirmed there was no verification or review of such education for student nurse aides.
The facility did not ensure timely reporting of abuse allegations involving three residents with cognitive impairments. In two cases, student nurse aides observed a staff member making verbally abusive and sexually inappropriate comments to residents, but the incidents were not reported to the DNS until nearly a day later. In another case, a resident with a history of hallucinations alleged physical abuse, but the charge nurse failed to report the claim, believing it was not credible. Facility policy requires all such allegations to be reported immediately, which was not followed.
Student aides from a local Nurse Aide program began providing resident care without documented abuse education, as required by facility policy. The DNS confirmed there was no process to ensure student aides received this training before starting care, and no documentation or follow-up was maintained to verify completion of the required education.
A resident with multiple chronic conditions fell while attempting to get into an empty bed that was not in a low position. Although staff reported verbally instructing others to keep the bed low and educating the resident, there was no documentation in the clinical record or care plan to reflect the implementation of a new fall intervention after the incident, resulting in an incomplete and inaccurate record.
The facility failed to follow proper infection control practices, including inadequate cleaning of glucometers between residents and lack of PPE availability outside rooms requiring it. An LPN was observed not disinfecting a glucometer between uses, and staff shared PPE supplies due to missing carts. Additionally, the facility lacked infection surveillance and annual policy reviews, with the DNS unable to access necessary records.
The facility failed to ensure accurate and complete code status documentation for three residents upon admission or readmission. One resident's form lacked a code status and necessary signatures, another had a delayed completion due to confusion and family contact issues, and a third had conflicting information between the form and physician's orders. The DNS acknowledged the expectation for timely and accurate completion of advanced directives.
The facility failed to update care plans for residents with changes in health status, including transmission-based precautions for COVID-19 and personal care preferences. A resident with dementia was not updated in the care plan for COVID-19 isolation, and another resident's preference for a weekly shower was not documented, leading to a lack of proper care documentation.
The facility failed to ensure nursing staff received ongoing education and competency evaluations for IV Therapy. The DNS could not locate documentation for these evaluations, as the Infection Preventionist, the only staff member with access to the electronic files, was not on duty. This highlighted a lack of access to critical records by other staff members.
The facility failed to serve meals within a 14-hour gap, as required. Observations and interviews revealed that breakfast was often delayed, with food carts arriving between 7:45 AM and 8:00 AM, and some residents not being served until 8:50 AM or later. This resulted in a gap exceeding 14 hours between dinner and breakfast, affecting residents who eat in their rooms.
The facility failed to properly label and date food items in the dietary department and maintain adequate stock in nourishment refrigerators and snack cabinets. Observations revealed unlabeled food items and insufficient snacks on multiple floors. Interviews indicated confusion about stocking responsibilities, with the Food Service Director clarifying roles, but the policy lacked specificity.
The facility did not have an accessible Antibiotic Stewardship Program due to the absence of the Infection Preventionist (IP), who was the only person with access to the necessary information. The DNS could not provide evidence of an active program, only a policy with an unknown review date and a list of antibiotics used. The ADNS noted that the Staff Development Nurse, serving as IP backup, was unavailable for an interview.
A resident with hypertension experienced significantly low blood pressure readings after being administered Valsartan. Despite these readings, the nursing staff did not notify the physician promptly. The medication was held and later administered without consultation, leading to further low readings. The facility's policy required immediate physician notification for such changes in condition.
A resident, who was cognitively intact and required assistance with daily activities, reported feeling chastised by a nurse aide for having personal items in their room. Despite attempts to voice their concerns to staff and a nursing supervisor, the issue was not addressed promptly. The Director of Nursing Services admitted to forgetting to follow up, violating the facility's grievance policy that requires prompt resolution and keeping residents informed.
A facility failed to properly assess and document the use of a wandering device for a resident with mild cognitive impairment and a history of wandering. The resident was observed with a wandering device attached to their wheelchair, but there were no physician's or treatment orders for its use. The DNS acknowledged the device was used to prevent unsupervised exits, but the facility lacked a restraint policy and regular elopement risk assessments.
A resident with anxiety and a history of falls alleged mistreatment by a nursing assistant (NA) during care. Despite the initiation of an investigation, the NA was allowed to work a shift after the allegation, due to a communication failure by the Director of Nursing (DNS), who forgot to update the schedule to reflect the NA's administrative leave status.
A facility failed to order a Hoyer lift for a resident with mobility issues prior to discharge, despite recommendations from PT and the resident's care plan indicating the need for such equipment. Interviews with staff confirmed the oversight, and the facility's discharge policy was not followed.
A facility failed to complete a Significant Change Status Assessment (SCSA) MDS for a resident admitted to hospice care. The resident, with multiple diagnoses, elected for Medicare Hospice benefit, but due to discrepancies in hospice election forms and oversight by the MDS Coordinator, the required assessment was not completed within the mandated 14-day period.
