New Haven Center For Nursing & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 181 Clifton Street, New Haven, Connecticut 06513
- CMS Provider Number
- 075397
- Inspections on file
- 41
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 45 (1 serious)
Citation history
Health deficiencies cited at New Haven Center For Nursing & Rehabilitation Llc during CMS and state inspections, most recent first.
A resident admitted for short‑term rehab with unstable housing and diagnoses including bacteremia, intraspinal abscess, and anxiety disorder had an established goal of discharge back to the community, with the care plan directing social services and the IDT to coordinate community resources and needed services. Although clinical notes later showed the resident had completed IV antibiotics, was stable, and was being prepared for discharge home, the social service documentation from admission through the anticipated discharge date did not show evidence of ongoing discharge planning, IDT collaboration, referrals or resources for post‑discharge needs, or the resident’s participation in the discharge planning process. The social worker stated that discharge planning discussions occurred, that the resident was encouraged to contact family and friends, and was given 211 as a resource, but these actions were not documented, and the resident reported feeling there was no ongoing assistance with securing housing or discussion of aftercare, contrary to facility policy requiring ongoing, documented discharge planning for short‑stay residents.
Surveyors found that the facility failed to ensure proper functioning of call light indicators above resident room doors. During observation, two residents activated their call bells and the visual indicators outside their rooms did not illuminate, even though the audible signal and visual light at the nurses’ station did work. One resident reported that the call bell often did not work properly despite a recent attempt to fix it. An LPN confirmed that the over-door lights did not illuminate when tested, and the DON stated the expectation that these lights should come on with call bell activation. The Administrator reported that environmental rounds and call bell testing were done but could not specify frequency, and no documentation of such rounds or related maintenance requests was available, despite a written policy requiring both a room light and nurses’ station signal when a call bell is activated.
A resident with multiple medical conditions failed to return from a leave of absence as scheduled, and staff did not notify the physician, DON, or administration according to facility policy. Additionally, the provider was not informed when the resident missed several scheduled evening medications due to the absence. The LPN only notified the charge nurse, and the physician confirmed he expected prompt notification of both the resident's absence and missed medications.
A resident with moderate cognitive impairment and multiple medical conditions was issued a 30-day discharge notice for non-compliance with the smoking policy, but the facility failed to provide or document adequate discharge planning, orientation, or communication. Staff interviews revealed a lack of coordination, unresolved insurance issues, and no clear plan for a safe and orderly transfer, leaving the resident uninformed about their discharge status.
A resident with multiple medical conditions was readmitted from the hospital without a discharge summary, and staff did not obtain or review the required documentation as per facility policy. Additionally, when the same resident did not return from an LOA as expected, staff failed to act promptly or follow consistent procedures due to conflicting LOA policies, resulting in delayed notifications and unclear staff actions.
A resident with severe cognitive impairment and multiple medical conditions, who required supervision and an assistive device for ambulation, exited the facility unnoticed due to staff inattention and a delayed door locking mechanism. The resident was not identified as an elopement risk and did not have a Leave of Absence order. Staff delays in recognizing the resident's absence and in notifying police resulted in the resident being found several miles away, disoriented and injured, after an extended period.
A resident with diabetes and depression, who was cognitively intact and required supervision for ADLs, was verbally abused by a staff member who made derogatory remarks about the resident's appearance and personal loss. Another resident witnessed the incident and confirmed the statements. The facility's policy guarantees freedom from abuse, but the staff member's actions violated this right.
A facility failed to include discharge planning in a resident's care plan, despite the resident's desire to return to the community and an application for the Money Follows the Person program being completed. The care plan lacked discharge goals or interventions, and the social worker did not document the resident's discharge status or MFP application progress in the clinical record due to time constraints.
A resident with a history of myocardial infarction and other conditions was given Nitroglycerin, but the administration was not documented in the MAR as required. The RN supervisor noted the administration in a progress note but failed to update the MAR, contrary to the facility's documentation policy.