A resident with diabetes and anemia did not receive scheduled showers as per their care plan, resulting in a deficiency. The resident was supposed to receive weekly showers, but documentation was lacking, and the resident only received one bath in July. Staff interviews confirmed the absence of proper documentation and adherence to the care plan.
A facility failed to obtain a physician's order for a wandering device for a resident with cognitive impairment, despite the resident not exhibiting wandering behaviors. Additionally, another resident experienced a delay in hospice care due to a clerical error in the hospice agreement, resulting in a delayed hospice nursing visit. Interviews revealed a lack of awareness and communication among staff regarding these issues.
A resident with cognitive impairment and muscle weakness developed a new deep tissue injury due to the facility's failure to follow a physician's order for bilateral waffle boots for pressure relief. Observations showed inconsistent application of the boots, with the resident sometimes having no boots or only one boot applied. An LPN could not explain the absence of the second boot until prompted by surveyors, and records indicated non-compliance with the order on a specific date.
The facility failed to implement interventions for a resident at risk of falls, resulting in multiple unwitnessed falls. Additionally, inadequate supervision allowed a resident with a history of elopement to leave the unit unsupervised, despite having a wandering device. Staff were not adequately informed about the resident's elopement risk, leading to delayed response to the wandering alarm.
A resident experienced an 8.16% weight loss, but the LTC facility failed to confirm this according to policy. The Dietitian noted the discrepancy, but a re-weight was not performed. Staff interviews revealed that the nursing team did not document or communicate the need for a re-weight, leading to the deficiency.
A resident alleged mistreatment by a nursing assistant during care, but the facility failed to document an RN assessment following the incident. Although an RN confirmed conducting an assessment, it was not recorded, contrary to the facility's policy on abuse prevention.
The facility did not ensure that state inspection results were easily accessible to residents, violating Resident Rights. Although the rights were posted by the elevator, staff interviews revealed that residents must request to leave their unit and are sometimes escorted. The only copy of the survey results was located on the first floor of the administrative building, limiting resident access.
A resident with Alzheimer's and mobility issues reported an unwitnessed fall to a nurse aide, who failed to inform licensed staff, assuming they were aware. This led to a delay in assessing the resident for injuries, which were only discovered later when the resident showed bruising and confusion. The resident was eventually diagnosed with a subarachnoid hemorrhage and a UTI after being sent to the ED.
Failure to Implement and Update Fall-Prevention Interventions After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement timely, measurable fall-prevention interventions in the care plan for a resident with a known high risk for falls. The resident had metabolic encephalopathy, dementia, and glioblastoma, with severely impaired cognition (BIMS score of 5) and required maximal assistance with toileting and transfers. On admission, the resident was identified as high risk for falls, with care plan interventions including ensuring the call light was within reach and use of appropriate footwear (brown leather shoes and non-skid socks) when ambulating. The resident had a history of a fall prior to admission and sustained an abrasion to the mid back after a fall on 12/19/2025. A physician order directed daily aspirin therapy. On 1/7/2026, the resident was found on the floor in a prone position in the room, with no visible injury and denial of pain, and the incident report directed that the resident care plan be updated to ensure non-skid socks were used every shift. A nursing note documented that the resident was wearing regular socks at the time of this fall, had hit the head, and was transferred to the hospital. On 1/19/2026, the resident was again found on the floor, reported hitting the head and vomiting, and was transferred to the hospital; an abrasion to the left ankle was noted. The care plan was updated only to reflect the hospital transfer, neurological checks, and treatment of the abrasion, and record review did not identify any new fall-prevention interventions after this fall or after the resident’s readmission. Interviews with the DNS and ADNS confirmed that the resident was supposed to wear non-skid socks, that staff did not follow the care plan at the time of the 1/7/2026 fall, that the care plan was updated with a repeat intervention regarding non-skid socks, and that no new interventions were documented after the 1/19/2026 fall, despite facility policy directing that the care plan be updated with appropriate interventions after a fall.
Inadequate Supervision for High-Risk Resident Leading to Repeated Falls and Head Injury
Penalty
Summary
Failure to provide adequate supervision and prevent accidents occurred for a resident with metabolic encephalopathy, dementia, glioblastoma, a prior fall before admission, and severely impaired cognition (BIMS score of 5). On admission, the resident was identified as high risk for falls, required maximal assistance with toileting and transfers, and had a care plan that included ensuring the call light was within reach and use of appropriate footwear (brown leather shoes and non-skid socks) when ambulating. Despite these identified risks and interventions, the resident experienced multiple falls: on 12/19/2025 the resident was found sitting on the floor with a mid-back abrasion; on 1/7/2026 the resident was found prone on the floor, wearing regular socks, having hit the head and requiring hospital evaluation; and on 1/19/2026 the resident was again found on the floor, reporting having hit the head, with vomiting and a left ankle abrasion, and was transferred to the hospital. The resident sustained another fall on 1/25/2026 when a NA heard a loud sound during rounds and found the resident on the floor; the resident had not called for assistance before getting up and complained of pain on the back of the head, leading to hospital transfer. Hospital findings included an acute subarachnoid hemorrhage, a subdural hemorrhage, and bifrontal contusions. Interviews and record review with the DNS and ADNS showed that after the earlier falls, the care plan was updated only to direct use of non-skid socks every shift, and no additional measures or increased supervision were identified or implemented following the fall on 1/19/2026 to prevent the subsequent fall with injury on 1/25/2026. No facility policy related to this issue was provided for surveyor review.
Resident Moved After Fall in Violation of Post-Fall Protocol
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff did not move a resident after a fall, contrary to facility policy and professional standards of quality. The resident had dementia, a history of falls, muscle weakness, difficulty walking, and was care planned as a fall risk requiring assistance of one staff for stand-pivot transfers, while being independent with wheelchair mobility. The resident wheeled themself into the shower room to use the toilet without calling for assistance and experienced an unwitnessed fall, ending up on the floor with the commode frame on top and the right leg bent under the left leg. The resident complained of right hip pain, and the right hip appeared dislocated with swelling. A charge nurse, responding to a loud noise, found the resident on the floor with the commode frame on top of them and a nursing assistant standing over the resident. According to the facility’s report and staff interviews, the nursing assistant removed the commode frame from the resident and then attempted to move the resident’s legs using her foot, despite the resident’s complaints of pain and the nurse’s direction not to move the resident. The RN supervisor reported observing the nursing assistant try to move the resident’s foot/leg with her own foot after being told not to move the resident, which caused the resident to call out in pain. The nursing assistant acknowledged that she tried to uncross the resident’s legs by placing the sole of her shoe on the resident’s foot to guide the leg, and admitted she knew she was not supposed to move a resident after a fall, though she could not explain why she did so or why she used her foot. The DON confirmed that the nursing assistant attempted to move the resident’s legs after the fall, that this caused the resident pain, and that the assistant should not have moved the resident or used her foot, in conflict with the facility’s Falls, Management and Prevention Policy, which directs that residents are not to be moved prior to a nurse’s assessment following a fall.
Failure to Include Transfer Status in Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan that included a resident's transfer status. The resident in question had diagnoses of hemiplegia, hemiparesis affecting the left non-dominant side, and muscle weakness, and was identified as dependent for transfers according to the annual MDS. The resident's care plan noted deficits in activities of daily living and a risk for falls, but did not specify the use of a mechanical lift or any transfer status. There was also no physician order for transfer status or use of a mechanical lift documented in the record. An incident occurred when a nurse aide transferred the resident into bed using a mechanical lift without a second staff member present, resulting in the resident falling to the floor. The Director of Nursing confirmed that the resident had required a mechanical lift since admission and acknowledged that the care plan should have included this information. Although the nurse aide assignment sheet reportedly directed use of a mechanical lift, the facility was unable to provide a copy. Review of facility policy indicated that care plans should be comprehensive and individualized to meet residents' needs.
Failure to Routinely Monitor Hemoglobin A1C in Diabetic Resident
Penalty
Summary
A resident with a diagnosis of Type 2 diabetes was not routinely monitored for hemoglobin A1C levels over a 17-month period, despite care plan interventions directing monitoring of lab work as ordered by the physician. The resident was not receiving insulin or oral antidiabetic medications and was not on routine finger stick monitoring. Laboratory records showed periodic metabolic panels with glucose levels, but no hemoglobin A1C testing was documented during the review period. Interviews with clinical staff, including the APRN, attending physician, and Director of Nursing, confirmed that hemoglobin A1C testing should have been performed within the past year, but none could provide evidence that it was completed. The facility also lacked a policy for managing diabetic residents. The deficiency was identified after the resident experienced a fall during a transfer with a mechanical lift performed by a single nurse aide, contrary to safe transfer protocols. Following the fall, the resident was sent to the hospital, where an incidental finding revealed a critically elevated blood glucose level, leading to a diagnosis of hyperosmolar hyperglycemic state and ICU admission. The absence of routine hemoglobin A1C monitoring contributed to the lack of awareness of the resident's deteriorating glycemic control.
Failure to Follow Mechanical Lift Transfer Protocols Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a nurse aide (NA) transferred a resident with hemiplegia and hemiparesis using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who was alert, oriented, and dependent for transfers, was being moved from a wheelchair to bed when the NA attached the lift sling incorrectly. The right upper side of the sling did not lock completely, and as the resident was lifted, the hook separated, causing the resident to slide onto the floor. The resident complained of shoulder pain following the fall and was sent to the hospital, where imaging revealed a left anterior shoulder dislocation consistent with a chronic subluxation. Documentation and staff interviews confirmed that the NA was aware two staff were required for mechanical lift transfers but proceeded alone due to lack of available staff. Facility policy and the resident's care plan both specified the need for two staff during such transfers, which was not followed in this incident.