Failure to Implement and Document Ongoing Discharge Planning for Short‑Stay Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and document an ongoing discharge plan for a short‑stay resident to ensure a safe and effective transition back into the community. The resident had diagnoses including bacteremia, intraspinal abscess and granuloma, and anxiety disorder, and was admitted for short‑term rehabilitation after a hospital stay. On admission, the social service note documented that the resident had unstable housing, had been living at a friend’s house prior to hospitalization, and that discharge plans were discussed with the resident stating they would return to the friend’s house if no other housing options were available. The note also indicated a referral would be made to Money Follows the Person for housing supports, and the admission MDS and care plan identified a goal of discharge back into the community with social services and the IDT to coordinate needed equipment, services, and community resources. A Level of Care Screen by Maximus later confirmed that short‑term care was appropriate for a defined period and directed the facility to continue assisting with discharge planning for appropriate community and support services. Psychological services documented that the resident was experiencing anxiety related to potential early discharge and that the plan was to continue addressing discharge‑related anxiety. An APRN progress note indicated the resident had completed IV antibiotics, was clinically stable, and was preparing for discharge home later that week, pending final coordination. A Transition of Care/Discharge Summary identified an anticipated discharge date and a planned discharge location back into the community. Despite these documented goals and clinical readiness for discharge, review of social service notes from admission through the anticipated discharge date did not show evidence that social services had been working with the resident on discharge back into the community. There was no documentation of IDT collaboration, referrals and resources provided for post‑discharge needs, discharge readiness, or the resident’s participation in the discharge planning process, as required by facility policy. The social worker reported that discharge planning discussions occurred and that she met with the resident to discuss anticipated discharge, encouraged the resident to contact family and friends, and provided 211 as a resource, but these actions were not documented in the clinical record. The resident reported being told they were ready for discharge, needing to secure housing, being told to call 211 if housing could not be found, and feeling there was no ongoing assistance from the facility to secure housing or discussion of aftercare. Facility policy required that discharge planning begin at admission, be reviewed weekly for short‑stay residents, and that progress notes include participants, readiness for discharge, services arranged, and teaching provided, which was not reflected in the record for this resident.
Failure to Ensure Proper Functioning of Resident Call Light Indicators
Penalty
Summary
The deficiency involves the facility’s failure to ensure that resident call systems functioned as intended, specifically that the visual call light indicators above room doors illuminated when call bells were activated. During a tour of the third floor, when Resident #4 activated the call bell, the visual indicator light outside the room above the door did not illuminate, and the resident reported that the call bell often did not work properly and had recently been serviced by staff. Shortly thereafter, when Resident #1’s call bell was activated, the call light indicator outside that room also failed to illuminate. When the charge nurse (LPN #1) tested Resident #4’s call bell, the light above the room door again did not illuminate, although the audible signal and visual light at the nurses’ station did activate. The DON stated that the expectation was for the call light indicator above a room door to illuminate when the call bell was pressed. The Administrator reported that routine environmental rounds and testing of the call bell system were conducted but could not specify how often these occurred, and no documentation of such rounds or call bell testing was provided upon request. Review of the facility maintenance log from December 2025 through February 2026 did not show any repair requests for the call bell issues in the rooms of Residents #1 and #4. The facility’s Call Bell policy dated 1/1/24 directed that staff would be made aware of a call bell activation by both the buzzer at the nurses’ station and the light above the room, and stated that if a call bell was found to be defective, a hand bell would be provided, but there was no documentation in the report that these policy provisions were followed for these residents.
Failure to Notify Physician and Administration of Resident's Absence and Missed Medications
Penalty
Summary
The facility failed to ensure timely notification of a physician, medical director, and facility administration when a resident did not return as scheduled from a leave of absence (LOA). The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, was expected to return to the facility by 6:00 PM but did not return until nearly ten hours later. Staff did not notify the Director of Nursing Services (DNS), the administrator, the resident's physician, or local authorities as required by facility policy when the resident was missing. The DNS confirmed she was not informed until the following morning, and the physician stated he would have expected to be notified promptly if a resident did not return from LOA. Additionally, the facility failed to notify the provider when the same resident missed scheduled evening medications, including Furosemide, Gabapentin, Quetiapine, and Eliquis, due to the resident's absence. The LPN on duty did not contact the physician or advanced practice registered nurse (APRN) regarding the missed doses, only informing the charge nurse. The physician confirmed that he expected to be notified within one to two hours of missed medications to make appropriate decisions. Facility policies required staff to notify the provider and supervisory staff in the event of a medication administration error, which was not followed in this instance.
Failure to Prepare and Document Safe Discharge for Resident
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident who was issued a 30-day discharge notice due to non-compliance with the facility's smoking policy. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, and demonstrated moderate cognitive impairment, was identified as needing set-up assistance with personal hygiene and supervision with transfers and ambulation. Despite care plan interventions directing the social worker to utilize community resources, prepare the resident for discharge, and involve the resident in discharge planning, there was no evidence that these steps were taken. The social worker admitted to not having made additional discharge plans or discussed future arrangements with the resident after the initial notice was given. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's discharge. The DON was unaware of the discharge details and the resident's status was not included in daily meetings or on the facility's tracking board. The administrator was also unaware of the discharge notice and its reason. The MDS coordinator noted unresolved insurance issues and did not follow up further, while the admissions coordinator at the sister facility had not received a referral. Nineteen days after the notice, the social worker still had not arranged for a safe discharge, and the resident reported not receiving any further information about the transfer after the initial notice.