Failure to Protect Residents from Verbal and Sexual Abuse by Staff
Penalty
Summary
Two residents with severe cognitive impairment were subjected to verbal abuse and inappropriate sexual gestures by a nursing assistant (NA #1) during the provision of care. Both residents had diagnoses including anxiety, depression, dementia, and altered mental status, and were identified as having severely impaired cognition on their Minimum Data Set (MDS) assessments. The incidents were witnessed by two student nursing assistants during their clinical experience. For the first resident, NA #1 refused to provide a walker unless the resident said 'please,' made derogatory comments about the resident's relationship with their child, made inappropriate sexual remarks, and performed sexually suggestive gestures. When the resident protested, NA #1 responded with further verbal abuse and an obscene gesture. For the second resident, NA #1 made demeaning comments about the resident's hygiene and made inappropriate sexual remarks while providing incontinent care. Both student nursing assistants provided consistent accounts of the events during interviews. The facility's investigation, as confirmed by the Director of Nursing Services (DNS), substantiated the allegations of abuse. The facility's policy clearly prohibits verbal, sexual, physical, and mental abuse, but these incidents demonstrated a failure to protect the residents from mistreatment.
Lack of Abuse Education Verification for Student Nurse Aides
Penalty
Summary
The facility failed to ensure that its policy required abuse education for student nurse aides prior to their placement on resident units. Review of the facility's Elder Abuse, Neglect and Prevention Policies and Procedural Guidelines showed that while staff were to be trained to observe for and respond to abuse, and mandatory training was required for all staff, there was no specific direction for providing abuse education to student nurse aides before they began working on nursing units. During an interview, the Director of Nursing Services (DNS) confirmed that the facility relied on the school to provide abuse education to student nurse aides and did not review or maintain documentation verifying that this education was completed before the students were placed on the units. The policy did not address the need for abuse education prior to placement, and there was no evidence that such education was verified or documented for student nurse aides.
Failure to Timely Report Allegations of Abuse and Mistreatment
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and mistreatment for three residents with cognitive impairments and mental health diagnoses. In the first case, two student nurse aides observed a nurse aide making verbally abusive and sexually inappropriate comments, as well as inappropriate gestures, toward a resident with severely impaired cognition. The incident was reported to the evening supervisor by the students' instructor, but the Director of Nursing Services (DNS) was not informed until 23 hours after the event, contrary to facility policy requiring reporting within 2 hours. In the second case, the same two student nurse aides witnessed the same nurse aide making derogatory and inappropriate sexual comments to another resident with severe cognitive impairment during incontinent care. Again, the incident was not reported to the DNS until nearly a day later, despite the facility's policy on prompt reporting of abuse allegations. The third case involved a resident with moderate cognitive impairment and a history of hallucinations, who alleged that a nurse aide physically abused them. The charge nurse, upon hearing the allegation, decided not to report it, believing it was not real due to the resident's history. The DNS only became aware of the allegation after the social worker was informed. The facility's policy requires all allegations, regardless of perceived credibility, to be reported immediately, but this was not followed in this instance.
Failure to Provide Timely Abuse Education to Student Aides
Penalty
Summary
The facility failed to ensure that student aides from a local community Nurse Aide program received abuse education prior to providing resident care. On a specific evening shift, multiple student aides were present in the facility for their clinical experience, but facility documentation did not show that abuse education had been provided to them before they began caring for residents. An interview with the Director of Nursing Services (DNS) confirmed that there was no process in place to ensure student aides received abuse education before starting resident care. The DNS also stated that, although educational packets were previously given to the school program for completion before students arrived, there was no documentation or follow-up to confirm that the abuse education was completed prior to the students providing care. The facility's policy required mandatory orientation and training on resident abuse for all staff, but this was not documented or assured for the student aides.
Failure to Document Post-Fall Intervention in Clinical Record
Penalty
Summary
The facility failed to ensure that the clinical record for a resident was complete and accurate following a fall incident. The resident, who had diagnoses including dementia, muscle weakness, hypertension, and type 2 diabetes mellitus, experienced a fall while attempting to climb into an empty bed that was not in a low position. The resident was found on the floor with complaints of lower back pain and was sent to the emergency room for evaluation, where no injuries were found. The care plan and clinical record review did not reflect the implementation of a new fall intervention after this incident. Although staff verbally indicated that education was provided to the resident and staff were directed to keep the empty bed in a low position, there was no documentation in the clinical record or care plan to confirm that this new intervention was implemented. The facility's policy required care plans to be updated for changes in condition such as falls, but this was not done in this case, resulting in an incomplete and inaccurate clinical record.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, particularly in the cleaning and disinfection of glucometers between resident uses. Observations revealed that an LPN did not clean the glucometer after using it on one resident before proceeding to another, despite the facility's policy and manufacturer's guidelines requiring disinfection between uses. The LPN was unaware of the facility's policy and had not received training on the proper cleaning procedures, which contributed to the deficiency. Additionally, the facility did not ensure that PPE carts were available outside every resident room requiring PPE, leading to staff sharing PPE supplies from other rooms. This was observed when signage indicated the need for PPE, but no carts were present outside certain rooms. The Infection Preventionist confirmed that staff shared PPE supplies, which is not in line with proper infection control practices. The facility also lacked evidence of infection surveillance and annual review of infection control policies. The DNS was unable to provide information on infection control surveillance due to the absence of the Infection Preventionist, who was the only one with access to electronic records. Furthermore, the facility could not locate the water management plan, and there was no documentation of water management meetings, indicating a lack of comprehensive infection control oversight.
Incomplete and Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that the code status for newly admitted or readmitted residents was complete and accurate, as evidenced by the cases of three residents. Resident #25 was readmitted with diagnoses including pneumonia and chronic obstructive pulmonary disease. The Resident Code Status Form for this resident did not identify a code status and was signed by the physician but not by the responsible party or a witness. Despite this, physician's orders directed that the resident was to receive full code measures. The Director of Nursing Services (DNS) acknowledged that the advanced directive should have been completed on admission or readmission. Resident #227, admitted with a fracture of the left femur, was identified as self-responsible but had periods of confusion. The Resident Code Status Form lacked a selected code status and was signed by a registered nurse without the physician's or responsible party's signature. Although the facility was attempting to reach the family for signature, the resident had full code status prior to admission, and interventions would be initiated if needed. The form was eventually signed by the resident, but not in a timely manner. Resident #228, admitted with a mild gastrointestinal hemorrhage, had conflicting information between the Resident Code Status Form and the physician's orders, with the form indicating full code measures but the orders stating a Do Not Resuscitate (DNR) status. The DNS confirmed that the advanced directive should have been completed accurately upon admission.
Failure to Update Care Plans for Residents' Health Status Changes
Penalty
Summary
The facility failed to update the care plans for residents with changes in their health status, specifically regarding transmission-based precautions and personal care preferences. Resident #91, who was diagnosed with anemia, hypertension, and dementia, was placed on isolation precautions for COVID-19 from July 16 to July 26, 2024, as per a physician's order. However, the care plan was not updated to reflect this status change, as confirmed by the Assistant Director of Nursing Services (ADNS) during an interview and record review on July 31, 2024. Similarly, Resident #117, who has diabetes mellitus and anemia, required partial assistance for bathing. The care plan did not reflect the resident's preference for a shower on Mondays, and there was no documentation of showers being provided or refusals from July 3 to July 27, 2024. The ADNS confirmed the lack of documentation and the need for the care plan to reflect the resident's bathing preference. Additionally, Resident #276, diagnosed with dementia and anxiety, was placed on isolation precautions for COVID-19 from July 20 to July 26, 2024, but the care plan was not updated to reflect this change. The care plan was only revised after surveyor inquiry.
Lack of Ongoing IV Therapy Education and Competency Evaluations
Penalty
Summary
The facility failed to ensure that nursing staff received ongoing education and competency evaluations for Intravenous (IV) Therapy. During an interview and document review with the Director of Nursing Services (DNS), it was revealed that there was no documentation available for ongoing IV therapy education and competency evaluations for the licensed nursing staff responsible for providing IV therapy. The DNS acknowledged the absence of these records and noted that the Infection Preventionist, who was the only staff member with access to the electronic files containing this information, was not on duty. This situation highlighted the lack of access to critical competency records by other staff members in the Infection Preventionist's absence.
Failure to Serve Meals Within 14-Hour Gap
Penalty
Summary
The facility failed to ensure that meals were served within a 14-hour gap between dinner and breakfast, as required. During a tour of the kitchen and interviews with staff, it was identified that residents were served breakfast between 8:00 AM and 9:30 AM, while dinner was served by 6:30 PM, resulting in a gap exceeding 14 hours. Observations on multiple occasions confirmed that breakfast service was delayed, with food carts arriving on the units between 7:45 AM and 8:00 AM, and some residents not being served until 8:50 AM or later. Interviews with residents indicated that breakfast often arrived late, further corroborating the issue. This deficiency was observed to affect residents who eat in their rooms, as they were still not served by 9:23 AM, indicating a 15-hour gap between dinner and breakfast.
Inadequate Food Labeling and Stocking in Dietary Department
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items in the dietary department, as well as maintaining adequate stock in nourishment refrigerators and snack cabinets on each unit. During a kitchen tour, it was observed that a Boston Cream Pie and mashed potatoes were not labeled or dated. The Food Service Director indicated that the preparation staff or chef were responsible for labeling items, and after inquiry, the items were labeled. Additionally, the facility lacked a snack cart, and each floor had nourishment refrigerators that were not adequately stocked with snacks to provide residents with choices throughout the day or when the kitchen was closed. Observations on multiple floors revealed that the nourishment refrigerators and snack cabinets were inadequately stocked. For instance, the first floor had limited snacks, including a few ice creams, a fruit bowl, and a sandwich with a resident's name, while the snack cabinet had only three biscuits. Similar inadequacies were noted on other floors, with preassigned foods for residents and minimal snack options available. Interviews with nursing staff indicated confusion about responsibility for stocking these areas, with some believing the kitchen staff were responsible. The Food Service Director clarified that nursing was responsible for maintaining the refrigerators, while dietary was responsible for the snack cabinets, but the policy did not specify these responsibilities.