Failure to Obtain Hospital Discharge Summary and Inconsistent Leave of Absence Procedures
Penalty
Summary
The facility failed to obtain a hospital discharge summary in a timely manner after a resident was readmitted following a fall and hospital transfer. The resident, who had diagnoses including cerebral infarction, COPD, and adjustment disorder, returned to the facility without any hospital discharge paperwork. Despite facility policy requiring review of discharge paperwork within 24 hours of return, staff did not request or obtain the necessary documentation from the hospital. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the discharge summary was not obtained or reviewed, and there was no documentation explaining why this was not done. Additionally, the facility did not act promptly when the same resident failed to return from a Leave of Absence (LOA) at the expected time. The resident left the facility with a planned return time but did not come back as scheduled. Nursing notes indicated that the resident was still out nearly three hours after the expected return, and further documentation showed the resident was absent for almost ten hours before being returned by a Good Samaritan. Although the DNS stated that staff attempted to contact the resident's responsible party and local hospitals, there was no documentation of these efforts, and required notifications to the DNS, Administrator, local police, and physician were not completed as directed by facility policy. The investigation also revealed confusion and inconsistency regarding the facility's LOA policies. Multiple versions of the LOA policy were in circulation, with conflicting instructions on the steps staff should take when a resident does not return as expected. Staff had electronic access to a more recent policy, but the DNS and Administrator stated that an older policy was the one in use, as confirmed by corporate leadership. This lack of clarity resulted in staff not having clear, unified guidance on how to respond to residents who do not return from LOA in a timely manner.
Failure to Prevent Elopement and Delayed Response for Cognitively Impaired Resident
Penalty
Summary
A resident with multiple complex medical conditions, including opiate dependence, acute infective endocarditis, bacteremia, osteomyelitis, neuropathy, and severely impaired cognition, exited the facility without staff knowledge. The resident required supervision and an assistive device for ambulation, had a history of falls, and was receiving IV medications. Despite these needs, the resident was not identified as being at risk for elopement on the admission assessment, and there was no Leave of Absence (LOA) order in place for the resident. On the day of the incident, the resident was last seen stating an intention to retrieve a deck of cards. Surveillance footage later showed the resident exiting the main entrance behind the Administrator, unnoticed by staff at the front desk, including the Receptionist and the Administrator. The front door's locking mechanism had a 90-second delay before re-engaging, which allowed the resident to leave the building. Staff did not immediately realize the resident was missing; it was only after another resident reported seeing the individual outside that the Recreation Assistant began to investigate. There was a delay of up to ten minutes before the Administrator was notified and a code purple (missing resident) was called. The facility's elopement and code purple policies required immediate action and notification of police when a resident could not be located. However, there was a delay of approximately 54 minutes before the police were contacted. The resident was eventually found by police several miles from the facility, disoriented, inadequately dressed for the weather, and with injuries consistent with a fall. The incident was determined to be an Immediate Jeopardy situation due to the facility's failure to prevent the resident from exiting unsupervised and the delayed response in locating and reporting the missing resident.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes and major depressive disorder was subjected to verbal abuse by a staff member. The resident, who had intact cognition and required supervision with activities of daily living, reported that a nursing assistant made derogatory remarks, calling the resident ugly and stating that the resident's significant other died to get away from them. This account was corroborated by the resident's roommate, who overheard the same comments. The incident was documented in a reportable event form and confirmed through interviews with both the resident and the roommate. The facility's abuse policy states that residents have the right to be free from abuse. Despite this, the staff member involved denied making the statements, but the consistency of the resident's and roommate's accounts led to the substantiation of the verbal abuse allegation. The failure to protect the resident from verbal abuse constituted a violation of the facility's obligation to ensure residents are free from all forms of abuse.
Failure to Include Discharge Planning in Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident, which included discharge planning. The resident, diagnosed with depression, paranoid personality, and atrial fibrillation, was alert and oriented, requiring substantial assistance for ADL care. The Minimum Data Set (MDS) assessment indicated the resident's desire to be asked about returning to the community, yet no referral to a Local Contact Agency was made. The resident's care plan, dated January 8, 2024, did not identify discharge goals or interventions, despite the social worker completing an application for the Money Follows the Person (MFP) program on January 18, 2024, and providing a copy to the resident. Further review revealed that the care plan meeting on March 12, 2024, attended by the social worker and the resident, did not include information about the MFP application or discharge status. The social worker admitted to not documenting the resident's MFP program application or discharge status in the clinical record due to time constraints. The Director of Nursing Services confirmed that the social worker should have documented the progress of the MFP application in the resident's care plan or clinical record, as per the facility's Care Plan Policy, which mandates the inclusion of the resident's discharge preferences and referrals to support such desires.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate regarding medication administration. The resident, who had a history of myocardial infarction, chronic obstructive pulmonary disease, and heart failure, was identified as often non-compliant with medication administration. A physician's order was in place for Nitroglycerin 0.4mg to be administered sublingually as needed. On a specific date, the charge nurse informed the RN supervisor that the resident was given Nitroglycerin, and the APRN was updated with orders to monitor the resident. However, a review of the Medication Administration Record (MAR) for that month did not show documentation of the Nitroglycerin administration on the specified date. During an interview, the RN supervisor acknowledged documenting the administration in a progress note but failed to record it on the MAR. The Director of Nursing Services confirmed that the RN should have documented the medication administration in the MAR, as per the facility's documentation policy, which requires accurate and timely documentation in the resident's medical record.
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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