Lack of Accessible Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure an Antibiotic Stewardship Program was in place and available for review. During an interview and document review, it was revealed that the Infection Preventionist (IP) was absent, and the information related to the Antibiotic Stewardship Program and the infection control program was stored on a computer accessible only by the IP. The Director of Nursing Services (DNS) could only provide a facility policy for Antibiotic Stewardship, with an unknown date of the last annual review, and a pharmacy list of antibiotics used in the last month. There was no evidence of an active Antibiotic Stewardship Program. The DNS acknowledged that other staff should have access to these files in the IP's absence. Additionally, the Assistant Director of Nursing Services (ADNS) indicated that the Staff Development Nurse, who serves as the IP backup on certain days, was unavailable for an interview.
Failure to Notify Physician of Resident's Low Blood Pressure
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding a change in condition for a resident who was admitted with osteoarthritis and hypertension. The resident was prescribed Valsartan, an anti-hypertensive medication, to be taken daily. Upon admission, the resident's blood pressure was recorded at 165/83 mmHg. However, subsequent readings showed a significant drop in blood pressure, with measurements of 93/45 mmHg and lower on the following days. Despite these low readings, there was no documented evidence of a nursing progress note addressing the low blood pressure or any further action taken. The nursing staff, including RN #12, did not notify the physician after the initial low blood pressure reading and instead held the medication temporarily. The medication was later administered without physician consultation, even though the resident's blood pressure remained low. It was only after a second low blood pressure reading that the APRN was notified, and the medication was discontinued. Interviews with the Director of Nursing Services and the Medical Director revealed that they expected the physician to be notified immediately if a resident's blood pressure was out of range and did not improve after a few minutes. The facility's policy also directed that the physician be notified of any change in condition requiring such notification.
Failure to Address Resident Grievance Timely
Penalty
Summary
The facility failed to address a resident's grievance in a timely manner, violating the resident's right to voice grievances without discrimination or reprisal. Resident #35, who was cognitively intact and required assistance with activities of daily living, reported feeling chastised by a nurse aide for having personal items in their room. Despite leaving messages with staff and directly requesting to speak with a nursing supervisor, the resident's concerns were not promptly addressed. The Director of Nursing Services (DNS) acknowledged being contacted by the resident but admitted to forgetting to follow up on the issue. The facility's grievance policy, which mandates prompt resolution and keeping residents informed, was not adhered to in this case. The DNS eventually spoke with the resident about their concerns, but this was after a significant delay. The facility's policy designates the Social Worker as the Grievance Official responsible for investigating concerns or assigning them to the appropriate department head, but this process was not followed. Attempts to interview the nurse aide involved were unsuccessful, further highlighting the lack of timely and effective resolution to the resident's grievance.
Failure to Properly Assess and Document Use of Wandering Device
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for the use of a wandering device, which was not free from being a physical restraint. The resident, who was admitted with mild cognitive impairment and major depressive disorder, had a history of wandering and elopement attempts. However, the quarterly elopement evaluations showed inconsistencies, with one indicating wandering behavior and another not. Despite this, the resident was observed with a wandering device attached to their wheelchair, which triggered an alarm when they moved through the nursing unit doors. Staff interviews revealed that the resident required supervision when leaving the unit, but there were no physician's or treatment orders for the wandering device in the clinical record. The Director of Nursing Services (DNS) acknowledged the use of the wandering device to prevent the resident from leaving the building unsupervised, citing past incidents where the resident exited the building and refused to return. The DNS also noted that the facility had switched its electronic medical record system, which may have contributed to the lack of regular elopement risk assessments. The facility's policy required an assessment to determine the need for a wander guard device, but the DNS admitted that the facility did not have a restraint policy. This lack of proper assessment and documentation led to the deficiency identified by the surveyors.
Failure to Remove Staff After Allegation of Mistreatment
Penalty
Summary
The facility failed to ensure that an alleged staff member was removed from the schedule following an allegation of mistreatment involving a resident. The incident involved a resident with a diagnosis of anxiety and a history of falls, who reported that a nursing assistant (NA) was rough while providing care and made inappropriate comments. The resident alleged that the NA was rough during care and responded negatively when the resident reached out for comfort. The incident was reported, and an investigation was initiated by the Director of Nursing (DNS). Despite the initiation of the investigation, the NA in question was allowed to work a shift after the allegation was made, contrary to the facility's policy on handling abuse allegations. The DNS had instructed the NA not to return to work until the investigation was completed, but due to a failure in communication, the NA was called back to work. The DNS admitted to forgetting to update the schedule to reflect the NA's administrative leave status, resulting in the NA working a shift before the investigation was concluded.
Failure to Order Necessary DME for Resident Discharge
Penalty
Summary
The facility failed to ensure that Durable Medical Equipment (DME) was ordered in a timely manner for a planned discharge of a resident. The resident, who had diagnoses including foot drop, polyneuropathy, and hemiplegia, was recommended by Physical Therapy to be discharged with a Hoyer lift. The resident was dependent on assistance for activities of daily living and had a care plan indicating decreased mobility and a high risk for falls. Despite these needs, the discharge planning did not include arrangements for a Hoyer lift, which was necessary for the resident's safe transfer at home. Interviews with facility staff, including a physical therapist and a social worker, revealed that the necessary equipment was not ordered prior to the resident's discharge. The Director of Nursing Services confirmed the lack of documentation for the Hoyer lift order and acknowledged the facility's responsibility to ensure all required DME was in place before discharge. The facility's discharge policy emphasizes the importance of ensuring a safe and timely discharge, which was not adhered to in this case.
Failure to Complete Significant Change MDS Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) assessment for a resident who was admitted to hospice care. The resident, who had diagnoses including adult hypertrophic pyloric stenosis, atrial fibrillation, type 2 diabetes mellitus, and hypertension, elected for Medicare Hospice benefit on June 1, 2024. Despite the hospice nurse's assessment and the physician's order noting hospice care, the facility did not complete the required SCSA MDS assessment within the 14-day period as mandated by the Resident Assessment Instrument (RAI) 3.0 manual. The MDS Coordinator, RN #5, was responsible for scheduling and completing the MDS assessments. She acknowledged that a Significant Change MDS assessment should have been completed within 14 days of the resident's admission to hospice. However, due to a discrepancy in the hospice election forms, with one form dated June 1, 2024, and another dated June 11, 2024, the assessment was not completed appropriately. RN #5 was unaware of the mistake on the initial hospice election form and the existence of a new form, leading to the failure to conduct a valid SCSA MDS assessment for the resident.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #117, received a shower as per their care plan. Resident #117, who has diagnoses including diabetes mellitus and anemia, was assessed to require partial/moderate assistance for bathing. The care plan indicated that the resident had an ADL deficit due to fatigue and anemia, with a preference for dressing and grooming during morning care. However, the facility did not provide documentation of showers being given to the resident as scheduled. Interviews with staff revealed that the resident was scheduled for a weekly shower on Mondays during the 3-11 PM shift, but there was no documentation to confirm that these showers were provided. Further investigation showed that the resident only received bathing on one occasion in July, specifically on a Sunday, and did not receive a shower from early July through late July. The Assistant Director of Nursing Services (ADNS) confirmed the lack of documentation for showers or resident refusals during this period. The ADNS also indicated that it is the charge nurse's responsibility to update the nurse aide electronic documentation flow sheet when there is a change, but no such updates were found. This lack of documentation and adherence to the care plan resulted in a deficiency in providing necessary care for Resident #117.
Deficiencies in Wandering Device Use and Hospice Care
Penalty
Summary
The facility failed to obtain a physician's order for the use of a wandering device for a resident with severe cognitive impairment and major depressive disorder. Despite the resident not exhibiting behaviors related to wandering or elopement, a wandering device was attached to the resident's wheelchair without a physician's order. The device was used to prevent the resident from leaving the building unsupervised. Interviews with the Director of Nursing Services (DNS) and a charge nurse revealed a lack of awareness regarding the absence of a physician's order and the need for documentation in the Treatment Administration Record (TAR). Another deficiency involved a resident who was admitted to hospice care but did not receive timely hospice services due to a clerical error. The resident, with diagnoses including adult hypertrophic pyloric stenosis and atrial fibrillation, elected for Medicare Hospice benefit, but the hospice agreement contained an incorrect start date. This error led to a delay in hospice nursing visits, with the first visit occurring nearly two weeks after the initial admission date. Interviews with various staff members, including the Business Office Administrator and the DNS, highlighted a lack of communication and awareness regarding the resident's hospice status and the delay in care. The facility's failure to ensure timely hospice care and proper documentation for the wandering device reflects a breakdown in communication and procedural adherence. The hospice care delay was attributed to a clerical error, and the wandering device was used without the necessary physician's order, indicating lapses in the facility's processes for managing resident care and safety.
Failure to Follow Physician's Order for Pressure-Relieving Devices
Penalty
Summary
The facility failed to adhere to a physician's order regarding the use of pressure-relieving devices for a resident diagnosed with muscle weakness and unspecified dementia. The resident, who was identified as cognitively impaired and requiring assistance for mobility and transfers, developed a new deep tissue injury. A physician's order was issued for the resident to have bilateral waffle boots applied at all times for pressure relief, with removal only for hygiene purposes. However, observations revealed that the resident was not consistently provided with the prescribed pressure-relieving boots, as noted on multiple occasions. On one occasion, the resident was observed without the boots, and on another, only one boot was applied. An LPN was unable to explain the absence of the second boot until prompted by surveyors. Additionally, the Medication Administration Record indicated that the boots were not applied on a specific date. The facility's Pressure Ulcer Prevention policy requires CNAs to implement interventions to prevent skin breakdown, which was not followed in this case, leading to the deficiency.
Failure to Prevent Falls and Inadequate Supervision of Elopement Risk
Penalty
Summary
The facility failed to implement interventions to prevent future falls for a resident identified as a fall risk. This resident, who had diagnoses including muscle weakness, difficulty walking, and a history of falls, was noted to have impaired cognition and required maximal assistance for transfers. Despite being identified as a fall risk in the care plan, the facility did not update interventions after the resident experienced a fall on 7/31/24. Observations on 8/01/24 revealed another unwitnessed fall, and staff interviews indicated a lack of clarity on why interventions were not updated. Another deficiency involved inadequate supervision of a resident with mild cognitive impairment and a history of elopement. The resident was identified as an elopement risk and had a wandering device in place. However, on 7/31/24, the resident was able to leave the nursing unit unsupervised, triggering a wandering alarm. Staff members were unsure of the resident's elopement risk status, leading to a delay in response. Interviews revealed that staff were not adequately informed about the resident's need for supervision, and there was confusion regarding the resident's ability to leave the unit. The facility's policy required staff to be trained on the use and monitoring of wandering devices, but interviews indicated gaps in staff awareness and response to elopement risks. The Director of Nursing Services acknowledged that elopement risk assessments were not conducted quarterly as required, and staff were expected to respond quickly to wander alarms. The lack of consistent assessments and staff training contributed to the resident's unsupervised exit from the unit.
Failure to Confirm Significant Weight Loss
Penalty
Summary
The facility failed to confirm a significant weight loss for a resident, identified as Resident #35, according to its policy. Resident #35, who had diagnoses including obesity and Chronic Obstructive Pulmonary Disease, was noted to have a weight loss of 8.16% within a short period, as recorded in the weight logs. The facility's policy required a re-weight to confirm any weight discrepancy, which was not completed in this case. The Dietitian identified that the electronic medical record system did not alert the staff to the significant weight change, and upon returning to the facility, requested a re-weight that was not performed. Interviews with various staff members, including a Dietitian, Registered Nurse, and Licensed Practical Nurse, revealed that the nursing staff were responsible for monitoring weight changes and reporting them. However, the re-weight was not documented or communicated through the shift-to-shift calendar, as required by the facility's policy. The Director of Nursing Services confirmed that the expectation was for the nursing staff to obtain a re-weight and notify the family, dietitian, and physician once the weight loss was confirmed. The failure to follow these procedures led to the deficiency noted in the report.
Failure to Document RN Assessment After Allegation of Mistreatment
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate following an allegation of mistreatment. The resident, who was admitted with diagnoses including a fracture of the left femur, anxiety, and a history of falls, alleged mistreatment by a nursing assistant (NA) during care. The incident report noted that the resident rang the call bell early in the morning and was met with a dismissive response from the NA. The resident further alleged that the NA was rough during care and responded negatively when the resident reached out for comfort. Despite the seriousness of the allegation, the clinical record review revealed that no RN assessment was documented following the incident. An interview with an RN confirmed that an assessment was conducted but not documented, which was acknowledged as an oversight. The Director of Nursing Services (DNS) also confirmed the lack of documentation and emphasized that it was the nurse's responsibility to document assessments. The facility's policy on Elder Abuse, Neglect, and Prevention requires assessments for observable evidence of abuse, which was not adhered to in this case.
Inaccessible State Survey Results for Residents
Penalty
Summary
The facility failed to ensure that state inspection results were readily accessible to residents, which is a violation of Resident Rights. Observations revealed that the Residents Rights were posted by the elevator, indicating that residents have the right to access state survey results. However, interviews with staff, including an LPN and an RN, indicated that residents must ask to leave their unit and are sometimes escorted, and if any resident knows the code to exit, it is changed. Furthermore, the RN confirmed that there was no survey finding binder available on the units or floors, and the only copy of the state survey results was located on the first floor of the administrative building, next to the mail room and across from the Admissions Office. This limited accessibility to the survey results for residents.
Failure to Report and Assess Unwitnessed Fall
Penalty
Summary
A deficiency was identified in the facility's handling of a fall incident involving a resident with Alzheimer's Disease, difficulty walking, and a history of urinary tract infections and osteoarthritis. The resident, who required assistance with daily living tasks and was at risk for falls, reported an unwitnessed fall to a nurse aide. However, the nurse aide failed to report this fall to the licensed staff, assuming they were already aware. This lack of communication resulted in a delay in assessing the resident for potential injuries, which was only discovered later when the resident exhibited noticeable bruising and confusion. The resident was eventually sent to the Emergency Department after a nurse identified bruising and a bump on the resident's head, leading to a diagnosis of a subarachnoid hemorrhage and a urinary tract infection. The facility's policy required that all falls, especially unwitnessed ones, be reported and assessed immediately, including a full physical and neuro/cognition evaluation. The failure to adhere to this policy resulted in a significant delay in the resident receiving necessary medical attention.
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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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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